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Correspondence: Address correspondence to Carita Nygren, Research Unit of Occupational Therapy, Institute of Public Health, University of Southern Denmark, Winsløws vej 9B 5000, Odense C, Denmark. E-mail: cnygren{at}health.sdu.dk
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Abstract |
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Key Words: Person–environment fit • Accessibility • Usability • Housing-related control beliefs
With respect to objective aspects of housing, the ecological theory of aging (Lawton & Nahemow, 1973; Scheidt & Norris-Baker, 2004) has frequently guided environmental gerontology research (Gitlin, 2003; Wahl, 2001). According to this theory, a person is defined in terms of a set of competencies, and the environment is defined in terms of its demands, labeled environmental press (Lawton & Nahemow). Applications of this theory have shown that barriers in the physical environment cause different magnitudes of problems for individuals with varying functional capacities (Fänge & Iwarsson, 2003; Iwarsson, 2005; Stark, 2004; Wahl, Oswald, & Zimprich, 1999; Wahl, Schilling, Oswald, & Heyl, 1999). This underscores the necessity for investigating person–environment fit (P–E fit) and the dynamics among its components, rather than studying personal and environmental factors alone (Iwarsson 2004, 2005). In this kind of research, the term accessibility has been introduced to denote P–E fit, that is, the relationship between a person's functional capacity and the prevalence of physical environmental barriers in the home (Iwarsson & Ståhl, 2003). As a concept, accessibility originated in the field of rehabilitation (Steinfeld & Tauke, 2002). For decades, architects, public planners, and geographers with a specific interest in promoting possibilities for individuals with disabilities to participate in society have advocated accessibility and universal design. In rehabilitation services, occupational therapists continuously target accessibility in intervention processes. Within the field of environmental gerontology, this aspect of housing has been of interest in terms of descriptions of living arrangements and home modifications, most often referred to as P–E fit (Iwarsson, 2004). In our definition, accessibility is an objective aspect of housing and an aspect of P–E fit that can be assessed reliably and validly by professionals, in relation to existing norms and guidelines (Iwarsson & Slaug, 2001; Iwarsson & Ståhl, 2003). Throughout this article (and in Oswald et al., this issue), we use the term accessibility to denote this aspect of P–E fit.
Regarding research on perceived aspects of housing, researchers have traditionally used broad attitudinal, often single-item evaluations of housing satisfaction (Pinquart & Burmedi, 2004), although calls have been made for a more complex and sophisticated approach to investigating perceived housing. For example, perceived activity patterns in the home deserve explicit attention (Golant, 2003), and, according to literature within the field of occupational therapy, person–environment–activity (P–E–A) transactions are of critical importance (Law et al., 1996). Using the idea of P–E–A transactions as the starting point, Iwarsson & Ståhl (2003) defined an aspect of perceived housing, which they termed usability of the home, and the concept has been empirically validated (Fänge & Iwarsson, 2003, 2005a, 2005b). Usability includes P–E–A components and is defined as the extent to which the person's housing needs and preferences can be fulfilled in terms of activity performance (Fänge & Iwarsson, 2005a). Empirically it has been shown that housing accessibility and usability are related but different concepts; usability also includes the activity component and is based on individual perceptions (Fänge & Iwarsson, 2003).
Furthermore, concepts based on theories of place identity (e.g., Proshansky, Fabian, & Kaminoff, 1983; Stedman, 2002) have been advanced. According to these theories, the home environment is a major carrier of meanings related to the person's experience, biography, and personality. The meaning of the home concept covers subjective evaluations, goals, values, cognitions, and emotions of a person in relation to his or her home (Marcus, 1995; Moore, 2000; Oswald & Wahl, 2005). The meaning of home is thus the accumulation of a gamut of place-attachment processes, operating when people form affective, cognitive, behavioral, and social ties to a particular sociophysical setting (Brown & Perkins, 1992), thereby transforming objective spaces into personally meaningful places (Altman & Low, 1992; Rowles & Watkins, 2003).
