Concept of ageing in place and age-friendly communities

In general, only a small percentage – less than 5 per cent – of people aged 60 and over live in an institutional setting (United Nations, 2017c). The majority of people reside in private households their entire life; however, the proportion of older persons in institutional arrangements is increasing with age. The report of the United Nations on Living Arrangements of Older Persons (2017c) indicates that in 2011 4.1 per cent of the Belgian population aged 60 years or over lived in an institutional setting. Disaggregated by age, the report shows that 1.5 per cent of those between 60 and 79 years reside in institutions and this percentage increases to 13.5 per cent among those aged 80 years and over. Among the community-dwelling older people (60 and older), data from the Belgian Ageing Studies pointed out that 95.2 per cent live independently (alone or with a partner) in a single-family house, an apartment or a studio. Only a minority live together with their children (2.5 per cent) or in alternative housing (2.3 per cent) (such as sheltered housing, kangaroo housing or collective housing) (De Witte et al., 2012).

In the last decade, in many European countries as well as in Belgium, there has been growing attention within research and policy for the concept of ‘ageing in place’. Several scholars have demonstrated the wish of older people to remain in the familiar home environment for as long as possible (Löfqvist et al., 2013; Peace et al., 2011; Smetcoren, 2016; Wiles et al., 2012). In general, older people want to age in settings that are familiar in some way (Sixsmith & Sixsmith, 2008) and which reflect their own identity and the society in which they live (Peace et al., 2007). Furthermore, when reaching old age, there is a significant chance of being more attached to the dwelling, which possibly increases the desire to age in place in later life. Alongside this, both policy-makers and the public are largely in agreement and have responded to this desire (Cutchin, 2003; Golant, 2011), for example, by mediating ageing in place through the provision of formal care services, the promotion of home modifications and the development of adult daycare centres (Cutchin, 2003; Dury, 2018; Paraponaris, Davin, & Verger, 2012; Szanton et al., 2011). Additionally, there is the recent increasing tendency towards the organisation of community care for older people. This refers to the growing paradigm shift in which care for people in need becomes less institutionalised and, increasingly, becomes the responsibility of society. This paradigm shift in care for older people means that care takes place within the community, as opposed to institutionalisation, in addition, care is provided by the community, thereby underlining the role of informal caregivers (family, neighbours, volunteers, etc.) (De Donder et al., 2017). Older people are motivated to remain at home and will only make a move towards a residential care facility when the provision of informal and/or formal care within the home situation is no longer sufficient.

Taking in account all these tendencies – the ageing of the population, the wish to age in place and the move towards community care – both policy as well as public (e.g. community service organisations as well as citizens) are challenged by these tendencies – ageing populations, wish to age in place and move towards community care – to seriously rethink the design of both housing as well as communities which are accessible for all residents. A key player in raising awareness concerning this matter on a global level is the World Health Organisation (WHO). In 2007 the WHO launched the Age-Friendly Cities guide which aimed ‘to engage cities to become more age-friendly so as to tap the potential that older people represent for humanity’ (p. 1). An age-friendly community can be described as a community ‘where older people are actively involved, valued, and supported with infrastructure and services that effectively accommodate their needs’ (Alley et al., 2007, p. 4). Eight key domains were described that contribute to the development of age-friendly environments of which housing is considered one. Within the Age-Friendly Cities guide, it is stated that housing in which older people are supported to age comfortably and safely within the community to which they belong, is universally valued (WHO, 2007, p. 30). In order to create ‘age-friendly housing’ in the community, attention should go to affordability, essential services (water supply, electricity, sanitation, etc.), housing design, housing modifications, housing maintenance, access to services, community and family connections, different housing options and the close living environment (WHO, 2007). Adjoining this, the European Union is working on a European Reference Framework for Age-Friendly Housing (ERF-AFH) (Peine & Arentshorst, 2016). This reference framework is being co-created with national, relevant stakeholders from Europe and serves as a tool, resource and interaction platform. It offers guidance by using clear language and definitions to empower stakeholders to concerted and collaborative actions. At present, the concept of ‘age-friendliness’ is well known among policy and practice, however, it still requires greater recognition of the importance of housing in the lives of older people (Buffel et al., 2018). ‘Home’ should be considered as the primary context for growing old as this is the place where older people perform most of their daily activities.

