Negotiating and effectuating relocation to sheltered housing in old age: A Swedish study over 11 years

Abstract

The aim of this study was to explore how very old people consider and arrive at decisions on relocation, with specific attention
to housing and health relationships during the process of ageing. The sample included 13 very old participants of an 11-year
longitudinal study of relationships between housing and health. Applying a mixed-methods approach, data from qualitative interviews
and quantitative survey data from three data collection waves were utilised. The quantitative data were interwoven with the
qualitative findings into a coherent body of text. The core theme “Negotiating and effectuating relocation is a long process”
indicates a non-linear process consisting of five phases constituting the main categories of our findings. In the first phase,
some informants considered relocation while others avoided thinking about it. Next, relations between health and home changed
and led to turning points triggering relocation, i.e. when dependence in everyday activities reached critical points or when
sudden illness forced an involuntary move. In the third phase, once the decision to relocate was made it was set in stone
by the individual, but often questioned by the authorities, leading to a situation causing much frustration. While waiting
for the relocation, doubts as well as expectations about the new home were expressed. Finally, even though the actual move
caused different feelings, it was most often a positive experience and resulted in subjective health improvement and increased
social contacts. The results can be used for the development of positive, proactive strategies for improved housing provision
along the ageing process.

Full text

Journal of Housing For the Elderly, 26:61–70, 2012
Copyright © Taylor & Francis Group, LLC
ISSN: 0276-3893 print / 1540-353X online
DOI: 10.1080/02763893.2012.651378
Implementation of Research-Based Strategies
to Foster Person–Environment Fit in Housing
Environments: Challenges and Experiences
during 20 Years
SUSANNE IWARSSON
Department of Health Sciences, Lund University, Lund, Sweden
Since the early 1990s, we have engaged in the development of
methodology for the assessment of person–environment fit in hous-
ing and the determination of how such dynamics interact with
aspects of health. Ultimately, all projects are aimed at practice
implementation. Our research efforts represent methodology devel-
opment, problem-oriented studies among older people and individ-
uals with disabilities, and solution-oriented projects in interaction
with users and practitioners, aimed to implement research-based
solutions and evaluate their effects. The aim of this article is to
provide an overview of the strategies used, challenges met, and ex-
periences gathered while implementing research-based strategies to
overcome housing accessibility problems.
KEYWORDS accessibility, environmental barriers, housing en-
abler
Together with Bj¨
orn Slaug, the author holds the copyright for the Housing Enabler
methodology. The instrument, software, and related methodology courses are marketed and
sold by Iwarsson & Slaug via their private enterprises. According to current Swedish legislation,
after individual probation this arrangement has been formally approved by Lund University.
The author thanks Professor E. Steinfeld, University at Buffalo, NY, for permission to
translate and develop his original idea; B. Slaug and A. Johannisson for fruitful collaboration
through the years; staff at the Centre for Ageing and Supportive Environments (CASE) for
continuous contributions to the methodological development of the instrument; practicing
occupational therapists and others for stimulating cooperation and for providing information
to assist in the methodological development; partners in various countries for their valuable
opinions and rewarding collaboration. This article was prepared within the context of CASE
at Lund University, financed by the Swedish Research Council on Social Science and Working
Life. Financial support was also granted by the Swedish research Council and the Ribbingska
Foundation, Lund, Sweden.
Address correspondence to Susanne Iwarsson, Department of Health Sciences, Box 157,
22100 Lund University, Lund, Sweden. E-mail: susanne.iwarsson@med.lu.se
61