Another important aspect of perceived housing is its relation to the concept of perceived control (Lachman, 1986; Lachman & Burack, 1993; Levenson, 1973, 1981), which is based on the notion that striving for control has advantages for all species capable of influencing their environment (Schulz & Heckhausen, 1999). The potential of control beliefs for explaining the course and outcome of aging (Heckhausen & Schulz, 1995; Levenson, 1973; Smith, Marsiske, & Maier, 1996) has not been widely applied in housing-related research, but it has been introduced recently and a self-rating scale has shown good psychometric properties (Oswald, Wahl, Martin, & Mollenkopf, 2003).
Even though previous research has acknowledged the importance of objective as well as perceived aspects of the home environment for autonomy, well-being, and participation in old age (Oswald & Wahl, 2004), there is still a lack of research that comprehensively considers the relationship between objective and perceived aspects of housing. The main reasons are that traditional research approaches mostly focused on objective aspects of housing; different conceptual approaches emphasize either the objective or the perceived environment; and there are methodological limitations (Malett, 2004). Further, there is a lack of cross-national research that illuminates national similarities and differences in the relation between objective and perceived aspects of housing (Iwarsson, Wahl, & Nygren, 2004). Besides its potential to provide fundamental insights on aging in place across countries, such knowledge would be an important stimulus for conceptual and methodological advances in research on housing and health in old age.
We hypothesize that it is not objective environmental barriers as such, but the aspect of P–E fit known as accessibility that is related to perceived aspects of housing. In addition, we expect that the relationships between objective and perceived aspects of housing would be at least partially comparable across different countries. That is, such relationships should reflect the fundamental character of the home environment and aging in place issues, which we assume to be independent from the wider sociocultural background and socioeconomic conditions of different countries.
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Instruments
In this research, we used several assessments to capture the objective and perceived aspects of housing; an overview of these assessments is shown in Table 1.
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One administers the Housing Enabler instrument in three steps by using both interview and observation, with the first step being an assessment of the personal component of accessibility. One measures this by the presence or absence of functional limitations (13 items) and dependence on mobility devices (2 items). The second step is an assessment of the environmental component of accessibility. One measures this by conducting a detailed observation of the presence or absence of physical environmental barriers in the home and the immediate outdoor environment (188 items), divided into four sections: outdoor environment (33 items), entrances (49 items), indoor environment (100 items), and communication features (6 items). The third step is the calculation of a score indicating the magnitude of accessibility problems in the P–E constellation assessed. For each environmental barrier item, the instrument includes predefined severity ratings (Steinfeld et al., 1979), operationalized as points quantifying the severity of the accessibility problems predicted to arise in each case. The severity scale is scored 1 to 4, where 1 represents a potential accessibility problem and 4 represents a very severe accessibility problem. On the basis of the assessments in Steps 1 and 2, with use of a complex matrix including the predefined severity ratings, the profile of functional limitations identified for each person is juxtaposed with the environmental barriers present in the home environment. One runs this analysis item by item, and one quantifies each accessibility incongruence by means of the scale. The sum of all the predefined points yields a score quantifying the magnitude of the problems anticipated. In cases in which no functional limitations or dependence on mobility devices are present, the score is always zero. In cases in which the person has functional limitations or is dependent on mobility devices, higher scores mean more accessibility problems. In this project we used the Housing Enabler software to calculate accessibility scores (Slaug & Iwarsson, 2001; demonstration version available at http://www.enabler.nu).
Perceived Aspects of Housing
Housing Satisfaction
For the assessment of overall housing satisfaction we used a single question, adapted from the Housing Option for Older People (known as HOOP; see (Heywood, Oldman, & Means, 2002). We measured housing satisfaction by using a 5-graded rating scale ranging from 1 (definitely not satisfied) to 5 (yes, definitively satisfied; see Sixsmith & Sixsmith, 2002).
Usability of Home
To address the extent to which the physical environment of the home supports the performance of activities, we used the self-administered Usability in My Home questionnaire (Fänge & Iwarsson, 1999, 2003). This questionnaire consists of 16 items rated on a 7-graded scale, from 1 (not at all) to 7 (fully agree), targeting activity aspects, personal and social aspects, and physical environmental aspects. For this study, we applied a project-specific 5-graded scale with the same endpoint definitions as previously described. Because there was low internal consistency in this study (Cronbach's 
< 0.50), we excluded the 6 items concerning personal and social aspects. Thus, retained for analysis were the Physical Environmental Aspects subscale, which included 6 items such as "In terms of how you normally manage your washing up, to what extent is the home environment suitably designed?" (sum score, = 0.84), and the Activity Aspects subscale, which included 4 items such as "How usable do you feel that the entrance of your home is?" (sum score, = 0.84).
