Journal of Aging and Physical Activity, 2015, 23, 323-329 http://dx.doi.org/10.1123/japa.2013-0151 © 2015 Human Kinetics, Inc.
Official Journal of ICAPA www.JAPA-Journal.com SCHOLARLY REVIEW
The Built Environment, Physical Activity, and Aging in the United States: A State of the Science Review Elizabeth M. Haselwandter, Michael P. Corcoran, Sara C. Folta, Raymond Hyatt, Mark Fenton, and Miriam E. Nelson
Introduction and Methodology The vast majority of U.S. adults do not meet the 2008 Physical Activity Guidelines for Americans despite a myriad of known health benefits from exercise (Troiano et al., 2008). Less than 3% of older adults (aged 60 or older) are meeting these recommendations, with the majority of both men and women aged 70+ achieving less than 10 min per day of moderate-to-vigorous activity based on accelerometer data (Troiano et al., 2008). The reasons behind this physical inactivity epidemic are complex and multifaceted. One likely contributor to sedentary behavior is the built environment (Boehmer, Hoehner, Deshpande, Brennan Ramirez, & Brownson, 2007; Hoehner, Brennan Ramirez, Elliott, Handy, & Brownson, 2005), which refers to the physical environment in which an individual spends his or her time (e.g., home, neighborhood), including the internal or external features of this environment, such as staircases, sidewalks, crosswalks, and traffic density. The prevailing hypothesis centers on the notion that various characteristics of an individual’s physical environment may encourage or act as a barrier toward physical activity (Boehmer et al., 2007; Duncan, Spence, & Mummery, 2005; Feng, Glass, Curriero, Stewart & Schwartz, 2010; Lee, Ewing, & Sesso, 2009). With the high prevalence of obesity and other chronic health conditions associated with inactivity, understanding how the built environment can influence health-related behavior has become an important area of research. The existing evidence leaves many questions unanswered or provides conflicting results, and also highlights the need for additional research to determine environmental variables of importance (Brennan Ramirez, et al., 2006; Feng, et al., 2010). This is true across populations, but particularly true for older adults over the age of 65 (Cunningham & Michael, 2004), and much of the research focuses on the outside environment, leaving possibilities for exploring influences on indoor activity in older populations, particularly those in senior housing. Older adults are the fastest growing, yet least active, segment of Haselwandter is a Nestle doctoral fellow, Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, Tufts University, Medford, MA. Corcoran is an assistant professor of health sciences at Merrimack College, North Andover, MA. Folta is an assistant professor, Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, Tufts University, Medford, MA. Hyatt is president of Freeport Development Strategies, LLC, Burlington, MA. Fenton is an adjunct professor, Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, Tufts University, Medford, MA. Nelson is a professor at the Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy and associate dean at the Tisch College of Citizenship and Public Service, both at Tufts University, Medford, MA. Address author correspondence to Elizabeth M. Haselwandter at [email protected].
the population. It is estimated that by 2050, there will be 88.5 million Americans aged 65 and older and, of these, 19 million will be among the “oldest old” (i.e., aged 85 and up) (Vincent & Velkoff, 2010). The increase in the aging population will have a number of consequences, such as a rise in health care costs since health care spending increases with age (Orszag, 2008). Health care costs have risen over the past 30 years, from $714 billion in 1990 to more than $2.3 trillion in 2008 (Kimbuende, Ranji, Lundy, & Salganicoff, 2010). These rising costs have alarmed policy makers and individuals alike, and provide an incentive to prioritize successful aging, including reduced burden from chronic diseases and greater functional independence. Current physical activity recommendations for older adults in the United States are identical to recommendations for all adults: to achieve at least 150 min a week of moderate-intensity aerobic activity, 75 min of vigorous-intensity aerobic activity, or an equivalent mix of both moderate- and vigorous-intensity activity (Centers for Disease Control and Prevention, 2014). The benefits of physical activity for older adults are wide ranging and include the following: preserving muscle and bone mass, reducing rates of functional decline, and improving glucose control, cardiovascular health, balance, and stability (Sattelmair, Pertman, & Forman, 2009). Increasing physical activity in this population is very likely to support successful aging, which includes limiting disease and disease-related disability, ensuring physical and cognitive functioning is maintained, and preserving an older adult’s ability to engage actively in life (Carr, Weir, Azar, & Azar, 2013). One aspect of successful aging is aging in place, or the ability to live in one’s own home confidently and comfortably (Yen & Anderson, 2012). It is possible that a supportive built environment will both enhance one’s physical functioning and also make one’s home more comfortable for continued living. Researchers hypothesize that built environment effects likely differ by age and physical abilities, and that the built environment can have both facilitating and constraining effects on the activities of older adults (Brownson, Hoehner, Day, Forsyth, & Sallis, 2009; Carr et al., 2013). The role that the built environment could play in successful aging calls for a focus on determining which specific elements enhance the health and well-being of older adults, and identifying those factors that may impede older adults from activity. Maintaining mobility and independence are high priorities for older adults, and so it is crucial to determine which environmental factors could encourage these outcomes, and thereby prevent them from moving from more independent or assisted living conditions to nursing home facilities (Carr et al., 2013; Yen & Anderson, 2012). This paper aims to: (1) review the current literature to determine what relationships exist between the built environment and physical activity in older adults; (2) identify features that may act as barriers or enablers among older adults in senior-specific housing; and (3) identify areas of future research for this population. 323
324 Haselwandter et al.
To determine what we have learned about the built environment, older adults, and physical activity (including walking) thus far, the authors conducted a literature search using the following search terms: built environment, older adults, assisted living facilities, physical activity, and walkability. The literature search was conducted using the PubMed research database, and included filter criteria for participants aged 65+ and articles written in English. The various search terms returned 166 articles. Articles were then excluded if they were not conducted in the United States (n = 11), focused on methodology (n = 11), or did not contain relevant variables, associations, or outcomes (n = 76).