62 S. Iwarsson
INTRODUCTION
Concern about relationships between the housing and health has been
recorded over several centuries by architects, health care practitioners, and
social reformists. Today, following the results of studies in a range of dis-
ciplines, the residential environment is known to be an important determi-
nant of quality of life and well-being (Lawrence, 2010). For example, the
role of the home environment for maintaining independence in daily life
among older people and individuals with disabilities is widely recognized
in research and practice (Wahl, Oswald, Schilling, & Iwarsson, 2009) and
constitutes an important facet of environmental gerontology.
Interventions targeting individual needs for housing adaptation are ini-
tiated by rehabilitation specialists, most often occupational therapists. In
some countries, such adaptations are being supported by national legis-
lation providing individual grants, whereas in many countries it is up to
the individual to finance such interventions (Iwarsson, 2009). At the soci-
etal level, the responsibility to provide all citizens with appropriate housing
designed to support daily activities of living, despite frailty and disability,
rests with politicians and community planners. Against this background, it
seems reasonable to assume that gains could be made by an integration
of the knowledge and experience of health care staff specialized in hous-
ing adaptation case management and societal actors engaged in housing
provision.
Guidelines and standards for designing accessible built environments
have been gradually developed, especially in the past 25 years, but housing
still shows serious deficiencies regarding accessibility. The measures that
are taken in practice contexts are rarely based on systematic assessment,
and there is often insufficient consideration for the different perspectives
that should be included in the analysis preceding the measures (Iwarsson &
Slaug, 2010). Methods targeting accessibility problems should give a measure
of the degree to which a particular physical environment can prevent or
support daily activities of living and participation in society (Steinfeld &
Danford, 1999). According to an extensive literature review on housing and
health (Wahl et al., 2009), few psychometrically sound tools exist in this
field, and it is challenging to derive valid and reliable home measurement
tools.
Since the early 1990s, we have been engaged in the development of
methodology for the assessment of accessibility in housing and immediate
neighborhoods (Iwarsson & Slaug, 2010) and how person–environment fit
dynamics interact with aspects of health (Oswald et al., 2007). The aim
of this article is to provide an overview of the strategies used, challenges
met, and experiences gathered during 20 years of efforts aiming for im-
plementation of research-based strategies to overcome housing accessibility
problems.

Research-Based Strategies to Foster Person–Environment Fit 63
CONCEPTUAL AND THEORETICAL FOUNDATION
Constituting the core of environmental gerontology, theoretical models
that illuminate the relationship between the individual’s capacity and the
demands of the environment emphasize that maladaptive behavior and func-
tioning arise in the relationship between the individual and the environ-
ment. Lawton and Nahemow’s (1973) ecological model is the most cited in
person–environment studies. In 1968, Lawton and Simon stated the docility
hypothesis (Lawton, 1986), which says that a balance between the individ-
ual’s competence and environmental press can be achieved by changing
either component or both. Even if the individual’s functional competence
deteriorates, the capacity for activity can be improved by lowering the de-
mands made by the environment. Another assumption is that individuals with
lower competence are more sensitive to the demands of the environment
than individuals with higher competence.
Regarding accessibility, theory, practical experience, and research find-
ings support a definition of the term as the relationship between the indi-
vidual’s functional capacity and the demands of the physical environment.
Accessibility can be viewed as an aspect of person–environment fit and a
relative concept comprising two components: the personal component and
the environmental component (Iwarsson & St˚
ahl, 2003). The term is objec-
tive by nature, and the environment is described on the basis of guidelines
and standards (Preiser & Ostroff, 2001).
CORE METHODOLOGY
The Housing Enabler instrument is based on approximately 20 years of
method development, teaching, and research in cross-national collaboration
involving researchers and practitioners, with a systematic synthesizing of
knowledge and experiences used to nurture a continuous process of opti-
mization (Iwarsson & Slaug, 2010). The Housing Enabler is one of the few
instruments demonstrating the possibility and utility of a person–environment
fit assessment approach (Mitty, 2010) and rests theoretically on Lawton and
Nahemow’s (1973) ecological model. During the 1990s, we introduced the
instrument as a method with potential to support practitioners in producing
reliable and valid analyses as a basis for interventions targeting housing
accessibility problems (Iwarsson, 1999). The Housing Enabler is distin-
guished by a three-step assessment and analysis approach (Figure) based on
one checklist of functional capacity in the individual (personal component)
and one checklist of environmental barriers (environmental component),
followed by an analysis of person–environment fit resulting in a quanti-
tative accessibility score. This construction implies that the administration
and analysis procedure requires health-related and technical competence,

