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Swedish policy states that older adults should be able to age safely with continued independence and lead active lives. However, this plays out differently in different Swedish municipalities depending upon degree of demographic change, globalization, and urbanization. Internationally, older adults living in disadvantaged areas have worse physical and mental health, activity restrictions, and reduced life expectancy. In Sweden, research on how disadvantaged areas impact older adults’ quality of life is virtually nonexistent. We argue that disadvantaged areas exist in both urban and rural contexts.
We aimed to investigate how older adults’ homes and neighborhoods influence their community participation, quality of life, identity, and belonging in urban and rural disadvantaged areas in Sweden, and how these person–context dynamics are experienced by older adults in transitioning neighborhoods.
The study has a mixed methods design and includes 3 phases. Adults 65 years and older living in certain urban and rural disadvantaged areas in the south of Sweden will be included. Phase 1 is an interview study in which qualitative data are collected on neighborhood attachment, identity, and belonging through semistructured interviews and photo-elicitation interviews with 40 subjects. A variety of qualitative data analysis procedures are used. In phase 2, a survey study will be conducted to explore associations between observable and self-rated aspects of housing and neighborhood (physical, social, and emotional), participation, and quality of life; 400 subjects will be recruited and added to the 40 phase-1 subjects for a total of 440. The survey will include standardized measures and study-specific questions. Survey data will be analyzed with mainstream statistical analyses and structural equation modeling to understand the interactions between quality of life, home and neighborhood factors, and sociodemographic factors. In phase 3, the integration study, survey data from the 40 participants who participated in both data collections will be analyzed together with qualitative data with a mixed methods analysis approach.
As of the submission of this protocol (August 2022), recruitment for the interview study is complete (N=39), and 267 participants have been recruited and have completed data collection in the survey study. We expect recruitment and data collection to be finalized by December 2022.
With an increasing proportion of older adults, an increasing number of disadvantaged areas, and an increasing dependency ratio in more than 50% of Swedish municipalities, these municipalities are transforming and becoming increasingly segregated. This study will add unique knowledge on what it is like to be older in a disadvantaged area and deepen knowledge on housing and health dynamics in later life. Further, the design of the current study will allow future follow-up studies to facilitate longitudinal analysis (if funding is granted) on aging in a transforming societal context.
DERR1-10.2196/41255
Inclusive and accessible living environments are fundamental to well-being, and Swedish aging policy states that older adults should be able to age safely, maintain their independence, and continue to lead active lives. However, with demographic change, globalization, and urbanization, health inequality is a growing societal challenge. The chances of older adults being able to lead a good life vary depending upon which of Sweden’s 290 self-governed municipalities they live in. There is a lack of knowledge on what it is like to age in areas where the societal challenges are most evident. International studies show that the quality of life of older adults living in disadvantaged areas is affected in many ways. They have worse physical and mental health, activity, and participation restrictions—and shorter life expectancy. In Sweden, research on how living in a disadvantaged area affects older adults’ quality of life is virtually nonexistent. We argue that disadvantaged areas exist in both urban and rural contexts, but conditions, experiences, and perceptions may be quite different. This study addresses how the home and neighborhood influence quality of life for older adults who live in urban and rural disadvantaged areas and how these person–context dynamics are experienced. In the proposed study, we will investigate urban disadvantaged areas with a high proportion of crime, social unrest, fast population turnover, and a high percentage of unemployment [
In 2016, the Swedish National Police published their first-ever report on what they called “socially disadvantaged areas”; the most recent report, from 2017, listed 61 areas in Sweden. According to the Swedish National Police, a socially disadvantaged area is a geographically defined urban area with low socioeconomic status, high levels of crime, fast population turnover, and a high proportion of immigrants. Residents are at risk of being excluded, feeling alienated, losing faith in the future, and having health problems. Over time, criminal networks have become increasingly present [
Sweden could be described as a social democratic welfare state in transition. The Swedish population, and older adults in particular, are known to show high levels of trust toward government officials, media, and fellow citizens in general. The health care and social care systems have universal coverage, but local differences in service provision are a growing challenge to equality [
In general, older adults tend to move less often than younger adults, and the home becomes an essential arena for social life with increasing age. Health and quality of life are likely more influenced by the home and neighborhood in older adults than in younger people [
International reviews of older adults living in neighborhoods with low socioeconomic status (SES) show that a variety of neighborhood factors negatively impact depression, cognitive skills, and overall health [
Several authors conclude that there is a need for more nuanced measures of neighborhood quality, both objective and self-rated. It is also necessary to investigate contradictory results (eg, ethnic enclaves in the United States seem to have a positive effect on health for Latino populations but not for African American populations [
Researchers on rural aging have explored the challenges older adults experience when the need for support increases, but community changes have resulted in health and social care services being closed. This research highlights the strong desire to age in place and the constant negotiations that come with such a decision.
