Agneta Malmgren Fänge

The Home Environment and Disability-Related Outcomes in Aging Individuals: What Is the Empirical Evidence?

PURPOSE Building on the disablement process model and the concept of person-environment fit (p-e fit), this review article examines 2 critical questions concerning the role of home environments: (a) What is the recent evidence supporting a relationship between home environments and disability-related outcomes? and (b) What is the recent evidence regarding the effects of home modifications on disability-related outcomes? DESIGN AND METHODS Using computerized and manual search, we identified relevant peer-reviewed original publications and review articles published between January 1, 1997, and August 31, 2006. For Research Question 1, 25 original investigations and for Research Question 2, 29 original investigations and 10 review articles were identified. RESULTS For Research Question 1, evidence for a relationship between home environments and disability-related outcomes for older adults exists but is limited by cross-sectional designs and poor research quality. For Research Question 2, evidence based on randomized controlled trials shows that improving home environments enhances functional ability outcomes but not so much falls-related outcomes. Some evidence also exists that studies using a p-e fit perspective result in more supportive findings than studies that do not use this framework. IMPLICATIONS Considerable evidence exists that supports the role of home environments in the disablement process, but there are also inconsistencies in findings across studies. Future research should optimize psychometric properties of home environment assessment tools and explore the role of both objective characteristics and perceived attributions of home environments to understand person-environment dynamics and their impact on disability-related outcomes in old age.

Home as a signification of independence and autonomy: Experiences among very old Swedish people

The aim of this study was to explore independence in the home as experienced by very old single-living people in Sweden. A grounded theory approach was used and interviews were conducted with 40 men and women aged 80–89. Data analysis revealed the core category “Home as a signification of independence” with two main categories: “Struggle for independence” and “Governing daily life”. The findings showed that home is strongly linked to independence, and being independent is extremely valued. Explicit descriptions of the ageing process as an individual process of changing living conditions within the home emerged from the findings. Hence, the ageing process influences the participants’ perception of themselves as independent persons. Along the ageing process the participants’ view of independence changed from being independent in activity performance without help from others to experiencing independence in being able to make autonomous decisions concerning daily life at home. Consequently, there is a need to develop strategies to support very old people in staying as active and independent as possible in their own homes. In addition, since the findings highlight that independence is a complex construct, there is a need for conceptual differentiation between independence and a construct often used synonymously, namely autonomy.

Accessibility and usability in housing: construct validity and implications for research and practice

Purpose: The aim of this study was to validate the conceptual definitions of accessibility and usability, and to explore differences between objective accessibility assessments and subjective ratings of usability in different client groups. Method: The Housing Enabler and the Usability in My Home instruments were used for 131 persons above 18 years of age, living in ordinary housing and receiving a housing adaptation grant. Covariation between accessibility in four different housing sections and three different usability aspects were explored, for the total sample and for six sub-samples reflecting person-environment-activity transactions or demographic factors. Results: Significant correlations were found in the total sample, among clients aged 75 – 84, women, clients living alone, as well as among clients with high dependence in personal and instrumental ADL and in outdoor activities. Subjective usability evaluations of activity aspects and physical environmental aspects were correlated to accessibility indoors and outdoors, while personal and social aspects of usability were correlated to outdoor accessibility. Conclusions: Accessibility and usability are concluded to be different but related concepts. The results indicate that e.g. age, civil status and ADL dependence affect how clients assess aspects of their housing situation. For efficient planning and evaluation of housing adaptations, assessment of housing accessibility, usability, and dependence in ADL is recommended.

The multiple meaning of home as experienced by very old Swedish people

The aim of this study was to explore aspects of the meaning of home as experienced by very old single-living people in Sweden. A grounded theory approach was used, and interviews were conducted with 40 men and women aged 80–89. The findings indicate that home has a central place in the lives of very old people because it is where they live and spend so much time. The significance of the home is based on the fact that it means so many different things to the participants. The theme comprises two key categories: home means security and home means freedom. Each of these has three sub-categories. In home means security, these are: living in a familiar neighborhood, everything functions, and having memories to live on. Home means freedom comprises a place for reflection, a social meeting-point, and leaving your own mark. Home is part of the environment and influences the meaning and selection of activities that very old people decide to engage in. When occupational therapists prescribe assistive devices or recommend changes in the home environment, they must be very well aware of and reflect on what home means to their clients and base their measures on that.

Home as the locus and origin for participation: Experiences among very old Swedish people

Using a grounded theory perspective, this article focuses on experiences of participation in relation to home among very old people who are living alone. Eight people selected from the larger ENABLE-AGE Project were interviewed. Data analysis identified the core category as “home as the locus and origin for participation” with two main categories (“performance-oriented participation” and “togetherness-oriented participation”). The findings indicate that the home is the origin for participation both out of the home and within the home. However, as older peoples health declines, the home becomes the explicit locus for participation. Participation successively changes from taking part in more physically demanding activities out of the home to participation by means of watching others from within the home (i.e., by being a spectator). In appreciating self-defined goals for a meaningful life, thus enabling the experience of participation in very old age (age 80 to 89 years), this study contributes to the knowledge about relationships between participation and home in very old age.

Healthy ageing and home: The perspectives of very old people in five European countries.