64 S. Iwarsson
FIGURE Example illustrating the three-step assessment and analysis procedure of the Hous-
ing Enabler (Iwarsson & Slaug, 2010). Reprinted with permission.
coming with advantages and disadvantages for interdisciplinary implemen-
tation ambitions.
STRATEGY
Over the years, a series of projects has been accomplished in an inte-
grated and cumulative manner. The projects represent different types and
levels of scientific ambition, ranging from practice-based, small pilot stud-
ies (Iwarsson, Slaug, & Malmgren F¨
ange, 2011) and PhD student projects
(F¨
ange & Iwarsson, 2005; Helle et al., 2010; Iwarsson, Isacsson, & Lanke,
1998; Slaug, Schilling, Iwarsson, & Carlsson, 2010) to large-scale longitudinal,
cross-national studies (Iwarsson et al., 2007; Oswald et al., 2007). Ultimately,
all projects aim at practice implementation.

Research-Based Strategies to Foster Person–Environment Fit 65
Our strategy builds on three types of activities:
1. Methodology development to create a tool-kit feasible not only for re-
search, but also for structuring practices in community-based health care
and in housing provision and city planning (Iwarsson, 1999; Iwarsson &
Isacsson, 1996; Iwarsson, Nygren, & Slaug, 2005; Iwarsson et al., 2011;
Mitty, 2010).
2. Problem-oriented studies aimed to describe person–environment dynam-
ics and influences on health, among older (Iwarsson, 2005; Iwarsson et al.,
2007; Oswald et al., 2007) and younger individuals with disabilities (F¨
ange,
Iwarsson, & Persson, 2002; Iwarsson et al., 2004).
3. Solution-oriented projects in interaction with users and practitioners aimed
to implement research-based solutions and evaluate their effects (F¨
ange
et al., 2007; Iwarsson et al., 2004).
Based on the conviction that research in this field requires an explicit inter-
disciplinary approach, the core research team consists of senior and junior
scientists representing gerontology, occupational therapy, research engineer-
ing, traffic planning, education, sociology, and statistics. A practicing architect
experienced in accessibility and universal design issues serves as a consul-
tant. Over the years, we have expanded our research cooperation to include
additional individual researchers, practitioners, research teams, and repre-
sentatives for institutes of higher education, not only in European countries
but also in the United States and China.
With the Housing Enabler as the core instrument, we have made
numerous attempts to implement the use of research-based methodology
in different types of practice contexts (F¨
ange & Iwarsson, 2007; F¨
ange,
Risser, & Iwarsson, 2007; Helle et al., 2010; Iwarsson et al., 2011). Most
of the projects and studies were concentrated on housing environments,
but to expand our knowledge a few projects targeted other environ-
mental arenas, such as public facilities in the local community (F¨
ange
et al., 2002; Iwarsson, 2005). Our studies rest on a platform of mixed method-
ologies (Creswell & Plano Clark, 2007), using quantitative and qualitative ap-
proaches in combination (Nygren & Iwarsson, 2009). Another type of study
concerns the process of implementation, focusing on attitudes among prac-
titioners and organizational aspects fostering or hindering implementation
(F¨
ange et al., 2007; F¨
ange & Dahlin Ivanoff, 2009). Different strategies have
been used, all aiming to support the process of implementation:
•Methodology courses targeting practitioners such as occupational thera-
pists, architects, and technicians, as well as university teachers.
•Methodology teaching included in university education for professionals
(Carlsson, Slaug, Johannisson, F¨
ange, & Iwarsson, 2004).

