Influence of occupation and home environment on the wellbeing of ...

Clinical

Influence of occupation and home environment on the wellbeing of European elders ENABLE-AGE was a EU-funded project involving research teams in Germany, Hungary, Latvia, Sweden and the UK. A main aim was to study the relationship between home and healthy ageing for very old people living alone at home. In all, 1918 older people from the five EU countries were surveyed. This article addresses results from a sub-set of in-depth interviews, conducted with 80 octogenarians in Sweden and the UK. The impact of the home environments and patterns of occupational engagement on individual wellbeing is presented. Findings indicate that occupational pursuits are diverse, and not dictated by chronological age. Social activities outside the immediate home environment are particularly valued, as is easy access to favourite local venues. Additionally, being able to leave the home to pursue chosen activities is enjoyed and nurtured. House-bound elders find their occupational satisfaction increasingly dependent upon both their own ingenuity and the accessibility of the interior home. Key words: occupation, elderly, home, wellbeing Green S, Sixsmith J, IvanoffSD, Sixsmith A (2005) Influence of occupation and home environment on the wellbeing of European elders. Int J Ther Rehabil 12(11): 505-9

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NABLE-AGE was a multidisciplinary, multinational project funded by the EU, which extended over a 3-year period and finished in December 2004. It was carried out in Sweden, Germany, UK, Hungary and Latvia, with the major purpose of examining how the home environment influences healthy ageing in very old age. Occupational therapists hold particular interest in data that link wellbeing and occupational engagement in the context of the home environment. Researchers in the ageingfield,over the past decade, have all addressed the positive health and wellbeing effects of occupational engagement (Baum, 1995; Green, 1995; Clark et al 1997; Perrin, 1997; Hughes et al, 2002). There is also the recognition that wellbeing is further enhanced when challenging occupations are accomplished (Csikszentmihalyi, 1993). In light of current clinical practice, which must demonstrate an evidence base, Reilly's (1962) comment remains pertinent today: That man, through the use of his hands as they are energized by mind and will, can influence the state of his own health.' However, there is still limited research in the ageing field that demonstrates Reilly's position statement (Kaplan and Strawbridge, 1994; Wilcock, 2001). There is also limited research that actively involves

older people 'centre-stage' in giving their expert opinions about what they like to do (Horgas et al, 1998), or what brings quality to their lives (Gill and Feinstein, 1994). Additionally, the impact of context, i.e. where the occupation is carried out, needs to be studied. As people enter very old age, the home environment assumes a higher profile; the home itself is the place where most occupational involvement occurs (Perez et al, 2001; Rosel, 2003), together with the immediate environment outside the home (Peace, 1993). The benefits of 'staying put' at home are generally recognized (Gumey and Means, 1993) and supported by current policies (Department of Health, 2001). There does, however, continue to be an ongoing lack of productive research on the 'place effects on health' and how place of residence is linked with health outcomes (Macintyre et al, 2002). Such an intent formed a prime aim of the ENABLE-AGE project, which hypothesized that an older person's home environment and home occupations will influence the health and wellbeing of that person.

AIMS OF THE STUDY This study aimed to address some of the above limitations in knowledge, using analysed qualitative data

International Journal of Therapy and Rehabilitation, November 2005, Vol 12, No 11

Sharon Green is Occupational Therapist and Honorary Research Fellow, Department of Primary Care, University of Liverpool, Brownlow Hill, Liverpool L69 3GB, UK. Judith Sixsmith is Psychologist and Reader in Applied Psychology, Department of Psychology and Speech Pathology, Manchester Metropolitan University, Manchester, UK. Synneve Dahlin Ivanoff is Occupational Therapist, Sahlgrenska Academy at Goteborg University, Goteborg, Sweden. Andrew Sixsmith is Social Gerontologist and Lecturer, Department of Primary Care, University of Liverpool, Liverpool, UK Correspondence to: Sharon Green ssreen&.liv.ac. uk

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Clinical from the Sweden and the UK, by investigating: • How the home environment contributes towards ongoing occupational involvement for elderly European home-dwellers • How such occupational involvement influences wellbeing.

