A public health perspective to environmental barriers and accessibility problems for senior citizens living in ordinary housing

Transcription

1 Granbom t al. BMC Public Halth (2016) 16:772 DOI /s RESEARCH ARTICLE Opn Accss A public halth prspctiv to nvironmntal barrirs and accssibility problms for snior citizns living in ordinary housing Mariann Granbom *, Susann Iwarsson, Mariann Kylbrg, Ccilia Pttrsson and Björn Slaug Abstract Background: Housing nvironmnts that hindr prformanc of daily activitis and impd participation in social lif hav ngativ halth consquncs particularly for th oldr sgmnt of th population. From a public halth prspctiv accssibl housing that supports activ and halthy aging is thrfor crucial. Th objctiv of th prsnt study was to mak an invntory of nvironmntal barrirs and invstigat accssibility problms in th ordinary housing stock in Swdn as rlatd to th functional capacity of snior citizns. Particular attntion was paid to diffrncs btwn housing typs and building priods and to idntify nvironmntal barrirs gnrating th most accssibility problms for sub-groups of snior citizns. Mthods: Data on nvironmntal barrirs in dwllings from thr databass on housing and halth in old ag was analysd (N = 1021). Four functional profils rprsnting larg groups of snior citizns wr usd in analyss of th magnitud and svrity of potntial accssibility problms. Diffrncs in trms of typ of housing and building priod wr xamind. Rsults: High proportions of on-family houss as wll as multi-dwllings had substantial numbrs of nvironmntal barrirs, with significantly lowr numbrs in latr building priods. Accssibility problms occurrd alrady for snior citizns with fw functional limitations, but mor profound for thos dpndnt on mobility dvics. Th most problmatic housing sctions wr ntrancs in on-family houss and kitchns of multi-dwllings. Conclusions: Dspit a high housing standard in th Swdish ordinary housing stock th rsults show substantial accssibility problms for snior citizns with functional limitations. To mak housing accssibl larg-scal and systmatic fforts ar rquird. Kywords: Aging population, Built nvironmnt, Functional capacity, Halth, Policy, Aging-in-plac Background Th dmographic dvlopmnt is making housing provision for snior citizns a burning issu, and thr is a growing intrst on aging and th rol of th built nvironmnt to fostr activ and halthy aging [1, 2]. Th hom nvironmnt is th primary contxt for snior citizns to prform daily activitis and to participat in social lif. Morovr, accssibl and adquatly dsignd dwllings support continud indpndnc at old ag, * Corrspondnc: mariann.granbom@md.lu.s Dpartmnt of Halth Scincs, Lund Univrsity, Box Lund, Swdn which is associatd with positiv halth aspcts [3, 4]. Th conditions and charactristics of th built nvironmnt in th currnt housing stock ar thrfor important to xamin from a public halth prspctiv. In many countris diffrnt housing options for snior citizns ar dvloping and transforming in both contnt and dsign. Du to a strong aging-in-plac policy in many Wstrn countris and in Swdn in particular, [4] an incrasing shar of th aging population can b xpctd to liv in dwllings in th ordinary housing stock dspit halth problms and nd of halth- and social car srvics that oftn com with ag. In Swdn, Th Author(s). Opn Accss This articl is distributd undr th trms of th Crativ Commons Attribution 4.0 Intrnational Licns ( which prmits unrstrictd us, distribution, and rproduction in any mdium, providd you giv appropriat crdit to th original author(s) and th sourc, provid a link to th Crativ Commons licns, and indicat if changs wr mad. Th Crativ Commons Public Domain Ddication waivr ( applis to th data mad availabl in this articl, unlss othrwis statd.