66 S. Iwarsson
•Publication of books and information material, and presentations at nu-
merous conferences, in popular and scientific formats.
•Structured, systematic comparisons of standards for housing design be-
tween countries, engaging interdisciplinary expert panels, paralleled with
structured linguistic translation, involving researchers and practitioners
(Helle et al., 2010; Iwarsson et al., 2005).
•Validity and reliability studies, involving students, teachers, practitioners,
and researchers (Helle et al., 2010; Iwarsson & Isacsson, 1996, Iwarsson
et al., 2005).
•Piloting of research-based assessment instruments in health care, housing
provision, and city planning contexts, foremost in the Nordic countries
(F¨
ange & Iwarsson, 2003; Helle et al., 2010; Iwarsson et al., 2011).
•Definition of needs for environmental measures, involving individuals with
disabilities and different stakeholders (F¨
ange et al., 2002; Iwarsson et al.,
2004).
•Follow-up studies of different types of effects of environmental interven-
tions based on research-based methodology, such as adherence to advices
given and user satisfaction (Iwarsson et al., 2004).
•Studies about attitudes to evidence-based practices and barriers to imple-
mentation (F¨
ange & Dahlin Ivanoff, 2009; F¨
ange et al., 2007).
•Collaboration with private companies (e.g., software development, housing
provision) (Iwarsson et al., 2011).
CHALLENGES EXPERIENCED
Based on our research studies and systematic documentation of collaboration
with different actors over our approximate 20-year process, five interrelated
themes summarizing the challenges of implementation we have experienced
so far appeared.
The first theme is related to the fact that practitioners and researchers
have different missions, with practitioners mostly concentrated on doing a
decent work and earning a living and researchers driven by forces such as
scientific inquiry and scientific merit. This is manifested by differences in
attitudes, where researchers take for granted that the use of research-based
methods and results are positive and a driver of quality improvement, even if
it necessitates a change of traditional practices. This is often in contrast to the
attitudes not only of practitioners, but also of policymakers and politicians. It
should also be emphasized that, based on the difference in missions, it is not
at all self-evident among researchers to be willing to work in an integrated
manner, involving practitioners and end-users from the start of a research
project. That is, researchers are not always willing to make compromises
as regards scientific rigor. The second theme is communication, where ob-
vious but insufficiently reflected on differences in use of terminology and

Research-Based Strategies to Foster Person–Environment Fit 67
language, as well as the critical stance, often result in communication break-
down. The third theme is competence issues, which represent a distinctive
challenge because practitioners and researchers must develop specific skills
to be able to interact efficiently in implementation processes. For neither
of these groups of actors, knowledge about the facts is sufficient; they also
have to develop an understanding of the context in which they are acting.
Moreover, both groups need to be creative in how to apply research results
to practice (i.e., in how to adapt their well-known practices to new circum-
stances). The fourth theme is awareness of the influence of project context
as both a facilitator and a barrier to success. Because the research described
in this article involves complex structures, the power of factors such as staff
discontinuity, weak leadership commitment, and complex organizations can-
not be overestimated. The fifth theme, funding, plays a major role. As yet,
it is difficult for researchers to get sufficient funding for communication and
implementation beyond the traditional dissemination of results. For example,
funders and reviewers lack competence and routine to review applications
involving higher levels of implementation ambitions, but they may also be
prejudiced against the scientific merits of implementation science.
FUTURE PROSPECTS
For the future, we have ambitions for further optimization of the Housing
Eanbler methodology. During 2012, two PhD theses based on methodologi-
cal articles will be completed. Issues under study are methodology for iden-
tification of core items in large item pools (Carlsson et al., 2009), inter-rater
reliability in complex assessment situations (Helle et al., 2010), type pro-
files of functional limitations (Slaug et al., 2011), problems and examples of
the consequences of a lack of research-based standards for accessible hous-
ing (Helle, Brandt, Slaug, & Iwarsson, 2011), and scoring principles for the
quantification of person–environment fit.
We also have ambitions to enter the emerging field of social innova-
tions, using the Housing Enabler as the platform for the development of
tools fostering user-driven housing provision. The bearing idea behind this
initiative is to combine the Housing Enabler with computerized tools for city
planning already being used by architects and building constructors, and 3D
technology. An interactive computer interface will be developed based on
active end-user involvement, allowing older people with disabilities to iden-
tify their current profiles of functional limitations and identify which types
of existing and future housing units they would have the best possibilities to
live an active everyday life. Such initiatives are in line with the ambitions of
environmental gerontology, influencing research and practice to the benefit
of the ageing population.

