Numbers and narratives: Developing a mixed-methods approach to understand mobility in later life

What happens behind doors? Exploring everyday indoor activities when ageing in place

Engaging in social interaction and physical movement during everyday activities has a positive influence on wellbeing in later life. For older adults who age in place, the majority of activities occur indoors, yet studies typically focus on outdoors. Gender influences social and physical activities but is understudied in an ageing-in-place context. We aim to address these gaps by increasing insight into the indoor activities in later life, with a focus on gender differences in social interaction and physical movement. Through a mixed-methods approach, data were collected using global positioning system (GPS) trackers, pedometers and activity diaries. Twenty community-dwelling older adults (11 women and 9 men) who were living in Lancashire collected these data over seven days. An exploratory spatio-temporal analysis was conducted on the 820 activities they undertook. We discovered that our participants spend large amounts of time indoors. We also found that social interaction increases the duration of the activity and, conversely, decreases levels of physical movement. When zooming in to gender differences, men's activities took significantly longer than women's activities and were characterised by higher level of social interaction. Based on these results, we argue that there is a trade-off between social interaction and physical movement in everyday activities. We suggest establishing a balance between socialising and moving in everyday activities in later life, specifically because maintaining high levels of movement and social interaction at the same time seems unachievable. In conclusion, it is important to design indoor environments that facilitate choice between being active and resting, and between being social and being on one's own rather than assume they are mutually-exclusive and/or universally "good" or "bad" per se.

How different are objective operationalizations of walkability for older adults compared to the general population? A systematic review

Background

Walking is an essential activity for everyone and for older adults in particular, given that it is the most accessible form of physical activity and one of the healthiest transportation modes. Understanding how walkability (the potential of the environment to enable and/or encourage walking) has been objectively measured and analyzed for older adults is critical to create more inclusive, healthy, and sustainable environments and to promote healthy aging. Despite the numerous reviews on physical activity among older adults and its relationship with the built environment, the literature still lacks comparison reviews focusing specifically on objective operationalizations of walkability for older adults vs. the general population.

Methods

We conducted a systematic review of 146 empirical studies that measured walkability objectively in relation to walking-related outcomes. We compared studies focused on older adults (n = 24) and the general population (n = 122). Content analysis included the characteristics of the study design, walkability measures, spatial extent, and associations found between walkability and walking-related outcomes.

Results

In both groups of publications, the majority of studies were conducted in the US, Canada, and Europe, and largely in high-income countries. They were mostly published in health-related journals and used cross-sectional designs, operationalized walkability by using indexes, employed self-reported measures for walking-related outcomes, and found positive associations between walkability and walking outcomes. However, we observed some differences among studies focusing on older adults. Compared to studies focusing on the general population, a larger proportion of studies on older adults was conducted in the Middle East and Asia, and they used longitudinal designs, mixed methods to measure walking-related outcomes, variables related with land-use characteristics, safety from traffic and crime, and greenery, and a larger proportion found positive, as well as no associations between walkability and walking-related outcomes.

Conclusion

Although there is a promising increase in interest in older adults-focused walkability studies in the last decade, there is still a need for more studies focusing on different settings, using wider spatial extents, longitudinal designs, objective or mixed methods to collect outcome data, and specific variables and/or specially created indexes for older adults and for settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03233-x.

Facilitators and barriers to real-life mobility in community-dwelling older adults: a narrative review of accelerometry- and global positioning system-based studies

Real-life mobility, also called "enacted" mobility, characterizes an individual's activity and participation in the community. Real-life mobility may be facilitated or hindered by a variety of factors, such as physical abilities, cognitive function, psychosocial aspects, and external environment characteristics. Advances in technology have allowed for objective quantification of real-life mobility using wearable sensors, specifically, accelerometry and global positioning systems (GPSs). In this review article, first, we summarize the common mobility measures extracted from accelerometry and GPS. Second, we summarize studies assessing the associations of facilitators and barriers influencing mobility of community-dwelling older adults with mobility measures from sensor technology. We found the most used accelerometry measures focus on the duration and intensity of activity in daily life. Gait quality measures, e.g., cadence, variability, and symmetry, are not usually included. GPS has been used to investigate mobility behavior, such as spatial and temporal measures of path traveled, location nodes traversed, and mode of transportation. Factors of note that facilitate/hinder community mobility were cognition and psychosocial influences. Fewer studies have included the influence of external environments, such as sidewalk quality, and socio-economic status in defining enacted mobility. Increasing our understanding of the facilitators and barriers to enacted mobility can inform wearable technology-enabled interventions targeted at delaying mobility-related disability and improving participation of older adults in the community.

