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

Highlights

• Healthy ageing is strongly situated within the social, material and financial circumstances of older people's everyday lives.

• Experiential understandings of healthy ageing offer a potential tool to better inform policy and practice.

• Experiences of and supports for healthy ageing are highly gendered and dependent on cultural circumstances.

Abstract

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.

Introduction

This paper presents the results of qualitative research conducted across five countries in the European Union (Germany, Hungary, Latvia, Sweden and the United Kingdom), exploring the relationship between the home environment and healthy ageing. Healthy ageing refers not just to biological and medical aspects of ageing, but to the more holistic perspective that includes subjective experiences and meanings, functional definitions emphasising autonomy, participation and well-being (Bryant, Corbett, & Kutner, 2001) and ageing as a process rather than a state (Hansen-Kyle, 2005). The paper specifically focuses on the role of the home environment in supporting or constraining healthy ageing as a critical and under-researched factor in maintaining and improving quality of life amongst very old people. Such concerns are increasingly relevant in the light of current health and social care policy that aims to support ‘ageing-in-place’, and healthy ageing at home (Sixsmith & Sixsmith, 2008).

Ageing-in-place (Callahan, 1993) has become an important aspect of redefining health and social care policy for older people in recent years (Andrews & Phillips, 2005). Rather than channelling frail older people into institutional care, ageing-in-place policy emphasises support and resources to help the person remain living in their own homes and community settings (Means, 2007). Policymakers are attracted by the possibility of cost savings over expensive institutional care (Grabowski, 2006), while ageing-in-place also reflects the preferences of most older people, who generally wish to ‘stay put’ in their own homes (Wiles, 2005). Yet the home may also have negative connotations, including poor housing conditions, insecure tenancies and inappropriate design (Heywood, Oldman, & Means, 2002). These issues can undermine the skills and abilities of the older person, creating an environment that is isolating and excluding (Aneshenshel et al., 2007). Furthermore, the home can be a source of tension when the requirements of the older person conflict with family members or others involved in the decision-making processes concerning care provision (Lowenstein, 2009). As such, reasoning about ageing-in-place in very old age is a complex matter which is recognised by and articulated through a variety of reflections, emotions and behaviours (Löfqvist et al., 2013).

The notion of ageing-in-place assumes that the benefits to ‘staying put’ outweigh the disadvantages, provided that the health and social care needs of the older person can be supported. This is contingent upon sufficient environmental and social supports being provided at home (Johansson, Josephsson, & Lilja, 2009), as well as the older person's physical ability to retain a high quality of life, level of activity and sense of independence. The availability of supports to assist older people to age-in-place are likely to vary according to national context (Cutchin, 2003). However, if high standards of domiciliary care can be maintained, ‘ageing-in-place’ in one's own home is seen to fundamentally and positively enhance well-being, autonomy, social participation and healthy ageing amongst older people (AARP, 2000, Rosel, 2003). While the home may play a crucial role, the health benefits of ageing-in-place at home have yet to be fully explored.

The term ‘healthy ageing’ signals an increasingly positive perspective on health and wellbeing in old age (Cutchin, 2005). Healthy ageing is more than just a matter of extension of life, it also emphasises quality of life as a key concern for health and social care practitioners (Bartlett & Peel, 2005). There is considerable overlap between healthy ageing and other concepts such as ‘successful’, ‘active’ and ‘productive’ ageing (Peel, Bartlett, & McClure, 2004). Thus there is recognition that health and well-being are central to quality of life issues for older people, as well as having implications for resource allocation (Bryant et al., 2001). Healthy ageing has been conceptualised from a number of different perspectives. From a biomedical perspective, the elimination of risk factors for chronic illness, and promotion of optimal responses to illness have been central (Hansen-Kyle, 2005). A more holistic perspective encompasses accessible and supportive living environments (Bartlett & Peel, 2005) and various psychosocial dimensions, including individual dispositional factors, social support networks and structural inequalities (Walker, 2004).

A key question is whose definition of “healthy ageing” should be considered. It may be that, as Bartlett and Peel (2005, p. 101) argue, ‘…to reflect the realities of ageing, the most appropriate people to define what healthy ageing means are older people themselves.’ Importantly, meanings of health amongst older people can vary with age, sociocultural context and gender, and are influenced by a person’ perceived chances of healthy ageing as well as the roles and representations associated with ageing. Notwithstanding such variability, Bartlett and Peel (2005) note that a number of consistent themes have emerged from recent studies in healthy ageing:

‘For the individual, healthy ageing means having a sense of well-being, the capacity for independent activity, meaningful involvement, supportive environments and positive attitudes. Being healthy is seen as having the resources for an everyday life that is satisfying to self and others’

Bartlett & Peel, 2005, p. 101.