2 Granbom t al. BMC Public Halth (2016) 16:772 Pag 2 of 11 million popl agd 65 or oldr (95 %) liv in ordinary housing; approximatly half liv in multi-dwlling blocks and half liv in on-family houss [5]. Out of th total ordinary housing stock in Swdn (4.5 million dwllings, Dc 31, 2013) 28 % ar occupid by at last on individual agd 65+ [5]. This situation puts a high dmand on socity to provid ordinary housing that mts th nds of snior citizns also if halth problms and functional limitations gradually mrg. As yt, th body of rsarch that has addrssd such topics is limitd. In gnral, th housing standard in Swdn is high [6], but for th ordinary housing stock to b suitabl to all snior citizns rgardlss of functional capacity implis spcific dmands on accssibility. It is stimatd that half of all snior citizns living in multi-dwllings liv in buildings lacking lifts, and for many of thos having lifts, stps or othr lvl diffrncs still nd to b forcd in ordr to ntr or xit th dwlling. Furthrmor, it is stimatd that a similar proportion (49 %) livs in dwllings with a bathtub instad of showr plac, which constituts a fall risk [7]. Sinc at last 25 yars, building lgislation and housing standards in Swdn hav incorporatd aspcts on accssibility for all citizns [8, 9]. Howvr, sinc th production of nw dwllings is vry low th ffcts of such dirctivs do not kp pac with th rapid dmographic chang. Evn though lif xpctancy has incrasd globally as wll as in Swdn, th numbr of yars livd with disability has not dcrasd [10]. That is, multi-morbidity incrass markdly with ag and with that also functional limitations and disabilitis [11, 12]. Th complxity of combinations of functional limitations and th functional trajctoris that ar charactristic for th aging procss ar sldom accountd for in rsarch but is important for public halth policis to considr [1, 13]. Accssibility can b dfind as th intraction btwn th dmands of th physical nvironmnt (E) and th individual s functional capacity (P). Accssibility is supportd thortically by th Ecological Modl of Aging [14] and is on aspct of Prson-Environmnt (P-E) fit. According to Lawton & Nahmow [14], adaptiv bhaviour is th outcom of P-E fit. Thus, accssibility is influntial on disability, and this kind of thorizing is wll in lin with mor rcnt bio-psychosocial modls such as th Intrnational Classification of Functioning, Disability and Halth (ICF) [15] that mphasis th importanc of nvironmntal factors for disability. Accssibility is usually considrd as an objctiv aspct of housing; th E componnt is dscribd on th basis of national guidlins and standards for dsign and th P componnt is dscribd basd on profssional assssmnts [16]. Housing accssibility problms ar commonly dalt with on an individual lvl providing housing adaptations. Howvr, aiming for accssibl housing that supports aging-in plac, masurs must b takn also on a group or population lvl. Forsightd housing provision with potntial to accommodat th aging population rquirs knowldg on th occurrnc of nvironmntal barrirs in th ordinary housing stock. Howvr, valid information on th dtaild lvl rquird is lacking and th consquncs nvironmntal barrirs gnrat in trms of accssibility problms for thos snior citizns having diffrnt combinations of functional limitations ar unknown. Th objctiv of th prsnt study was to mak an invntory of nvironmntal barrirs and invstigat accssibility problms in th ordinary housing stock in Swdn as rlatd to th functional capacity of snior citizns. Particular attntion was paid to diffrncs btwn typs of housing and building priods. A spcific aim was to idntify th nvironmntal barrirs that gnrat th most accssibility problms for sub-groups of th aging population with diffrnt combinations of functional limitations. Mthods Study contxt Th prsnt study mad us of data on th physical hom nvironmnt in ordinary dwllings from thr sparat rsarch projcts on housing and halth, all basd on data collctd with oldr popl in th south of Swdn. Th ENABLE-AGE Projct (EA Projct) targtd vry old popl, living alon in ordinary housing in fiv Europan countris; for th prsnt study data from th Swdish sub-sampl wr usd (N = 397; man ag = 85 yars; yars old). Th participants wr randomly slctd from National Public Rgistr [17] basd on th inclusion critria living alon in ordinary housing, stratifying for 25 % mn. Th study district containd thr stratgically slctd municipalitis with mainly urban and smi-urban aras (Hlsingborg, Halmstad and Lund). Th Hom and Halth in Popl Aging with Parkinson s Disas Projct (PD Projct) targtd popl with Parkinson s disas (PD). Participants diagnosd with PD mor than on yar ago wr rcruitd via Nurology dpartmnts at thr Skån County hospitals (N = 255, man ag = 70 yars, rang yars) [18]. Th study ara was limitd to th catchmnt ara of th hospitals i.., svral municipalitis in Skån County containing both urban, smi-rural and rural aras. Th Hom and Halth in th Third Ag Projct (Third Ag Projct) targtd youngr snior citizns and includd 371 participants living in ordinary housing in Skån County (man ag = 68 yars, rang yars) [19]. Th sampl of Th Third Ag projct was mad by random sampling of all inhabitants at th spcific ag group in fiv municipalitis in Skån County