Geographical life-space and subjective wellbeing in later life

Geographical life-space is an important factor to consider when studying subjective wellbeing of older adults. The purpose of this article is twofold: to provide an in-depth understanding of 1) the geographical life-spaces in which the lives of older adults take place and 2) the relation between life-space and experienced levels of subjective wellbeing. Seventy-six older adults (aged 65 and older) participated in our qualitative study. We applied a qualitative research approach, through combining indepth-interviews with visual life-space diagrams. Our findings show that most older adults continue to experience a high level of subjective wellbeing, regardless of the extent of their life-space. We conclude that the possibility to fulfill one's needs, even in a restricted life-space, is more conducive to maintaining subjective wellbeing than the extent of life-space itself.

Fidelity and utility of GPS loggers as a tool for understanding community participation of older adults

OBJECTIVE

The purpose of this research was to examine the fidelity and utility of global positioning system (GPS) technology for studying community mobility indicators, and to explore implications for community participation for older adults.

METHOD

A longitudinal cohort design with community-dwelling older adults (n = 33) was employed. GPS spatial data and activity logs were collected at baseline and one year later. Data were analysed to evaluate the fidelity of the GPS protocol, the nature and frequency of destinations, and the stability of community mobility over time.

RESULTS

Findings include evidence for high reliability of the GPS loggers to record out-of-home trips when compared to activity logs; utility of the technology for identifying frequency and type of occupational destinations; and the relative stability of two community mobility variables over time. GPS loggers generate key insights into how older adults move in and through their community as they engage in a range of occupations.

CONCLUSION

GPS technology is a robust and useful tool for gathering novel information, especially when combined with qualitative data. GPS loggers may be incorporated in evaluation or to tailor interventions. Community mobility enables social participation, and warrants further research using these methods to support processes of aging in place.

Technology to Improve Autonomy and Inform Housing Decisions for Older Adults With Memory Problems Who Live at Home in Canada, Sweden, and the Netherlands: Protocol for a Multipronged Mixed Methods Study

BACKGROUND

Understanding the mobility patterns and experiences of older adults with memory problems living at home has the potential to improve autonomy and inform shared decision making (SDM) about their housing options.

OBJECTIVE

We aim to (1) assess the mobility patterns and experiences of older adults with memory problems, (2) co-design an electronic decision support intervention (e-DSI) that integrates users' mobility patterns and experiences, (3) explore their intention to use an e-DSI to support autonomy at home, and (4) inform future SDM processes about housing options.

METHODS

Informed by the Good Reporting of A Mixed Methods Study (GRAMMS) reporting guidelines, we will conduct a 3-year, multipronged mixed methods study in Canada, Sweden, and the Netherlands. For Phase 1, we will recruit a convenience sample of 20 older adults living at home with memory problems from clinical and community settings in each country, for a total of 60 participants. We will ask participants to record their mobility patterns outside their home for 14 days using a GPS tracker and a travel diary; in addition, we will conduct a walking interview and a final debrief interview after 14 days. For Phase 2, referring to results from the first phase, we will conduct one user-centered co-design process per country with older adults with memory issues, caregivers, health care professionals, and information technology representatives informed by the Double Diamond method. We will ask participants how personalized information about mobility patterns and experiences could be added to an existing e-DSI and how this information could inform SDM about housing options. For Phase 3, using online web-based surveys, we will invite 210 older adults with memory problems and/or their caregivers, split equally across the three countries, to use the e-DSI and provide feedback on its strengths and limitations. Finally, in Phase 4, we will triangulate and compare data from all phases and countries to inform a stakeholder meeting where an action plan will be developed.

RESULTS

The study opened for recruitment in the Netherlands in November 2018 and in Canada and Sweden in December 2019. Data collection will be completed by April 2021.

CONCLUSIONS

This project will explore how e-DSIs can integrate the mobility patterns and mobility experiences of older adults with memory problems in three countries, improve older adults' autonomy, and, ultimately, inform SDM about housing options.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04267484; https://clinicaltrials.gov/ct2/show/NCT04267484.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/19244.