METHODS A grounded theory approach was adopted. In this method, theory is 'derived from data, systematically gathered and analysed through the research process' (Strauss and Corbin, 1998). An initial agenda of open-ended research questions focussing on project issues was designed, covering the key concepts underlying the ENABLE-AGE project: • Meaning of home • Health and wellbeing in the home environment • Social and community participation • Home and independence • Societal supports for ageing well. An iterative process of data collection and thematic analysis allowed new issues to be introduced into the research schedule as it progressed. The research process was conducted in both countries. A team of trained interviewers was recruited and a diversity sub-sample of 40 participants was established in the UK and Sweden. Individual home-based interviews, lasting 1-2 hours, were taped and conducted over a 6-month period. The thematic analysis involved teamwork collaboration at both the national and international levels with discussion and analysis being conducted during and beyond this period. National reports of findings were compiled and a cross-national report of comparative findings was produced. These are available at the ENABLE-AGE website (www, enableage.arb.lu.sel The sample The ENABLE-AGE project surveyed a total of 1918 people aged 80-89 years (75-84 years in Hungary and Latvia owing to lower life expectancies). In each country, a sub-sample for qualitative interviews was selected on the basis of diversity in terms of health, activity level in the home and the community and housing circumstances. Informed consent was obtained, privacy protected and anoSwedish and UK sample groups Age group 80-84 years 85-90years Sex:

Total

506

Total

Male

17

16

33

Female .

21

26

47

38

42

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__

80

nymity assured (hence pseudonyms are used in all reports). The Swedish and UK sample groups are shown in Table 1. The gender balance reflected both the higher numbers of octogenarian women living alone in the community, and the willingness of women to be involved in such time-consuming research. Survey scores on the Activities of Daily Living Staircase, an assessment of independence in relation to activities of daily living (Sonn and Hulter-Asberg, 1991), provided diversity for dependency in basic activities. Housing diversity was ensured by a wide range of person-environment fit scores, obtained from the Housing Enabler, an instrument for assessing and analysing accessibility (Iwarsson and Slaug, 2001), and by different types of current housing, from sheltered to single family homes. Leisure time activities recorded in the survey indicated those participants who were able to engage in outdoor participation as opposed to being homebound. Additional attention was paid to the inclusion of participants who came from economically varied backgrounds.

FINDINGS Home environment and occupation when health is good Here, the home was commonly seen to be important as the base of day-to-day life, a place of comfort and safety to return to. The nearby location of friendly neighbours and accessible local shops and the 'nottoo-big garden' were all recognized as important for personal wellbeing. A wide range of active pursuits was noted, with age being no barrier to participation, albeit with some modifications: '...my golf, even though it has become troublesome...if you may call it golf nowadays...! can no longer manage to do all 18 holes...It has to be 9 holes or half the distance.' (Rolf, Sweden) In the UK, Marge, at the age of 88 years, took an active stance towards her own health, wellbeing and participation. She still rose at 5 am every morning to go to her nearby gym, declaring: 'I think it's everybody's duty to look after their own body, you see. I feel this very strongly. Because if you don't look after your body, you are a burden on other people and you are a burden on the state because of the health service. Ifs up to us all to live a healthy lifestyle...l go to college of course, thafs Wednesday. I'm studying the history of [place name]; we are writing a book. Then the history society, we go on field meetings.' (Marge, UK)


Challenging and absorbing pastimes brought an enhanced sense of wellbeing. In the UK, Edith, aged 88 years, liked to mentally 'tick off' her accomplishments of the day when she went to bed each night, and she described her best days as occurring when she had been sculpting: 'I could work and work and work, suddenly at 4 am in the morning I'd discover I'm frozen...rm hungry, I'm thirsty, I'm tired, I haven't known any of that because I've been concentrating...it's an intense thing, and when I'm working on them, I'm working on them and nothing else gets done really.' (Edith, UK) Participation and socializing were highly valued - all participants spoke of this. Even when friendships and contacts had dwindled, the importance of getting out, taking a regular walk and being with other people was highlighted: '...it is like this, you are one among others...even if there isn't anybody I know...to be part of the society...' (Svea, Sweden)

