building an age-friendly environment
TRANSCRIPT
BUILDING AN AGE-FRIENDLY ENVIRONMENT
by understanding the perception and wishes of native versus non-native Dutch elderly regarding the contribution of the physical environment to active ageing
MSc Thesis by Saskia Nijland
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MSc Thesis Communication, Health and Life Sciences
Specialisation Health and Society
Wageningen University & Research
HSO-80333
BUILDING AN AGE-FRIENDLY ENVIRONMENT
by exploring the perception and wishes of native versus non-native Dutch
elderly regarding the contribution of the physical environment to active ageing
By: Saskia Nijland
E-mail address: [email protected]
Registration number: 940322614010
Program: Communication, Health & Life Sciences
Specialisation: Health & Society
1st Academic supervisor: C. Q. Wentink-Kroon MSc
Examiner: Prof. Dr. M. A. Koelen
Date: 12th of April 2018
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“We don’t see things as they are,
we see them as we are.”
Anais Nin
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Preface
Dear reader,
In front of you lies my Master thesis on the perception and wishes of native versus non-native Dutch
elderly regarding the contribution of the physical environment to active ageing. This thesis is part of
my Master Communication, Health and Life Sciences, specialisation Health and Society, at Wageningen
University in the Netherlands. As a result of doing a summer job in a care home for elderly in 2014 and
2015, my particular interest within the broad area of health and society lies in the field of active ageing.
Therefore, it was clear to me that I wanted to write this thesis about a related topic. By writing this
thesis, I hope to have contributed to the well-being, vitality and quality of life of older people, as that
is where I am passionate about.
I have been working on this thesis from September 2017 until April 2018. A process that was very
educational, often challenging and even hard at times, but most of all an enjoyable experience. I have
gained new research skills and experience, improved my analytical skills, and challenged myself to be
continuously critical about my own work and to reflect on the process. Also, conducting interviews as
part of this thesis brought me in touch with a variety of people who were all sincere and open, which
was a valuable experience. As a result, I did not only collect data for this thesis, but I also collected
good memories and life lessons from meeting these participants.
I would like to thank my supervisor Carlijn Wentink-Kroon for guiding me along the process of writing
this thesis. She provided me with constructive feedback and useful insights, challenged me to be
thinking critically about the steps I took and still needed to take, and managed to motivate me with
the rights words when that was necessary. Consequently, she guided me towards progress and result.
I enjoyed being supervised by Carlijn and have learned a lot from her.
My mother also deserves my thanks for putting a lot of effort in helping me to find participants, which
was not an easy search. Last, but certainly not least, I would like to thank all the native and non-native
Dutch elderly aged 60 years or older that participated in this research for their time and effort, as I
would not have been able to finish this thesis without their valuable contribution.
I hope you will enjoy reading my work.
Saskia Nijland
Wageningen, 12th of April 2018
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Abstract
Background: The World Health Organisation introduced the concept of an ‘age-friendly environment’,
which aims to enable active ageing. By taking into account the perceptions of migrant elderly, an age-
friendly environment is found to have the potential to contribute to diminishing ethnic and culture
related health inequalities that migrant elderly experience. This is relevant as migrant elderly form a
substantial part of older populations in many European countries nowadays. However, research
studying the potential influence of having a migrant background on elderly’s perception of how the
(age-friendly) physical environment can contribute to active ageing appears to be limited so far.
Research aim: To understand the perception and wishes of native versus non-native Dutch elderly
regarding the contribution of the physical environment to active ageing.
Methods: A mixed methods design was used. Participants had a minimum age of 60 years. The
photovoice method asked 7 native and 8 non-native participants to take photos of places or things in
the physical environment that they perceived to either contribute to or hinder active ageing, after
which a face-to-face in-depth semi-structured interview was conducted. A questionnaire was used to
supplement and validate qualitative data, and to assess the importance of characteristics of an age-
friendly environment. It was completed by 92 natives and 21 non-natives.
Results: Natives perceived active ageing more often as mental activity, and independence and
autonomy, than non-natives did. Likewise, natives perceived an age-friendly environment more often
as one that facilitates cultural activity and support. In addition, accessibility and opportunity to be
physically active were more important to natives for an age-friendy environment. Non-natives
perceived social activity to be more important for active ageing than non-natives. Likewise, the
facilitation of social contact was perceived to be more important for an age-friendly environment to
non-natives than to natives. For both native and non-native Dutch elderly, the physical environment
was found to influence active ageing mostly via behaviour, or via perception and behaviour.
Conclusions: The pathways through which the physical environment can influence active ageing do
not differ for natives versus non-natives, but the environmental conditions related to age-friendliness
do and these depend on perception. Nevertheless, a one-size-fits-all age-friendly environment cannot
be designed based on the results of this research as the sample size was too small and the variety
within the group of migrants too wide to be able to do so. Future research has the potential to obtain
more complete results if more targeted sampling is applied. However, based on this research, it is
debatable to what extent non-native elderly can be considered as one specific group of people and
should be treated as such.
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Table of contents Preface ...................................................................................................................................................... i
Abstract ................................................................................................................................................... vi
List of figures ........................................................................................................................................... ix
List of tables ............................................................................................................................................ ix
List of textboxes ....................................................................................................................................... x
List of images ............................................................................................................................................ x
Chapter 1 – Introduction ......................................................................................................................... 1
1.1 Context .......................................................................................................................................... 1
1.2 Research problem ......................................................................................................................... 4
1.3 Research aim and main research question ................................................................................... 5
1.4 Outline of the thesis ...................................................................................................................... 5
Chapter 2 - Theoretical framework ......................................................................................................... 6
2.1 Relations of interest to this research ............................................................................................ 6
2.2 Four pathways of environmental health etiology ......................................................................... 6
2.3 Perception and perceived environment ........................................................................................ 8
2.4 Active ageing ................................................................................................................................. 9
2.5 WHO’s concept of an age-friendly environment......................................................................... 12
2.6 Conceptual model ....................................................................................................................... 16
Chapter 3 – Sub-questions .................................................................................................................... 18
Chapter 4 - Research methods .............................................................................................................. 19
4.1 Research design ........................................................................................................................... 19
4.2 Research population .................................................................................................................... 19
4.3 Qualitative method – photovoice ............................................................................................... 21
4.4 Quantitative methods – questionnaire ....................................................................................... 23
4.5 Ethical considerations ................................................................................................................. 27
Chapter 5 – Results ................................................................................................................................ 29
5.1 Participants .................................................................................................................................. 29
5.2 Ageing in general ......................................................................................................................... 33
5.3 Perception of active ageing ......................................................................................................... 33
5.4 Perception of an age-friendly environment and related facilitators and barriers ...................... 41
5.5 Characteristics of an age-friendly environment as identified by the WHO ................................ 65
Chapter 6 - Discussion ........................................................................................................................... 73
6.1 Interpretation of main findings ................................................................................................... 73
6.2 Strengths of the research ............................................................................................................ 79
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6.3 Limitations of the research .......................................................................................................... 80
6.4 Recommendations for future research ....................................................................................... 81
6.5 Translation into practice ............................................................................................................. 82
Chapter 7 - Conclusion .......................................................................................................................... 85
References ............................................................................................................................................. 86
Appendices ............................................................................................................................................ 92
Appendix 1 – Checklist of essential features of an age-friendly environment (WHO, 2007) ........... 92
Appendix 2 – Photo journal ............................................................................................................... 94
Appendix 3 – Interview guideline ...................................................................................................... 97
Appendix 4 – Questionnaire ............................................................................................................ 100
Appendix 5 – Identified themes and codes ..................................................................................... 121
Appendix 6 – Informed consent/permission form .......................................................................... 126
Appendix 7 – Ethical approval ......................................................................................................... 127
List of figures
Figure 1 Relations of interest to this research ........................................................................................ 6
Figure 2 Four pathways of environmental health etiology as identified by Commers et al. (2006) ....... 7
Figure 3 Schemtatic illustration of the process of perception ................................................................ 8
Figure 4 Determinants of active ageing (WHO, 2002) .......................................................................... 11
Figure 5 Dimensions and domains of an age-friendly environment (WHO, 2016) ............................... 14
Figure 6 Conceptual model to gain understanding in the perception of native versus non-native Dutch
elderly regarding the contribution of the physical environment to active ageing ............................... 17
Figure 7 Distribution of native Dutch photovoice participants ............................................................. 30
Figure 8 Distribution of non-native Dutch photovoice participants ..................................................... 30
Figure 9 Distribution of native Dutch questionnaire respondents ....................................................... 31
Figure 10 Distribution of non-native Dutch questionnaire respondents .............................................. 31
List of tables
Table 1 Overview research design......................................................................................................... 19
Table 2 Overview of native Dutch photovoice participants .................................................................. 29
Table 3 Overview of photovoice participants with a migrant background ........................................... 30 Table 4 Questionnaire sample characteristics ...................................................................................... 31
Table 5 Photovoice participants’ perception of their migrant background .......................................... 32
Table 6 Summary of natives’ versus non-natives’ perception of active ageing .................................... 41
Table 7 Summary natives’ versus non-natives’ perception of age-friendly environment .................... 62
Table 8 Summary native versus non-native elderly’s perception of facilitators of the physical
environment for active ageing .............................................................................................................. 64
Table 9 Assessment of characteristics active ageing as defined by the WHO ...................................... 65
Table 10 Assessment of domains without context ............................................................................... 66
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Table 11 Assessment of Outdoor environments ................................................................................... 67
Table 12 Assessment of Transport and mobility ................................................................................... 69
Table 13 Assessment of Housing ........................................................................................................... 70
Table 14 Summary native versus non-native elderly’s assessment of importance of characteristics
age-friendly environment as identified by the WHO ............................................................................ 72
Table 15 Specific recommendations for building an age-friendly environment that takes migrant
elderly into account ............................................................................................................................... 83
Table 16 General recommendations for building an age-friendly environment .................................. 84
Table 17 Identified themes for native versus non-native participants’ perception of active ageing . 121
Table 18 Identified themes and codes for natives versus non-native participants’ perception of an
age-friendly environment and facilitators and barriers of the physical environment for active ageing
............................................................................................................................................................. 122
List of textboxes
Textbox 1 Active ageing in the conceptual model ................................................................................ 12
Textbox 2 Physical environment in the conceptual model ................................................................... 15
Textbox 3 Categorisation of non-native participants according to Statistics Netherlands (…) ............. 19 Textbox 4 Selected characteristics of an age-friendly environment – Outdoor environments ............ 25
Textbox 5 Selected characteristics of an age-friendly environment – Transport and mobility ............ 25
Textbox 6 Selected characteristics of an age-friendly environment – Housing .................................... 25
List of images
Image 1 Straight stairs inside house ...................................................................................................... 43
Image 2 Cars parked over the pavement .............................................................................................. 44
Image 3 Fallen branches on footpath .................................................................................................... 45
Image 4 Stairs in public space ............................................................................................................... 45
Image 5 Not suitable surface of footpath ............................................................................................. 46
Image 6 Lack of street lighting .............................................................................................................. 47
Image 7 Dangerous crossroad ............................................................................................................... 48
Image 8 Bus stop ................................................................................................................................... 49
Image 9 Seating ..................................................................................................................................... 50
Image 10 Cycle path .............................................................................................................................. 51
Image 11 Footpath ................................................................................................................................ 52
Image 12 Walking in the city ................................................................................................................. 52
Image 13 Nature to walk in ................................................................................................................... 53
Image 14 View on nature out of house ................................................................................................. 53
Image 15 Park ........................................................................................................................................ 54
Image 16 Shopping street ..................................................................................................................... 56
Image 17 Cultural square ...................................................................................................................... 57
Image 18 Direction signs in public space ............................................................................................... 59
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Chapter 1 – Introduction
To put the current research into context, this chapter starts with providing background information on
population ageing, the concept of an age-friendly environment, and why specific attention should be
paid to migrant elderly when building such an age-friendly environment. Thereafter, the research
problem, aim, and main research question are discussed. Although aware of the negative connotation
the term ‘elderly’ may have, older people will also be referred to as elderly in this research, to limit the
length of sentences and to contribute to the comprehensibility of this report in that way.
1.1 Context
1.1.1 Population ageing
Populations worldwide are ageing rapidly. By the year 2050, more than one in five world citizens is
expected to be 60 years or older. This equals about 2.1 billion people, compared to 901 million in 2015
(World Health Organization [WHO], 2015). In addition, a total of 434 million people will be aged 80
years or above by the year 2050, which is an increase of 347.2% when compared to the year 2015
(United Nations [UN], 2015). Consequently, the world is currently experiencing a change in its global
age structure (Beard & Bloom, 2015; Zimmer, 2016).