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The Built Environment and Older Adults: Encouraging and Inhibiting Physical Activity The built environment can be defined in many ways, but it is useful to think of it as encompassing various domains. Brownson et al. (2009) suggest the following four domains: functional, destination, aesthetics, and safety. Safety includes both safety from crime, such as maintenance of local buildings, street lighting, and neighborhood surveillance, and safety from traffic, such as safe crosswalks, bike lanes, and sidewalks (Day, Boarnet, Alfonzo, & Forsyth, 2006). Aesthetics generally refer to the “perceived attractiveness of the setting for physical activity” and addresses issues such as litter, broken glass, and plantings along walking paths (Day et al., 2006; Hoehner, Ivy, Brennan Ramirez, Handy, & Brownson, 2007). Other factors, such as accessibility, the prevalence of parks and green spaces, land-use characteristics and land-use mix, foot and bike trails, land slope, availability of public transport, and street connectivity are also often included in built environment assessments (Berke, Koepsell, Moudon, Hoskins, & Larson, 2007; Day et al., 2006; Saelens, Sallis, Black, & Chen, 2003; Takano, Nakamura, & Watanabe, 2002). There is some evidence linking each of these domains with physical activity in older adults (Table 1). More generally, a number of associations between the built environment and physical activity measures have been investigated. Studies have shown that factors such as safety from crime, presence of light traffic, sidewalks, access to parks, access to indoor gyms and treadmills, and less urban sprawl are associated with physical activity levels in adults (Brownson, Baker, Housemann, Brennan, & Bacak, 2001; Casagrande, Whitt-Glover, Lancaster, Odoms-Young, & Gary, 2009; Lee et al., 2009). High walkability, an indication of a more facilitating built environment, has also been consistently associated with more minutes of moderate-to-vigorous and moderate-intensity activity in adults (Carlson et al., 2012; Saelens et al., 2003; Sallis et al., 2009). These results indicate that various built environment factors may have an effect on physical activity levels and overall health. Many studies focus on the built environment’s relationship to walking. Walkability was influenced by such factors as the presence or absence of curb ramps, parking, lighting, weather, crosswalks, sidewalks, amenities or land-use mix, walking paths or trails, safety, density of intersections or street connectivity, traffic conditions, and green space (Rosenberg, Huang, Simonovich, & Belza, 2013; Rosso, Auchincloss, & Michael, 2011;). Older adults often perceive the walking environment differently than the general population. Michael, Beard, Choi, Farquhar and Carlson (2006) found that when trained researchers’ measurements of the built environment were compared with older adults’ perceptions, older adults reported sidewalk obstructions where the researchers saw none. This supports the
notion that older adults may have different concerns when walking, and that a more thorough understanding of older adults’ perceptions of the built environment are needed. Walking is a meaningful source of activity for older adults; a number of studies cited walking as the primary form of activity in this population (Michael, Gold, Perrin, & Hillier, 2011; Sawchuk et al., 2011;). As an example, Michael et al. (2011) found that 60% of the women aged 65 or older reported walking for exercise or as a part of a daily routine. There is also evidence for associations among other facilitating built environmental factors and healthy behaviors and outcomes. Street density and connectivity were significantly associated with the number of blocks walked among women aged 65+ who reported walking (Michael et al., 2011). Older adults living in senior living residences reported greater self-rated health and less sedentary time if they also reported more supportive outdoor physical activity features (Kerr et al., 2011). Other positive associations between physical activity and the built environment were related to land-use mix and destinations, such as grocery stores, restaurants, and shops (Berke et al., 2007; Sawchuk et al., 2011). Barriers may also play a role, as issues such as fear of falling are common, especially among older women (Walsh, Pressman, Cauley, & Browner, 2001). Fear of traffic-related injuries may also play a role in limiting outdoor physical activity (Shendell et al., 2011). In a study by Theis and Furner (2011), building design, sidewalks, curbs, and crowds were the most frequently cited environmental barriers for adults aged 50 or older. However, the question remains as to whether improvements in these barriers would translate to increased physical activity, or which features play the most meaningful role. A study by Rosenberg et al. (2013) attempted to gain in-depth, qualitative data on barriers or facilitators to walking among seniors with mobility disabilities. In focus groups, seniors perceived not feeling visible to drivers; fast moving traffic; lack of driver attention; sidewalk surfaces and quality (particularly navigating over brick, cobblestones, and metal grates); lack of sidewalk; rain, heat, and sun exposure; hills; and outdoor stairs as barriers to walking (Rosenberg et al., 2013). In particular, crossing the street was mentioned as a particularly stressful event; crossing signal times often felt too short, and participants felt rushed and at a greater risk of falling (Rosenberg et al., 2013). They also felt that a lack of street crossings were a problem, and some coped with issues involving crossing streets by staying home (Rosenberge al., 2013). Participants also mentioned a number of perceived facilitators: smooth and wide sidewalks, presence of a grass strip between the sidewalk and the road, presence of ramps, stair handrails, and feeling safe from crime (Rosenberg et al., 2013). Places to rest were a common theme, particularly in communal outdoor spaces, such as parks or walking trails, and in lines at places such as food banks (Rosenberg et al., 2013). Participants mentioned feeling fatigued if they had to stand or walk for too long, and shelter for rest and from the weather at public transportation stops and on local streets were considered to be important facilitators, as well as accessible drinking fountains and restrooms (Rosenberg et al., 2013). While this study focused on seniors with mobility disabilities, it is easy to imagine that frail, older adults who are able to walk without assistive devices may cite similar concerns; future focus groups could confirm this. While some aspects of the built environment are more fixed and harder to change, other aspects could be addressed, and provide opportunities for study. In particular, improved sidewalk quality and extended crossing times could be addressed, and then the impact of these changes can measured by self-report of objective measures, such as accelerometer data.