As an adjunct to meeting people outside the home, accessibility of own homes and nearby valued venues was of great importance. A number of elderly Swedish participants lived in apartment blocks where positive features were noted: 'You recognized how easy it was to get in the elevator here. It isn't that easy everywhere. It means a lot to know that if I get out, I can get back home again.' (Agneta, Sweden)

Violet spoke for several of the UK participants concerning access to local shops: 'And I take my trolley and we do our shopping in the village. On a Friday we'd go down to the butchers and down to the general, er, [store] because there's all sorts you can buy there.' (Violet, UK) In the UK, a commonly held pastime for the more active older people was gardening. While a large garden could become burdensome, a plot that could be tended independently brought a great deal of pleasure. John spoke of his garden and greenhouse with enthusiasm: 'I've got piles of tomatoes in and coming out, and I grow piles of beans and I give all those away, but I just like growing things.' (John, UK)

Inside the home there was a wide range of occupational pursuits that brought pleasure and feelings of wellbeing, from bread making (Agnes) to surfing the internet (Violet) and other computer-related activities. While some participants expressed scepticism about computers, five of the UK sample were avid users. Email kept them in touch with younger

relatives, the internet provided endless sources of information and it was possible to play card games without physical companionship: 'I like my computer maybe because it's a wonderful word processor and I play bridge on it' (Stan, UK)

A pursuit mentioned by female participants was the satisfaction their home afforded them when they could support their own children by looking afrer grandchildren or even great-grandchildren. Violet spoke about this, suggesting that her grandparenting role was eased because she had a home computer: ...and the one that's four -1 bought games for him, I've got them here and he's as good as gold. As good as gold, they just sat there the two of them (laughs).' (Violet, UK) Despite busy days, whether in or out of the home, these older people really appreciated coming home to a place where they could feel familiar, relaxed and at ease. In the UK, Belle, a very active woman, described instances that reminded her of the positive impact of her home in terms of her wellbeing: 'You can close your own door and there's nobody to bother you. You know, people that come in, you invite them in, they just don't come in any old how...oh no, I wouldn't want to leave my home. Even when I go away down to my sons, I'm always glad to get back...Oh yes, I like to get home to my own bed (laughs) - there's something about it (laughs).' After a local weekend retreat, she said: 'Yes, a lot of things were going on there, but it was very nice and lovely. But I was quite pleased to come home because I was worn out and I didn't have to do anything. I didn't even have to lift a cup! Here, I can sit down and put my feet up and do things in my own time, you see.' (Belle, UK)

Perhaps put most succinctly, this participant from Sweden indicated the importance of her home to her wellbeing: 'Being at home and coming home is like putting on a cosy coat or cardigan.' (Barbro, Sweden)

The range of activities talked about by participants was surprisingly diverse, demanding sustained energy (golf) and being linked to modem ways of living (for example, the computer). Activities supported individual preferences (gardening) as well as enabling older people to feel valued and engage with younger generations. While the home acted as an important base for activity, it also afforded privacy, security and a space to restore themselves out of sight of the world outside.


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Clinical Home environment and occupation when health is poor For those older people who were experiencing poor health and/or severe mobility restrictions, the internal layout assumed a higher priority in enabling home-based occupation. These participants indicated that as their spatial worlds were reduced, the highly accessible home became all-important. The ability to view the outside world and in a sense to remain part of it, was expressed in both countries. In Sweden, balconies were seen as a practical viewing platform to the outside world: 'I live my life at the balcony, from there I can see the green area and the sky and it feels so good.' (Ulrika, Sweden) In the UK, where balconies feature rarely, Shirley, now house-bound and receiving a complex daily care package, appreciated her home of many years because of its outlook. From her lounge window she could interact and immediately feel part of the community: 'I'm very lucky because that is a golf course...and I know quite a lot who play, and they wave to me!' (Shirley, UK) Accessible internal space was of high importance to the more houseboimd participants, as one 86-yearold man commented in the UK: 'I think I would be very frustrated if I was unable to move around...I have a desk in what should be the second bedroom...if I am fed up with here I can go and sit there and do some writing or checking or something.' (Charles, UK)