Home as a social, emotional and psychological construct

Because of the growing number of older people who opt for ageing at home, conducting research on person–environment relationships with a focus on inclusive, flexible housing design remains a key focal point (Golant, 2015; Smetcoren, 2016; Wright et al., 2017). At first buildings, such as houses, are shaped as a result of an architect or housing developer’s idea about what houses should look like, but, over time, as people live in their houses they give meaning to the physical structures and materials, which in return changes and eventually shapes them. On the one side, this refers to the house as a physical structure, a defined space providing shelter and protection for domestic activities, and, on the other hand, to the home as a social, cultural and emotional construct (Easthope, 2004; Oswald & Wahl, 2005). It is argued by Easthope (2004) that the ‘home’ should be considered as a significant type of place, whereby the concept of ‘place’ is located within time and space and whereby place provides the link between one’s dwelling place and one’s wellbeing and identity. Also Oswald & Wahl (2005, p. 22) point out that ‘Addressing the meaning of home focuses attention on the relationship between the objective socio-physical setting and subjective evaluations, goals, values, emotions, and observable or potential behaviors that people pursue’. Across the life span, from childhood until late adulthood, people interact with their social and physical environment, ‘which leads to meaningful representations of the self within the environment’ (Oswald & Wahl, 2003, p. 568). When growing older, various researchers have emphasised the meaning of home in later life (Cristoforetti et al., 2011; Oswald & Wahl, 2005; Peace, Holland & Kellaher, 2011; Severinsen, Breheny & Stephens, 2015).

Oswald and Wahl (2005) describe three reasons why the immediate home environment becomes more important as people age. These contribute to our understanding of the role and variety of meanings assigned to the home. The first reason, ‘sociostructural antecedents’, refers to the typical household composition of community-dwelling older people. The majority of older people live independently in the community, either alone or with their partner. Only a small number of people live in a residential institution. Alongside this is the time a person spends living in the same home, which has also an influence on the meaning of home (Oswald & Wahl, 2005). Many older people have lived in their houses and neighbourhoods for a very long time, which can create strong attachments to place. The home covers memories and symbolises their entire life (Heylen et al., 2009, p. 232) and housing should be regarded as an essential player in the unfolding of a life history (Severinsen, Breheny & Stephens, 2016, p. 724). A second antecedent of the meaning of home in later life denotes the ‘everyday life dynamics’ (Oswald & Wahl, 2005). Older people tend to spend a higher amount of time within their immediate home environment because of a reduction in their action radius and because their home is the place where most of their daily activities occur. A German study by Brasche and Bischof (2005) about the daily time spent indoors indicated that on average people spend 15.7 hours at home. Older people in particular (aged 65 and older) were characterised by the longest period at home, namely 19.5 hours. Besides higher amounts of time spend inside the home, the immediate neighbourhood also provides opportunities for daily activities. The study of Föbker and Grotz (2006) demonstrated that more than half of the leisure activities of older people occurred in their immediate residential environment, for example 88 per cent of walks were performed within the neighbourhood. The home environment is significant for maintaining an active and healthy life (Sixsmith et al., 2014). Third, Oswald and Wahl (2005) point towards the ‘health- and environment-related antecedents’ of the meaning of home. ‘The home acquires new meaning in old age because it serves to compensate for the reduced functional capacity of the aging individual, especially in very old age’ (Oswald & Wahl, 2005, p. 25). Reaching old age can bring with it certain changes and losses on several levels: the social level (e.g., death of a spouse or of peers or friends) (Cristoferetti et al., 2011), the physical level (higher probability of health and mobility problems) (Balfour & Kaplan, 2002) and the psychological level (cognitive decline) (Jokela, Batty & Kivimäki, 2013). When experiencing these life-changing events, the home environment acts as an important supportive resource for maintaining control over their lives and ensures the continuation of habits, daily structure and identity (Cristoforetti et al., 2011; Oswald & Wahl, 2005; Severinsen, Breheny & Stephens, 2016).