3 Granbom t al. BMC Public Halth (2016) 16:772 Pag 3 of 11 (Eslöv, Osby, Malmö, Hässlholm and Ystad). This projct was a part of th Swdish National Study on Aging and Car (SNAC), targting ag groups ranging from 66 to 81 yars [20]. For all thr projcts data wr collctd at hom-visits by xprincd data collctors that undrwnt projct-spcific training. For dtails, s [17 19]. Sampl of dwllings Du to intrnal missing data for two obsrvations, th poold sampl (N = 1021) comprisd 662 dwllings in multi-dwlling blocks (65 %) and 359 on-family houss (35 %). Diffrnt kinds of tnur wr rprsntd. Th dwllings wr situatd in 34 municipalitis in th south of Swdn (ranging from 7,500 to 320,000 inhabitants) rprsnting urban, smi-rural and rural districts. For dwllings whr th yar of build was known (n = 609; not availabl for th Third Ag Projct), 39 % wr built bfor 1960, (n = 236), 37 % wr built (a priod in tim in Swdn with massiv multi-dwlling block construction; n = 225) and 24 % wr built 1980 or latr (a priod dominatd by on-family houss construction; n = 148). Masurs Dscriptiv data on typ of housing and tnur as wll as yar of build in th EA Projct wr collctd with projct-spcific qustions. For th PD Projct data on yar of build wr rtrivd from th Swdish National Board of Housing, Building and Planning. For th Third Ag Projct such information was not possibl to rtriv. Environmntal barrirs wr assssd by mans of th nvironmntal (E) componnt of th vrsion of th Housing Enablr Instrumnt (HE) availabl at th tim for data collction. Th nvironmntal componnt of HE includs profssional obsrvation by traind data collctors of th prsnc (ys) /absnc (no) of nvironmntal barrirs, dfind according to national standards and guidlins for housing dsign. For th prsnt study w usd a rducd list of 60 nvironmntal barrirs (27 indoors, 13 at ntrancs and 20 in th clos xtrior surroundings) rprsnting th cor barrirs in trms of dtcting accssibility problms [21]. Th HE also includs a prsonal (P) componnt for assssmnts (intrviw and obsrvation) of prsnc (ys) /absnc (no) of functional limitations and dpndnc on mobility dvics (14 itms, displayd in Fig. 1). Th magnitud of accssibility problms in a cas is calculatd by combining th E and P componnts using a scoring matrix (s Fig. 1). For ach intrsction btwn th two componnts, th matrix assigns prdfind svrity ratings (0 4) that ar summd up to an accssibility problm scor, which rprsnts a quantification of prdictd problms (thortical rang for th rducd list, 0 904). For individuals with no functional limitations or dpndnc on mobility dvics, this scor is always 0; highr scors indicat gratr accssibility problms. Th HE is an intrnationally acknowldgd, rliabl and valid instrumnt availabl in svral languags [22]. Th validity of th HE has bn succssivly optimisd during 20 yars of rsarch, including mpirical studis of mor than 2000 snior citizns and thir dwllings across Europ [14]. Sufficint intr-ratr rliability has bn dmonstratd in svral studis, in Swdn and othr countris [23 26]. Th rducd list usd in th prsnt study was obtaind through a rigorous rsarch procss, utilizing statistically dfind critria and an xprt panl approach. Th validity of th rducd vrsion was dmonstratd by clos to prfct rank corrlations btwn th accssibility scors gnratd by th original and rducd vrsions [18]. Data analyss In ordr to arriv at mor gnralizabl rsults, w did not us any prson-rlatd data of th individuals actually living in th dwllings. Instad, to analys accssibility problms at group lvl w usd functional profils dvlopd through simulations and statistical analyss of larg data sts on functional limitations of oldr popl from prvious studis with th Housing Enablr [27]. Th functional profils wr basd on a catgorization of th 14 functional limitations into broadr catgoris (s Tabl 5 in th Appndix). Four functional profils with incrasing complxity wr usd; Profil I: limitations in movmnt only; Profil II: limitations in movmnt and uppr xtrmity; Profil III: limitations in movmnt, uppr xtrmity and dpndnc on mobility dvics; and Profil IV: limitations in movmnt, uppr xtrmity, dpndnc on mobility dvics and loss of sight. To xplor and stimat th accssibility problm scor for all profils in all dwllings, ach functional profil was combind with th nvironmntal barrirs prsnt in ach dwlling, using th scoring matrix (Fig. 1). Howvr, sinc ths analyss targtd profils with functional limitations itms joind into broadr catgoris, w applid a somwhat modifid scoring procdur. W first calculatd th avrag rating for ach catgory of functional limitations, and thn summd up ths avrag ratings to an accssibility problm scor. Dscriptiv statistics wr usd to prsnt nvironmntal barrirs and accssibility scors. Diffrncs du to housing typ and building priod wr tstd by mans of Kruskal-Wallis tst. Diffrncs in accssibility scor du to functional profils and building priod wr tstd by mans of Kruskal-Wallis tst and also displayd graphically.