Nevertheless, other researchers have questioned the social sustainability of depopulated areas, arguing that rural aging needs more attention [
It has been suggested that older adults are more dependent than younger adults on the home and neighborhood context and are more vulnerable to neighborhood change; however, this has not been empirically supported by recent studies. Contrastingly, it has also been suggested that older adults with lower SES might be more resilient to neighborhood stressors than older adults from areas with high SES [
Acknowledging the complex individual–context dynamics and quality of life in disadvantaged areas calls for several theoretical perspectives. We ground our study in a theoretical framework of ecological theories on aging, social networks, human geography, occupational justice, and a perspective of the social life course [
Early models from Lawton and Nahemow [
We also add a social layer that includes identity, roles, and the norms that are created and formed within the social context. Moreover, being, acting, and meaning-making are interactive processes between the individual and the social context. The individual takes part in creating the context and the context creates the individual. The complexity of and the forces within social contexts need to be acknowledged to better understand the effects of exclusion and marginalization on disadvantaged areas and the effects of inclusion and creation of community in seemingly harsh areas [
The social life-course perspective explains that aging is contextual and that the journey of individuals across the life course is parallel to development and changes in the surrounding society [
We use the World Health Organization Quality of Life Group definition of quality of life as a construct that captures an individual’s physical and psychological health, social relationships, and the environment and defines quality of life as an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns [
The World Health Organization defines participation as an individual’s involvement in life situations that let them take part in society [
We define the environment surrounding the individual as their context, focusing on the home and neighborhood. This context includes physical factors (eg, buildings and spaces), social factors (eg, family, friends, neighbors, and social networks) and emotional or identity factors (eg, place attachment and belonging).
The study objective is to investigate how home and neighborhood influence participation, quality of life, identity, and belonging of older adults living in urban and rural disadvantaged areas in Sweden, and how these person–context dynamics are experienced by older adults in transitioning neighborhoods. We have three research questions. First, how do older adults in disadvantaged areas reason about their home and neighborhood in relation to their quality of life, and how do they act on concerns regarding their neighborhoods? We will pay particular attention to ways that identity and belonging are manifested, ways that participants relate to the existing media images of the area they live in, participants’ thoughts on relocation, and how they place themselves in a transforming neighborhood context. Second, how are observable and self-rated home and neighborhood factors associated with the quality of life of older adults in disadvantaged areas? We will pay particular attention to urban/rural, gender, and Swedish born/non–Swedish born subgroup differences as potential mediators. Third, how can we contribute to existing theoretical perspectives on aging in context by contrasting and integrating knowledge of older adults’ quality of life in urban and rural disadvantaged areas?
This baseline study has an explanatory sequential mixed methods design [
The study population is community-living adults aged 65 years and older who have lived in any of the targeted disadvantaged areas for at least 5 years.
The urban areas targeted (N=5) are located in 2 smaller cities in the south of Sweden (with populations of 46,000 and 150,000) and are seen as typical examples of how multi-dwelling neighborhoods that were built in the 1960s and 1970s have transitioned over time into disadvantaged neighborhoods, as defined by the Swedish National Police. In recent years, efforts have been made to increase police presence to reduce crime rates and improve safety. In one area, city officials have taken drastic measures to improve housing standards by demolition and new construction, and the neighborhood transition is characterized by gentrification—so far, a rare approach in Sweden.
The rural areas targeted are rural municipalities in the south of Sweden (with 10,000 to 15,000 inhabitants). The municipalities have been characterized by depopulation for approximately the last 20 years, with the exception of 2015 to 2016, when a large influx of immigrants changed the population structure and increased the population. However, the dependency ratios are still unfavorable. The dependency ratios in these 2 municipalities are between 87% and 91%, compared to 77% in both the south region, Skåne, and in Sweden in general. The municipalities are characterized by several smaller villages, among which there is a “municipality capital” that is usually of similar size to the other villages. Unlike rural municipalities in the central and northern parts of Sweden, these municipalities are within 45 minutes by car of a larger city.
Participants were recruited via community centers serving older adults, libraries, and nonprofit organizations located in the targeted areas. Because of the COVID-19 pandemic, we had to adapt our strategy. Thus, recruitment was also done by mail, after retrieving the addresses of all adults over the age of 65 in each disadvantaged area from the Swedish state personal address register (SPAR). A set of 20 randomly chosen residents received a letter with information about the study that was followed up with a telephone call, a procedure that will be repeated if needed. We aimed for a sample of N=40.
The data collection included semistructured interviews for which we developed an interview guide (
Data will be analyzed with different qualitative data-analysis approaches, such as the thematic analysis described by Braun and Clarke [
We aim for a sample size of N=400 in phase 2. Power calculations were made based on the World Health Organization 10 Wellbeing index [
The survey was developed based on the aim of the study and contains standardized instruments and study-specific questions on quality of life, participation, and health, as well as physical, social, and emotional aspects of housing and neighborhood. Sociodemographic information and information on possible confounders will also be collected.