While older people can be of value as cultural, social, economic and familial resources, ageing
populations are also linked to a declining work force, changing age dependency ratios, and a higher
demand for health care and social pensions (OECD, 2011; Beard & Bloom, 2015; Eurostat, 2016). As
such, population ageing is considered a current global key policy issue, affecting nearly every country
in the world (Biggs & Haapala, 2015; WHO, 2015; Zimmer, 2016). To make the demographic transition
towards an ageing society work, successfully responding to the challenges and opportunities caused
by population ageing is required (WHO, 2011). If this is not done adequately and adaption to the
demographic shift fails, high costs to society will be the result (WHO, 2015).
1.1.2 The role of the physical environment
One of the challenges caused by population ageing is to adjust the physical environment to the
changing population structure and the needs of older people (WHO, 2016). This is of significant
importance since the physical environment influences mobility and independence, which both
decrease as people get older (Abbott & Sapsford, 2005; Scharf, Phillipson, & Smith, 2007; WHO, 2018).
People that live in supportive environments are better able to remain doing the things that are
important to them. Consequently, the quality of the physical environment is found to be of significant
influence on how well older people adjust to loss of function in their later years, and therefore on
elders’ health and quality of life (Menec, Means, Keating, Parkhurst, & Eagles, 2011; Kerr, Rosenberg,
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& Frank, 2012; Phillipson, 2012; WHO, 2015; WHO, 2017).
This is also acknowledged by policy makers at the international, national and the local level, who are
challenged to build physical environments that enable older people to maintain their functional
independence. By doing so, older people are offered opportunities to keep contributing to society and
to preserve their health until their last years of life (Beard & Petitot, 2010). As a result, quality can be
added to extended years and there is a higher chance that both individuals and society will benefit
from the extended life span (WHO, 2016). Moreover, as a result of being supported by modifications
of the environment in order to compensate for disabilities and limitations, people can grow old in their
own home. Supporting older people to age and continue living in their home, neighbourhood or
community for as long as possible, also described as ‘ageing in place’, is recognised by international
organisations and governments to make both economic and social sense (Lui, Everingham, Warburton,
Cuthill, & Barlett, 2009). Therefore, this is widely adopted as a main policy goal (Means, 2007; Lui et
al., 2009).
1.1.3 An age-friendly environment
To provide policy makers and governments with tools for building environments that are supportive
to ageing people, the WHO introduced the concept of an ‘age-friendly environment’. Together with
the social environment and municipal services, the physical environment is considered to be one of
the three dimensions of an age-friendly environment (WHO, 2007). According to the WHO, an age-
friendly environment is one that aims to “encourage active and healthy ageing by optimizing health,
stimulating inclusion and enabling well-being in older age” (WHO, 2016, p.12), in which active ageing
is considered to be “the process of optimizing opportunities for health, participation and security in
order to enhance quality of life as people age” (WHO, 2002, p.12).
In other words, an age-friendly environment refers to “a place where older people are actively involved,
valued, and supported with infrastructure and services that effectively accommodate their needs”
(Alley, Liebig, Pynoos, Banerjee, & Choi, 2007, p.4). These needs could concern basic daily activities like
shopping and driving, but also refer to further involvement in the community by participating in
political or service organisations (Fitzgerald & Caro, 2014). Age-friendly environments, so
environments that are ‘good’ to age in, are also referred to as ‘livable’, ‘elder-friendly’, and ‘lifetime’
environments in literature (Lui et al., 2009; Emlet & Moceri, 2012).
Age-friendly physical environments can make a difference for all individuals as it comes to the extent
to which one can be independent, but are of particular importance to people that are ageing. For
example, elderly who live in an environment that is unsafe or that has physical barriers, are less likely
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to leave the house. As a result, they are less physically active and have a higher chance of having to
deal with loneliness, isolation, and mobility problems (Philipson, 2012). Therefore, building and
maintaining an age-friendly environment is widely regarded as a core component in positively
addressing the challenges that population ageing causes (Lui et al., 2009; WHO, 2007).
1.1.4 Does one size fit all?
In order to support policy makers and governments in building age-friendly environments, the WHO
identified characteristics of what an age-friendly environment should look like from the perspective of
elderly and service providers (Plouffe & Kalache, 2010). Although these characteristics were identified
by means of a bottom-up participatory approach involving elderly, the WHO also received criticism for
not recognising the diversity of elderly and communities (Plouffe, Kalache, & Voelcker, 2016). This
recognition is considered to be important because in every society there is a wide diversity of groups
of elderly to be found, who have different needs. These different needs suggest that there are different
age-friendly environments that have resources adequately matching those needs (Menec et al., 2011;
Keating, Eagles, & Philips, 2013).
Migrant elderly for example, generally have a disadvantaged position compared to the native
population. As a result, they have specific needs (Van Wieringen, 2014; Buffel, 2015). It was in 1978
already that Dowd and Bengtson reported the so called ‘double disadvantage’ that older migrants face.
These older people do not only have to cope with disadvantages that are a result of the ageing process,
but also with disadvantages related to race and ethnic background. Examples of these are limited
education, poor housing and working conditions, financial insecurity, discrimination based on race and
religion, and barriers related to language causing a lower level of social activity (Buffel, 2015; Fokkema
& Naderi, 2013; Kristiansen, Razum, Tezcan-Güntekin, & Krasnik, 2016).
Moreover, the general health of migrant elderly has been identified as worse than that of the native
older population: both mortality and morbidity rates are found to be higher for migrant groups
(Fokkema & Naderi, 2013; Stegeman, Otte-Trojel, Costongs, & Considine, 2012). Although there is
diversity among individuals, migrant elderly were found to suffer more from chronic conditions like
Diabetes Mellitus, obesity, COPD, heart and vascular disease, psychological conditions, and physical
limitations in daily life (Van Wieringen, 2014), and to have stronger feelings of loneliness than their
native peers (Fokkema & Naderi, 2013; Victor, Burholt, & Martin, 2012).
1.1.5 Age-friendly environments with sensitivity to migrant elderly
Nowadays, the population in the Netherlands is becoming more and more culturally diverse and
migrants form a substantial part of the older population. This also applies to other European countries
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and North America (Ciobanu, Fokkema, & Nedelcu, 2017). In the Netherlands, the number of people
with a migrant background aged 60 years or older was 597.532 on the 1st of January 2017, which
equalled about 14.1% of the total Dutch elderly population (CBS, 2017). This share is expected to grow
over the years, due to the flow of refugees from several Arabian countries to Europe (Ciobanu et al.,
2017).
To diminish the ethnic and culture related health inequalities experienced by migrant elderly, health
promotion programs and interventions that are sensitive to their specific culture, backgrounds and
circumstances should be designed (Stegeman et al., 2012). Building an age-friendly environment with
this sensitivity is an example of such a health promoting intervention, as the level to which older
migrants suffer from loneliness, social exclusion and health related issues is found to be influenced not
only by individual characteristics, but also by those of the physical environment. The availability of
social meeting places is an example of such a characteristic (Ciobanu et al., 2017).
When building an age-friendly environment that is sensitive to migrant elderly, it also needs to be
taken into account that culture is found to be of significant influence on the way one perceives (active)
ageing (Keith, Fry, & Ikels, 1990; Fry et al., 1997; Torres, 2001; Willcox, Willcox, Sokolovsky, & Sakihara,
2007; Löckenhoff et al., 2009; Boudiny, & Mortelmans, 2011). Culture generally refers to “the set of
attitudes, values, beliefs and behaviours that are shared by a group or people” (Matsumoto, 1996,
p.16). This is relevant as the aim of an age-friendly environment is to encourage active ageing.
Furthermore, it needs to be taken into account that perception is found to influence the relation
between the physical environment and active ageing (Commers, Gottlieb, & Kok, 2006). By means of
perception, an individual gives meaning to elements of the environment (Zonn, 1984). Depending on
culture, and age, experience, background, and conditions of life, the same environment means
different things to different people (Deregowski, 1972; Lindheim & Syme, 1983; Gifford, Steg, & Reser,
2011)).
1.2 Research problem
Due to the influence of culture and perception, active ageing and an age-friendly environment can be
considered to be relative concepts, of which the meaning depends on cultural context and culture
related norms and values. This suggests that what is an age-friendly environment to one person or
group of people that share the same culture, might not be to another (Collings, 2001; Willcox et al.,
2007). Therefore, in order to effectively build an age-friendly environment that takes into account the
needs of migrant elderly, understanding the specific experiences and perceptions of the concerned
older adults is found to be important (Bacsu et al., 2014). By doing so, an age-friendly environment has
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the potential to contribute to diminishing ethnic and culture related health inequalities experienced
by migrant elderly. However, research studying the potential influence of having a migrant background
on elderly’s perception of an age-friendly physical environment, how such an environment can
contribute to active ageing, and related wishes, appears to be limited so far.
1.3 Research aim and main research question
To respond to this observed knowledge gap, the aim of this research is to understand the perception
and wishes of native versus non-native Dutch elderly regarding the contribution of the physical
environment to active ageing.
Achieving the research aim will be done by finding an answer to the main research question ‘What are
differences between the perception and wishes of native versus non-native Dutch elderly regarding the
contribution of the physical environment to active ageing?’.
By gaining this knowledge, this research aims to contribute to a successful response to the
demographic transition towards an ageing society, of which elderly migrants have become a
substantial part. The growing share of migrants in the elderly population in the Netherlands, North-
America, and other European countries makes this research especially relevant. Insights obtained from
this research can provide policy makers and governments with lines of approach that can help them
to use the available resources for building an age-friendly environment as adequately as possible. As
such, the results could be of support in building an age-friendly environment that has a right fit with
the specific composition of the population. This will ideally lead to an improved quality of life for the
concerned elderly and diminished health inequalities experienced by migrant elderly. Also, this will be
of positive influence on whether or not people and society can benefit from the extended life span,
as that depends highly on one significant factor: health (WHO, 2015; WHO, 2016).
1.4 Outline of the thesis
The next chapter of this thesis discusses theoretical concepts that were combined into a conceptual
model which serves to gain understanding in differences between the perception of native versus non-
native Dutch elderly regarding the contribution of the physical environment to active ageing.
Thereafter, the methods used for this researched will be explained. Subsequently, the results will be
presented, followed by the discussion of the results and of the research in general. Strengths,
limitations and practical implications of this research will also be considered in the discussion, just as
recommendations for future research. Lastly, the conclusion of this thesis is provided.
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Chapter 2 - Theoretical framework
This chapter presents the theoretical concepts that were used for this research. First, the relations of
interest to this research are discussed and illustrated, so that it becomes clear what the purpose of the
used theoretical concepts is. Then, theory about how an environment can influence health and about
perception is provided. Hereafter, the theoretical concept used to answer sub-question 1 will be
presented. The same will be done for sub-question 2, and for sub-questions 3 and 4 together. These
concepts were merged into a conceptual framework that was used to achieve the research aim. This
developed conceptual model will be presented lastly.
2.1 Relations of interest to this research
This research aims to understand the perception of native versus non-native Dutch elderly regarding
the contribution of the physical environment to active ageing, and to identify potential different
environmental wishes by doing so. Therefore, what is of interest to this research is how the physical
environment influences active ageing, and how this is mediated by perception depending on having a
native or non-native background. As the physical environment, or age-friendly environment to be more
specific, is the ‘starting point’ and active ageing is the intended ‘outcome’ of this relation, it will first
be researched what native versus non-native Dutch elderly perceive to be active ageing and an age-
friendly environment. The above mentioned relations of interest are represented schematically in
Figure 1.
2.2 Four pathways of environmental health etiology
Commers, Gottlieb and Kok (2006) have identified four pathways through which the environment can
influence health and be health promoting as such. These are described in a model which is portrayed
Figure 1 Relations of interest to this research
Active ageing (Age-friendly) Physical
environment
Perception
Native versus non-native
?
?
?
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in Figure 2. To be more specific, this model describes how environmental conditions can influence
health, or a desired health outcome. An environmental condition is defined as “a particular state of a
given environment” (Commers et al., 2006, p.81). So, within for example the economic environment,
different environmental conditions that influence health to a different extent can be distinguished,
such as ‘low economic equity’ and ‘high economic equity’. In case of an age-friendly environment, ‘high
level of inclusion’ or ‘low level of inclusion’ could be examples of environmental conditions that
influence health, in this case active ageing.
The four identified environment-health pathways are:
1) Unmediated environmental influence via behaviour that is health-related
Without the mediation of one’s perception and/or conscious awareness, an environmental
condition can influence behaviour and consequently, health.
2) Environmental influence mediated by perception, via behaviour that is health-related
An environmental condition can influence behaviour with the mediation of one’s perception
and/or conscious awareness. Therefore, it can be assumed that certain behaviours can either
promote or inhibit health.