Home as control centre and a source of continuity

Taken as a whole, housing is one of the most important social determinants of a person’s health during their lifetime (Shaw, 2004). A systematic review by Bambra et al. (2010) underlines that housing is one of the responsible domains for improving health for all age groups within the population. When growing older, needs and expectations within the home environment may alter, stressing the importance of ageing in an easily adaptable environment (Tinker et al., 2013). Dwellings adapted to the needs of their older residents play a crucial role in the possibility of continuing to live independently. Despite this knowledge, previous research has indicated that home environments can encompass certain risk factors influencing the health of older people. In terms of physical health, older people are at a higher risk of diseases and injuries inside the home (Mack & Liller, 2010; Shaw, 2004). A review by Mack and Liller (2010) concerning the epidemiology and burden of home injuries across different life stages in the US pointed out that the leading causes of home injury and deaths among older people are often housing-related: falls, burns, poisoning, natural or environmental exposure (exposure to excessive heat or cold) and suffocation. The dwellings of older people contain a high prevalence of hazards, with multiple hazards in rooms where they perform complex daily routines (e.g., the bathroom is the most hazardous room) (Carter et al., 1997). Furthermore, another study of Brookfield et al. (2015) revealed that stairs, very small spaces, the location and design of certain fixtures (e.g., height or design of cupboards, switches, sockets, etc.) create complicated everyday activities resulting in a less active, more sedentary lifestyle, which in turn contributes to health problems such as diabetes, cardiovascular complaints and premature mortality (Dempsey et al., 2014; Dunstan et al., 2012). However, even if housing is unsuitable in terms of functional decline, it remains of significant importance for maintaining continuity in older people’s lives and is a key aspect in narrating their identity (Severinsen, Breheny & Stephens, 2016).

Few studies have examined the influence of interior design on older people’s subjective wellbeing. For example, the early work of Lawton (1985) formulated the concept of ‘control centres’ that older people create in their home environment, which refer to favoured comfortable places at home where older people have the maximum feeling of autonomy and control. Lawton found some repeated characteristics such as: (1) the location of the control centre was often the living room (as age decreases and impairments increase, the living room becomes the main occupied space); (2) the focus of the ‘control centre’ was a favoured chair (often chosen by the participants with their present need in mind, e.g., offering good support); (3) a telephone and a television were placed within reach and sight of the chair ; (4) the chair was placed to have overview of the (front) door and a window (often so that the person could look outside); and (5) side tables were placed close to the chair and were covered with objects (e.g., remote control, medicine, magazines, pencil, photographs, etc.) and information (e.g., telephone numbers, magazines, etc.) of highest salience to the person (Lawton, 1985). Also meaningful objects around the house and photographs can symbolise a person’s identity and life history (Sixsmith et al., 2014). These ‘control centres’ clearly indicate that older people also think about and arrange (or design) their interior in order to be in their comfort and control zones. Research of Wright and colleagues (2017) concerning design principles for people with complex and cognitive disability emphasises that architects ought to consider the physical, social, natural, symbolic and care environment in relation to the housing design and neighbourhood context for improved outcomes.

Given the results of these previous studies, it is clear that the physical structure and interior design of the physical environment people live in is of major concern for both physical as well as psychological wellbeing, and, thus, that they support or hinder ageing ‘well’ in place.

Background

The ageing population and the provision of age-friendly housing and neighbourhoods are a major challenge for all three regions in Belgium, but in particular for the Brussels-Capital Region. First of all, the group of older single households and older people with a migration background is rising (Knowledge Centre Housing & Care, 2016). Second, the Brussels region contains a (much) higher proportion of the general population that experience poverty compared to the two other regions in Belgium, 38.4 per cent of the Brussels population is at risk of poverty or social exclusion in comparison with 26.3 per cent in the Walloon region and 15.3 per cent in Flanders. The region also faces an increasing percentage of older people relying on a minimum income (Brussels-Capital Health and Social Observatory, 2015). As well as this, the housing stock also has its challenges: 30 per cent of the housing stock in the Brussels-Capital Region was built before 1919. Many dwellings in Brussels lack basic facilities and the most frequently mentioned problems are poor electricity, faulty heating systems, high risk of CO₂ intoxication and the presence of damp problems (Van Mieghem, 2011). Moreover, Winters & Heylen (2014) made a comparison using the European Union Statistics on Income and Living Conditions (EU-SILC) data for 2009 and Eurostat indicators. Their study concluded that poor housing outcomes (overcrowding, damp problems and housing cost overburden) turned out to be at their worst for the Brussels-Capital Region, with the best conditions being in the Flemish Region. There is also a gap between produced housing stock (3,800 units per year since 2003) and the expressed demand (5,000 units per year between 2001 and 2015) in the Brussels-Capital Region. This tension nourishes the rise in real estate prices and rent, which affects the most vulnerable income groups as there are a limited number of affordable dwellings available (Dessouroux et al., 2016).