Housing satisfaction is measured with 7 study-specific questions regarding housing standards, including size, design, internet, parking, storage, and accommodation of guests, as well as an overall question: “In general, how satisfied are you with your current housing situation?” The questions are answered on a scale from 0 (extremely dissatisfied) to 10 (extremely satisfied). Five questions concern the extent to which the bathroom, kitchen, entrance, bedroom, and living room are practical to use. The questions are answered on a scale from 0 (extremely impractical) to 10 (extremely practical). Five questions concern different aspects of safety at home. The questions are answered on a scale from 0 (extremely unsafe) to 10 (extremely safe). The questions were inspired by a subset of questions from an earlier version of the online self-help tool “Housing Options for Older People” [
To capture the emotional aspects of the neighborhood, we use the Person-Place Fit Measure for Older Adults (PPFM-OA), developed by Weil [
For the presence and use of services in the neighborhood, we use the Participation in Activities and Places Outside Home Questionnaire (ACT-OUT). ACT-OUT was developed to explore social citizenship through out-of-home participation in activities and places for older adults with and without dementia. We use the first part of ACT-OUT, which registers whether or not the respondent uses 24 types of services and places, including consumer, administrative, and self-care places, places for medical care, social, cultural, and spiritual places, and places for recreational and physical activities [
For social interaction and activities, the participants respond to questions on how often they do any of 13 activities. The activities include different forms of interacting with friends, relatives, and neighbors, participating in leisure activities, exercising with others, engaging with nonprofit organizations, participating in religious events, discussing or engaging in local politics, and participating in adult education and study groups. Responses include the following: “every day,” “1 to 2 times a week,” “1 to 2 times a month,” “1 to 2 times a year,” and “less than once a year or never.”
Survey overview of instruments and study-specific questions.
Area/focus | Instrument | Source | |||
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Quality of Life | World Health Organization Quality of Life Assessment—Brief Scale | World Health Organization Quality of Life Group 1998 [ |
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Year of build | Study-specific | N/Aa | ||
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Number of rooms | Study-specific | N/A | ||
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Number of bathrooms | Study-specific | N/A | ||
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Number of levels | Study-specific | N/A | ||
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Garden/balcony | Study-specific | N/A | ||
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Housing satisfaction | Study-specificb | N/A | ||
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Housing safety | Study-specificb | N/A | ||
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Housing discomfort | Study-specific | N/A | ||
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Neighborhood satisfaction/age-friendliness | Person-Place Fit Measure for Older Adults | Weil 2020 [ |
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Presence and use of services | Participation in Activities and Places Outside Home for Older Adultsc | Margot-Cattin 2019 [ |
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Participation | World Health Organization Disability Assessment Schedule 2.0 (section 6) | Üstün et al 2010 [ |
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Social networks | Survey of Health, Ageing and Retirement in Europe | Litwin et al 2013 [ |
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Social interactions and activities | Study-specific | N/A | ||
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Caregiving | Survey of Health, Ageing and Retirement in Europed | Börsch-Supan et al 2005 [ |
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Disease | Survey of Health, Ageing and Retirement in Europe | Börsch-Supan 2019 [ |
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Self-rated health | SF-36 | Sullivan et al 1994 [ |
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Pain | Study-specific | N/A | ||
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Falls | Study-specific | N/A | ||
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Hospital stays | Study-specific | N/A | ||
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Activities of daily living | ADLe staircase | Iwarsson et al 2009 [ |
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Receiving care | Survey of Health, Ageing and Retirement in Europed | Börsch-Supan et al 2005 [ |
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Age | Study-specific | N/A | ||
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Sex | Study-specific | N/A | ||
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Number of years living in the neighborhood | Study-specific | N/A | ||
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Cohabiting | Study-specific | N/A | ||
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Marital status | Study-specific | N/A | ||
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Country of origin | Study-specific | N/A | ||
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Education | Study-specific | N/A | ||
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Work | Study-specific | N/A | ||
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Income | Study-specific | N/A | ||
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Housing supplement | Study-specific | N/A | ||
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Type of dwelling | Study-specific | N/A | ||
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Housing tenure | Study-specific | N/A | ||
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Access to car | Study-specific | N/A |
aN/A: not applicable.
bThese questions were inspired by a subset of questions from an earlier version of the online self-help tool “Housing Options for Older People” [
cWe added a question on presence—“Does the service exist in your neighborhood?”—prior to questions regarding use of services included in the Participation in Activities and Places Outside Home for Older Adults instrument [
dThese questions were based on the Survey of Health, Ageing and Retirement in Europe [
eADL: activities of daily living.