3) Environmental influence directly mediated by perception
Due to environmental conditions, biological changes can occur, either acute or chronic. These are
significant for one’s health as a result of one’s perception of that specific environmental condition.
4) Direct environmental influence
Health can also be directly influenced by an environmental condition (Commers et al., 2006). If
people live in an environment with good air quality for example, this contributes to their health
directly.
Figure 2 Four pathways of environmental health etiology as identified by Commers et al. (2006)
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The described pathways in the model of Commers et al. (2006) will be used in the current research to
understand how the physical environment can contribute to active ageing and how this might be
different for natives versus non-natives depending on their perception of an age-friendly environment,
active ageing, and facilitators and barriers of the physical environment for active ageing. An age-
friendly environment can therefore be considered as the environmental condition in this research, and
active ageing as the desired health outcome.
2.3 Perception and perceived environment
As perception is a concept that is central to the current research, this chapter serves to make clear
what is understood by perception in this research. Perception refers to a mode of experience (Jacobs,
2006). It describes how we make sense of the world around us by means of interpretation and analysis
of sensations (Ittelson, 1978; Zube, Sell, & Taylor, 1982; Goldstein, 2009). In other words, “perception
is the process of experiencing organized and interpreted information extracted from sensations”
(Jacobs, 2006, p.122). So, perception of the physical environment starts with sensation, following the
definition of Jacobs. This means that the physical environment is obtained through or senses of sight,
smell, taste, touch and sound. The raw information that is obtained in this way is then interpreted by
making use of mental concepts. Those mental concepts are pre-existing in our minds and help to sort
stimuli into categories. Stimuli refer to environmental aspects. As such, what was sensed in the
environment is processed in the mind, which creates a perceived environment. This process is
illustrated in Figure 3.
The physical environment is about experiencing objects or elements in the external world, which
makes it perceptual experience by definition. So, although an environment is experienced in a holistic
way, different aspects can be perceived on their own (Mattila & Wirtz, 2001). Due to a difference in
sensory sensitivities, personal characteristics, and personal experiences of the past, individuals each
have their own way of experiencing their environment (Mehrabian & Russel, 1974; Bakker, 2014).
Migration is an example of such a personal experiences of the past. Also, perception has been found
Actual
environment
Perceived
environment
Information
obtained
through
senses
Interpretation
by use of
mental
concepts to
sort stimuli
into
categories
Figure 3 Schemtatic illustration of the process of perception
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to exhibit effects of culture, as culture influences our values, beliefs and preferred behaviour. These,
in turn, influence the way that information is organised in the brain, and recalled during the process
of interpretation (Golledge & Stimson, 1987).
2.4 Active ageing
The next concept of interest to this research is active ageing. Although an age-friendly environment is
described to aim to encourage both active and healthy ageing (WHO, 2016), only the term ‘active
ageing’ will be used for this research. The next two paragraphs will explain why.
In gerontological literature, the terms ‘active ageing’ and ‘healthy ageing’ are used interchangeably by
different authors, just like ‘successful’, ‘optimal’, ‘positive’ and ‘productive’ ageing are (Lowry, Vallejo,
& Studenski, 2012; Ranzijn, 2010; Fernández-Ballesteros, Robine, Walker, & Kalache, 2013; Lassen &
Moreira, 2014). However, although these terms are all used to cover the concept of ‘ageing well’
(Foster & Walker, 2015), coming up with a universal definition is hard because ageing well is a relative
concept depending on a given cultural context with related culturally relevant norms and values
(Willcox et al., 2007). Moreover, although used interchangeably, some authors claim that the meaning
of these terms is different (Deeming, 2009; Ranzijn, 2010).
Active ageing has been found to be the most prevalent employed term over recent decades in Europe
(Paúl, Ribeiro, & Teixeira, 2012). Therefore, ‘active ageing’ will be used for this research. However,
even the concept of active ageing lacks a precise universally accepted definition (Boudiny &
Mortelmans, 2011; Walker & Maltby, 2012; Lassen & Moreira, 2014;). According to Zaidi et al. (2017)
the WHO’s definition of active ageing is the most widely accepted definition, and is hence preferred
for this research. This definition states that:
“Active ageing is the process of optimizing opportunities for health, participation and security
in order to enhance quality of life as people age. It applies to both individuals and population
groups. Active ageing allows people to realize their potential for physical, social, and mental
well-being throughout the life course and to participate in society, while providing them with
adequate protection, security and care when they need.” (WHO, 2002, p.12).
Health
Preserving health and quality of life for all people as they age, and extending life expectancy as such,
can be considered as aims of active ageing (WHO, 2002). Whereas the majority of the existing
definitions of active ageing focuses on active ageing with a strong health oriented or economic
perspective, the definition of the WHO takes a multidimensional approach and a broader view of
health (Boudiny & Mortelmans, 2011; Paúl et al., 2012). The word ‘health’ in the WHO’s definition of
10
active ageing refers to the WHO’s definition of health (1978). Therefore, it includes both physical,
mental and social well-being, and does not merely refer to the absence of disease. As such, promoting
mental health and social participation are equally important for active ageing policies as improving
physical health status is (WHO, 2002).
Participation
Moreover, the word active refers to “continuing participation in social, economic, cultural, spiritual
and civic affairs, not just the ability to be physically active or to participate in the labour force” (WHO,
2002, p.12). So although people might be retired from work, they can still be of value to society by
contributing to their peers, families or communities (WHO, 2002). Doing voluntary work is a way to do
so. This was found to make people feel useful to others and to have a purpose, which positively
influences elderly’s well-being (O’Neill, Morrow-Howell, & Wilson, 2011).
Security
Security in the WHO’s definition of active ageing concerns the access of older people to social and
physical environments that are safe. Also, income security and the securing of a rewarding
employment, if applicable, belong to this (Sidorenko, & Zaidi, 2013).
Autonomy and independence
In addition, the maintenance of autonomy and independence as people age are considered to be key
goals of active ageing (Sidorenko & Zaidi, 2013). Autonomy refers to someone’s perceived ability to
cope with, have control over, and make his or her own decisions about one’s life and how to live it on
a daily basis, according to one’s own preferences (Paúl et al., 2012). Independency is about being able
to perform tasks related to daily life and the ability to live with no or little help from others (WHO,
2002).
Positive experience
As such, active ageing is considered to be the key in providing opportunities for ageing to be a positive
experience (WHO, 2002). This was also confirmed by Martin (2012), who found that the common view
of ageing as a process of decline has changed into ageing being viewed as a time of opportunities and
possibilities. To achieve this positive experience, the focus should be on providing people with
adequate security, protection and care in respond to their desires, needs and capacities (WHO, 2002).
2.4.1 Determinants of active ageing
Whether or not an individual can actively age is found to depend on various determinants surrounding
not only the individual, but also families and nations (WHO, 2002). In addition to the three pillars of
11
active ageing mentioned in its definition, respectively participation, health and security, six groups of
determinants have been identified (Paúl et al., 2012). These are portrayed in Figure 4.
Culture
Culture, central to the current research, has been identified as cross-cutting determinant of active
ageing. Culture is found to shape how one ages as it influences all of the other determinants of active
ageing (WHO, 2002). This is because to a large extent, cultural norms, values, and traditions regulate
how older people and the ageing process are being viewed by a given society. As such, cultural factors
influence aspects such as health seeking behaviour, attitude towards smoking, or whether or not living
in a household with multiple generations is the norm. Consequently, the process of ageing varies across
and within different population groups, as populations are heterogeneous and culturally diverse
(Kristiansen et al., 2016). This current research aims to get insight in how one’s culture influences one’s
perception of active ageing, and of an age-friendly environment in its turn. In other words, the
influence of the cross-cutting determinant ‘culture’ in relation to the determinant ‘physical
environment’ is researched.
2.4.2 Previous research on native versus non-natives’ perception of active ageing
The theory about active ageing provided in the previous sections was based on literature and represent
Figure 4 Determinants of active ageing (WHO, 2002)
12
the understanding of policy makers and health care professionals. As this study aims to gain
understanding in native versus non-natives’ perception of active ageing it is useful to describe findings
from previous studies on this topic. However, to the researchers knowledge, very few studies on this
topic have been conducted so far. Bowling (2009) studied divergences of perceptions of active ageing
between minority ethnic and whole population samples in the United Kingdom by using surveys. Active
ageing was defined by respondents as having health (both physical and mental/psychological); fitness,
and exercise; psychological factors such as attitude; social activities and roles; independence; and
neighbourhood. Non-natives were found to associate active ageing with physical health and fitness
less than native participants did. Moreover, in general, the views of participants were found to be more
dynamic and more multidimentional than the established view of active ageing (Bowling, 2009).
2.4.3 Active ageing in the conceptual model
The concept of an age-friendly environment was introduced by the WHO and aims to encourage active
ageing as defined by the WHO. Therefore, the WHO’s definition of active ageing will be used in the
conceptual model. Hence, health, participation, security, autonomy and independence have been
included in the conceptual model of this research to represent the theoretical concept of active ageing.
These aspects have been extracted from chapter 2.4. Participants’ perception of active ageing will be
compared to these established aspects of active ageing, so to the existing knowledge, shown in Error! R
eference source not found.. The conceptual model is portrayed in Figure 6.
2.5 WHO’s concept of an age-friendly environment
To be able to compare the findings from this research concerning natives and non-natives’ perception
of an age-friendly environment to the existing knowledge, this chapter will provide more information
Active ageing
Health o Well-being o Mental, physical, social
Participation o Economic, social, cultural, civic,
spiritual
Security o Access to safe environments, income
security Autonomy
Independence
Textbox 1 Active ageing in the conceptual model
13
about an age-friendly environment in general and its characteristics as identified by the WHO.
The concept of an age-friendly environment derives from the WHO’s active-ageing framework (2002)
(Novek & Menec, 2014). The definition of an age-friendly environment as established by the WHO
states that:
“An age-friendly environment aims to encourage active and healthy ageing by optimizing
health, stimulating inclusion and enabling well-being in older age.” (WHO, 2016, p.12).
So, an age-friendly environment aims to encourage people to actively age. Therefore, it can be
considered to be a supportive environment which has the purpose of achieving a positive health
outcome. The WHO considers age-friendly environments to be a requirement for achieving health for
all (WHO, 2018). Regardless of wealth or health status, sex or gender, age, and cultural or ethnic
background, having the opportunity to achieve the highest possible level of health and well-being
should be possible for everyone. Maintaining one’s functional ability when getting older is considered
to be important for this purpose (Michel, Beattie, Walston, & Martin, 2017). As such, building an age-
friendly environment can be achieved by enabling and improving people’s functional ability, in order
to ensure that people with different capacity levels can do the things that they consider to be valuable
(WHO, 2016; Michel et al., 2017). In interaction with each other, functional ability and environmental
characteristics hold potential for active ageing (Lawton & Nahemow, 1973).
2.5.1 Dimensions and domains of an age-friendly environment
In order to build inclusive age-friendly environments that are supportive to older people with different
capacities, three dimensions should be addressed, which are the ‘physical environment’, ‘social
environment’ and ‘municipal services’ (WHO, 2016). The WHO has categorised eight domains within
these three interdependent dimensions, which are portrayed in Figure 5 on the next page.
14
2.5.2 Physical environment
This research will focus on the physical environment, which was defined for the included participants
as “all the material things in your environment, like buildings, parks, forests, roads, and so on.”. The
choice to focus on the physical environment has been made because physical environments are found
to be highly influential on the opportunities that ageing brings and the extent to which ageing people
are able to remain doing the things that are important to them (WHO, 2018). Also, research has shown
that the quality of the physical environment is closely related to well-being in later life, which is an
important factor that mediates the ageing experience and related opportunities (Lawton, 1983;
Cunningham & Michael, 2004; Philipson, 2004). As such, with regards to the WHO’s concept of an age-
friendly physical environment, the specific domains of interest to this research are outdoor
environments, transport and mobility, and housing. However, it needs to be taken into account that
the three dimensions of an age-friendly environment are interdependent and hence cannot be fully
separated from each other.
2.5.3 Checklist WHO
To support cities to become more age-friendly and to create inclusive environments, the World Health
Organization (2007) published a guide for designing global age-friendly cities and set up a related global
Figure 5 Dimensions and domains of an age-friendly environment (WHO, 2016)
Outdoor environments (physical environment dimension)
Transport and mobility (physical environment dimension)
Housing (physical environment dimension)
Social participation (social environment)
Social inclusion and non-discrimination (social environment)
Civic engagement and employment (social environment)
Communication and information (municipal services)
Community and health services (municipal services)
15
network (Plouffe et al., 2016). It focusses on cities, as population ageing takes place at the same time
with urbanisation, causing more of a challenge for cities (Phillipson, 2012). However, the concept is
not limited to cities only. Instead, it has expanded to include rural communities as well, and the guide
can therefore be approached in a broader sense (Menec, & Nowicki, 2014).