4 Granbom t al. BMC Public Halth (2016) 16:772 Pag 4 of 11 Fig. 1 Exampl of th gnration of accssibility problm scor for functional profil 1 by combining functional limitations of th profil with nvironmntal barrirs prsnt in a spcific dwlling Th HE Softwar and SAS 9.3 softwar wr usd for th analyss. Th lvl for statistical significanc was st at p < Rsults Th mdian numbr of nvironmntal barrirs prsnt was 31 (of 60) in multi-dwlling blocks and 32 in onfamily houss (p = 0.003). Environmntal barrirs indoors wr mor frqunt in on-family houss (p < 0.001). For dtails, s Tabl 1. Thr wr fwr nvironmntal barrirs in dwllings from latr building priods than arlir (p < 0.001), and most notably so in xtrior surroundings and ntrancs (Tabl 2). With th xcption of for nvironmntal barrirs indoors, a smallr but significant diffrnc was sn for on-family houss, with fwr nvironmntal barrirs in total for thos built in latr priods. Rgardlss of housing typ and building priod, all dwllings would giv accssibility problms for oldr popl with any of th four functional profils. Statistical tsting showd highly significant diffrncs btwn all four profils (p < ), rgardlss of building priod. Dwllings built bfor 1960 gnratd mor accssibility problms than nwr dwllings (Fig. 2). Diffrncs in accssibility problms btwn housing typs wr small, ranging from no diffrnc to 35 accssibility problm scor. With a mor complx functional profil th highr th accssibility problm scors in alldwllings.formultidwllings built bfor 1960 profil IV gnratd an accssibility problm scor 3.7 tims highr compard to profil I. Indoors in multi-dwllings, among th top-tn nvironmntal barrirs causing accssibility problms, svral wr found in kitchns. For on-family houss th barrirs wr mor vnly distributd on th sctions kitchns, bathrooms and indoors in gnral. Thr barrirs wr among top-tn barrirs rgardlss

5 Granbom t al. BMC Public Halth (2016) 16:772 Pag 5 of 11 Tabl 1 Numbr of nvironmntal barrirs in dwllings of snior citizns in ordinary housing, according to housing typ (N = 1021) Multi-dwlling block On-family hous (n = 662) (n = 359) Md (q1-q3) p-valu Effct siz b 95 % CI Extrior surrounding (0 20 a ) 9 (7 11) 7 (5 9) < ; 1.0 Entrancs (0 13 a ) 7 (5 9) 6 (5 7) < ; 1.0 Indoors (0 27 a ) 15 (13 17) 18 (17 20) < ; 4.0 In total (0 60 a ) 31 (27 35) 32 (28 35) ; 2.0 Not Md (q1-q3) Mdian and (first quartil - third quartil), CI confidnc intrval a Possibl rang b Location shift, Hodgs-Lhmann stimation of housing typ or functional profil; stps/thrshold/ diffrncs in lvl btwn rooms; wall-mountd cupboards and shlvs placd too high in kitchn and no grab bars at showr/bath and toilt (Tabl 3). Onfamily houss had mor top-tn nvironmntal barrirs causing accssibility problms at ntrancs than in xtrior surroundings, in multi-dwllings thy wr mor vnly distributd. Rgardlss of housing typ or functional profil; irrgular/unvn surfac in xtrior surroundings; high thrsholds and/or stps at th ntranc; stairs th only rout (no lift/ramp) and storag aras can only b rachd via stps or othr diffrnc in lvl wr among th top-tn barrirs (Tabl 4). Discussion Dspit a high housing standard in Swdn and fforts from policy-makrs to improv lgislation and building rgulations, th rsults show that many nvironmntal barrirs ar prsnt in multi-dwllings as wll as in on-family houss. Whil thr is a tndncy towards fwr nvironmntal barrirs in dwllings built during latr priods th progrss is slow and th diffrncs btwn priods ar small. Th analyss using functional profils show that all dwllings with nvironmntal barrirs will caus accssibility problms alrady for snior citizns with fw functional limitations. Rgardlss of housing typ and building priod, accssibility problms gt mor profound for mor complx functional profils - most notably so whn rsidnts ar dpndnt on mobility dvics. It should b notd that in trms of accssibility, th problms diffr btwn housing sctions, with th most problmatic nvironmntal barrirs at ntrancs in on-family houss and in kitchns of multi-dwllings. Tabl 2 Numbr of nvironmntal barrirs in dwllings of snior citizns in ordinary housing, according to building priod (N = 609) Housing typ Multi-dwlling block (n = 416) Extrior surrounding (0 20 a ) Built bfor 1960 Built in Built aftr 1979 Md (q1-q3) p-valu Effct siz b 95 % CI Effct siz b 95 % CI Effct siz b 95 % CI (n = 141) (n = 153) (n = 122) Bfor 1960 vs Bfor 1960 vs. aftr vs. aftr (8 11) 9 (7 11) 8 (6 9) < ; ; ; 1.0 Entrancs (0 13 a ) 8 (7 9) 6 (5 8) 5 (4 6) < ; ; ; 1.0 Indoors (0 27 a ) 14 (12 17) 14 (12 15) 13 (11 15) ; ; ; 0.0 Total (0-60 a ) 32 (29 35) 30 (26 33) 26 (22 29) < ; ; ; 2.0 On-family hous (n = 193) Extrior surrounding (0 20 a ) (n = 95) (n = 72) (n = 26) Bfor 1960 vs Bfor 1960 vs. aftr vs. aftr (7 10) 7 (5 9) 7 (6 9) ; ; ; 1.0 Entrancs (0 13 a ) 7 (6 8) 6 (5 8) 5 (3 6) ; ; ; 0.0 Indoors (0 27 a ) 18 (16 21) 18 (17 20) 18 (16 19) ; ; ; 0.0 Total (0 60 a ) 33 (30 36) 31 (28 36) 30 (26 32) ; ; ; 1.0 Not Md (q1-q3) Mdian and (first quartil - third quartil) CI confidnc intrval a Possibl rang b Location shift, Hodgs-Lhmann stimation