Meaning of Home
We assessed the meaning of home by using the Meaning of Home Questionnaire, which was developed to capture older adults' subjective meanings (Oswald, Mollenkopf, & Wahl, 1999). The 28-item questionnaire captures four different aspects of meaning of home. The physical aspect includes 7 items such as "Being at home means for me living in a place which is well designed and geared to my needs"; the behavioral aspect includes 6 items such as "... being able to do whatever I please"; the cognitive–emotional aspect includes 10 items such as "... feeling comfortable and cozy"; and the social aspect includes 5 items such as "... being able to receive visitors." Each item is judged on a scale ranging from 0 (strongly disagree) to 10 (strongly agree). Because the items were purposefully developed to represent a wide range of meanings related to the home, internal consistency was limited (Kline, 1993). To be specific, such consistency was as follows: physical aspects, = 0.69; behavioral aspects, = 0.67; cognitive–emotional aspects, = 0.66; and social aspects, = 0.55.
Housing-Related Control Beliefs
We assessed control beliefs related to housing with the 24-item Housing-Related Control Beliefs Questionnaire (Oswald et al., 2003), which is based on the psychological dimensions of internal control (8 items), external control: powerful others (8 items), and external control: chance (8 items). Each item is assessed in terms of responses to a statement; the level of agreement is judged on a scale ranging from 0 (not at all) to 5 (very much). The term internal control means that housing-related events are highly contingent upon a person's own behavior, where personal responsibility implies that one is responsible for what happens. The term external control means either that some other person is responsible or that things happen by mere luck, chance, or fate. Psychometric analyses of the ENABLE–AGE data set indicated low internal consistency ( < 0.50) for internal control, whereas each of two dimensions of external control reached a medium level. Thus, we decided to exclude the dimension of internal control. After combination of the two dimensions of external control, this 16-item scale reached = 0.67; we used it in the combined form in our analyses.
Procedure
After project-specific training and completion of an interrater reliability study (Iwarsson, Nygren, et al., 2005), interviewers collected data at home visits. In Sweden, Germany, and Latvia, the interviewer teams consisted of occupational therapists; in the UK and Hungary, the teams were multidisciplinary (Iwarsson et al., 2004). Following the ethical guidelines and procedures of each country, we enrolled all participants after they gave informed consent. We handled all data with strict anonymity. Interviewers informed participants that they were allowed to withdraw from the interviews if they wished, including potential withdrawal of their data up to the time of the publication of results.
Data Analysis and Statistical Methods
First, we calculated means or medians on background descriptors for each of the variables for each national sample. For an analysis of cross-national differences on the mean level, we used the Kruskal–Wallis or F test. Because the sample size was large, we set the statistical significance level at p <.001. Given the goal of obtaining measures of objective and perceived housing, the statistical exploration of relationships called for the use of multivariate analysis techniques. We used canonical correlations, which, according to Stevens (1996), is the most appropriate technique for exploring relationships among multivariate combinations of variables. Canonical correlations parsimoniously describe the number and nature of mutually independent relationships between two different sets of variables. In the present study, the objective housing variable set consisted of the total number of environmental barriers and total accessibility scores. The subjective housing variable set consisted of two Usability in My Home aspects, four Meaning of Home Questionnaire aspects, the Housing-Related Control Beliefs Questionnaire external control scale, and the single item on housing satisfaction. We calculated the canonical correlations for each national sample separately.
The statistical procedure calculates linear combinations of the variables in each set of variables (i.e., canonical variates), such that the between-set correlation (i.e., canonical correlations, or R) is maximized. Computation proceeds in a stepwise fashion, with the first pair of canonical variates extracted by finding the linear combinations maximizing the covariance between them. The second canonical variates are calculated in the same fashion, and so on. The analysis focused on identifying the significant canonical correlations, meaning that from each national sample only statistically significant (p <.001) linear composites for the first or second pair are reported. For the interpretation of the significant canonical variates, we used a cutoff correlation of >.35 (Tabachnik & Fidell, 1989). Further, we used standardized canonical coefficients to provide information on the contribution of single variables to the linear combination in the canonical variates. Canonical coefficients yield information on patterns of associations, and their relation to the correlation of the variables gives information on redundancy, meaning that high correlation and low standardized canonical coefficients indicate redundancy. For comparison of the patterns of canonical correlations (i.e., loadings) across the countries, we used Tucker's coefficient of congruence (Broadbooks & Elmore, 1987). This coefficient ranges from –1 to 1; the closer to 1, the higher the similarity between the samples. Tucker's coefficient was originally designed to compare patterns of factor loadings derived from different samples, but it is applicable to comparisons of canonical loadings as well.