68 S. Iwarsson
CONCLUSIONS
When starting this journey in the early 1990s, no literature on what we now
know as implementation science was available. With that in mind, it is never-
theless reasonable to conclude that it would have been beneficial if we had
adopted a more systematic approach to document and study the complex
process of development we have experienced so far. In retrospect, our learn-
ing process could have been more structured and efficient, but it might still
be valuable to share some of our experiences with others. We conclude our
research has informed policies and practices in Sweden and other European
countries, while obvious, direct, and sustainable effects in practice contexts
still are scarce. With ambitious prospects for the future based on our previ-
ous results and experiences, we envision that we will be able to continue
to contribute to the development of environmental gerontology and to the
development of social innovations.
REFERENCES
Carlsson, G., Schilling, O., Slaug, B., F¨
ange, A., St˚
ahl, A., Nygren, C., et al. (2009).
Towards a screening tool for housing accessibility problems: A reduced version
of the Housing Enabler. Journal of Applied Gerontology,28, 59–80.
Carlsson, G., Slaug, B., Johannisson, A., F¨
ange, A., & Iwarsson S. (2004). The Housing
Enabler: Integration of a computerised tool in occupational therapy undergrad-
uate teaching. CAL-laborate,11,5–9.
Creswell, J. W., & Plano Clark, V. L. (2007). Designing and conducting mixed-
methods research. Thousand Oaks, CA: Sage.
F¨
ange, A., & Dahlin Ivanoff, S. (2009). Integrating research into practice. A challenge
for local authority occupational therapy. Scandinavian Journal of Occupational
Therapy,16, 40–48.
F¨
ange, A., & Iwarsson, S. (2003). Accessibility and usability in housing: Construct
validity and implications for research and practice. Disability and Rehabilitation,
25, 1316–1325.
F¨
ange, A., & Iwarsson, S. (2005). Changes in ADL dependence and aspects of usabil-
ity following housing adaptation: A longitudinal perspective. American Journal
of Occupational Therapy,59, 296–304.
F¨
ange, A., & Iwarsson, S. (2007). Challenges in the development of strategies for
housing adaptation evaluations. Scandinavian Journal of Occupational Ther-
apy,14, 140–149.
F¨
ange, A., Iwarsson, S., & Persson, Å. (2002). Accessibility to the public environment
as perceived by teenagers with functional limitations in a south Swedish town
centre. Disability and Rehabilitation,24, 318–326.
F¨
ange, A., Risser, R., & Iwarsson, S. (2007). Challenges in implementation of re-
search methodology in community-based occupational therapy: The Housing
Enabler example. Scandinavian Journal of Occupational Therapy,14, 54–
62.