6 Granbom t al. BMC Public Halth (2016) 16:772 Pag 6 of 11 Fig. 2 Accssibility problms for snior citizns in multi-dwlling blocks and on-family houss from diffrnt building priods basd on four diffrnt functional profils (I: functional profil with limitd mobility; II: functional profil with limitd mobility and limitd uppr xtrmity function; III: functional profil with limitd mobility, limitd uppr xtrmity function and dpndnc on mobility dvics and; IV: functional profil with limitd mobility, limitd uppr xtrmity function, dpndnc on mobility dvics and visual impairmnt) Considring th incrasing attntion to accssibility in Swdish building lgislation and housing standard ovr th yars [8, 9], th rduction of nvironmntal barrirs ovr tim is small. As oftn rflctd in th public dbat, it is rmarkabl that also nwr dwllings hav considrabl nvironmntal barrirs. Th fact that that vn th most rcntly built multi-dwllings had as many as 26 nvironmntal barrirs (from a 60 itm chcklist) will lad to substantial accssibility problms for th incrasing population of snior citizns, and thrby also to mor halth issus [4]. Morovr, th lif tim of a dwlling implis that th probability that at last on rsidnt with disability will liv thr is as high as % [28, 29]. This highlights th importanc for th housing construction sctor as wll as for policy-makrs to tak rsolut actions to avoid continuing to build dwllings with nvironmntal barrirs. It should also b notd that snior citizns mor oftn liv in oldr dwllings [7], whr accssibility problms tnd to b mor xtnsiv and mor svr. Morovr, th finding that on-family houss hav mor nvironmntal barrirs than multi-dwllings, point to th fact that thr is also an urgnt nd for incrasd knowldg on accssibility issus for all actors of th privat building industry sctor as wll as for th gnral population. Efficint upgrading of th xisting ordinary housing stock basd on th bst possibl knowldg is calld for [7]. Th rsults showing that th accssibility problms will b 3 4 tims highr for snior citizns having functional profil IV, than for thos with profil I ar striking and call for attntion. Considring that rluctanc to mov incrass with ag [30] as wll as th prvalnc and complxity of functional limitations and disabilitis ovr tim [11, 12], th dmands on barrir fr housing ar high. For countris lik Swdn, activly supporting aging-in-plac, improvd accssibility in th ntir ordinary housing stock is thrfor of utmost importanc. Taking an intrnational prspctiv, arlir rsarch from Grmany, Latvia and th USA indicats that a high prvalnc of nvironmntal barrirs and accssibility problms xists in ordinary housing [25, 31]. Considring that in a country lik Swdn, known to hav a high housing standard, th xisting housing stock displays considrabl accssibility problms for th aging population, this study highlights a larg-scal problm for th Wstrn world at larg. Growing vidnc show that inaccssibl housing is rlatd to dpndnc in activitis of daily living (ADLs) [32] falls [33] and institutionalization [34, 35]. Housing accssibility problms also incras th risk for a lowr dgr of social participation, which may turn into poorr slf-managmnt, isolation and ultimatly highr halth car nds [36]. Dsrving a widr rcognition as an important public halth issu, improvd housing accssibility for snior citizns will likly hav positiv ffcts on population halth. It should b notd that th rsults of our study hav widr implications. That is, disability and functional limitations ar common also in youngr ag groups [37], thus knowldg of accssibility problms in ordinary housing has implications for halth and