For receiving and giving care we use a modified set of questions from the Survey of Health, Ageing and Retirement in Europe (SHARE) [
The survey also asked the participants about pain, as follows: “Have you in the last 30 days been bothered by pain? If yes, how bad is the pain most of the time (mild, moderate, or severe)?” We then asked a question about where in their body they experienced pain. The survey also includes questions about whether or not the respondent has fallen in the last 12 months, where falls occurred, and if the respondent needed medical care due to falls. We also ask about the number of overnight hospital admissions in the last 12 months, regardless of cause.
Data collection was intended to take place at home. However, due to COVID-19 restrictions at the time, we changed this to telephone interviews. The participants return the signed consent form by mail before the phone interview takes place. Questions and scales are mailed to the participants to serve as visual aids during the interview. Answers are recorded by the data collector using RedCap software (Research Electronic Data Capture; Vanderbilt University). Interviews can be completed in Swedish, English, Arabic, Persian, Slavic languages, Polish, or Danish if needed. We will use an interpreter when needed.
Besides the research team doing the interviews (who all have a bachelor’s degree or PhD in health science or social science), the data collectors are students in an occupational therapy bachelor’s program. All data collectors have received study-specific training. At the start of the study, 3 data collectors performed 2 interviews each (n=6), after which data collection was paused and the data collectors and research teams engaged in a thorough discussion and evaluation. Minor alterations to and clarifications of the instructions were edited into RedCap before the data collection continued. Frequent meetings with the data collectors and the principal investigator of the study will be held throughout the data collection period.
For newly translated measures not before used in this context (eg, PPFM-OA [
In accordance with a mixed methods approach [
All participants will sign written consent forms when entering the study. The study was approved by the Swedish Ethical Review Authority (phase 1: Dnr. 2020-03468; phases 2 and 3: Dnr. 2021-03588).
As of the submission of this protocol (August 2022), recruitment for the interview study has been completed (N=39), and 267 participants have been recruited and completed data collection for the survey study. We expect recruitment and data collection to be finalized by December 2022.
This study will provide detailed knowledge on what role the home and neighborhood play in older adults’ quality of life and their participation in the community and society by focusing on different kinds of disadvantaged areas. By collecting qualitative and quantitative data and addressing physical, social, and emotional aspects of the environment, we will be able to address complex person–environment dynamics [
In Sweden, the development of and changes in disadvantaged areas in cities and depopulated areas in rural municipalities are caused by shared challenges on a societal level, such as demographic changes, urbanization, and globalization, but also due to local challenges in Sweden’s 290 self-governing municipalities [
The study design allows for studying older adults not only as they are affected by the environment, when the neighborhood changes and they have to adapt, but also as active agents, who likely contribute to change in the neighborhood and build the community. The knowledge generated will be useful to better understand the effects of exclusion and marginalization and the effects of inclusion and the creation of community [
Inclusive and accessible living environments are fundamental to well-being, and Swedish aging policy states that older adults should be able to age safely, maintain their independence, and continue to lead active lives. The right to be active, live independently, and participate in the community and society can be considered an occupational justice issue, not only an individual health matter, and is important for future research and policy interventions on healthy aging [
The disadvantaged areas selected for the study are not representative of all disadvantaged areas in Sweden, but they constitute interesting examples that show the diversity of living conditions of older adults. The study was started in 2019, and recruitment, as well as quantitative and qualitative data collection, had to adjust to the COVID-19 pandemic. This likely also influenced the data collected, which we will consider in future analyses and interpretation of results.
With an increasing proportion of older adults, an increasing number of disadvantaged areas, and an increasing dependency ratio in more than 50% of Swedish municipalities, Swedish cities and municipalities are transforming and becoming increasingly segregated. This study will add unique knowledge on what it is like to be older in disadvantaged areas and deepen knowledge on housing and health dynamics in later life. Further, the design of the current study will allow future follow-ups and longitudinal analysis (if granted funding) of aging in a transforming societal context.
Interview Guide.
Peer-review reports from the Forskningsrådet för hälsa, arbetsliv och välfärd (FORTE, Swedish Research Council for Health, Working Life, and Welfare) (Stockholm, Sweden).
Participation in Activities and Places Outside Home Questionnaire
Person-Place Fit Measure for Older Adults
structural equation modeling
socioeconomic status
Survey of Health, Ageing and Retirement in Europe
Swedish state personal address register
The study is financed by the Swedish Research Council for Health, Working Life, and Welfare (Forte) (grant 2019-00107) and the Ribbingska Foundation in Lund, Sweden. The study was conducted at the transdisciplinary Centre for Ageing and Supportive Environments, which is financially supported by the Faculty of Medicine and Faculty of Engineering at Lund University, Sweden.
The data sets generated during the current study will be made available after data collection is completed upon reasonable request to the corresponding author.
None declared.