This guide, called Global Age-friendly Cities: A Guide, describes characteristics of what an age-friendly
city should look like from the perspective of elderly and service providers. A checklist is included, which
contains essential features for each of the eight domains within the three interdependent dimensions
of an age-friendly environment (physical environment, social environment, municipal services). As
elaborated on in chapter 1.1.4, it was established by using a bottom-up participatory approach
involving elderly to identify experienced barriers and facilitators in the physical environment.
Facilitators, also called enablers, have been defined by the WHO as “environmental factors in a
person’s environment that, through their absence or presence, improve functioning and reduce
disability” (2001, p.160). Barriers, on the other hand, are considered to be “environmental factors in a
person’s environment that, through their absence or presence, limit functioning and create disability”
(WHO, 2001, p.160). The identified facilitators and barriers were translated into characteristics that
could be considered as action points for building an age-friendly environment (Buffel, Philipson, Scharf,
2012). As such, the developed checklist supports authorities to achieve predetermined guidelines and
to assess communities against established criteria (Lui et al., 2009). The checklist can be found in
Appendix 1 of this report and will be used to compare the findings of the current research to.
2.5.4 An age-friendly environment in the conceptual model
This research focusses on the physical environment. Therefore, the three specific domains of an age-
friendly environment as established by the WHO of interest to this research are Outdoor
environments, Transport and mobility, and Housing. The characteristics or essential features identified
for these domains, described in the WHO’s checklist presented in Appendix 1, represent the
environmental condition in the conceptual model. Findings from participants can then be compared
to the existing knowledge, so to these established characteristics. However, as these characteristics
are too many in number to put in the model, the domain titles will be used only.
Age-friendly physical environment
Outdoor environments
Transport and mobility
Housing
Textbox 2 Physical environment in the conceptual model
16
2.6 Conceptual model
The model of Commers et al. (2006) describing environment-health pathways (chapter 2.2), and theory
about active ageing (chapter 2.4) and an age-friendly environment (chapter 2.5) were merged. This
was done in order to develop a conceptual model that can serve to gain understanding in differences
between the perception of native versus non-native Dutch elderly regarding the contribution of the
physical environment to active ageing.The conceptual model is presented in Figure 6 on the next page.
Used arrows indicate an influence on the box pointed at, which can both be a positive or negative
influence. Continuous lines derive from the theory discussed in this chapter and are therefore
evidence-based. Dashed lines refer to influences suggested in literature, which are investigated in the
current research. The numbers appointed to the four pathways via which an an age-friendly
environmental condition can influence the desired health outcome of active ageing correspond with
the numbers as provided in the model of Commers et al. (2006).
17
Behaviour
Age-friendly physical
environment
Outdoor environments
Transport and mobility
Housing
Active ageing
Health o Well-being o Mental, physical,
social
Participation o Economic, social,
cultural, civic, spiritual
Security o Access to safe
environments o Income security
Autonomy
Independence
Perception
Native or
non-native
Dutch
background
= influence is proven = influence is suggested, and investigated in current research
1 1 & 2
4
2 & 3 3
Figure 6 Conceptual model to gain understanding in the perception of native versus non-native Dutch elderly regarding the contribution of the physical environment to active ageing
18
Chapter 3 – Sub-questions
This research aimed to find an answer to the question ‘What are differences between the perception
and wishes of native versus non-native Dutch elderly regarding the contribution of the physical
environment to active ageing?’ For this purpose, based on the theoretical framework of this research,
the following sub-questions are answered:
1. What do native versus non-native Dutch elderly perceive to be ‘active ageing’?
2. What do native versus non-native Dutch elderly perceive to be an ‘age-friendly environment’?
3. What do native versus non-native Dutch elderly perceive to be facilitators and barriers of the
physical environment for active ageing?
4. How important are the characteristics of an age-friendly physical environment as identified by the
WHO to native versus non-native Dutch elderly for being able to actively age?
The methods used to answer these sub-questions are discussed in Chapter 4. Subsequently, the results
are provided in the results section, Chapter 5, and discussed Chapter 6. The main research question is
answered in Chapter 7, the conclusion of this thesis.
19
Chapter 4 - Research methods
This chapter presents the methods that were used for this research. First, research design and
population are discussed. This research includes both qualitative and quantitative data collection.
These methods are explained separately in chapter 4.3 and 4.4. The chapter concludes with the ethical
considerations.
4.1 Research design
This research aimed to gain understanding of the perception and wishes of native versus non-native
Dutch elderly regarding the contribution of the physical environment to active ageing. This was done
by using a mixed methods approach. To answer the first, second and third sub-question, a qualitative
method, the so called ‘photovoice method’, was used as primary method for data collection. A
quantitative method, a questionnaire, was used to collect additional data for sub-questions 1, 2 and 3,
and to answer sub-question 4. By using this mixed methods design, data from both methods could be
compared, validated and integrated in order to get more complete results (Wisdom & Creswell, 2013).
With regards to the limited time span for this research, data was collected concurrently. An overview
of the research design is provided in Table 1. A further explanation of the two used methods is provided
in chapters 4.3 and 4.4.
Table 1 Overview research design
4.2 Research population
The data collection for this research took place in the Netherlands between December 2017 and March
Sub-question: Qualitative: Quantitative:
What do native Dutch elderly versus non-native Dutch elderly
perceive to be ‘active ageing’?
X X
What do native Dutch elderly versus non-native Dutch elderly
perceive to be an ‘age-friendly environment’?
X X
What do native Dutch elderly versus non-native Dutch elderly
perceive to be facilitators and barriers of the physical environment
for active ageing?
X X
How important for being able to actively age are the characteristics
of an age-friendly physical environment as identified by the WHO to
native versus non-native Dutch elderly?
X
20
2018. The theoretical population consisted of native and non-native Dutch men and women aged 60
years or older. Although “there is no general agreement on the age at which a person becomes old”
(Kowal & Dowd, 2001, p.1), the age of 60 was chosen as bottom limit for this research because the
United Nations generally refer to the older population as people being 60 years or older (UN, 2001)
and the WHO uses 60 years or older to describe elderly in their guide on age-friendly cities (2007).
The included Dutch elderly were men and women aged 60 years or older who still lived at home, as
age-friendly environments can be of specific contribution to enabling people to age in place, so in one’s
own home, neighbourhood or community. People that still lived at home but received home care or
care from relatives could participate as well. Participants could come from either cities, towns or
villages. People could participate in both the quantitative part as well as the qualitative part, or either
one of these. As the questionnaire was anonymous, it is not known how many people participated in
both.
The categorisation as established by Statistics Netherlands ([CBS], 2016), portrayed in Textbox 3, was
used as a reference for categorising participants as either native or non-native.
Based on this categorisation, participants were asked for their own country of birth and that of their
mother and father. Also, non-native participants could be subdivided into ‘non-western migrants’ and
‘western migrants’ in this way. By doing so, it was not only possible to compare the perception of
native Dutch elderly with the perception of non-native Dutch elderly in general, but also to compare
the perception of western versus non-western migrants. Consequently, if significant differences would
be found between these two groups of non-native participants, even more specific advice for policy
makers concerned with building age-friendly environments could be provided.
Someone is considered to be non-native, or in other words to have a migrant background, when
either that person and/or one or both of their parents was/were born in another country than the
Netherlands (Statistics Netherlands, 2016).
A person with a migrant background in one of the countries of Europe (excluding Turkey), North-
America or Oceania is considered to be a western migrant. Based on their socio-economic and
socio-cultural position, migrants from Indonesia or Japan are also classified as being western.
These are mainly people from the former Dutch East Indies, and employees of Japanese
companies.
A person with a migrant background in one of the countries in Africa, Latin-America and Asia
(excluding Indonesia and Japan) or Turkey is considered to be a non-western migrant. Although
the Dutch Antilles are still part of the Kingdom of the Netherlands and Surinam has been part of
the Netherlands until 1975, people originating from these countries are also considered to be non-
western migrants.
Indonesia and Japan
Textbox 3 Categorisation of migrants according to Statistics Netherlands (2016)
21
4.3 Qualitative method – photovoice
To answer sub-question 1, 2 and 3, the so called ‘photovoice method’ was used. This method is based
on the participatory research by Wang and Burris (1997). It asks participants to take photos of places
or things that are of interest to the research, after which these photos will be used for discussion during
an interview (Julien, Given, & Opryskho, 2013). This photographic technique enables participants to
actively reflect on the weaknesses and strengths of their own community or neighbourhood (Wang &
Redwood-Jones, 2001). Deeper insight in and understanding of a topic can be gained by integrating
visual information in the research (Given, Opryshko, Julien, & Smith, 2011). Therefore, the photovoice
method is suitable for elderly to communicate and define their own perception and interpretation of
what an age-friendly environment is. Also, the characteristics related to that, including facilitators and
barriers, can be identified in this way (Dempsey & Tucker, 1991; Novek & Menec, 2014). For research
that aims at improving the quality of life of older adults, including their perspective and priorities is
found to be an important requirement (Wang & Burris, 1997; Gabriel & Bowling, 2004).
4.3.1 Sampling strategy
Photovoice participants were recruited through the researcher’s personal network, by making an
announcement on Facebook, and spreading flyers door-to-door. Also, snowball sampling was used. In
total, 15 participants were included, of which 7 were native and 8 were non-native Dutch. More
detailed sample characteristics are provided in chapter 5.1.
4.3.2 Procedure
Recruited photovoice participants were approached via e-mail, or via telephone, or both, depending
on the availability of their contact addresses. They were asked to take a minimum of three and a
maximum of ten photos of things or places in the physical environment that they perceived to
contribute to active ageing. Also, they were asked to take at least two photos of things or places in the
physical environment that they perceived to be a barrier to active ageing. They were provided with so
called ‘photo journals’, in which the same four questions were asked for every taken photo. These
were to be answered by the participants during the process of taking the photos and included:
1. Where did you take this photo?
2. What is in the photo?
3. What does this photo mean to you?
4. Why did you take this photo with regards to active ageing?
22
The photo journal is included in Appendix 2. It was left for the participants own interpretation what
active ageing is, as this was of interest to the research. Background information and the aim of the
research were also provided in the photo journals, as well as instructions for the number of photos to
be taken and for answering the questions, so that participants could use this as a reminder. Taken
photos were digitally sent to the researcher before the interview took place, or printed by the
participant. It turned out that a couple of participants were not able to take photos themselves.
Instead, these participants had simply written down their facilitators and barriers of the physical
environment for active ageing, so without illustrative footage.
Interviews
Face-to-face semi-structured in-depth interviews served to contextualise the taken photos and to gain
insight into the participant’s perception of active ageing, an age-friendly environment, and facilitators
and barriers of the physical environment for active ageing. Completed photo journals served as a
reminder for participants for when they were asked to elaborate on the photos they had taken. A
structured interview guideline was used, which can be found in Appendix 3. Consequently, comparable
data could be obtained. However, since the interviews were semi-structured, there was also space to
complement this guideline by asking more in-depth questions if that appeared to be necessary during
the interview. For the development of the interview guideline, two previously conducted studies were
consulted. One of these had also made use of the photovoice method in relation to age-friendly
environments (Novek & Menec, 2014), the other had studied elderly’s perception of healthy ageing
(Naaldenberg, Vaandrager, Koelen, & Leeuwis, 2012). Researchers of these studies were contacted in
order to consult the interview guidelines they had made use of.
The interviews were conducted between January 12 and March 5, 2018. They took place at the
participants’ home or at the home of the researcher, depending on the interviewee’s preference, and
took 40 minutes on average. All interviews were conducted in Dutch, except for one in English. Broadly,
three categories of questions were asked: 1) the participant’s perception of active ageing; 2) the
participant’s perception of an age-friendly environment; 3) and questions related to the photovoice
assignment in order to collect data for participants’ perception of facilitators and barriers of the
physical environment for active ageing. As for this last category, the four questions from the photo
journal were used as a foundation. All participants except for one gave their permission for the
interview to be recorded.
23
4.3.3 Data analysis
After the interviews had been conducted, they were transcribed verbatim in Word. Completed photo
journals served to supplement or validate the interview transcripts. The one interview that could not
be recorded was transcribed by using the detailed notes that were made by the researcher. Thematic
analysis was then applied to the interview transcripts. By using this method of analysis, patterns of
meaning (themes) within the data were identified and interpreted. This was done in five steps, as
described by Braun and Clarke (2006). First, the researcher familiarised herself with the data by reading
the transcripts thoroughly and critically. Second, initial codes were generated. Third, a search for
themes was applied, in which a theme was considered to “capture something important about the
data in relation to the research question, and represents some level of patterned response or meaning
within the data set” (Braun and Clarke, 2006, p.87). Fourth, identified themes were reviewed. Fifth,
‘final’ themes were defined and named. These five steps were carried out separately for the first,
second and third research question. As a result, themes related to ‘active ageing’, ‘an age-friendly
environment’, and ‘facilitators and barriers of the physical environment for active ageing’ were
defined. An overview of all defined themes, including codes, can be found in Appendix 5.