The less mobile and more frail participants prized general accessibility features such as a walk-in shower or an eye-level grill and assistive devices such as chair raisers and mobility aids. Ann's sheltered apartment had all of these features and she was grateful for both the therapists' input and the fact that they had respected her desire to retain control over her lifestyle: '...once I'm sitting down, I'm down for the night. You know, I don't get in and out of the chair so easily...the therapist that came in gave me this chair...and I do think the man who invented bed levers should get a knighthood! '...and they got me a tilter and they highered the toilet and they wanted to put something in the bathroom for me but we do have, on each corridor, a very nice shower. So they think I needed...l couldn't get in and out of the bath - if I got in, I couldn't get out at all. Now, with my figure and all the lumps on it...I don't want anyone to see me in my nude...and 508

they agreed, you see, there's bars all around that I can hold onto and there's a seat in the shower. So the shower suits me.' (Ann, UK)

Ann, due to frequent falls, had become housebound during the 3-year ENABLE-AGE project. Nevertheless, she highly prized her independence maintained through various housing adaptations, and her subsequent ability to remain 'at home'. This was a common theme; however difficult to attain, independence was always valued highly as this Swedish participant expressed: '...the most important thing with home is that I am independent, which means that I must force myself to manage. Even if it is hard I have to do it.' (Kerstin, Sweden) Participants with limited mobility generally found their horizons raised and their quality of life improved when correct mobility devices were supplied. Charles, almost housebound at project commencement, spoke later of his delight in acquiring his 'liberator' - an outdoor 3-wheeled walker. Not only could he move safely around indoors, but with nearby accessible shops, he could once again walk down the high street, go to his bank, get his hair cut and do many other day-to-day 'normal' activities. His confidence was generally boosted: 'But again, these kind of things give you a help as well. The moment a driver sees me coming up with this towards the crossing, they stop automatically...So, it is a great help.' (Charles, UK) Again, there was additional pleasure and heightened sense of wellbeing when occupations were challenging and absorbing. These activities could mask less pleasant aspects of growing old (such as aches and pains and social isolation). Des, now severely disabled by Parkinson's disease, outlined his pleasure in receiving a challenge: 'I've got some friends that I used to know when I went to Italian lessons. And they keep in touch with me and send me postcards when they go on holiday. And letters. And sometimes they try to stump me with an Italian phrase or an idiom, just to keep me on my toes! (Des, UK) For those participants who were in poor health and with mobility problems, home became an essential resource for promoting a good quality of life. Here, activities that absorbed and challenged the person's skills and capabilities were prized and more subtle forms of activity, such as looking out of the window, were integral to positive wellbeing. Housing adaptations were highlighted as important not just in aiding activity, but in contributing to a psychological sense of independence and personal wellbeing.

International Journal of Therapy and Rehabilitation, Novennber 2005, Vol 12, No 11

DISCUSSION The ENABLE-AGE qualitative study illustrates the importance of the home environment for the retained independence and wellbeing of very old people. The home environment is valued for many reasons, including its support of familiar pastimes and its repository of occupational tools and places such as the books and the manageable garden. 'Staying put' (Gurney and Means, 1993; Department of Health, 2001) is highly valued by these older community dwellers. Occupational tools, such as the home computer, were seen to foster both real and proxy social contact and to support valued roles such as grandparenting. Occupations offering particular challenge or complexity brought a heightened sense of wellbeing and personal value, as Csikszentmihalyi (1993) has described. Participants appreciated that the location and accessibility of their homes was instrumental in supporting mental wellbeing through participation in chosen and familiar occupations. Evidence is offered to support the 'place effects on health'(Macintyre et al, 2002), where health involves a sense of personal wellbeing. Because social interaction and participation is so highly valued, the less mobile participants showed ingenuity in bringing the world to them, from the balcony or the lounge window. From the rich data material obtained, it has only been possible to highlight a selection of the findings that address the key themes of this article. Nevertheless, the rigour of the methodology supports the presented findings. Participants were given a centre-stage position (Horgas et al, 1998) throughout, with their words being frequently revisited by the researchers during iterative inter- and intranational discussion. Further findings fh)m the ENABLE-AGE project are currently being explored with respect to important related areas, such as control and choices in later-life housing and the promotion of health-related occupations in later life.