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Table 1 A Review of Measures and Results in Studies Examining the Built Environment in Seniors Population
Sample Size
Reference Functionality Berke et al., 2007
Adults aged 65 and older
936
Crosssectional
Walkability score (objectively measured)
Carlson et al., 2012
Adults aged 65 or older
719
Crosssectional
Walkability (GISderived)
Carlson et al., 2012
Adults aged 65 or older
719
Crosssectional
Walkability (GISderived)
Carlson et al., 2012 Frank, Kerr, Rosenberg, & King, 2010
Adults aged 65 or older Adults aged 65 or older
719
Crosssectional Crosssectional
Walkability (GISderived) Walkability (GISderived)
147
Crosssectional
147
Crosssectional
APARS “Outside Supportive PA Features” 12-item subscale (objectively measured) APARS “Outside Supportive PA Features” 12-item subscale (objectively measured)
147
Crosssectional
147
Crosssectional
719
Crosssectional
Crosssectional
Kerr et al., 2011 Seniors living in senior living residences (mean age of 80 years) Kerr et al., 2011 Seniors living in senior living residences (mean age of 80 years) Kerr et al., 2011 Seniors living in senior living residences (mean age of 80 years) Kerr et al., 2011 Seniors living in senior living residences (mean age of 80 years) King et al., Adults aged 66 2011 and older
1,970
Michael et al., 2011
Women aged 65 and older
1,008
Michael et al., 2011
Women aged 65 and older
1,008
Study Type BE Measure
APARS “Outside Exercise Facilities” 10-item subscale (objectively measured) APARS “Outside Exercise Facilities” 10-item subscale (objectively measured) Walkability (GISderived)
Street connectivity and street density (block length) (GIS-derived)
Prospective Street connectivity cohort (GIS-derived)
Outcome
Results
Walking for exercise (self-report)
A walkability score in the 75th percentile increased the odds of walking for exercise in men at all three buffer zone sizes (100 m, 500 m, 1000 m) when compared with the 25th percentile; for women, results were only significant at the 1000 m buffer MVPA minutes/ Walkability was positively associweek (measured via ated with total minutes per week accelerometer) of moderate-to-vigorous physical activity Walking for transWalkability was positively associportation (selfated with self-reported walking for report) transportation Walking for leisure Walkability was positively associated (self-report) with self-reported walking for leisure Walked at least Older adults living in a high walkonce in 2 days (self- ability neighborhood were twice as report) likely to walk at least once a day in two days compared with those in low walkability (but not medium walkability) neighborhoods Sedentary minutes/ More supportive outdoor features hour (measured via were associated with less sedentary accelerometer) time among residents living in Senior Living Residences. More supportive outdoor features MVPA minutes/ hour (measured via were associated with greater minutes per hour of moderate to vigorous accelerometer) physical activity among residents in senior living residences Sedentary minutes/ Having outside exercise facilities hour (measured via was related to less sedentary time for residents in senior living residences accelerometer) MVPA minutes/ hour (measured via accelerometer) Walking for transportation (selfreport)
Blocks walked (self-report)
Dynamic leg strength (chair stand score)
Having outside exercise facilities was related to engaging in more moderate to vigorous physical activity for residents in senior living residences Higher walkable neighborhood quadrants were associated with higher average number of minutes per week of walking for transportation compared with lower walkable quadrants Among women who walked at baseline (n = 1008, out of total sample of 1671), both BE measures were associated with blocks walked per week; greater street density (shorter block size) and greater connectivity were associated with more blocks walked Among women who walked, greater street connectivity was associated with less decline in dynamic leg strength (continued)
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Table 1 (continued) Reference
Population
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Functionality (continued) Michael et al., Women aged 65 2011 and older
Sample Size
Study Type BE Measure
Outcome
Results
1,008
Prospective Street density (block cohort length) (GIS-derived)
Dynamic leg strength (chair stand score)
Prospective Street connectivity and cohort Street density (block length) (GIS-derived)
Lower extremity physical performance (chair stand scores and timed walks)
Among women who walked, greater street density (shorter block size) was associated with less decline in dynamic leg strength Neighborhood walkability (encompassing both street connectivity and street density) were not associated with physical performance over time in women who reported not walking at baseline in adjusted models Greater land use mix access was related to more reported walking for transportation among the older study participants
Michael et al., 2011
Women aged 65 and older
663
Shigematsu et al., 2009
Adults aged 66 and older
360
Crosssectional
Land use mix-access Transportation (NEWS 6-item subwalking (selfscale measuring ease of report) access to nonresidential uses) (perceived)
147
Crosssectional
147
Crosssectional
360
Crosssectional
360
Crosssectional
APARS (Adult Physical Activity Resources for Seniors) “Onsite services/destinations” 17-item subscale (objectively measured) APARS “Inside Social Facilities” 19-item subscale (objectively measured) Land use mix-diversity (NEWS 23-item subscale measuring proximity to nonresidential land uses, such as restaurants and retail stores) (perceived) Recreational facilities near home (perceived)
147
Crosssectional
APARS “Outside Aes- Sedentary minutes/ thetics” 3-item subscale hour (measured via (objectively measured) accelerometer)
147
Crosssectional
APARS “Outside Aes- MVPA minutes/ thetics” 3-item subscale hour (measured via (objectively measured) accelerometer)
147
Crosssectional
APARS “Outside Hazards” 4-item subscale (objectively measured)
Sedentary minutes/ hour (measured via accelerometer)
147
Crosssectional
APARS “Outside Hazards” 4-item subscale (objectively measured)
MVPA minutes/ hour (measured via accelerometer)
Destinations Kerr et al., 2011 Seniors living in senior living residences (mean age of 80 years)
Kerr et al., 2011 Seniors living in senior living residences (mean age of 80 years) Shigematsu et Adults aged 66 al., 2009 and older
Shigematsu et al., 2009
Adults aged 66 and older
Aesthetics Kerr et al., 2011 Seniors living in senior living residences (mean age of 80 years) Kerr et al., 2011 Seniors living in senior living residences (mean age of 80 years) Safety from traffic and crime Kerr et al., 2011 Seniors living in senior living residences (mean age of 80 years) Kerr et al., 2011 Seniors living in senior living residences (mean age of 80 years)
Sedentary minutes/ hour (measured via accelerometer)
Increased number of onsite services was related to increased sedentary time for seniors living in senior living residences
Sedentary minutes/ hour (measured via accelerometer)
A greater number of inside social facilities was related to increased sedentary time for residents of senior living residences Greater land use mix diversity was related to greater self-reported walking for transportation among older adults
Transportation walking (selfreport)
Transportation walking (selfreport)
Reporting more recreational facilities near home was positively associated with transportation for walking Outside aesthetics subscale score was unrelated to sedentary time among residents of senior living residences Outside aesthetics subscale score was unrelated to minutes per hour of moderate to vigorous physical activity among residents of senior living residences Score on the outside hazards subscale was unrelated to sedentary time among residents of senior living residences Score on the outside hazards subscale was unrelated to moderate to vigorous physical activity among residents of senior living residences
Note. BE = built environment; APARS = Adult Physical Activity Resources for Seniors; GIS = geographic information system; MVPA = moderate-to-vigorous physical activity.