7 Granbom t al. BMC Public Halth (2016) 16:772 Pag 7 of 11 Tabl 3 Rank ordr of th nvironmntal barrirs contributing most to th accssibility problm scor indoors, according to functional profil and housing typ (N = 1021) Environmntal barrir (n = 27) Multi-dwlling block (n = 662) On-family hous (n = 359) Profil I. a Profil II. b Profil III. c Profil IV. d Profil I. a Profil II. b Profil III. c Profil IV. d Indoors in gnral Stps/thrshold/diffrncs in lvl btwn rooms Narrow passags/corridors Narrow doors Complx manouvrs rquird Us rquir hands Controls in high/inaccssibl position Stairs to uppr story with ncssary dwlling functions Stairs to basmnt with ncssary dwlling functions No handrails/handrail only on on sid Handrails too short Kitchn Insufficint manouvring spacs around whit goods Wall-mountd cupboards and shlvs placd too high No surfac at a hight suitabl for sitting whil working Shlvs too dp Complx manouvrs rquird Us rquir hands Controls in high/inaccssibl position Bathroom Insufficint manouvring spacs whr turning is ncssary Insufficint spac for stool/bath board in showr/bath No grab bars at showr/bath and toilt Complx manouvrs rquird Us rquir hands Controls in high/inaccssibl position Wash-basin placd at hight for us only whn standing Toilt 47 cm or lowr Showr stall with krb/lvl diffrnc Bathtub instad of showr Not: Top-10 barrirs of ach functional profil and housing typ ar boldd a Profil I: Functional profil with limitd mobility b Profil II: Functional profil with limitd mobility and limitd uppr xtrmity function c Profil III: Functional profil with limitd mobility, limitd uppr xtrmity function and dpndnc on mobility dvics d Profil IV: Functional profil with limitd mobility, limitd uppr xtrmity function, dpndnc on mobility dvics and loss of sight Did not gnrat any accssibility problm scor quality of lif of svral sub-groups of th gnral population. In lin with prvious rsarch th rsults show that ntrancs, kitchns and bathrooms oftn hav svral nvironmntal barrirs [38, 39] that gnrat accssibility problms for popl with functional limitations. Kitchns and bathrooms ar crucial for many activitis of daily living such as bing abl to cook or showr indpndntly. Thus, ths rsults can b usd to dvlop targtd actions for improving accssibility and indpndnc in ADL and thrby influnc halth positivly. In Swdn, th individual housing adaptation grant is a wll-stablishd intrvntion to liminat problmatic nvironmntal barrirs in th hom. Whil this typ of intrvntion is prson-cntrd and targt individual nds, our rsults rval that th

8 Granbom t al. BMC Public Halth (2016) 16:772 Pag 8 of 11 Tabl 4 Rank ordr of th nvironmntal barrirs contributing most to th accssibility problm scor in th clos xtrior surroundings and at ntrancs, according to functional profil and housing typ (N = 1021) Environmntal barrir (n = 33) Multi-dwlling block (n = 662) On-family hous (n = 359) Profil I. a Profil II. b Profil III. c Profil IV. d Profil I. a Profil II. b Profil III. c Profil IV. d Extrior surroundings Paths narrowr than 1.5 m Irrgular/unvn surfac Unstabl surfac Stp gradint Routs with stps No/insufficint tactil cus of abrupt lvl chang High krbs Krb ramps with stp gradints No handrails on stp gradints No rsting surfac or too long distancs btwn thm on slops Poor lightning along circulation paths Passngr loading zon far from ntranc No/too fw sating placs Rfus room/bin can only b rachd via stps or othr diffrnc in lvl Lttrbox can only b rachd via stps or othr diffrnc in lvl Rfus bin difficult to rach Lttrbox difficult to rach Narrow door opnings Entrancs High thrsholds and/or stps at th ntranc Insufficint manouvring spac at doors, outsid and insid No rsting ara in front of ntranc door Havy doors without automatic door opnr Doors do not stay in opn position/clos quickly Complicatd/illogical opning procdur Stairs th only rout (no lift/ramp) High, low and/or irrgular hights of risrs No handrails/handrail only on on sid Handrails too short Narrow doors to sitting-out plac/balcony High thrshold/lvl diffrnc/stp to sitting-out plac/balcony Storag aras can only b rachd via stps or othr diffrnc in lvl Laundry room can only b rachd via stps or othr diffrnc in lvl Inappropriat dsign of door to laundry room Not: Top-10 barrirs of ach functional profil and housing typ ar boldd a Profil I: Functional profil with limitd mobility b Profil II: Functional profil with limitd mobility and limitd uppr xtrmity function c Profil III: Functional profil with limitd mobility, limitd uppr xtrmity function and dpndnc on mobility dvics d Profil IV: Functional profil with limitd mobility, limitd uppr xtrmity function, dpndnc on mobility dvics and loss of sight Did not gnrat any accssibility problm scor