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The second variate also revealed significant patterns of relationships for three of the national samples, that is, for the Swedish (R =.30), Hungarian (R =.30), and Latvian (R =.29) samples. However, the degrees of overall explained variance were considerably lower (
22%) than in the first variate. The second variate revealed a pattern in which higher numbers of environmental barriers in all three samples were strongly (>.5) related to activity aspects of usability in the Hungarian sample, and further with meaning of home in behavioral aspects in the Swedish and physical aspects in the Latvian sample, and finally with satisfaction with the condition of the home in the Hungarian sample (see Table 4).
The coefficients of congruence (Table 5) indicated a high similarity of the pattern of relationship represented by the first canonical correlations across all research sites; that is, the first canonical correlations appear to be general and not specific to the national samples, and they indicate a common pattern of relationships between objective and subjective housing.
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Our results reveal the considerable contribution of the magnitude of accessibility problems to the patterns of relationships. This finding gives further evidence for the feasibility of operationalizing the objective home environment as the relationship between functional limitations and physical environmental barriers, as previously put forward by Iwarsson & Ståhl (2003; also see Iwarsson, 2005). Because accessibility is an aspect of P–E fit, this result also lends support to the ecological theory of aging (Kahana, 1982; Lawton, 1982, 1987; Lawton & Nahemow, 1973; Nahemow, 2000) for gerontological research on housing and very old adults.
Referring to the specific definition of accessibility used in the ENABLE–AGE Project, we are of course aware of the fact that different disciplines use different vocabularies. Besides increasing multidisciplinarity in research in general, in practice contexts many actors are involved in processes aiming to produce efficient housing solutions for senior citizens. Moreover, the terms used to describe environments that promote human functioning differ between countries (Ostroff, 2001). For example, there are differences between Europe and the United States. That is, in the United States the term accessibility has connotations related to regulations such as the ADA and the Fair Housing Amendments Act, whereas in Europe the definition we use (Iwarsson & Slaug, 2001; Iwarsson & Ståhl, 2003) is gaining increased acceptance. The problem is that words denoting core concepts are frequently being used in everyday communication between actors in planning processes, in legislation and other official documents, in disability movement material, in research reports, and so on, without explicit definitions. Consequently, the new knowledge contributed by this study would not have been possible without the positioning and definition of accessibility and the valid methodological operationalization of the concept (Iwarsson & Slaug, 2001).
Another important finding is the substantial relationship between the behavioral aspects of meaning of home with accessibility in all five national samples, and that activity aspects of usability had an important influence on the pattern in four of the samples. We did not find this surprising, as these two aspects of perceived housing seem to be conceptually close to each other. More specifically, the behavioral aspects of meaning of home as well as activity aspects of usability are in different ways connected to the individual's use of space and construction of personal rituals that are implemented into routines (Pastalan & Barnes, 1999) and activity performance (Kielhofner, 2002). Further, in all national samples, the participants had lived a long time in their present dwelling, suggesting the existence of well-established personal routines and habits as a result of the ongoing interaction with the environment over time (Kielhofner, 2002; Shenk, Kuwahara, & Zablotsky, 2004). Physical aspects of meaning of home could have been expected to be more closely aligned to the magnitude of accessibility problems in all samples, because physical aspects address the experience of housing conditions, access, and furnishing (Oswald et al., 1999). We have no explanation for the differences among the national samples in this respect, and this has to be investigated further. The substantial relationship between the magnitude of accessibility problems and physical environmental aspects of usability in four of the samples is consistent with previous research showing that a more accessible home is perceived as a more usable home (Fänge & Iwarsson, 2003).