This paper reports on in-depth research, using a grounded theory approach, to examine the ways in which very old people perceive healthy ageing in the context of living alone at home within urban settings in five European countries. This qualitative study was part of a cross-national project entitled ENABLE-AGE which examined the relationship between home and healthy ageing. Interviews explored the notion of healthy ageing, the meaning and importance of home, conceptualisations of independence and autonomy and links between healthy ageing and home. Data analysis identified five ways in which older people constructed healthy ageing: home and keeping active; managing lifestyles, health and illness; balancing social life; and balancing material and financial circumstances. Older people reflected on their everyday lives at home in terms of being engaged in purposeful, meaningful action and evaluated healthy ageing in relation to the symbolic and practical affordances of the home, contextualised within constructions of their national context. The research suggests that older people perceive healthy ageing as an active achievement, created through individual, personal effort and supported through social ties despite the health, financial and social decline associated with growing older. The physicality and spatiality of home provided the context for establishing and evaluating the notion of healthy ageing, whilst the experienced relationship between home, life history and identity created a meaningful space within which healthy ageing was negotiated.

Accessibility to the public environment as perceived by teenagers with functional limitations in a south Swedish town centre.

Purpose : Owing to physical inaccessibility persons with mobility restrictions and other functional limitations often face problems in public environments, leading to restrictions in activity and participation. To investigate general accessibility and perceived problems of accessibility to the public environment in a town centre, as well as visiting preferences to public facilities, among teenagers with functional limitations. Methods : An interview questionnaire specific to a south Swedish town was constructed and used with 33 Swedish teenagers with functional limitations. Results : To a varying degree, all 33 teenagers commented on accessibility problems, e.g. concerning uneven surface material outdoors, steps at entrances, heavy doors and restricted space indoors. The results also indicated that teenagers with functional limitations to a high extent want to visit the same environments as other teenagers, but that it is often impossible owing to accessibility problems. Furthermore, because of accessibility problems, many of the teenagers were dependent on personal assistance. Conclusion : Inaccessibility results in dependence, which might affect personal development negatively, and much effort are required in order to ensure activity and societal participation. Efficient priorities in public environment accessibility matters and discussions with the actors involved require valid and reliable data on local accessibility problems.

Toward a Screening Tool for Housing Accessibility Problems A Reduced Version of the Housing Enabler

To present a reduced version of the Housing Enabler, useful as a screening tool in practice contexts and in research, this study identifies the core items of the environmental component of the instrument, that is, the items most important in terms of the instruments overall validity to measure accessibility problems. Utilizing cross-national data and interdisciplinary knowledge through an iterative process, a set of core items was identified. The environmental component of the reduced version comprises 61 items, compared to 188 in the original instrument. The rank correlation between the accessibility scores generated by the original and reduced versions was r ≥ .97 (p < .001). Based on comprehensive empirical research in three countries, the reduced version of the Housing Enabler is a time-efficient and valid screening instrument. It is a powerful tool for research and interventions focusing on housing accessibility problem identification.

Challenges in the development of strategies for housing adaptation evaluations

Founded on recent empirical experiences and results from a Housing Adaptation Project accomplished in a Swedish municipality, this paper aims to elucidate and problematize challenges inherent in the process of developing research-based strategies for housing adaptation (HA) evaluations feasible for municipality contexts. In this paper, theory and conceptual definitions of client-level outcomes related to Swedish HA legislation—i.e. accessibility, usability, and activity—are presented. In order to lay the ground for the presentation and discussion on challenges, the Housing Adaptation Project is described with regard to design sampling and data collection, client-level outcomes and assessment instruments used, as well as longitudinal results. The challenges faced during the project were related to the assessment of outcomes, the logistic flow of the data-collection process, client availability for follow-up assessments as well as interpretation of changes in accessibility. Some challenges were due to the organizational HA framework in the municipalities, while others were related to the methodology used for outcomes assessment. Based on our experiences with this project, a set of evaluation recommendations for practice and research is provided.

Clients’ experiences of housing adaptations: a longitudinal mixed-methods study.

Purpose: To explore clients’ experience of the housing adaptations (HAs) over time in relation to housing and health. Method: A multiple longitudinal case study, employing an embedded mixed-method design was used. Four participants were included and data from semi-structured interviews were combined with data from structured survey assessments. Results: HA made it possible to maintain valuable roles and activities, to continue to live in the participants’ own homes and to take part in the society. The participants strived for autonomy and control, and in order to do so they needed different kinds of support, in terms of HA and mobility devices as well as support from professionals. HA also challenged the participants’ routines and habits, as well as their perception about how an appealing HA aesthetically. Thus, the decision to apply for a HA was not always straightforward. Instead, the participants were constantly engaged in negotiations with themselves, concerning benefits and drawbacks of different decisions. Conclusions: HAs involve complex person–environment–activity (P-E-A) transactions, and enhance clients’ activity and independence in spite of functional decline. The knowledge generated is important in order to improve individual HA, as well as improving the efficiency and effectiveness of the intervention. Implications for Rehabilitation Clients need different kinds of support from professionals. Clients needs and preferences should be at the forefront throughout the housing adaptation process. Clients individual meaning of the housing adapation as well as the social environment are important aspects.