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Built Environment, PA, and Aging 327
Taylor et al. (2007) explored a similar theme among older minority women (aged 50–75 years of age) living in Brooklyn and the Bronx. Using qualitative data from 45 subjects in nine different group sessions, a prioritized list of environmental recommendations that might make physical activity more appealing emerged. While many of the responses were specific to the neighborhood the women live in, a number of the top twelve recommendations may apply to the general older adult population: cleaner streets, more street lights, walking groups, free gyms, more bicycle paths, fewer unleased dogs, streets closed for exercise, and senior citizen facilities (Taylor et al., 2007). Taken together, these two qualitative looks at potential challenges or concerns for older adults suggest that there are a number of improvements that could be tested to improve outdoor walking and physical activity in this population, and that there may be an opportunity to focus on indoor forms of activity that may make seniors feel more comfortable. Walking is likely to be a vital and accessible means for older adults, particularly those living in assisted living or senior living residences, to achieve sufficient levels of activity. Walking is generally categorized as low-light physical activity or high-light physical activity when measured using an accelerometer, and both of these categories of activity have been associated with physical health and well-being (Buman et al., 2010). This is important, as two studies have found that older adults (aged 65 and up) engage in this type of activity for significant portions of the day (Buman et al., 2010). Buman et al. (2010) found that older adults spent, on average, about 4.9 hr per day in activity that fell between sedentary and moderate-to-vigorous. The health benefits of such activity are not negligible. The benefits of activity categorized as high-light physical activity are in the same range as that of moderate-to-vigorous (Buman et al., 2010). Given this, encouragement of walking behaviors, whether it be indoors or out, should be highlighted to seniors as a way to improve overall health and physical functioning. Future research should focus on measuring these types of physical activity in older adults, so as to more thoroughly capture the full range of physical activity in this population.
The Built Environment and Senior-specific Housing Currently, there are more than 6,000 assisted living facilities in the United States (Assisted Living Federation of America, 2013). However, very little research exists on how internal environmental features may influence physical activity in this population. Kerr et al. (2011) looked at built environment features and used an objective measure of physical activity levels in seniors residing in senior living residences. Here, supportive outdoor features were associated with residents achieving greater levels of moderate-to-vigorous physical activity, but no effect was seen for inside building features (Kerr et al., 2011). However, the study focused more on exercise facilities within the building rather than the overall building features (Kerr et al., 2011). Furthermore, their focus on moderate-to-vigorous physical activity may have limited the ability to see an effect, and future studies in these populations need to include all types of activity, including activity defined as light intensity, as mentioned previously.
Future Directions for Research Other studies provided support for the further examination of building features as they relate to activity levels. Building design as a barrier to community participation in older adults was reported more frequently than other factors, such as lighting or sound, and
was highest among those adults with arthritis, a common condition in older adults (Theis & Furner, 2011). Takahashi, Baker, Cha and Targonski (2012) noted that many senior apartments and assisted living facilities are built at the edges of towns, and not within walking distance of retail shops and other amenities. In such cases, facility grounds and buildings would be the primary, if not only, opportunity for meaningful physical activity. Given the concerns that older adults have about outdoor physical activity and walking, and the importance of light intensity activity to this population, exploring ways to encourage walking within facilities and facility grounds is an area for further focus. While the reasons for inactivity are complex, the physical environment must be considered should we hope to achieve a more active aging population. More research is needed in this regard, with emphasis placed not only on independent communities, but also on institutionalized settings such as assisted living facilities. Assisted living facilities offer a unique opportunity to test modifications to the immediate environment of a group of older adults. A possible framework of factors specific to senior housing and assisted living facilities is shown in Figure 1. Some aspects are familiar from general literature on the built environment, but facility features and facility programming are relevant only to these types of living situations. Assisted living facilities, in particular, offer many more services and amenities to older adults for those who need a greater degree of care. They often offer extensive programming, some of which is geared toward physical activity. The same is true for other types of senior housing, although they may or may not provide services such as medication supervision, rehabilitation programs, meal programs, and help with activities such as bathing, dressing, or cleaning. One of the major challenges with studying the built environment is the difficulty by which research findings may be applied to already existing structures or neighborhood layouts. In most cases, research findings limited to existing environments will have to contend with high costs, time, and effort, as well as “community buy-in” before the area in question can be remodeled to a more physical activityconducive setting. This may be unrealistic for most environments, particularly those with a complex infrastructure. Therefore, the challenge lies in determining feasible and cost-effective methods to improve environments that already exist. One such remediable aspect for assisted living or other types of senior housing would be aesthetics. Would improvements to the look and feel of internal and external walking paths increase walking behaviors in residents? Such changes would be testable, and perhaps palatable to facility administrators. The first step in determining the needs of a particular environment, whether this environment is internal or outdoors, is to rate the environment. Research shows that rating the environment for walkability is especially relevant to this population. However, the tools to accurately measure the degree of walkability in an institutional setting, such as an assisted living facility, are lacking. Scant research exists to determine the relationship between physical activity and the built environment for older adults residing in assisted living facilities. The only study attempting to look at the built environment in assisted living facilities focused on identifying built environmental variables, and thus far the tool has not been tested for reliability or validity (Lu, 2010). The created built environment checklist provided a snapshot of built environment features in assisted living facilities, but did not attempt to measure physical activity levels in residents (Lu, 2010). By developing such tools and confirming their validity, researchers, planners, and organizations can better target areas of improvement. The fundamental goal of all
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328 Haselwandter et al.
Figure 1 — A conceptual framework for understanding environmental influences on physical activity in older adults in continuing care facilities.
improvements is to encourage physical activity for older adults in a safe, supportive manner such that health outcomes are improved and disease burden is reduced. Research should focus on identifying built environment factors that can impede or encourage activity both inside the facility and on facility grounds. Improvements to facilities and surroundings that encourage physical activity may be more easily tested, and provide a foundation for research in the larger population of older adults. These “close to home” areas are likely to impart the greatest impact on physical activity levels for their residents and consequently, reduce disease burden for the fastest growing segment of the human population. Acknowledgments Doctoral research funding was provided by Nestle, S.A.