Research-Based Strategies to Foster Person–Environment Fit 69
Helle, T., Brandt, Å., Slaug, B., & Iwarsson, S. (2011). Lack of research-based stan-
dards for accessible housing design: examples and consequences. International
Journal of Public Health,56(6), 635–644.
Helle, T., Nygren, C., Slaug, B., Brandt, Å., Pikkarainen, A., Hansen, A.-G., et al.
(2010). The Nordic Housing Enabler: Inter-rater reliability in cross-Nordic occu-
pational therapy practice. Scandinavian Journal of Occupational Therapy,17,
258–266.
Iwarsson, S. (1999). The Housing Enabler: An objective tool for assessing accessibil-
ity. British Journal of Occupational Therapy,62, 491–497.
Iwarsson, S. (2005). A long-term perspective on person-environment fit and ADL
dependence among older Swedish adults. Gerontologist,45, 327–336.
Iwarsson, S. (2009). Housing adaptations: Current practices and challenges for the
future. In I. S¨
oderback (Ed.), International handbook of occupational therapy
interventions (pp. 63–69). New York, NY: Springer.
Iwarsson, S., F¨
ange, A., Hovbrandt, P., Carlsson, G., Jarbe, I., & Wijk, U. (2004).
Occupational therapy targeting physical environmental barriers in buildings with
public facilities. British Journal of Occupational Therapy,67, 29–38.
Iwarsson, S., Isacsson, Å., & Lanke, J. (1998). ADL dependence in the elderly: The
influence of functional limitations and physical environmental demand. Occu-
pational Therapy International,5, 173–193.
Iwarsson, S., & Isacsson, Å. (1996). Development of a novel instrument for occupa-
tional therapy assessment of the physical environment in the home: A method-
ologic study on “The Enabler.” Occupational Therapy Journal of Research,16,
227–244.
Iwarsson, S., Nygren, C., & Slaug, B. (2005). Cross-national and multi-professional
inter-rater reliability of the Housing Enabler. Scandinavian Journal of Occupa-
tional Therapy,12, 29–39.
Iwarsson, S., Slaug, B., & Malmgren F¨
ange, A. (2011). The Housing Enabler Screen-
ing Tool: Feasibility and inter-rater reliability in a real-estate company practice
context. Journal of Applied Gerontology. doi: 10.1177/0733464810397354.
Iwarsson, S., & Slaug, B. (2010). Housing Enabler: A method for rating/screening and
analysing accessibility problems in housing. Manual for the complete instrument
and screening tool. Lund & Staffanstorp, Sweden: Veten & Skapen HB and Slaug
Enabling Development.
Iwarsson, S., & St˚
ahl, A. (2003). Accessibility, usability, and universal design: Posi-
tioning and definition of concepts describing person-environment relationships.
Disability and Rehabilitation,25, 57–66.
Iwarsson, S., Wahl, H.-W., Nygren, C., Oswald, F., Sixsmith, A., Sixsmith, J., et al.
(2007). Importance of the home environment for healthy aging: Conceptual and
methodological background of the European ENABLE-AGE Project. Gerontolo-
gist,47, 78–84.
Lawrence, R. J. (2010). Housing and health promotion: moving forward. Interna-
tional Journal of Public Health,55, 145–146.
Lawton, M. P. (1986). Environment and aging. Albany, NY: Center for the Study of
Aging.
Lawton, M. P., & Nahemow, L. (1973). Ecology and the aging process. In C. Eis-
dorfer & M. P. Lawton (Eds.), The psychologist of adult development and aging.
Washington, DC: American Psychological Association.

70 S. Iwarsson
Mitty, E. (2010). An assisted living community environment that optimizes function:
Housing Enabler assessment. Geriatric Nursing,31, 448–451.
Nygren, C., & Iwarsson, S. (2009). Negotiating and effectuating relocation to sheltered
housing in old age: A Swedish study over 11 years. European Journal of Ageing,
6, 177–189.
Oswald, F., Wahl, H.-W., Schilling, O., Nygren, C., F¨
ange, A., Sixsmith, A., et al.
(2007). Relationships between housing and healthy ageing aspects in very old
age: Results from the European ENABLE-AGE Project. Gerontologist,47, 96–107.
Preiser, W. F. E., & Ostroff, E. (Eds.). (2001). Universal design handbook.NewYork,
NY: McGraw-Hill.
Slaug, B., Schilling, O., Iwarsson, S., & Carlsson, G. (2011). Defining profiles of
functional limitations in groups of older persons: How and why? Journal of
Aging and Health,23, 578–604.
Steinfeld, E., & Danford, G. S. (1999). Theory as a basis for research on enabling
environments. In E. Steinfeld & G. S. Danford (Eds.)Enabling environments.
Measuring the impact of environment on disability and rehabilitation.New
York, NY: Kluwer Academic/Plenum.
Wahl, H.-W., Oswald, F., Schilling, O., & Iwarsson, S. (2009). The home environment
and Quality of Life related outcomes in advanced old age: Findings of the
ENABLE-AGE Project. European Journal of Ageing,6, 101–111.