9 Granbom t al. BMC Public Halth (2016) 16:772 Pag 9 of 11 high numbr of nvironmntal barrirs and magnitud of accssibility problms could not possibly b liminatd by housing adaptation grants. Thus, larg scal and systmatic actions ar ndd if socity wants to support activ and halthy aging for snior citizns [40]. Th possibilitis to financ larg scal upgrading of th xisting ordinary housing stock might b qustiond, and unfortunatly rsarch on cost-ffctivnss for housing intrvntions is rar [41]. A financial valuation of rnovations in multi-dwllings in Swdn showd that, whn accomplishd simultanously with pip rplacmnt, making th bathroom accssibl did not cost mor than a rgular rnovation [42]. In fact, it was suggstd that ffcts in trms of postpond or rducd nd for hom hlp srvics, informal car and spcial housing would mak ths actions profitabl for th municipalitis. Th rsult showing how common th nvironmntal barrir Stairs th only rout (no lift/ramp) at ntrancs ar, undrlins th rlvanc for adopting a socital planning prspctiv to support activ and halthy aging. Thus, in th most rcnt govrnmntal commission on housing for th aging population in Swdn a main rcommndation was to provid multi-dwlling stat ownrs govrnmntal financial support up to 50 % of th cost for th installation of lifts in xisting multi-dwllings [7]. To dat, th prsnt study is th largst, dtaild onsit invntory on nvironmntal barrirs and accssibility problms of dwllings in Swdn. To us traind data collctors administring structurd assssmnts at hom visits using a rsarch-basd instrumnt has rliability strngths compard to mor commonly usd slf-rport invntoris [36]. As to rprsntativity, th dwllings includd wr basd on sampling stratgis and inclusion critria in thr diffrnt original rsarch projcts. Sinc w usd functional profils [27] to stimat th magnitud of accssibility problms for diffrnt groups of snior citizns, th waknsss rgarding gnralisability wr small. Actually, w considr th us of functional profils to targt combinations of functional limitations of snior citizns as a mthodological strngth. Today, no public statistics ar availabl on th consquncs that combinations of diffrnt disass and symptoms gnrat in trms of functional limitations. Th functional profils usd is on way of approaching this complxity and th analyss computd is a way to prsnt a socital prspctiv on housing accssibility for snior citizns [27]. Though th cass in th simulatd analyss could b considrd as hypothtical, thy still provid an approximation of a rality that is likly applicabl for many individuals. Prvious studis using authntic cass of oldr popl living in ordinary housing hav shown comparabl rsults with rgard to housing accssibility problms [33]. Howvr, additional rsarch is ndd to furthr validat th mthodology with functional profils, and a not of caution is thrfor in plac whn intrprting th rsults. Th dwllings locatd in urban and rural districts in th south of Swdn wr fairly rprsntativ for th Swdish housing stock rgarding building priods as wll as housing typs. Du to th complxity of th scoring matrix undrlying th accssibility scors gnratd with th HE, th magnituds of accssibility problms might b considrd challnging to intrprt. Optimisation on th scoring matrix and dfinition of rfrnc valus ar in progrss but furthr rsarch fforts ar ndd to prsnt an optimal analysis mthodology [43]. Still, with th possibility to mak comparisons btwn diffrnt typs of dwllings, bfor and aftr housing intrvntion programs, tc. th HE plays an important rol. Anothr limitation is that th HE mainly addrsss nvironmntal barrirs in rlation to physical functional limitations. Assssmnts on nvironmntal barrirs rlating to cognitiv limitations in a mor qualifid way than in th prsnt vrsion is ndd, as ar assssmnts focusing on supportiv faturs of th built nvironmnt. It should b kpt in mind that accssibility is only on out of svral aspcts of housing shown to b associatd with wll-bing and quality of lif. Nighbourhood charactristics and prcivd aspcts of hom and ar at last as important for th individual facing disability or ag-rlatd functional dclin [44, 45]. Howvr, accssibility is an objctiv aspct rlvant for physical planning and housing provision at th socital lvl. Conclusions Dspit high housing standard in th Swdish ordinary housing stock th rsults show a high prvalnc of nvironmntal barrirs and substantial accssibility problms for snior citizns with functional limitations. Considring thr ar many countris with a similar dmographic situation and with comparabl standard and conditions of th ordinary housing stock, our findings highlight a larg-scal problm for th Wstrn world at larg. Accssibl housing is th basis for activ and halthy aging and a ncssity in countris with a strong aging-in-plac policy. To mak housing accssibl for snior citizns larg-scal and systmatic fforts involving many actors ar rquird. Th rsults of th prsnt study provid additional imptus to such fforts.