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American Journal of Preventive Medicine, 31(6), 515–524. PubMed doi:10.1016/j.amepre.2006.07.026 Brownson, R.C., Baker, E.A., Housemann, R.A., Brennan, L.K., & Bacak, S.J. (2001). Environmental and policy determinants of physical activity in the United States. American Journal of Public Health, 91(12), 1995–2003. PubMed doi:10.2105/AJPH.91.12.1995 Brownson, R.C., Hoehner, C.M., Day, K., Forsyth, A., & Sallis, J.F. (2009). Measuring the built environment for physical activity: State of the science. American Journal of Preventive Medicine, 36(4, Suppl) S99–S123. PubMed doi:10.1016/j.amepre.2009.01.005 Buman, M.P., Hekler, E.B., Haskell, W.L., Pruitt, L., Conway, T.L., Cain, K.L., . . . King, A.C. (2010). Objective Light-Intensity Physical Activity Associations With Rated Health in Older Adults. American Journal of Epidemiology, 172(10), 1155–1165. PubMed doi:10.1093/ aje/kwq249 Carlson, J.A., Sallis, J.F., Conway, T.L., Saelens, B.E., Frank, L.D., Kerr, J., . . . King, A.C. (2012). Interactions between psychosocial and built environment factors in explaining older adults’ physical activity. Preventive Medicine, 54(1), 68–73. PubMed doi:10.1016/j. ypmed.2011.10.004 Carr, K., Weir, P.L., Azar, D., & Azar, N.R. (2013). Universal design: A step toward successful aging. Journal of Aging Research, 2013. PubMed doi:10.1155/2013/324624 Casagrande, S.S., Whitt-Glover, M.C., Lancaster, K.J., Odoms-Young, A.M., & Gary, T.L. (2009). Built environment and health behaviors among African Americans: A systematic review. American Journal of Preventive Medicine, 36(2), 174–181. PubMed doi:10.1016/j. amepre.2008.09.037 Centers for Disease Control and Prevention. (2014). How much physical activity do older adults need? [Web site]. Available from http://www. cdc.gov/physicalactivity/everyone/guidelines/olderadults.html Cunningham, G.O., & Michael, Y.L. (2004). Concepts guiding the study of the impact of the built environment on physical activity for older adults: A review of the literature. American Journal of Health Promotion, 18(6), 435–443. PubMed doi:10.4278/0890-1171-18.6.435
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Official Journal of ICAPA www.JAPA-Journal.com SCHOLARLY REVIEW
The Built Environment, Physical Activity, and Aging in the United States: A State of the Science Review Elizabeth M. Haselwandter, Michael P. Corcoran, Sara C. Folta, Raymond Hyatt, Mark Fenton, and Miriam E. Nelson
Introduction and Methodology The vast majority of U.S. adults do not meet the 2008 Physical Activity Guidelines for Americans despite a myriad of known health benefits from exercise (Troiano et al., 2008). Less than 3% of older adults (aged 60 or older) are meeting these recommendations, with the majority of both men and women aged 70+ achieving less than 10 min per day of moderate-to-vigorous activity based on accelerometer data (Troiano et al., 2008). The reasons behind this physical inactivity epidemic are complex and multifaceted. One likely contributor to sedentary behavior is the built environment (Boehmer, Hoehner, Deshpande, Brennan Ramirez, & Brownson, 2007; Hoehner, Brennan Ramirez, Elliott, Handy, & Brownson, 2005), which refers to the physical environment in which an individual spends his or her time (e.g., home, neighborhood), including the internal or external features of this environment, such as staircases, sidewalks, crosswalks, and traffic density. The prevailing hypothesis centers on the notion that various characteristics of an individual’s physical environment may encourage or act as a barrier toward physical activity (Boehmer et al., 2007; Duncan, Spence, & Mummery, 2005; Feng, Glass, Curriero, Stewart & Schwartz, 2010; Lee, Ewing, & Sesso, 2009). With the high prevalence of obesity and other chronic health conditions associated with inactivity, understanding how the built environment can influence health-related behavior has become an important area of research. The existing evidence leaves many questions unanswered or provides conflicting results, and also highlights the need for additional research to determine environmental variables of importance (Brennan Ramirez, et al., 2006; Feng, et al., 2010). This is true across populations, but particularly true for older adults over the age of 65 (Cunningham & Michael, 2004), and much of the research focuses on the outside environment, leaving possibilities for exploring influences on indoor activity in older populations, particularly those in senior housing. Older adults are the fastest growing, yet least active, segment of Haselwandter is a Nestle doctoral fellow, Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, Tufts University, Medford, MA. Corcoran is an assistant professor of health sciences at Merrimack College, North Andover, MA. Folta is an assistant professor, Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, Tufts University, Medford, MA. Hyatt is president of Freeport Development Strategies, LLC, Burlington, MA. Fenton is an adjunct professor, Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, Tufts University, Medford, MA. Nelson is a professor at the Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy and associate dean at the Tisch College of Citizenship and Public Service, both at Tufts University, Medford, MA. Address author correspondence to Elizabeth M. Haselwandter at [email protected].
the population. It is estimated that by 2050, there will be 88.5 million Americans aged 65 and older and, of these, 19 million will be among the “oldest old” (i.e., aged 85 and up) (Vincent & Velkoff, 2010). The increase in the aging population will have a number of consequences, such as a rise in health care costs since health care spending increases with age (Orszag, 2008). Health care costs have risen over the past 30 years, from $714 billion in 1990 to more than $2.3 trillion in 2008 (Kimbuende, Ranji, Lundy, & Salganicoff, 2010). These rising costs have alarmed policy makers and individuals alike, and provide an incentive to prioritize successful aging, including reduced burden from chronic diseases and greater functional independence. Current physical activity recommendations for older adults in the United States are identical to recommendations for all adults: to achieve at least 150 min a week of moderate-intensity aerobic activity, 75 min of vigorous-intensity aerobic activity, or an equivalent mix of both moderate- and vigorous-intensity activity (Centers for Disease Control and Prevention, 2014). The benefits of physical activity for older adults are wide ranging and include the following: preserving muscle and bone mass, reducing rates of functional decline, and improving glucose control, cardiovascular health, balance, and stability (Sattelmair, Pertman, & Forman, 2009). Increasing physical activity in this population is very likely to support successful aging, which includes limiting disease and disease-related disability, ensuring physical and cognitive functioning is maintained, and preserving an older adult’s ability to engage actively in life (Carr, Weir, Azar, & Azar, 2013). One aspect of successful aging is aging in place, or the ability to live in one’s own home confidently and comfortably (Yen & Anderson, 2012). It is possible that a supportive built environment will both enhance one’s physical functioning and also make one’s home more comfortable for continued living. Researchers hypothesize that built environment effects likely differ by age and physical abilities, and that the built environment can have both facilitating and constraining effects on the activities of older adults (Brownson, Hoehner, Day, Forsyth, & Sallis, 2009; Carr et al., 2013). The role that the built environment could play in successful aging calls for a focus on determining which specific elements enhance the health and well-being of older adults, and identifying those factors that may impede older adults from activity. Maintaining mobility and independence are high priorities for older adults, and so it is crucial to determine which environmental factors could encourage these outcomes, and thereby prevent them from moving from more independent or assisted living conditions to nursing home facilities (Carr et al., 2013; Yen & Anderson, 2012). This paper aims to: (1) review the current literature to determine what relationships exist between the built environment and physical activity in older adults; (2) identify features that may act as barriers or enablers among older adults in senior-specific housing; and (3) identify areas of future research for this population. 323
324 Haselwandter et al.
To determine what we have learned about the built environment, older adults, and physical activity (including walking) thus far, the authors conducted a literature search using the following search terms: built environment, older adults, assisted living facilities, physical activity, and walkability. The literature search was conducted using the PubMed research database, and included filter criteria for participants aged 65+ and articles written in English. The various search terms returned 166 articles. Articles were then excluded if they were not conducted in the United States (n = 11), focused on methodology (n = 11), or did not contain relevant variables, associations, or outcomes (n = 76).