After all transcripts had been fully coded, an overview of answers per code was made. In this way, it
became clear what was said by who in every interview per code/theme. This provided insight in
participants’ perception of active ageing, an age-friendly environment, and facilitators and barriers of
the physical environment for active ageing. Also, in this way, differences and similarities between
native and non-native participants could be identified.
4.4 Quantitative methods – questionnaire
For the quantitative part of this research, a questionnaire was developed by using the online survey
software Qualtrics. The questionnaire that was used for this research can be found in Appendix 4.
4.4.1 Procedure and sampling strategy
After the questionnaire had been developed, it was pre-tested by three of the researcher’s
acquaintances aged 60 years or older in order to remove linguistic errors and to check on the
comprehensibility and length of the questionnaire. Based on this pilot, adjustments were made to the
questionnaire. The questionnaire was then spread via the researcher’s personal network, by making
use of snowball sampling, Facebook, by sending it to organisations for (migrant) elderly, and by
spreading flyers door-to-door. People were provided with the digital link to the questionnaire, but the
contact address of the researcher was also provided in case people wanted to fill in the questionnaire
on paper. The questionnaire contained 46 questions. About 15 minutes were needed to answer these
24
all. Quantitative data was collected from December 20, 2017 till March 19, 2018. In total, 129 people
started the questionnaire and 113 people completed it, of which 21 were non-native. More detailed
sample characteristics are provided in chapter 5.1.
4.4.2 Measures
Broadly, four categories of questions were asked, which will be explained one by one below.
Age and living situation
Participants were first asked for their age (interval of 5 years) and their living situation (four options to
choose from), to make sure that only participants aged 60 years or older who still lived at home, either
with or without help from home care or relatives, were included.
Perception of active ageing and an age-friendly environment
Second, respondents were asked to provide a qualitative description of what they perceived to be
active ageing and of what an age-friendly environment looked like to them. They could answer both
questions in either whole sentences, or by using key words. These questions about active ageing and
an age-friendly environment served to gain data for sub-question 1, 2 and 3.
Characteristics of an age-friendly environment as identified by the WHO
Third, respondents were provided with the WHO’s definition of active ageing and asked whether they
agreed with this definition. Also, they were asked to asses a few aspects out of this definition on their
importance for active ageing. As an age-friendly environment aims to encourage active ageing, the
WHO’s definition served as a comparable reference point for respondents to answer questions meant
to obtain information about the fourth sub-question, which was ‘How important for being able to
actively age are the characteristics of an age-friendly physical environment as identified by the WHO
to native versus non-native Dutch elderly?’. These questions were based on the checklist for an age-
friendly physical environment as established by the WHO, which can be found in Appendix 1.
It was not feasible to ask participants for their perception or opinion on all of the characteristics from
this checklist. Therefore, a selection was made. If applicable, pictures served as a comparable reference
point for participants to assess the characteristics of interest. Therefore, the selection was based on
the researcher’s assessment of whether it was possible to make a representative picture of the given
characteristic. Also, the researcher’s assessment of whether the interpretation of the characteristic of
concern would lead to too much unclarity was used as a selection criterium. Selected characteristics
are presented in Textbox 4, Textbox 5 and Textbox 6.
25
A five-point Likert scale, ranging from not important at all (1) to very important (5) was used to answer
these questions, so that respondents could give value to the characteristics of interest. In this way,
ordinal variables were measured with equally spaced intervals. Moreover, respondents were provided
with space to come up with more characteristics that they considered to be part of an age-friendly
environment, and with facilitators and barriers of the physical environment for active ageing, in case
they wanted to. Provided answers were used as supplementary data for answering sub-question 3.
Control variables
Fourth, questions concerning socio-demographic factors were included in the questionnaire as control
Safe pedestrian crossing with nonslip markings
Cycle paths are separate from pavements and other pedestrian walkways
Outdoor safety is promoted by good street lighting
Outdoor safety is promoted by police patrols
There are sufficient public toilets, both indoors and outdoors, and they are clean and well-
maintained
Public toilets are accessible for elderly
Public space is clean and pleasant
There is sufficient safe green space
Benches and other public seats are well-maintained
Pavements have dropped curbs to road level
Special customer service arrangements are provided, such as separate queues or service
counters for older people
Services are situated together
Public space and buildings facilitate social encounters
All districts in a city or village can be reached with public transport
Doctors and other services can be reached with public transport
Public transport is affordable
Public transport is reliable and frequent, also at night and in the weekend
Houses have even surfaces
Houses have passages that are wide enough for wheelchairs
Bathrooms, toilets and kitchens are adjusted for older people, or have this opportunity
There is sufficient affordable housing in safe areas
Houses are available close to services and other houses
Textbox 6 Selected characteristics of an age-friendly environment – Housing
Textbox 5 Selected characteristics of an age-friendly environment – Transport and mobility
Textbox 4 Selected characteristics of an age-friendly environment – Outdoor environments
26
variables. Next to age and living situation, these were sex, monthly net income, educational level,
occupational status, marital status, and composition of the household. Sex was dichotomized, whereas
the other control variables were to be answered by using a multi-option format, for which only one
option could be chosen. Also, the numbers of the respondents’ postal code were asked for. In this way,
distribution of participants over the Netherlands could be monitored. Lastly, respondents were asked
to rate their health, to what extent they were hindered in their physical activity as a result of their
health, their mobility, and how active they considered themselves to be, both physically and socially,
by means of a five-point Likert scale.
4.4.4 Data analysis
Qualitative part of the questionnaire
Like for the interview transcripts from the qualitative part of this research, thematic analysis was
applied to the open questionnaire questions about participants’ perception of active ageing and an
age-friendly environment, and the additional facilitators and barriers of the physical environment for
active ageing. This was done in the same five steps as described in chapter 4.3.3. The themes that
derived from the questionnaire data were compared to those identified in the interview data. As
additional themes were found, the existing overview was supplemented by the themes and codes that
derived from the quantitative data. An overview of all defined themes, including codes, can be found
in Appendix 5.
Quantitative part of the questionnaire
The quantitative answers concerning the characteristics of an age-friendly physical environment as
established by the WHO were analysed by using IBM Statistical Package for the Social Sciences (SPSS).
Only completed surveys were analysed. MANCOVA was conducted to test the influence of the
independent variable ‘background’ on the dependent variables, which were the characteristics that
were to be assessed. So, significant differences between the mean scores of natives and non-natives
for the importance of these characteristics of an age-friendly physical environment as established by
the WHO was tested for. By using MANCOVA, it was possible to test this while at the same time the
influence of covariates could be both tested and controlled for. These covariates included ‘age
interval’, ‘sex’, ‘income’, ‘living situation’, ‘self-rated health’, ‘self-rated mobility’, ‘self-rated physical
activity’, ‘self-rated social activity’, ‘self-rated limitation in moving due to health status’, ‘education’,
‘years living in neighbourhood’, ‘occupational status’, ‘household composition’, and ‘marital status’.
Consequently, the true effect of background (native versus non-native) on the importance of
characteristics of an age-friendly environment as identified by the WHO for being able to actively age
27
could be tested for without the interference of covariates.
To be able to conduct MANCOVA, assumptions for MANCOVA were tested beforehand. As such,
outliers were detected using boxplots. However, they were left in as all assessment scores were
considered to be valuable to the aim of this research and there was no grounded reason to remove
these outliers. Independent sampling was controlled for by the sampling procedure that was used in
this research, which was more or less random. Equal variances was proven by Levene’s test. Normality
was checked for by using both the Shapiro-Wilk test and normal Q-Q plots. For individual dependent
variables normality was not present, which is not to be expected for ordinal data obtained by using a
Likert scale. However, by averaging the dependent variables within the predefined domains (Outdoor
environments, Transport and mobility, and Housing) a continuous scale was formed, for which
normality was almost always met. Nevertheless MANCOVA was used as this test is relatively robust
against non-normality, and suggested to not differ from a non-parametric test like Mann-Whitney-
Wilcoxon (De Winter & Dodou, 2010). Correlation coefficients between the dependent variables were
all well below the 0.9 treshold, therefore no multicollinearity was present and all dependent variables
were left in the MANCOVA model.
A significance level of p<0.05 was operated. The scores of non-western and western participants were
initially combined, in order to compare the assessment of native versus non-native participants. If
significant results were found, an ANOVA Post Hoc Test with LSD 0.05 and background as fixed factor
was performed to test if this significance could be accounted for because of the difference in scores
between non-western and native participants, or western and non-native participants. Outcomes of
the conducted tests can be found in chapter 5.5.
4.5 Ethical considerations
As this research used human beings as a resource for data, several ethical considerations were taken
into account. First of all, participants were fully informed about the research. They were informed
about the goal of the research, that their participation was on a voluntary basis and that they had the
right to freely withdraw at any time. Moreover, anonymity and confidentiality were guaranteed. For
the photovoice participants, an informed consent was to be signed beforehand, which is attached in
Appendix 6. They were also asked to sign for their permission to record the interviews. The same
informed consent was provided for questionnaire respondents. They had to confirm to have read it by
clicking ‘yes’, after which the actual questionnaire started. Ethical approval for this research was given
by the Social Science Ethics Committee of Wageningen University & Research, attached in Appendix 7.
28
Moreover, elderly are potentially a vulnerable group of people. Therefore, research was conducted
with respect and dignity at all times. Well-being of participants was considered a priority, as well as
doing them no harm.
29
Chapter 5 – Results
In this chapter, a participant overview is provided first, after which the findings from this research will
be presented. Findings will be illustrated by quotes of photovoice participants, referring to with P#, with
the number corresponding to the participant numbers provided in Table 2 and Table 3. Additionally,
quotes from questionnaire respondents will be provided, for which category (native, western, non-
western), sex and age interval will be given between brackets to contextualise the provided quotes with
regards to the main research question: ‘What are differences between the perception and wishes of
native versus non-native Dutch elderly regarding the contribution of the physical environment to active
ageing?’.
5.1 Participants
5.1.1 Photovoice participants
In this part of the research, 15 people were included, of which 7 were native Dutch, 4 had a western
migrant background and 4 had a non-western migrant background. Except for one woman from
Indonesia, all non-native participants were not born in the Netherlands and could therefore be
considered as first-generation migrants (CBS Statline, 2017). Participants’ age varied from 60 to 75
years and all lived independently without the help of family/friends or care organisations. An overview
of native photovoice participants is provided in Table 2 and an overview of non-native photovoice
participants is provided in Table 3. Furthermore, the distribution of photovoice participants in the
Netherlands is provided in Figure 7 and Figure 8 on page 37.
Table 2 Overview of native Dutch photovoice participants
Participant # Category Sex Age interval Residence
1 Native Dutch Female 60-64 Ridderkerk
2 Native Dutch Female 60-64 Ridderkerk
3 Native Dutch Female 65-69 Ridderkerk
4 Native Dutch Female 70-74 Ridderkerk
5 Native Dutch Female 70-74 Papendrecht
6 Native Dutch Male 60-64 Den Haag
7 Native Dutch Male 70-74 Wageningen
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Table 3 Overview of photovoice participants with a migrant background
Participant # Category Sex Age interval Residence In the Netherlands since age
8 Western (Indonesia)
Female 65-69 Capelle a/d IJssel 0
9 Western (Indonesia)
Female 75-79 Wageningen 13
10 Western (Australia)
Female 65-69 Ridderkerk 51
11 Western (Indonesia)
Male 60-64 Nijmegen 4
12 Non-western (Surinam)
Male 75-79 Ridderkerk 10
13 Non-western (South-Africa)
Male 65-69 Veenendaal 26
14 Non-western (Turkey)
Male 60-64 Ridderkerk 22
15 Non-western (Afghanistan)
Female 60-64 Ridderkerk 38
5.1.2 Questionnaire respondents
Of the 113 people who completed the questionnaire, 92 were native and 21 were non-native. Of these
Figure 7 Distribution of native Dutch photovoice participants
Figure 8 Distribution of non-native Dutch photovoice participants
31
non-native participants, 12 had a western migrant background and 9 had a non-western migrant
background. Further questionnaire sample characteristics are provided in Table 4.