10 Granbom t al. BMC Public Halth (2016) 16:772 Pag 10 of 11 Appndix Tabl 5 Catgorization of functional limitations/dpndnc on mobility dvics, th Housing Enablr instrumnt [27] Functional limitation Functional limitation catgory. Itms includd markd with I Difficulty intrprting information Loss of sight Svr loss of haring Limitations in movmnt Limitations in uppr xtrmity Dpndnc on mobility dvics Difficulty intrprting I information Visual impairmnt - I Blindnss - I Loss of haring - - I Poor balanc I - - Incoordination I - - Limitations of stamina I - - Difficulty in moving had I - - Rducd uppr xtrmity I - function Rducd fin motor skills I - Loss of uppr xtrmity I - function Rducd spin and/or lowr I - - xtrmity function Dpndnc on walking aids I Dpndnc on whlchair I Not: Basd on this catgorization, four functional profils wr usd. Profil I: limitations in movmnt only; Profil II: limitations in movmnt and uppr xtrmity; Profil III: limitations in movmnt, uppr xtrmity and dpndnc on mobility dvics; and Profil IV: limitations in movmnt, uppr xtrmity, dpndnc on mobility dvics and loss of sight Abbrviations ADL, activitis of daily living; EA Projct, Enabl-Ag Projct; HE, Housing Enablr instrumnt; PD Projct, hom and halth in popl aging with Parkinson s disas projct; PD, Parkinson s disas; P-E fit, prson-nvironmnt fit; Third Ag Projct, hom and halth in th third ag projct Acknowldgmnts This study was basd on data from th Swdish part of th EA Projct. (QLRT ) and w thank th all th consortium and national tam mmbrs for thir contributions. Thanks ar also xtndd to Dr. Maria H. Nilsson, P.I. for th PD Projct, and Dr. Sölv Elmståhl, P.I. for th SNAC-GÅS Projct. Funding Financial support is gratfully acknowldgd from th Europan Commission (FP5), th Swdish Rsarch Council, th Swdish Council for Working Lif, Public Halth and Wlfar (Fort), th Ribbingska Foundation in Lund, th Norrbacka-Eugnia Foundation, MultiPark and th Faculty of Mdicin, Lund Univrsity, Swdn. Availability of data and matrials Th databass usd ar stord undr th rsponsibility of th Dpartmnt of Halth Scincs at th Faculty of Mdicin, Lund Univrsity, Swdn. Th data supporting th findings in th prsnt papr can b accssd by contacting th author rsponsibl for data managmnt, dr. B Slaug. Contact addrss: bjorn.slaug@md.lu.s. Authors contributions In a collaborat ffort, all authors mad substantial contributions to concption and dsign of th study. BS xcutd th statistical analyss, followd by discussion and joint dcisions rgarding th prsntation of th rsults. MG draftd th manuscript, followd by an itrativ procss whr all authors rvisd it critically for important intllctual contnt. All authors approvd th final vrsion to b publishd. Compting intrsts S. Iwarsson and B. Slaug ar copyright holdrs and ownrs of th HE mthodology, providd as a commrcial product (s Th rmaining authors dclar no compting intrsts. Consnt for publication Not applicabl. Ethics approval and consnt to participat All projcts wr dsignd and carrid out in accordanc with th Dclaration of Hlsinki and all participants providd informd consnt to participat in th studis. Th Swdish part of th EA Projct was approvd by th local Ethics Committ at Lund Univrsity (LU 324, 2002). Th Third Ag Projct (2010/431) and th PD Projct (2012/558) wr approvd by th rgional Ethical Board in Lund, Swdn. Rcivd: 25 Fbruary 2016 Accptd: 23 July 2016 Rfrncs 1. Bard J, Bloom D. Towards a comprhnsiv public halth rspons to population aging. Lanct. 2015;385: Burton E, Mitchll L, Strid C. Good placs for aging in plac: dvlopmnt of objctiv built nvironmnt masurs for invstigating links with oldr popl s wllbing. BMC Public Halth. 2011;11: Wahl HW, Fang A, Oswald F, Gitlin LN, Iwarsson S. Th hom nvironmnt and disability-rlatd outcoms in aging individuals: What is th mpirical vidnc? Grontologist. 2009;49: Mahlr M, Sarvimäki A, Clancy A, t al. Hom as a halth promotion stting for oldr adults. Scand J Public Halth. 2014;42: Statistiska Cntralbyrån (SCB). Statistikdatabasn. Stockholm: Statistiska Cntralbyrån URL:

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Submit your nxt manuscript to BioMd Cntral and w will hlp you at vry stp: W accpt pr-submission inquiris Our slctor tool hlps you to find th most rlvant journal W provid round th clock customr support Convnint onlin submission Thorough pr rviw Inclusion in PubMd and all major indxing srvics Maximum visibility for your rsarch Submit your manuscript at