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The Built Environment and Older Adults: Encouraging and Inhibiting Physical Activity The built environment can be defined in many ways, but it is useful to think of it as encompassing various domains. Brownson et al. (2009) suggest the following four domains: functional, destination, aesthetics, and safety. Safety includes both safety from crime, such as maintenance of local buildings, street lighting, and neighborhood surveillance, and safety from traffic, such as safe crosswalks, bike lanes, and sidewalks (Day, Boarnet, Alfonzo, & Forsyth, 2006). Aesthetics generally refer to the “perceived attractiveness of the setting for physical activity” and addresses issues such as litter, broken glass, and plantings along walking paths (Day et al., 2006; Hoehner, Ivy, Brennan Ramirez, Handy, & Brownson, 2007). Other factors, such as accessibility, the prevalence of parks and green spaces, land-use characteristics and land-use mix, foot and bike trails, land slope, availability of public transport, and street connectivity are also often included in built environment assessments (Berke, Koepsell, Moudon, Hoskins, & Larson, 2007; Day et al., 2006; Saelens, Sallis, Black, & Chen, 2003; Takano, Nakamura, & Watanabe, 2002). There is some evidence linking each of these domains with physical activity in older adults (Table 1). More generally, a number of associations between the built environment and physical activity measures have been investigated. Studies have shown that factors such as safety from crime, presence of light traffic, sidewalks, access to parks, access to indoor gyms and treadmills, and less urban sprawl are associated with physical activity levels in adults (Brownson, Baker, Housemann, Brennan, & Bacak, 2001; Casagrande, Whitt-Glover, Lancaster, Odoms-Young, & Gary, 2009; Lee et al., 2009). High walkability, an indication of a more facilitating built environment, has also been consistently associated with more minutes of moderate-to-vigorous and moderate-intensity activity in adults (Carlson et al., 2012; Saelens et al., 2003; Sallis et al., 2009). These results indicate that various built environment factors may have an effect on physical activity levels and overall health. Many studies focus on the built environment’s relationship to walking. Walkability was influenced by such factors as the presence or absence of curb ramps, parking, lighting, weather, crosswalks, sidewalks, amenities or land-use mix, walking paths or trails, safety, density of intersections or street connectivity, traffic conditions, and green space (Rosenberg, Huang, Simonovich, & Belza, 2013; Rosso, Auchincloss, & Michael, 2011;). Older adults often perceive the walking environment differently than the general population. Michael, Beard, Choi, Farquhar and Carlson (2006) found that when trained researchers’ measurements of the built environment were compared with older adults’ perceptions, older adults reported sidewalk obstructions where the researchers saw none. This supports the
notion that older adults may have different concerns when walking, and that a more thorough understanding of older adults’ perceptions of the built environment are needed. Walking is a meaningful source of activity for older adults; a number of studies cited walking as the primary form of activity in this population (Michael, Gold, Perrin, & Hillier, 2011; Sawchuk et al., 2011;). As an example, Michael et al. (2011) found that 60% of the women aged 65 or older reported walking for exercise or as a part of a daily routine. There is also evidence for associations among other facilitating built environmental factors and healthy behaviors and outcomes. Street density and connectivity were significantly associated with the number of blocks walked among women aged 65+ who reported walking (Michael et al., 2011). Older adults living in senior living residences reported greater self-rated health and less sedentary time if they also reported more supportive outdoor physical activity features (Kerr et al., 2011). Other positive associations between physical activity and the built environment were related to land-use mix and destinations, such as grocery stores, restaurants, and shops (Berke et al., 2007; Sawchuk et al., 2011). Barriers may also play a role, as issues such as fear of falling are common, especially among older women (Walsh, Pressman, Cauley, & Browner, 2001). Fear of traffic-related injuries may also play a role in limiting outdoor physical activity (Shendell et al., 2011). In a study by Theis and Furner (2011), building design, sidewalks, curbs, and crowds were the most frequently cited environmental barriers for adults aged 50 or older. However, the question remains as to whether improvements in these barriers would translate to increased physical activity, or which features play the most meaningful role. A study by Rosenberg et al. (2013) attempted to gain in-depth, qualitative data on barriers or facilitators to walking among seniors with mobility disabilities. In focus groups, seniors perceived not feeling visible to drivers; fast moving traffic; lack of driver attention; sidewalk surfaces and quality (particularly navigating over brick, cobblestones, and metal grates); lack of sidewalk; rain, heat, and sun exposure; hills; and outdoor stairs as barriers to walking (Rosenberg et al., 2013). In particular, crossing the street was mentioned as a particularly stressful event; crossing signal times often felt too short, and participants felt rushed and at a greater risk of falling (Rosenberg et al., 2013). They also felt that a lack of street crossings were a problem, and some coped with issues involving crossing streets by staying home (Rosenberge al., 2013). Participants also mentioned a number of perceived facilitators: smooth and wide sidewalks, presence of a grass strip between the sidewalk and the road, presence of ramps, stair handrails, and feeling safe from crime (Rosenberg et al., 2013). Places to rest were a common theme, particularly in communal outdoor spaces, such as parks or walking trails, and in lines at places such as food banks (Rosenberg et al., 2013). Participants mentioned feeling fatigued if they had to stand or walk for too long, and shelter for rest and from the weather at public transportation stops and on local streets were considered to be important facilitators, as well as accessible drinking fountains and restrooms (Rosenberg et al., 2013). While this study focused on seniors with mobility disabilities, it is easy to imagine that frail, older adults who are able to walk without assistive devices may cite similar concerns; future focus groups could confirm this. While some aspects of the built environment are more fixed and harder to change, other aspects could be addressed, and provide opportunities for study. In particular, improved sidewalk quality and extended crossing times could be addressed, and then the impact of these changes can measured by self-report of objective measures, such as accelerometer data.