Ageing as well as you can in place: Applying a geographical lens to the capability approach

Despite policy commitments to support ageing in place, we know very little about the everyday realities and experiences of older people living in different environmental circumstances, with varying personal capabilities. This paper: 1) examines the valued place-based functionings of older people through the use of geo-spatial and in-situ methods, where functionings are defined as states of being and doing, and place-based functionings are defined as places, activities, interactions, routes, and routines that support these beings and doings; and 2) demonstrates the utility of a capability approach by amalgamating the interconnected concepts 'ageing in place' and 'ageing well'. Three in-depth individual experiences of ageing at home in a Dublin (Ireland) suburb show how differing health and mobility challenges are managed, and illustrate how conceptions of ageing well in place can be identified from geographically-grounded lifeworlds. Participants' place-based functionings are identified by combining qualitative and geo-spatial approaches through the use of annotated maps, using data obtained from traditional interviews, go-along interviews, and mapping exercises. Results demonstrate the diversity of place-based functionings valued by each individual, and how functionings are negotiated depending on different needs, wishes, and health or mobility challenges. Results also highlight the importance of supportive environments and social supports in enabling older people to realise their most valued functionings over time, which include being able to get out and about, engage and connect with others, carry out daily tasks and errands confidently, and remain independent. By paying attention to subjectively valued place-based functionings, as well as the specific supports required to sustain them, we can facilitate older people to not just age in place, or age well, but to age - as well as they can - in place.

Using the concept of activity space to understand the social health of older adults living with memory problems and dementia at home

Globally as the population ages, the prevalence of dementia will increase. Simultaneously, there is a trend toward people ageing at home. Therefore, more people will be ageing at home with dementia, as opposed to institutional environments. In this context, there has been a recent shift in research exploring ways that people can live well with the consequences of the disease. As a part of this emerging research, the social and spatial aspects of the lives of people living with memory problems are becoming increasingly of interest. The aim of this article is to use the concept of activity space to examine the social health of older adults with memory problems and dementia who live at home. Activity space data were collected from seven older adults experiencing memory problems and living at home in the Netherlands. Using a mixed-methods approach, insight into their activity spaces were gained through walking interviews, 14 days of global positioning system (GPS) movement data, travel diary entries and in-depth interviews. The GPS data, travel diary data and interview transcripts were analyzed using a grounded visualization approach. Our findings show that participants interact independently in routine activity spaces but depend on others to participate in occasional activity spaces. Interactions within both these spaces contribute to the social health of older adults with memory problems and dementia who live at home. Additionally, participants used coping strategies and decision-making to maintain autonomy in daily life. The findings can inform dementia-friendly initiatives and social health care planning.

Giving Voice to the Environment as the Silent Partner in Aging: Examining the Moderating Roles of Gender and Family Structure in Older Adult Wellbeing

Gerontological scholarship has long seen the environment to be a silent partner in aging. Environmental Gerontology, an established approach in Social Gerontology, has shown how the everyday lives of older adults are deeply entangled in socio-spatial environments. Adopting an Environmental Gerontology approach, we explore social and cultural dimensions of the association between out-of-home mobility and wellbeing among older adults in a north western city of India. This was established by combining high resolution time-space data collected using GPS receivers, questionnaire data and time diaries. Following a multi-staged analytical strategy, we first examine the correlation between out-of-home mobility and wellbeing using bivariate correlation. Second, we introduce gender and family structure into regression models as moderating variables to improve the models' explanatory power. Finally, we use our results to reinterpret the Ecological Press Model of Aging to include familial structure as a factor that moderates environmental stress. Findings emphasize the central role that social constructs play in the long-established relationship between the environment and the wellbeing of older adults.

Using geographic information systems to map older people's emergency department attendance for future health planning

Objectives

This study aimed to assess the pattern of use of EDs, factors contributing to the visits, geographical distribution and outcomes in people aged 65 years or older to a large hospital in Dublin.

Methods

A retrospective analysis of 2 years of data from an urban university teaching hospital ED in the southern part of Dublin was reviewed for the period 2014–2015 (n=103 022) to capture the records of attenders. All ED presentations by individuals 65 years and older were extracted for analysis. Address-matched records were analysed using QGIS, a geographic information systems (GIS) analysis and visualisation tool to determine straight-line distances travelled to the ED by age.