Table 4 Questionnaire sample characteristics
Category Total nr. of participants Sex Age interval
Native Dutch 92 Female: 51 Male: 41
60-64: 19 65-69: 27 70-74: 18 75-79: 17 >/80: 11
Western migrants 12 Female: 9 Male: 3
60-64: 5 65-69: 4 70-74: 0 75-79: 2 >/ 80: 1
Non-western migrants 9 Female: 6 Male: 3
60-64: 5 65-69: 3 70-74: 0 75-79: 1 >/80: 0
Error! Reference source not found.Figure 9 and Figure 10 show the respondents’ distribution over the N
etherlands, based on the numbers of their postal code.
Figure 10 Distribution of non-native Dutch questionnaire respondents
Figure 9 Distribution of native Dutch questionnaire respondents
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5.1.3 Perception of participants’ migrant background
First of all, to find out to what extent non-native participants agreed with how they were categorised
in this research based on the categorisation as described in chapter 4.2, they were asked how they
would describe or categorise themselves in terms of their migrant background. Photovoice participants
were not restricted to optional answers, whereas questionnaire respondents could choose from 1)
Native; 2) Western migrant; 3) Non-western; 4) Differently, namely: … (to be filled in by respondent).
Most participants perceived themselves different than Statistics Netherlands considers them to be. No
photovoice participant used ‘western’ or ‘non-western migrant’ to describe him or herself. Table 5
provides an overview of how these participants did perceive their migrant background.
Table 5 Photovoice participants’ perception of their migrant background
Participant Category Statistics Netherlands
Sex Age interval
In the Netherlands since age
Perceived him/herself to be
1 Western (Indonesia)
Female 65-69 0 Moluccan
2 Western (Indonesia)
Female 75-79 13 Dutch
3 Western (Australia)
Female 65-69 51 Australian
4 Western (Indonesia)
Male 60-64 4 Dutch with non-western background
5 Non-western (Surinam)
Male 75-79 10 Dutch
6 Non-western (South-Africa)
Male 65-69 26 African with European influences
7 Non-western (Turkey)
Male 60-64 22 Dutch Turk
8 Non-western (Afghanistan)
Female 60-64 38 Dutch with Afghan roots
As for the questionnaire respondents, only 1 of the 12 respondents with a western migrant background
answered to be a western migrant. Six answered to be native, 3 to be non-western migrants, and 2 to
be ‘Indo’/’Moluccan’, specifically referring to their country of origin (Indonesia). For the respondents
with a non-western migrant background, 2 out of 9 participants considered themselves to be non-
western migrants, whereas 3 others considered themselves to be native, 3 to be western migrants and
1 said to be ‘non-native’.
Although this difference compared to the categorisation of Statistics Netherlands was found, the
objective categorisation of Statistics Netherlands was still used for further analysis in this research.
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5.2 Ageing in general
To find out more about photovoice participants’ perception of active ageing, they were first asked
whether or not they were consciously concerned with the ageing process in general. Most participants,
both native and non-native Dutch elderly, were not. Moreover, most did not experience any
complaints related to ageing. Participants resided in the fact that they simply get older.
“I am not concerned with ageing, you just get older, it happens, there is nothing you can do about it, it
is just a fact.” (P13)
Some participants however, both native and non-native Dutch respondents, reported to be consciously
aware of the fact that they were ageing because of the physical complaints they experienced, such as
rigidity when waking up in the morning or during cold weather. Also, increased tiredness and
decreased energy level were experienced due to getting older. No one reported to experience mental
complaints due to ageing.
5.3 Perception of active ageing
To find out what native versus non-native Dutch elderly consider to be active ageing, participants were
asked to give a description of this term. This question was part of both the interviews and the
questionnaire. For both native and non-native participants, active ageing was primarily found to be
about activity, in multiple forms. A couple of differences between native and non-native participants’
perception of active ageing were found. All identified themes for active ageing including differences
between native and non-native participants will be elaborated on in the following paragraphs, after
which an interim conclusion will be provided.
5.3.1 Physical activity
The majority of photovoice respondents, both native and non-native, perceived physical activity to be
an important part of active ageing, if not the most important part. Within this theme, several different
physical activities could be distinguished, of which cycling and walking were mentioned most
frequently. In addition, jogging, doing exercises from the television, senior gymnastics, going to the
gym, and playing a specific sport like tennis were reported as part of being physically active. Just
standing up instead of sitting all the time, just being outside or gardening, and doing physical tasks as
part of housekeeping were also mentioned by participants as ways of being physically active. Native
participants were found to take part in sport through sports clubs or in groups more often than non-
native participants. Also, less non-native than native participants were found to be physically active
through cycling. Non-natives were found to walk more often than that they cycled.
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To keep moving, staying in good condition, maintaining good health, and preventing obesity were the
main reasons for participants to consider being physically active to be important with regards to active
ageing. For these reasons, participants mentioned to put specific effort in moving as much as possible
or to consciously make time for doing sports with a certain frequency or regularity.
The results from the questionnaire confirmed that physical activity is an important part of active ageing
to both native and non-native Dutch elderly, as the majority of questionnaire respondents’ answers
were related to moving, exercising, or doing sports.
“Being able to walk and jog until I die.” (native, male, 70-74)
5.3.2 Social activity
Being socially active and to have social contacts were mentioned as part of active ageing by 4 out of 7
native Dutch photovoice participants, 3 out of 4 western migrant photovoice participants and 2 out of
4 non-western migrant photovoice participants. Moreover, all photovoice participants confirmed the
importance of social activity with regards to active ageing when directly asked for. This importance
was stressed more by non-native than by native participants. Besides, social activity was frequently
mentioned together with physical activity. As such, the word ‘active’ was not perceived to be just about
physical or social activity, but the combination of both. This applied to both natives and non-natives.
Social activity was found to contribute to active ageing mainly because it stimulates the mind and it
keeps one busy. Moreover, social contact was reported to combat loneliness, and was therefore
purposively searched for by a few non-native participants. Furthermore, three native Dutch
photovoice participants (P1, P2 and P6) specifically mentioned that active ageing is about having social
contact with younger people. Knowing what is going on amongst younger generations was mentioned
as main benefit. This helped these participants to stay youthful and to keep abreast of the times, which
they perceived to be beneficial to staying active.
Two photovoice participants with a migrant background (P10 and P15) who mentioned social activity
as an important part of active ageing experienced a language barrier. As a result, making contact with
Dutch people or people speaking other languages than their own was experienced to be harder,
making it is less easy to be engaged in social activity.
“Having contact with Dutch people is very important. If you cannot talk well, you only have little
contact.” (P15)
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A participant with a Turkish background (P14) also had difficulties with speaking Dutch, but as his
network mainly consisted of people from Turkey, he did not experience this as a burden for active
ageing.
Concerning the questionnaire respondents, 27 out of 92 native Dutch, 1 out of 9 non-western migrants
and 3 out of 12 western migrants mentioned active ageing to be about social activity. This does not
validate the qualitative finding that social activity is more important to non-natives. However, this
could be due to the fact that photovoice participants were specifically asked for the importance of
social activity for active ageing, while questionnaire respondents were not.
5.3.3 Mental activity
‘Keeping your mind fit’, ‘to remain stimulating your brain’ and ‘staying curious for new things’ were
repeatedly found to be associated with active ageing. These were mostly native photovoice
participants. As such, besides physical activity and social activity, mental activity was also identified as
a theme. Physical and mental activity were also reported together as combination several times.
Moreover, mental activity and social activity were found to be interrelated.
“Social activity, to be among other people. That you keep using your brain and stay alert.” (P1)
Mental activity was reported to contribute to active ageing because it helps to keep developing oneself
and to keep stimulating the brain. Preserving one’s mental capacities by being mentally active, or in
other words by training oneself, was also mentioned as a benefit. Reading, trying out new things, doing
board or committee work and studying were reported as ways of being mentally active. Cultural
activities like going to the theatre, a museum or concert were also linked to gaining new impressions
and to be beneficial to mental activity and active ageing as such.
“To be involved in art and culture, that challenge your mind time after time and provide new insights
and surprises, even make you stunned every now and then. That helps you to keep your mind lean,
because I think that in your head, I should all keep going.” (P6)
Questionnaire respondents also mentioned mental activity as part of active ageing, either in
combination with physical activity or apart. These too were natives, and a few western migrants.
Several of them specifically mentioned that following the daily news contributes to mental activity and
to active ageing as such.
5.3.4 Staying active otherwise
A couple of native and non-native photovoice participants mentioned that active ageing to them
36
meant not to be sitting still, or to be about the continuation of activities or hobbies like going on
holidays. “To keep doing that what keeps you moving, in its widest sense.”, as one participant (P11)
described this. Questionnaire respondents, both native and non-native, also reported active ageing to
be about the continuation of these kind of activities. Since the activities mentioned could not be
gathered under physical activity nor social activity nor mental activity, the theme ‘staying active
otherwise’ was identified.
5.3.5 Health
Having and maintaining a good health was perceived to be an important part of active ageing for
several photovoice participants, or even to be a requirement for active ageing. Native participants
mentioned this more often than non-natives did.
“There is only one thing, and that is health, and if you can maintain a good health for as long as possible,
then you can do a lot in this world, and stay active for a long time.” (P7).
Physical activity and social activity, and particularly the combination of both, were considered to
contribute to maintaining a good health when ageing. Healthy eating, smoking and not drinking too
much alcohol were mentioned as well. These three specific health aspects however, where mentioned
by native Dutch respondents only, whereas non-native respondents talked about health more
generally.
Out of the 113 questionnaire respondents, 14 out of 92 natives mentioned health, whereas for the
western migrants this was only 1 out of 12, and 1 out of 9 for the non-western migrants. So,
proportionally natives mentioned health more often. This finding confirms the qualitative finding that
natives are more likely than non-natives to perceive active ageing as health.
5.3.6 Mindset
Active ageing was mentioned by several photovoice participants to be about one’s mindset. Both
native and non-native participants mentioned this. However, proportionally this answer was provided
more by non-native participants. Generally, a positive mindset was mentioned. More specifically,
having the will and intention to be able to actively age was mentioned as mindset. This was even
considered to be a requirement for achieving active ageing.
“Look, in my opinion, active ageing is something that you need to go and train, you need to want it, to
have the will, the mindset. And you need to be convinced that it contributes to your overall well-being.”
(P13)
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Secondly, to continue doing what you had always done was mentioned frequently as a mindset
towards active ageing, and also as a way of achieving active ageing as a result.
“You have to keep doing what you did, stay active, then it automatically continues. But if you sit back,
and stop, yes then it is finished, done.” (P12)
In addition, questionnaire respondents mentioned not to think about what you cannot do anymore,
but to think about what you still can do instead in order to stay active as a mindset. Not being limited
by your age in general, and not accepting the limitations that you experience as a result of your age
were mentioned too.
“Do not think in limitations, but in possibilities.” (native, female, 70-74)
Lastly, to enjoy life and to enjoy in general were also coded under this theme, for this was considered
to be related to having a positive mindset. Both photovoice participants and questionnaire
respondents touched upon this topic.
“To enjoy, yes, that is active ageing.” (P8)
5.3.7 Mobility
Several photovoice participants mentioned active ageing to be about having and maintaining the
ability to move around. Hence, mobility was identified as a theme. It were mainly native Dutch
participants who touched upon this topic. Mobility was perceived to enable one to go to places, see
things, or visit people. This was valuable to participants with regards to staying active because it
enables one to see more of the world than just one’s own neighbourhood or place of residence.
“That is also part of active ageing, that you can still move yourself to see things. And that you can often
visit things.” (P3)
Moreover, being mobile was reported to contribute to the ability to have social contact. As such, social
activity and mobility were found to be interrelated themes.
Questionnaire respondents also touched upon mobility. These were natives only. From their answers,
it was furthermore confirmed that the importance of maintaining one’s mobility becomes more
relevant once elderly are not able to drive a car anymore, or just do not have a car.
5.3.8 Independence and autonomy
This theme covers all provided descriptions of active ageing that were related to being independent of
the help of others, able to make one’s own choices based on one’s own preferences, and to be self-
38
reliant. Although not completely similar, independency and autonomy were merged as a theme, since
both terms are to some extent related to the idea of freedom of choice and making one’s own
decisions.
“Active ageing means that you are still able to do everything on your own and to decide for yourself.”
(native, female, 75-79)
Two native Dutch photovoice participants touched upon this topic, just as 16 native Dutch, 1 western
and 2 non-western migrants did in the questionnaire. Therefore, this theme was considered to be
mainly related to natives’ perception of active ageing.
Independence and autonomy were important to people with regards to being able to remain living in
one’s own home, being able to drive a car, not needing too much help from others, or simply to
“independently be able to earn a living and give substance to life” (P2). Moreover, being independent
was reported to be of influence on the opportunity to have social contact. Mobility in its turn was
found to influence the extent to which one can be independent. Therefore, social activity, mobility and
independence can be considered to be interrelated themes.