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Table 1 A Review of Measures and Results in Studies Examining the Built Environment in Seniors Population
Sample Size
Reference Functionality Berke et al., 2007
Adults aged 65 and older
936
Crosssectional
Walkability score (objectively measured)
Carlson et al., 2012
Adults aged 65 or older
719
Crosssectional
Walkability (GISderived)
Carlson et al., 2012
Adults aged 65 or older
719
Crosssectional
Walkability (GISderived)
Carlson et al., 2012 Frank, Kerr, Rosenberg, & King, 2010
Adults aged 65 or older Adults aged 65 or older
719
Crosssectional Crosssectional
Walkability (GISderived) Walkability (GISderived)
147
Crosssectional
147
Crosssectional
APARS “Outside Supportive PA Features” 12-item subscale (objectively measured) APARS “Outside Supportive PA Features” 12-item subscale (objectively measured)
147
Crosssectional
147
Crosssectional
719
Crosssectional
Crosssectional
Kerr et al., 2011 Seniors living in senior living residences (mean age of 80 years) Kerr et al., 2011 Seniors living in senior living residences (mean age of 80 years) Kerr et al., 2011 Seniors living in senior living residences (mean age of 80 years) Kerr et al., 2011 Seniors living in senior living residences (mean age of 80 years) King et al., Adults aged 66 2011 and older
1,970
Michael et al., 2011
Women aged 65 and older
1,008
Michael et al., 2011
Women aged 65 and older
1,008
Study Type BE Measure
APARS “Outside Exercise Facilities” 10-item subscale (objectively measured) APARS “Outside Exercise Facilities” 10-item subscale (objectively measured) Walkability (GISderived)
Street connectivity and street density (block length) (GIS-derived)
Prospective Street connectivity cohort (GIS-derived)
Outcome
Results
Walking for exercise (self-report)
A walkability score in the 75th percentile increased the odds of walking for exercise in men at all three buffer zone sizes (100 m, 500 m, 1000 m) when compared with the 25th percentile; for women, results were only significant at the 1000 m buffer MVPA minutes/ Walkability was positively associweek (measured via ated with total minutes per week accelerometer) of moderate-to-vigorous physical activity Walking for transWalkability was positively associportation (selfated with self-reported walking for report) transportation Walking for leisure Walkability was positively associated (self-report) with self-reported walking for leisure Walked at least Older adults living in a high walkonce in 2 days (self- ability neighborhood were twice as report) likely to walk at least once a day in two days compared with those in low walkability (but not medium walkability) neighborhoods Sedentary minutes/ More supportive outdoor features hour (measured via were associated with less sedentary accelerometer) time among residents living in Senior Living Residences. More supportive outdoor features MVPA minutes/ hour (measured via were associated with greater minutes per hour of moderate to vigorous accelerometer) physical activity among residents in senior living residences Sedentary minutes/ Having outside exercise facilities hour (measured via was related to less sedentary time for residents in senior living residences accelerometer) MVPA minutes/ hour (measured via accelerometer) Walking for transportation (selfreport)
Blocks walked (self-report)
Dynamic leg strength (chair stand score)
Having outside exercise facilities was related to engaging in more moderate to vigorous physical activity for residents in senior living residences Higher walkable neighborhood quadrants were associated with higher average number of minutes per week of walking for transportation compared with lower walkable quadrants Among women who walked at baseline (n = 1008, out of total sample of 1671), both BE measures were associated with blocks walked per week; greater street density (shorter block size) and greater connectivity were associated with more blocks walked Among women who walked, greater street connectivity was associated with less decline in dynamic leg strength (continued)
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Table 1 (continued) Reference
Population
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Functionality (continued) Michael et al., Women aged 65 2011 and older
Sample Size
Study Type BE Measure
Outcome
Results
1,008
Prospective Street density (block cohort length) (GIS-derived)
Dynamic leg strength (chair stand score)
Prospective Street connectivity and cohort Street density (block length) (GIS-derived)
Lower extremity physical performance (chair stand scores and timed walks)
Among women who walked, greater street density (shorter block size) was associated with less decline in dynamic leg strength Neighborhood walkability (encompassing both street connectivity and street density) were not associated with physical performance over time in women who reported not walking at baseline in adjusted models Greater land use mix access was related to more reported walking for transportation among the older study participants
Michael et al., 2011
Women aged 65 and older
663
Shigematsu et al., 2009
Adults aged 66 and older
360
Crosssectional
Land use mix-access Transportation (NEWS 6-item subwalking (selfscale measuring ease of report) access to nonresidential uses) (perceived)
147
Crosssectional
147
Crosssectional
360
Crosssectional
360
Crosssectional
APARS (Adult Physical Activity Resources for Seniors) “Onsite services/destinations” 17-item subscale (objectively measured) APARS “Inside Social Facilities” 19-item subscale (objectively measured) Land use mix-diversity (NEWS 23-item subscale measuring proximity to nonresidential land uses, such as restaurants and retail stores) (perceived) Recreational facilities near home (perceived)
147
Crosssectional
APARS “Outside Aes- Sedentary minutes/ thetics” 3-item subscale hour (measured via (objectively measured) accelerometer)
147
Crosssectional
APARS “Outside Aes- MVPA minutes/ thetics” 3-item subscale hour (measured via (objectively measured) accelerometer)
147
Crosssectional
APARS “Outside Hazards” 4-item subscale (objectively measured)
Sedentary minutes/ hour (measured via accelerometer)
147
Crosssectional
APARS “Outside Hazards” 4-item subscale (objectively measured)
MVPA minutes/ hour (measured via accelerometer)
Destinations Kerr et al., 2011 Seniors living in senior living residences (mean age of 80 years)
Kerr et al., 2011 Seniors living in senior living residences (mean age of 80 years) Shigematsu et Adults aged 66 al., 2009 and older
Shigematsu et al., 2009
Adults aged 66 and older
Aesthetics Kerr et al., 2011 Seniors living in senior living residences (mean age of 80 years) Kerr et al., 2011 Seniors living in senior living residences (mean age of 80 years) Safety from traffic and crime Kerr et al., 2011 Seniors living in senior living residences (mean age of 80 years) Kerr et al., 2011 Seniors living in senior living residences (mean age of 80 years)
Sedentary minutes/ hour (measured via accelerometer)
Increased number of onsite services was related to increased sedentary time for seniors living in senior living residences
Sedentary minutes/ hour (measured via accelerometer)
A greater number of inside social facilities was related to increased sedentary time for residents of senior living residences Greater land use mix diversity was related to greater self-reported walking for transportation among older adults
Transportation walking (selfreport)
Transportation walking (selfreport)
Reporting more recreational facilities near home was positively associated with transportation for walking Outside aesthetics subscale score was unrelated to sedentary time among residents of senior living residences Outside aesthetics subscale score was unrelated to minutes per hour of moderate to vigorous physical activity among residents of senior living residences Score on the outside hazards subscale was unrelated to sedentary time among residents of senior living residences Score on the outside hazards subscale was unrelated to moderate to vigorous physical activity among residents of senior living residences
Note. BE = built environment; APARS = Adult Physical Activity Resources for Seniors; GIS = geographic information system; MVPA = moderate-to-vigorous physical activity.