their hobbies, re-planned their weekly schedules or accepted aids or assistance in order to accomplish their daily tasks, with an overriding determination to succeed. Similarities in the two project countries far outweighed any differences in the topic areas. UHl Conflict of interest: none. Baum C (1995) The contribution of occupation to function in persons with Alzheimer's disease. J Occup SciAust 2(2): 59-67 Claik F, Azen S, Zemke R et al (1997) Occupational therapy for independent-living older adults. J^mAferfAsioc 278(16): 1321-6 Csikszentmihalyi M (1993) Activity and happiness: towards a science of occupation. Occup SciAust 1(1): 38-42 Department of Health (2001) National Service Framework for Older People. Her Majesty's Stationery Office, London Gill T, Feinstein A (1994) A critical appraisal of quality of life measurements. JAM4 272: 619-26 Green S (1995) Elderly mentally ill people and quality of life: who wants activities? BrJ Occup Ther 58(9): 377-82 Gurney C, Means R (1993) The meaning of home in later life. In: Arber S, Evandrou M, eds. Ageing, Independence and the Life Course. Jessica Kingsley Publishers, London Horgas A, Wilms H-U, Baltes M (1998) Daily life in very old age: everyday activities as expression of successful living. Gemntologist 3S(5): 556-^8 Hughes G, Bennett K, Smith P (2002) 'It was no good sitting at home sewing a fine seam...' The importance of keeping busy in later life widow(er)hood. BSG Arinual Conference Active Ageing: Myth or Reality: 73-7 Iwarsson S, Slaug B (2001) Housing Enabler An Instrument for Assessing and Analyzing Accessibility Problems in Housing. Studentlitteratur, Lund, Sweden Kaplan GA, Strawbridge WJ (1994) Behavioral and social factors in healthy aging. In: Abeles R, Gift H, Ory M, eds. Aging and Quality of L^e. Springer Publishing Company, New York: 57-78 Macintyre S, Ellaway A, Cummins S (2002) Place effects on healfli: how can we conceptualise, operationalise and measure them? Soc SciAferf 55: 125-39 Peace S (1993) The living environments of older women. In: Bernard M, Meade K, eds. Women Come of Age: Perspectives on the Lives of Older Women. Edward Arnold, London Perez F, Rivera G, Abuin J (2001) Ageing in place: predictors of the residential satisfaction of elderly Soc Indie Res 54: 173-208 PerrinT (1997) Occupational need in severe dementia: a descriptive study JAdv Nurs 25: 934-41 Reilly M (1962) The Eleanor Clarke Slagle Lecture: occupational therapy can be one of the great ideas of 20th century medicine. ^myOccw/)77ie/-16(1): 1-9 Rosel N (2003) Ageing in place: knowing where you are. Int J Aging Hum Dev 57(1): 77-90 Sonn U, Hulter-Asberg K (1991) Assessment of activities of daily living in the elderly Scand J Rehabil Med 13: 193-202 Strauss A, Corbin (1998) The Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. Sage, London Wilcock A (2001) Occupational science: the key to broadening horizons. BryOccMp77ier 64(8): 412-17

KEY POINTS

CONCLUSIONS Irrespective of age, the 80 participants in the qualitative study in Sweden and the UK demonstrated strong ambitions to remain independent, in order to be able to remain 'at home', in their familiar environments. Being meaningfully occupied, whether inside or outside the home, was seen as proof of the ability to 'carry on', as ongoing evidence of being in control, and was normally accompanied by a sense of achievement and wellbeing. Being able to mentally 'tick oflF' the day's accomplishments was valued, as were challenging activities that were all-absoibing. In the face of poor health or restricted mobility, the participants used ingenuity; they adapted

Health professionals need to understand the importance of remaining 'at home' in relation to the wellbeing of their older clients. Being meaningfully occupied at home brings feelings of achievement and wellbeing to older people. Age is immaterial; absorbing activities help people to lose themselves in the present moment. With older clients at home, therapists need to promote their ongoing dayto-day coping strategies, so a sense of control and wellbeing is retained. Access to the immediate environment and community outside the home is very important to mental health. Ingenuity, adaptation and determination help when health or mobility is restricted.


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