Furthermore, it does not seem as if accessibility per se is of great concern for the cognitive–emotional meaning of home, which is consistent with the theoretical notion that this aspect is more connected to internal psychological processes and interactions (Oswald et al., 1999; Oswald & Wahl, 2004). Taken together, these results demonstrate the importance of investigating usability and meaning of the home in relation to objective aspects of housing. More specifically, the results underscore the need to explicitly consider the physical environmental and behavior-related aspects of meaning of home, as well as P–E–A transactions in the home in very old age. The specific advantage of a usability and meaning of home assessment is that it enhances the understanding of perceived housing from the perspective of the impact of the home environment on everyday activity performance. Given that the performance of meaningful activities is known to support independence and health in old age (Clark et al., 1997), housing that is considered useful for the performance of activities is likely to support health and social participation among older people (Iwarsson, 2005; Iwarsson & Isacsson, 1997; see also Oswald et al., this issue).
Concerning housing-related control beliefs, this study demonstrated that, across all national samples, a high magnitude of accessibility problems was related to the high use of external control strategies (Oswald et al., 2003) in order to overcome age-related functional decline. It can be argued that the findings are of less importance as no conclusions on the dynamics between external and internal housing-related control (Heckhhausen & Schulz, 1995; Oswald et al.) can be drawn, because this study did not include data on internal housing-related control. However, earlier longitudinal research (Baltes, Freund, & Horgas, 1999; Clark-Plaskie, & Lachman, 1999) has noted that in particular external control beliefs are sensitive to age-related changes, and thus they are crucial for analyses in relation to independence in everyday life and well-being in old age. Thus, the consideration of external control addresses a major facet of the full control dynamics as people age. Even though there is a need for more research, it could well be that intervention directed at decreasing accessibility problems in the home would have an impact on the use of external coping strategies. There is an obvious need for optimization of the subscales that do not fulfill psychometric properties for this study, but still the results provide knowledge furthering our understanding of how housing-related external control in relation to accessibility affects the maintenance of everyday activities and the ability to age in place (Oswald & Wahl, 2004). Such knowledge could alert health care professionals and others to acknowledge personal preferences of older people regarding their home environment.
Despite the exploratory design of this study, the Tuckers coefficient revealed a cross-national similar pattern of relationships between P–E fit and accessibility and the more activity-oriented aspects of perceived housing. The generalizability of our findings on national as well as cross-national levels is restricted by the fact that the sample was composed of rather healthy very old people living in urban districts. Further research is needed to reveal whether comparable patterns of relationships between objective and perceived housing among very old people can be found in other regional settings such as rural areas. Further, in order to investigate whether relationships between objective and perceived aspects of housing are stable over time, longitudinal research is needed. Information on the stability of the patterns over time would provide information vital to social planning and the specific factors of importance to supplying good housing throughout old age.
In conclusion, this study demonstrates the importance of bringing together objective and perceived aspects of housing in order to develop more knowledge and a better understanding of the complexity of housing in very old age. The results revealed relationships between objective and perceived aspects of housing not previously presented, and they underscore the importance of describing objective housing in terms of accessibility as an aspect of P–E fit. Bearing in mind the explorative nature of the ENABLE–AGE Project, we find that the results demonstrate that very old people seem to share a common experience of objective and perceived aspects of housing across different countries and cultures. This study also contributes to the awareness that, in order for researchers to obtain a comprehensive and more accurate picture of housing in old age, they have to address objective as well as perceived aspects of housing in future research. The findings presented here support ongoing theoretical development within environmental gerontology and represent a resource for future empirical research. Further, the integrative, comprehensive, and systematic methodology that we used can be applied in practice contexts targeting older people living at home. The results have the potential to contribute to the development of more holistic housing interventions, involving very old people more actively in individual home adaptations as well as in housing provision targeting senior citizens in general.
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1 Department of Health Sciences, Lund University, Sweden.
2 Department of Psychological Ageing Research, University of Heidelberg, Germany.
3 Department of Psychology and Speech Pathology, Manchester Metropolitan University, England.
4 Division of Primary Care, University of Liverpool, England.
5 Institute for Sociology, Hungarian Academy of Sciences, Budapest, Hungary.
6 Academic School of Occupational Therapy, Riga Stradins University, Riga, Latvia.
Decision Editor: Linda S. Noelker, PhD
Received for publication November 7, 2005. Accepted for publication September 11, 2006.
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