“As long as you are independent, so as long as you can move yourself, that your body still allows that,
you can make your own decisions about what you want and what you do not want. Then you can go
out and you can make contacts. I think.” (P1)
5.3.9 Keeping up
This theme was also identified from the questionnaire data solely. Respondents specifically mentioned
that active ageing was about keeping up with younger generations, remaining interested in daily life,
and being able to cope with new current developments, both societal and technological developments,
and the current times in general. It were almost only native Dutch respondents who perceived active
ageing to be about keeping up.
“To be able to keep up with new developments.” (native, female, 60-64)
As already elaborated on under the theme ‘social activity’, being in contact with younger people was
also mentioned as a way of keeping up with younger generations, which was perceived to be useful
with regards to staying active. As such, ‘social activity’ and ‘keeping up’ can be considered as
interrelated themes. Moreover, reading the newspaper daily was reported by some participants to be
part of keeping up, but by others to be part of mental activity. This shows that the same strategy or
39
medium, reading the newspaper in this case, can contribute to different parts of active ageing
depending on the perception or goal of a person.
5.3.10 Participation
Active ageing was multiple times described as to keep participating in things, for example by doing
voluntary work or societal engagement, and to be of meaning to others in general.
“To keep participating in a lot of things. It means to help other people, whenever possible, for example
by doing voluntary work.” (P9)
Participating in voluntary work was considered to be beneficial because one can be of meaning to
others and to society. More specific, contributing to society by means of participation was mentioned
to provide a sense of satisfaction and to contribute to active ageing as such. Also, doing voluntary work
was mentioned as a way to have social contact. As such, participation and social activity were found
to be interrelated themes.
In the photovoice sample, it were only non-natives who mentioned active ageing to be about
participation or doing voluntary work in specifc. In the questionnaire sample however, this was almost
solely mentioned by native respondents.
5.3.11 Non-native participants’ perception of influence migrant background
Non-native photovoice participants were asked whether they themselves thought that their migrant
background was of influence on their perception of active ageing. Whereas two (Surinam, Indonesian
male) did not think so, five participants (Moluccan, Indonesian female, Turk, Australian, Afghan, South-
African) did. Reasons to confirm this influence were mainly because being (physically) active (until old
age) was very important in their country of origin and was stressed from young age onwards, or
because the perspective on growing old and on elderly in general was different in the culture of that
country, and was related to a higher level of social activity. However, in that sense it appeared not
necessarily to be the fact that these participants migrated which had influenced their perception of
active ageing, but the cultural norms, values, traditions and attitudes with which they were raised.
“I do not think my view on active ageing is different because I migrated, no. But, Indonesian elderly
remain very active until old age, they do that, yes. So I do think that I also have that.” (P9)
Still, one participant (P10) did consider the fact that she had migrated at age 51 from Australia to the
Netherlands to be of influence on her perception of active ageing. This was because of the language
barrier she faced, resulting from moving to a new country with a foreign language that was hard to
40
learn. Consequently, she was less able to participate in social activity while she did consider this to be
an important part of active ageing. As a result, she had a lower level of active ageing than admired for
staying active and had to adjust her expectations of active ageing.
“I think so, yes. Yes because in Australia we all speak the same language. But here I cannot go to many
places, because I cannot communicate. I cannot go to my neighbours and say ‘oh I am bored’. In
Australia it is different. I had my car. I am bored, I go to the sea, and drive, then walk. I cannot do that
here. That is the part that I am missing. That I am regretting coming, in that sense. You feel more alone.
And being alone is not always good. Because then your mind starts thinking negative all the time and
it is not good for your body.” (P10)
5.3.12 Interim conclusion
This section serves to summarise the most important findings regarding native versus non-native Dutch
participants’ perception of active ageing. Ten themes were identified. Many of these were found to be
interrelated or to be of influence on each other. For both native and non-native participants, active
ageing appeared to be about multiple forms of activity and staying active by participating in these
different activities. Physical activity can be considered to be the most dominant, as the majority of
both native and non-native participants appeared to associate the word active in active ageing at least
with physical activity. Non-native participants were found to walk more than cycle in order to actively
age. Also, they were found to be less involved in sport through clubs or in groups than their native
peers. After physical activity, social activity was mentioned most often, and also the combination of
physical and social activity. The importance of social activity for active ageing was stressed more by
non-native than by native participants, amongst others because it combats loneliness. Another
difference for the theme of social activity was that native participants attached more value to social
contact with younger generations. Furthermore, mental activity, health, mobility and independence
and autonomy were (proportionally) mainly touched upon by native participants. The same applies to
keeping up, which can be linked to the finding that natives attached more value to having social contact
with younger generations. Mindset on the other hand, was mainly touched upon by non-native
participants. No specific differences between western and non-western migrants were found. The
results for the perception of native versus non-native participants’ perception of active ageing are
summarised in Table 6.
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Table 6 Summary of natives’ versus non-natives’ perception of active ageing
All mentioned aspects of active ageing: Physical activity
Social activity
Mental activity
Staying active otherwise
Health
Mindset
Mobility
Independence and autonomy
Keeping up
Participation
More important to natives: Social activity with younger people
Mental activity
Health
Mobility
Independence and autonomy
Keeping up
More important to non-natives: Social activity in general
Mindset
Furthermore, the observation of interrelatedness between identified themes turned out to be
characteristic for active ageing being a broad concept that can be perceived in multiple ways. Physical
activity and social activity for example was perceived to be related to health. Mobility in its turn, was
perceived to be related with physical activity and social activity. As such, active ageing turned out not
to simply be about physical activity or social activity to participants, but to be about a variety of aspects
which often interact with each other. This applied to both native and non-native participants. However,
the answers of native participants about their perception of active ageing were generally more
multidimensional and touched upon more themes than the answers of non-native participants.
5.4 Perception of an age-friendly environment and related facilitators and barriers
First of all, for a few photovoice participants it appeared to be a challenge to come up with a
description of an age-friendly environment because they thought that an age-friendly environment
would only become relevant to them once they would start to experience physical limitations or health
problems. It were mostly native participants who specifically mentioned this.
“Yes, an age-friendly environment, well I have never thought about that. An age-friendly environment
only becomes relevant if you start to have limitations.” (P7)
A few native questionnaire respondents mentioned this too.
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“Seniors do not need specific services, that is only when they start to have handicaps.” (native, male,
70-74)
As such, for these participants it was not their age in itself that defined whether they needed special
services, but their health status or physical ability. This is something to take into account when
designing age-friendly environments. Moreover, the questionnaire data also showed that it was hard
for some respondents to give a description of what they perceived to be an age-friendly environment
simply because they did not yet consider themselves to belong to the aged. These respondents were
natives or western-migrants.
The main finding regarding both native and non-native Dutch elderly’s perception of an age-friendly
environment is that an age-friendly environment is primarily about the facilitation of certain needs.
These needs are related to being able to remain functioning in daily life and in society, and to stay
active, despite possible physical limitations experienced due to the ageing process. Although
both natives and non-natives were found to agree on this, some differences between both groups
were found for which specific needs were perceived to be important for an environment to be age-
friendly. These differences will be elaborated on in the following paragraphs of this chapter.
As almost all identified facilitators and barriers of the physical environment for active ageing were
found to be linked to the identified themes for an age-friendly environment, the answers to the second
and third sub-question were integrated. In practice, this means that specific examples in the form of
facilitators and barriers will be provided for the identified themes of an age-friendly environment, in
case these examples were described by participants and/or respondents. Although sub-question 2 and
3 were integrated, an interim conclusion will be provided for both sub-questions separately in chapter
5.4.13 and 5.4.14.
5.4.1 Accessibility
Accessibility at different levels and in different ways was found to be important for an environment to
be age-friendly to many photovoice participants. Both native and non-native participants mentioned
this, but natives more often. The two biggest similarities between all findings within this theme were
that 1) accessibility is mainly about being able to enter (public) buildings/shops/the house and move
within these buildings, and 2) accessibility is desirable as walking in general and things like climbing
stairs can get harder with age. Also, as a result of a decrease in physical ability due to getting older,
some people have to use a rollator or mobility scooter. This was mentioned to require adjustments of
the physical environment, so that accessibility remains guaranteed in order for people to stay active.
43
As such, accessibility can enable people to keep walking, and supports both mobility and physical
activity in that way. In addition, if accessibility enables people to go places, social activity is promoted.
Financial accessibility was also coded under this theme. This was mentioned with regards to housing,
public transport and organised activities, by both native and non-native participants. If the financial
barrier is too high for people to be able to make use of public transport or to join in organised activities,
they were found to be less likely to stay active as they cannot afford to go. Moreover, affordable houses
need to be available for people to comfortably live in.
The questionnaire data validated accessibility to be of significant importance for an environment to be
age-friendly. The need for accessibility was mentioned many times, by both native and non-native
respondents.
Identified facilitator: accessible housing
Accessible housing was perceived to be an important facilitator of an age-friendly environment, mostly
by native participants. It can prevent people from having to move home when getting older, which was
considered to be valuable and desirable. Moreover, if housing is accessible, people are enabled to live
independently for as long as possible. This was a wish of many participants. To have everything at
street level and to have no doorsteps were mainly mentioned to be important for accessible housing,
as well as the presence of an elevator in an apartment building. Moreover, if a house is not at street
level, accessibility can still be facilitated by adjustments to e.g. the shower and by installing a stair lift.
Accessible housing was mentioned by questionnaire respondents too, mostly natives.
“A house that is easy and with that I mean accessible. It does
not necessarily have to be at street level, because you can also
install stair lifts and make adjustments to things like the shower.
We have straight stairs for example, designed in such a way that
when we get older and it is simply not possible anymore to climb
it, installing a stair lift is very well possible. That means that you
can live in your own home for a long time. That it remains
accessible and we can remain doing or own thing. And the same
applies to the second stairs to the upper floor.” (P1, Image 1)
Image 1 Straight stairs inside house
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Identified facilitator: accessible public buildings, shops, and pavements
Both photovoice participants and questionnaire respondents specifically mentioned accessible public
buildings, shops and pavements to be requirements for an environment to be age-friendly. In this case
too, this were mostly native participants. However, non-native participants were found to perceive
accessible public buildings, shops and pavements to be more important for an age-friendly
environment than accessible housing.
For public buildings and shops, the presence of an elevator and easy entrance without steps were
found to contribute to accessibility and to age-friendliness as such. For pavements, equal and no loose
paving stones were desired, also with regards to safety. In addition, dropped curbs to road level were
reported to facilitate accessibility. These enable people using a rollator, wheelchair or mobility scooter
to access pavements as well. For the same reason, cars not being parked over or on the pavement was
identified to be a facilitator of accessibility and accessible pavements in specific. One native photovoice
participant identified this facilitator, as well as a few native questionnaire respondents.
“At this day it was not that bad, but sometimes the cars are
parked so far on the pavement that there is just enough or
not enough space left to pass for people with a mobility
scooter. The accessibility of the pavements should be
assured.” (P2, Image 2)
Identified facilitator: keeping public space free from ‘natural material’
Leaves being removed in autumn, snow in winter, and fallen branches after a storm were desired in
order to facilitate accessibility of roads, pedestrian areas, and footpath. This was mentioned by both
native and non-native participants.
Image 2 Cars parked over the pavement
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“You see a path here, in a nature reserve. Well, this causes
an impregnable threshold for people in a wheelchair or
people that have difficulties walking, it is not accessible.
They cannot come past this point. (P11, Image 3)
Identified barrier: stairs in public space
Stairs in public were mentioned by a couple of photovoice participants to be a barrier for accessibility
and therefore to active ageing. These were both native and non-native. They were of this opinion
because the less well people are able to walk, which generally comes with age, the less well people are
able to climb these stairs. Placing grips and slopes were suggested as ways to make stairs in public
space more accessible.
“There is the road, and this is about a meter below. So from
our front door, we need to climb that stairs. How am I going
to do that when I can walk less well? This is not age-friendly.
Does this stimulate me to go outside? I do not think so. This
is a barrier to active ageing.” (P13, Image 4)
There were also a few participants who made a comment about the presence of stairs in public space
being perceived as a barrier to active ageing. They mentioned that these stairs could instead also be
perceived as a challenge for elderly, because stairs can help them to stay active in an easier way than
by e.g. doing sports. It were only native participants who touched upon this topic.