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Built Environment, PA, and Aging 327
Taylor et al. (2007) explored a similar theme among older minority women (aged 50–75 years of age) living in Brooklyn and the Bronx. Using qualitative data from 45 subjects in nine different group sessions, a prioritized list of environmental recommendations that might make physical activity more appealing emerged. While many of the responses were specific to the neighborhood the women live in, a number of the top twelve recommendations may apply to the general older adult population: cleaner streets, more street lights, walking groups, free gyms, more bicycle paths, fewer unleased dogs, streets closed for exercise, and senior citizen facilities (Taylor et al., 2007). Taken together, these two qualitative looks at potential challenges or concerns for older adults suggest that there are a number of improvements that could be tested to improve outdoor walking and physical activity in this population, and that there may be an opportunity to focus on indoor forms of activity that may make seniors feel more comfortable. Walking is likely to be a vital and accessible means for older adults, particularly those living in assisted living or senior living residences, to achieve sufficient levels of activity. Walking is generally categorized as low-light physical activity or high-light physical activity when measured using an accelerometer, and both of these categories of activity have been associated with physical health and well-being (Buman et al., 2010). This is important, as two studies have found that older adults (aged 65 and up) engage in this type of activity for significant portions of the day (Buman et al., 2010). Buman et al. (2010) found that older adults spent, on average, about 4.9 hr per day in activity that fell between sedentary and moderate-to-vigorous. The health benefits of such activity are not negligible. The benefits of activity categorized as high-light physical activity are in the same range as that of moderate-to-vigorous (Buman et al., 2010). Given this, encouragement of walking behaviors, whether it be indoors or out, should be highlighted to seniors as a way to improve overall health and physical functioning. Future research should focus on measuring these types of physical activity in older adults, so as to more thoroughly capture the full range of physical activity in this population.
The Built Environment and Senior-specific Housing Currently, there are more than 6,000 assisted living facilities in the United States (Assisted Living Federation of America, 2013). However, very little research exists on how internal environmental features may influence physical activity in this population. Kerr et al. (2011) looked at built environment features and used an objective measure of physical activity levels in seniors residing in senior living residences. Here, supportive outdoor features were associated with residents achieving greater levels of moderate-to-vigorous physical activity, but no effect was seen for inside building features (Kerr et al., 2011). However, the study focused more on exercise facilities within the building rather than the overall building features (Kerr et al., 2011). Furthermore, their focus on moderate-to-vigorous physical activity may have limited the ability to see an effect, and future studies in these populations need to include all types of activity, including activity defined as light intensity, as mentioned previously.
Future Directions for Research Other studies provided support for the further examination of building features as they relate to activity levels. Building design as a barrier to community participation in older adults was reported more frequently than other factors, such as lighting or sound, and
was highest among those adults with arthritis, a common condition in older adults (Theis & Furner, 2011). Takahashi, Baker, Cha and Targonski (2012) noted that many senior apartments and assisted living facilities are built at the edges of towns, and not within walking distance of retail shops and other amenities. In such cases, facility grounds and buildings would be the primary, if not only, opportunity for meaningful physical activity. Given the concerns that older adults have about outdoor physical activity and walking, and the importance of light intensity activity to this population, exploring ways to encourage walking within facilities and facility grounds is an area for further focus. While the reasons for inactivity are complex, the physical environment must be considered should we hope to achieve a more active aging population. More research is needed in this regard, with emphasis placed not only on independent communities, but also on institutionalized settings such as assisted living facilities. Assisted living facilities offer a unique opportunity to test modifications to the immediate environment of a group of older adults. A possible framework of factors specific to senior housing and assisted living facilities is shown in Figure 1. Some aspects are familiar from general literature on the built environment, but facility features and facility programming are relevant only to these types of living situations. Assisted living facilities, in particular, offer many more services and amenities to older adults for those who need a greater degree of care. They often offer extensive programming, some of which is geared toward physical activity. The same is true for other types of senior housing, although they may or may not provide services such as medication supervision, rehabilitation programs, meal programs, and help with activities such as bathing, dressing, or cleaning. One of the major challenges with studying the built environment is the difficulty by which research findings may be applied to already existing structures or neighborhood layouts. In most cases, research findings limited to existing environments will have to contend with high costs, time, and effort, as well as “community buy-in” before the area in question can be remodeled to a more physical activityconducive setting. This may be unrealistic for most environments, particularly those with a complex infrastructure. Therefore, the challenge lies in determining feasible and cost-effective methods to improve environments that already exist. One such remediable aspect for assisted living or other types of senior housing would be aesthetics. Would improvements to the look and feel of internal and external walking paths increase walking behaviors in residents? Such changes would be testable, and perhaps palatable to facility administrators. The first step in determining the needs of a particular environment, whether this environment is internal or outdoors, is to rate the environment. Research shows that rating the environment for walkability is especially relevant to this population. However, the tools to accurately measure the degree of walkability in an institutional setting, such as an assisted living facility, are lacking. Scant research exists to determine the relationship between physical activity and the built environment for older adults residing in assisted living facilities. The only study attempting to look at the built environment in assisted living facilities focused on identifying built environmental variables, and thus far the tool has not been tested for reliability or validity (Lu, 2010). The created built environment checklist provided a snapshot of built environment features in assisted living facilities, but did not attempt to measure physical activity levels in residents (Lu, 2010). By developing such tools and confirming their validity, researchers, planners, and organizations can better target areas of improvement. The fundamental goal of all
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Figure 1 — A conceptual framework for understanding environmental influences on physical activity in older adults in continuing care facilities.
improvements is to encourage physical activity for older adults in a safe, supportive manner such that health outcomes are improved and disease burden is reduced. Research should focus on identifying built environment factors that can impede or encourage activity both inside the facility and on facility grounds. Improvements to facilities and surroundings that encourage physical activity may be more easily tested, and provide a foundation for research in the larger population of older adults. These “close to home” areas are likely to impart the greatest impact on physical activity levels for their residents and consequently, reduce disease burden for the fastest growing segment of the human population. Acknowledgments Doctoral research funding was provided by Nestle, S.A.
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