This lasting crisis in the housing sector and the challenge of an increasing population ageing in place pointed to an innovative approach being needed to respond to the particular care needs of a diverse ageing population. The Brussels Institute for Research and Innovation (Innoviris) launched a collaboration with IWT¹ called ‘Innovative Brussels Care’. One of the projects accepted for funding was ‘Entour-Age Noord: Inspiring and innovative housing and work’. In close collaboration with different stakeholders, the objective of the Entour-Age Noord project was to develop various innovative and small-scale housing models for older people and to generate new work models within the field of housing and care for older people. The new housing as well as work models are designed to reinforce the quality of life of older people who are ageing in the neighbourhood while allowing them to choose the models best suited to their needs and wishes.

Co-creation of new housing models for later life

In order to answer to these aims, and given their complexity and multidimensionality, the project was divided into six different ‘work packages’ (WPs). Within these WPs the different stakeholders and end-users (older people, informal caregivers, neighbourhood residents, etc.) were involved during various activities (service design methodology, architectural workshops, inspiring visits, etc.) in order to co-create the answers and recommendations. In a first step, the persona technique was used to generate answers to the question ‘for whom should we build?’. Personas can be described as conceptual models of targeted user group(s) and can be used to generate a shared understanding among the different stakeholders. ‘The primary advantage of the multi-dimensional persona is to enable the development team to identify with target users, communicate effectively with them and to be a constant reminder to integrate user needs into the system’ (Le Rouge et al., 2013, p. 255). Personas were created at the start of the design process and are based on field data, surveys, user interviews, observations and a combination of these (Nielsen & Hansen, 2014). Eight different personas were constructed, e.g., an independent persona, one who has a lot of energy, relies on him/herself and will do so as long as possible, willing to help others; or a persona in distress, a person who faces a cumulation of different problems (financial, housing, social, health, etc.). Personas were used to test the different developed conceptual models of housing.

During the project two future ‘alternative’ housing models were detailed on paper. Alternative housing can be understood by whatever form that does not fit within the traditional group (notably residential care facilities and single-family houses) (Lawton, 1981). These alternative housing schemes differ from traditional housing in several aspects and contain the following common characteristics (inspired by the early work of Powell Lawton in 1981): (1) they are more custom-built for people who cannot find a solution for their needs within the traditional housing types; (2) they are relatively small-scaled; (3) they include a certain degree of communal life; (4) these alternatives emphasise the ability of living independently (within a supportive and caring environment) and focus less on the availability of medical care. The first housing model focused on older people who wanted to ‘share a house’ as good neighbours, with private units and some common spaces, where residents could occasionally meet and talk, where good ‘neighbourliness’ is highly valued, and a ‘social porter’ is present to help residents with small questions. The second model is intended for older people who want to ‘live together’ in a familial atmosphere sharing a common house with private rooms, where residents meet every day in communal areas, where friendship, care and support are central, and where family members can play an active role.

In the discussions, several architectural and spatial design characteristics were raised by older people that are important for the development of future housing models for later life:

1. 1) provide ‘encounter-friendly’ communal facilities (e.g., staircase, entrance, mailboxes, elevator, etc.) – these should be more than solely functional, also providing opportunities for casual social contact (e.g., noticeboard, a shared bookshelf, decorative elements, a hallway that is wide enough, placement of plants/flowers which need maintenance and care);
2. 2) provide a common space outside where residents can meet and interact (e.g., a garden or a terrace);
3. 3) able to share basic functional areas (e.g., laundry facility/‘salon-lavoir’, common freezer, dumpster area, etc.)
4. 4) have a polyvalent area for all sort of activities (but which can also act as a room for the neighbourhood);
5. 5) have a spare room for guests (or as shelter for people in a crisis situation by working together with an organisation);
6. 6) take into account guidelines on design for later life (e.g., wide doors, grab rails, etc.).

These characteristics are not limited to older adults but can be of interest to any age group. Each future housing development could take these suggestions into consideration. Most important is to involve the future residents in the decision-making process: which common rooms would they like to see realised? How do they want to manage these common rooms? For example, some people will prefer to have a shared laundry facility, but for others this will not be the case. And what about the presence of housing adaptations? For example, the study of Sixsmith et al. (2014) demonstrated that, for some older people, overcoming everyday challenges posed by one’s frailties, such as stairs, resulted in feelings of achievement. And for some people in this study, adaptations were seen as symbolic of their frailty and thus they preferred an environment that was familiar and reflective of their identity rather than instrumentally supportive.