Results

Of the 49 538 non-duplicate presentations in the main database, 49.9% of the total are women and 49.1% are men. A subset comprised of 40 801 had address-matched records. When mapped, the data showed a distinct clustering of addresses around the hospital site but this clustering shows different patterns based on age cohort. Average distances travelled to ED are shorter for people 65 and older compared with younger patients. Average distances travelled for those aged 65–74 was 21 km (n=4177 presentations); for the age group 75–84, 18 km (n=2518 presentations) and 13 km for those aged 85 and older (n=2104 presentations). This is validated by statistical tests on the clustered data. Self-referral rates of about 60% were recorded for each age group, although this varied slightly, not significantly, with age.

Conclusions

Health planning at a regional level should account for the significant number of older patients attending EDs. The use of GIS for health planning in particular can assist hospitals to improve their understanding of the origin of the cohort of older ED patients.

Towards meaningful mobility: a research agenda for movement within and between places in later life

Mobility or physical movement contributes to health and wellbeing in later life. Most studies have focused on the contribution of outdoor mobility to active ageing, but physical and cognitive impairments restrict the mobility of many older adults. This article aims to explore the gaps in the current literature on mobility in later life, and identify required innovations in the field through laying out key areas for future research. It discusses two, largely separate, areas of research, namely on mobility patterns and mobility experiences. The first focuses on quantitative and spatial research on outdoor mobility patterns in terms of routes, timing and transport modes. The second mainly concerns qualitative research on how older adults perceive mobility in their everyday lives. This article identifies three areas for future research on mobility in later life: (a) beyond outdoor movement; (b) diversity in mobility; and (c) the role of time in mobility. To conclude, addressing these areas jointly will contribute to further unpacking the concept of mobility as meaningful practice and to integrating quantitative and qualitative methods when studying mobility in later life. This will result in policy inputs on the mobility and wellbeing of our ageing population.

Activity spaces in studies of the environment and physical activity: A review and synthesis of implications for causality

Activity spaces are increasingly used to understand how people interact with their environment and engage in activity but their use may raise challenges regarding causal inference. We conducted a systematic review of findings and the methodological, analytical and conceptual issues relevant to causal inference. Studies were included if they comprised a spatial summary of locations visited, assessed any part of the causal pathway between the environment, physical activity and health, and used quantitative or qualitative methods. We searched seven electronic databases in January 2018 and screened 11910 articles for eligibility. Forty-seven studies were included for review. Studies answered research questions about features of or environmental features within activity spaces using a range of spatial and temporal summary techniques. The conceptual challenge of using activity spaces to strengthen causal inference was rarely considered, although some studies discussed circularity, temporality, and plausibility. Future studies should use longitudinal and experimental designs and consider the potential and actual use of spaces for physical activity, and their relationship with total levels of activity.

A geographically explicit ecological momentary assessment (GEMA) mixed method for understanding substance use

Tobacco use is increasingly concentrated within marginalized groups, including LGBTQ+ young adults. Developing tailored interventions to reduce tobacco-related health disparities requires understanding the mechanisms linking individual and contextual factors associated with tobacco use to behavior. This paper presents an in-depth exploration of three cases from a novel mixed method study designed to identify the situational factors and place-based practices of substance use among high-risk individuals. We combined geographically explicit ecological momentary assessment (GEMA) with an adapted travel diary-interview method. Participants (young adult bisexual smokers, ages 18-26) reported on non-smoking and smoking situations for 30 days with a smartphone app. GEMA surveys captured internal and external situational factors (e.g., craving intensity, location type, seeing others smoking). Continuous locational data was collected via smartphone GPS. Subsequently, participants completed in-depth interviews reviewing maps of their own GEMA data. GEMA data and transcripts were analyzed separately and integrated at the case level in a matrix. Using GEMA maps to guide the interview grounded discussion in participants' everyday smoking situations and routines. Interviews clarified participant interpretation of GEMA measures and revealed experiences and meanings of smoking locations and practices. The GEMA method identified the most frequent smoking locations/times for each participant (e.g., afternoons at university). Interviews provided description of associated situational factors and perceptions of smoking contexts (e.g., peer rejection of bisexual identity) and the roles of smoking therein (e.g., physically escape uncomfortable environments). In conclusion, this mixed method contributes to advancing qualitative GIS and other hypothesis-generating approaches working to reveal the richness of individuals' experiences of the everyday contexts of health behavior, while also providing reliable measures of situational predictors of behaviors of interest, such as substance use. Limitations of and future directions for the method are discussed.