The subjective dimension is of particular importance as older people may consider themselves as healthy within their own meaning-systems irrespective of chronic illness (Bryant et al., 2001). Moreover, while physiological, functional and psychosocial issues have featured strongly, the role of place in healthy ageing has only recently been explored (Cutchin, 2005). The home may become especially significant for older people in the context of decreased income, impaired mobility and reduced social networks (Gilroy, 2005, Sixsmith, 1990) and elucidating the links between the living context and the capacities, needs and preferences of the individual is essential to understanding the health of older people.

Research has explored the relationship between older adults and meanings of home. The ways in which older people inhabit their homes, psychologically, socially and physically can undergo substantial change in the context of increasing frailty and declining health as people become less able to negotiate and care for their home (Kellaher et al., 2004, Sixsmith, 1990, Sixsmith and Sixsmith, 1991). As people and their homes age together, family relationships within the home change throughout different life stages and the home environment can take on different meanings (Sixsmith & Sixsmith, 1990). As such the home is a transitional space rather than a static entity where the ageing process is ‘emplaced’ (McHugh, 2003). For instance, the happy family home of middle adulthood can become a place of loneliness and despair in very old age. Furthermore, it is difficult to understand the meaning of home without placing the home in its immediate contexts such as the local neighbourhood or community. Past research has shown the ways in which home and community are integrally intertwined (see Peace, Wahl, Mollenkopf, & Oswald, 2007) in complex, meaningful socio-spatial relationships which change over time, particularly in dynamic urban districts i.e. under processes of gentrification or urban regeneration.

Researchers have begun to draw out some of the implications of home for the health of older people, describing the objective and subjective aspects of housing in old age in relation to health-related outcomes (Oswald et al., 2007, Oswald and Wahl, 2004). Housing type and housing conditions have been understood in relation to life satisfaction and well-being, whilst subjective notions of control and autonomy influence how meanings of home are negotiated and re-negotiated in old age. Extending the notion of control, another strand of research has focused on the home as a place of health and social care provision (Twigg, 2000, Wiles, 2005). The experience of and meanings associated with in-home care can be seen from the competing perspectives of both older people and their carers (Twigg, 1999). The home may serve as an important power-base through which older people can resist the dominance of care workers. By exercising power to exclude care workers from the home altogether, or from certain parts of it, an older person may be in a position to retain more control of their immediate private environment than would be the case in other (e.g. institutional) settings (Angus, Kontos, Dyck, McKeever, & Poland, 2005). Positive implications for independence, self-determination and wellbeing have been noted when care is delivered in the home (Twigg, 1999), as opposed to provision in institutional care settings (Milligan, 2009). However, this is itself contingent upon illness and disability and may require the older person to accept assistance and relinquish control over access to the home, as well as home care providers considering notions of home within care delivery (Efraimson Hoglund, & Sandman, 2001). The home environment may become difficult to negotiate in old age (Haak, Malmgren Fänge, Iwarsson, & Dahlin-Ivanoff, 2011) and moving to more supported environments can be a relief for older frail people (Heywood et al., 2002). Nonetheless, Twigg (1999) argues that the home can provide the socio-physical and psychological conditions to ameliorate the depersonalisation and dependency that is often associated with transition into institutional settings.

Previous studies on the qualitative Swedish data within the ENABLE-AGE Project, have shown that home is a place of meaning (Dahlin-Ivanoff, Haak, Fänge, & Iwarsson, 2007) and perceived as an important place linked to self-perceived health in very old age (Fänge & Dahlin-Ivanoff, 2009). Health was described in terms of being able to manage daily activities at home and participate in broader society. Managing daily activities supports experiences of independence (Haak, Fänge, Iwarsson, & Ivanoff, 2007) and is strongly linked to very old people's notion of home. When studying the relation between home, participation and the process of ageing (Haak, Dahlin-Ivanoff, Sixsmith, & Iwarsson, 2007), participation ranges from taking part in and performing more physically and mentally demanding activities to the performance of less strenuous activities. Out-of-home activities are successively replaced with activities performed within the home. The role of the home is transformed from a key origin for out-of–home activities to being the locus for everyday activities that take place in the lives of very old people. Very old people want to remain at home as long as possible, and they want to be active in their everyday lives and participate in society on their own terms (Dahlin-Ivanoff et al., 2007, Mollenkopf et al., 1997, Valdemarsson et al., 2005). Further research shows that, over time, very old people manage increased frailty by means of evolving intertwined and transactional processes connecting the home and awareness of their frailty (as a state of mind) with changes in everyday life which maintain participation, independence and health at home (Haak et al., 2011). Summing up, healthy ageing is a highly fluid and complex issue which requires further studies examining the relationship between the home and the very old person in order to develop theoretical and empirical understanding of this under-researched area.