Image 4 Stairs in public space
Image 3 Fallen branches on footpath
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“As for an age-friendly environment, I am a bit two-sided about that. Stairs for example. You can
interpret that both in a positively and in a negative way. You can say that you do not want that, as a
senior, because at a certain moment that can get to hard or difficult. On the opposite, you can also say
that taking the stairs keeps you very young and vigorous. I think it is good if there are services for people
who cannot walk well anymore, like an elevator, so that all seniors can come in, but do not make it too
easy, it may contain something of a challenge.” (P6)
Identified barrier: surface of footpaths
The presence of footpaths was found to be a facilitator active ageing. However, the extent to which
footpaths are accessible and thus useable for all elderly, appeared to depend on the surface of the
path. Certain surfaces were namely reported to be too influenceable to weather conditions like rain,
causing mud pools. This barrier was identified by a few photovoice participants, both native and non-
native.
“This is a path with shells. It is beautiful, a park-like
path which takes you to the city centre. But there are
many water holes here when it rains. Due to the
selected surface, you have to slalom sometimes, or
jump. And not all elderly can do that. This is a footpath,
so you should make sure that people can walk here,
including elderly.” (P13, Image 5)
5.4.2 Safety
The facilitation of safety was found to be a requirement for an environment to be age-friendly.
Participants reported to be more likely to go outside in a safe environment, because they felt more
secure and thus encouraged. This was found to be of positive influence on one’s level of activeness,
both socially and physically. Also, safety was found to contribute to mobility. Non-native photovoice
participants seemed to be concerned with safety more than their native peers. This was confirmed by
the information retrieved from the questionnaire respondents.
Furthermore, the wish to live in a clean environment, including good air quality, and in a trusted
surrounding were also coded under this theme, as those answers were considered to be linked to
safety. These features were mentioned by both native and non-natives.
Image 5 Not suitable surface of footpath
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“The environment also needs to be clean, also in terms of air quality. Because that helps me to be
physically active and to be moving more easily.” (P2)
Identified barrier: lack of street lighting
A lack of street lighting was mentioned several times by both native and non-native participants to
cause a feeling of unsafety or danger. Consequently, participants reported to be less likely to go
outside. Whereas for natives this feeling of unsafety was mainly caused by the fear for falling over an
unseen ledge or not being noticed by other traffic users, non-natives mainly feared people with bad
intentions or the presence of loitering.
“Because it is badly enlightened, you see lots of youth. And in the evening, you do not go and walk there
alone, because then you feel unsafe. So if you put more street lighting there, that would be nice because
then you would feel more at ease. And elderly should not be hiding themselves at night. It is also nice
to go out at night sometimes, or to be able to join festivities that happen in the evening. So make sure
that elderly can go. More street lights can help.” (P13)
“The street lighting did not work in our street. It was
very dark, so dark that I considered it to be dangerous,
very dangerous. Not for people attacking you, but for
the traffic, for other users, that they do not see you, or
that I do not see it. I would cycle via another route
where it is less dark. Because when you get older, your
vision gets worse.” (P1, Image 6)
Identified barrier: dangerous traffic situations
A couple of non-native photovoice respondents mentioned dangerous traffic situations to be a barrier
to safety and to active ageing as such. These concerned cars driving too hard in residential areas and
a dangerous crossroad. Both were found to cause a feeling of unsafety, resulting in being scared to
cross a road or go out in general.
Image 6 Lack of street lighting
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“This is a very busy road in Nijmegen. I find that this is
a kind of highway in the city, a kind of race-track. You
have to make sure that this does not become an
impregnable threshold, especially for older people.
Because when the light turns green, they need to have
sufficient time to make it to the other side. And a lot of
cars run a red light. Recently, two people died here.”
(P11, Image 7)
Several questionnaire respondents also mentioned dangerous traffic situations to be a barrier to safety
and to an age-friendly environment as such. Besides more general traffic-related things like cars driving
too hard in the neighbourhood and the presence of scooters and mopeds on cycle paths, specific traffic
situations in the respondents’ place of residence were also described. Next to the design of
infrastructure, especially cyclists were blamed for causing dangerous situations by unexpectedly
crossing the road or riding on the wrong side. It were native respondents who mentioned this.
5.4.3 Mobility
Being able to move oneself from one place to another was mentioned as a feature of an age-friendly
environment by several photovoice participants, both native and non-native. As such, the theme of
mobility was identified. Supporting mobility in an environment was considered to be especially
relevant for people who would or could not cycle or drive a car anymore, or who experienced
difficulties walking. This was mentioned by both native and non-native participants.
Identified facilitator: public transport
Public transport was repeatedly mentioned by both native and non-native participants to be an
essential facilitator of mobility. Also, public transport was reported to be important because a
reasonable amount of elderly needs to visit doctors regularly and not everyone can be transported
there by their relatives or by using one’s own car. Hence, public transport was perceived to contribute
to independency. Moreover, by making use of public transport, parking problems, including having to
walk too far from the car to the place of destination, can be avoided. In addition, public transport was
perceived to contribute to social contact, not only inside the vehicle, but also because it enables people
to go to places and meet people. Non-native participants were found to attach more value to the use
of public transport than their native peers.
Image 7 Dangerous crossroad
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“For me, this bus stop symbolises mobility, or in other words:
the gate to ‘the rest of the world’. To me, active ageing
means not only staying physically active, but also being free
to decide where you want to go. Now it is still the car, but if
that is not possible anymore, the presence of public transport
in the immediate surrounding is a must. I think that people
should be enabled to move themselves. I think that is very
important.” (P11, Image 8)
For public transport to contribute to mobility, several requirements should be met. These
requirements were put forward by both native and non-native photovoice participants as well as
questionnaire respondents. First, stops should be close by participants home’s and the place of
destination and they should be covered, so that people do not have to walk too far and do net get wet
when it rains. Second, public transport should be safe. To ensure safety, paying more attention to the
visible presence of conductors in the train was mentioned. Third, public transport should be accessible.
This was mostly mentioned with regards to people with walking problems being able to enter the
vehicle.
“Public transport that is physically doable: that I do not need vaulting-poles to get in.” (western,
female, 65-69)
Fourth, public transport should be affordable, for which free travelling for elderly was identified to be
a way to achieve this.
“We have free travelling for 65 plus, that is lovely, a salvation. It is cheaper than by car. So we can move
ourselves and go to places.” (P8)
If there is public transport available, but it is not accessible, safe and/or affordable, elderly are not
enabled to make use of it, which is of negative influence on one’s mobility. Therefore, it is important
to not only pay attention to the availability of public transport, but also to these boundary conditions
for being able to make use of public transport.
Identified facilitator: availability of seating
The availability of seating in nature or green space, but also in public buildings or space, was
Image 8 Bus stop
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mentioned repeatedly to be beneficial to one’s level of mobility and to be a facilitator of the physical
environment for active ageing because of that. Covering a certain distance while experiencing
limitations in walking or physical condition was found to get easier when seating is provided. In this
way, one can sit down and take a rest every now and then, after which one can continue the journey.
As such, the need for this seating was found to be higher for people with a lower health status or
mobility level. Moreover, it were mainly non-native participants who put the importance of availability
of seating for mobility purposes forward.
“If there are more benches, then when you get tired you can
sit down and rest. And there is a lot of people who hardly
can walk. They should do more for that. They should put
more benches, for example like this one. If I go for a walk or
go to the shop, I need to rest every now and then. If there is
a bench where you can rest, it would be nicer, more
enjoyable, and I would be better able to move myself
because I can go more easily.” (P10, Image 9)
5.4.4 Opportunity to be physically active
A considerable part of the photovoice participants mentioned the facilitation of opportunities to be
physically active as their perception of an age-friendly environment. These were mostly native
participants. Although the majority of desired opportunities to be physically active were mentioned to
take place outside, inside opportunities were also considered to be important for an age-friendly
environment.
“An environment where there are opportunities to move or play sports, also for seniors, such as
walking, cycling, swimming, fitness, yoga, or dancing. So, both indoors and outdoors.” (P2)
Questionnaire respondents also mentioned an age-friendly environment to be one with opportunities
to be physically active. These were also mostly natives. Moreover, they mentioned to preferably have
these opportunities to move close to their homes.
Identified facilitator: sports club
Besides having the opportunity to be moving individually through walking or cycling, a few photovoice
Image 9 Seating
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participants and questionnaire respondents also desired to have a sports club in their environment, of
which some preferred that those would offer senior-tailored activities. These were all natives.
Identified facilitator: cycle paths
The availability of cycle paths was mentioned by several participants to create opportunity to be
physically active, and to be a facilitator of the physical environment for active ageing as such.
Preferably, cycle paths surrounded by nature were desired, as these contribute to experiencing a
feeling of relaxation or joy when cycling. Moreover, participants preferred to be cycling in the nature
over cycling in urban areas because they felt safer when not having to pay attention to cars and other
traffic.
“If we go cycling we go to the forest or nature,
because it is too busy in the city to cycle. When we
were younger we did go cycling in the city on
Sundays, but now I sometimes do not feel safe in
the city, because of the bustle, I do not like the
bustle anymore. But in nature, it is nice to cycle,
relaxing. Just pleasant, to enjoy. And it helps us to
keep moving.” (P8, Image 10)
Next to cycle paths in general, several participants specifically mentioned separate cycle paths as a
facilitator of active ageing. These participants preferred to be cycling on separated cycle paths over
cycling on the regular road or on a cycle lane on the regular road, because they felt more safe when
not having to pay attention to cars and other traffic while cycling.
“I definitely prefer separate cycle paths. Because that is more safe, in general, but especially for older
people. And on a cycle lane on the regular road, or on small roads, yeah well racing cyclists also cross
there, and I find that dangerous sometimes. Not everyone rings his or her bell. And they do not take
into account that the hearing of a lot of elderly is not so good anymore. And all those scooters on the
cycle lane, that is also not good in my opinion. They should separate that more.” (P4)
For cycle paths it too applied that these were mostly mentioned as facilitators of the physical
environment for active ageing by native participants.
Image 10 Cycle path
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Identified facilitator: footpaths
Footpaths were also identified to facilitate opportunity to be physically active, and to contribute to
active ageing as such. Especially footpaths in nature were perceived as facilitators, because these made
participants experience relaxation and a feeling of freedom. More generally, footpaths were also
mentioned to facilitate a feeling of safety. This was because they prevent people from being hit by cars
or cyclists, which would be more likely to happen when walking on the street or non-separated walking
areas. Like for cycle paths, footpaths were also considered to be beneficial as they facilitate being
outside and contribute to mobility. Footpaths seemed to be more essential to non-native participants
than cycle paths. However, like for cycle paths, footpaths were found to be more important to native
than to non-native participants for an age-friendly environment.
“Preferably, I walk in the park, on a path. But I also do not mind to walk just on the pavement, that is
also nice.” (P15)
“I prefer to be walking on a path like this, over walking in the
city. Because that is not really relaxing in my opinion. I want
to walk, without being hit by cars or cyclists. That makes me
feel safe. And free. For me, this contributes to active ageing
as I keep moving, and keep being outside. So it is about
moving, relaxation, and being able to go somewhere.” (P5,
Image 11)
However, not all elderly were found to desire to walk in nature, as becomes clear from the following
quote:
“I like to walk in the city. I do, not in the forest or so. Because
active means to be between people. That is why we do city
walks, and then sit down on a terrace. Just enjoy. For me this
picture of the city illustrates a feeling of openness, to feel free
actually. We walk, we meet people, we talk to people. And
you also enjoy the architecture of the buildings.” (P8, Image
12)
Image 11 Footpath
Image 12 Walking in the city
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5.4.5 Presence of nature or green space
That an environment is age-friendly when there is nature or green space was a perception shared by
different photovoice participants, both native and non-native. The presence of nature or green space
was reported to enable people to be outdoors, which contributed to a feeling of overall well-being.
Also, it was perceived to facilitate physical activity. Moreover, being physically active in green space
was perceived to be more healthy and attractive than being physically active in an urban area and
therefore preferred and purposively looked for. As such, the themes ‘presence of nature or green
space’ and ‘opportunity to be physically active’ were found to be interrelated. Furthermore, the
presence of nature or green space was identified to be a facilitator to active ageing because it enables
people to find a moment of peace or relaxation, to enjoy the sun or things like insects and trees, to
experience a feeling of freedom, and to have a positive mood. All these effects were reported to
contribute to well-being.
“When I walk, I look for as much green space as possible.
Because some people do not think about that, and they just
walk next to the highway. And then I see the emission gasses
entering my nose, so to speak. If I were to choose, I would take
a path like the one on the picture. But they do not think about
that, they just walk along the highway for a long distance.
And then you are being healthy by walking, but at the same
time you are being unhealthy.” (P4, Image 13)
“This is the view from my window. This environment is ideal
to me, this is what I want. You know, with nature, that you
have the freedom to see things. If I look outside and I see the
freedom and the nature, I love that. It gives me a good
feeling.” (P12, Image 14)
Image 14 View on nature out of house
Image 13 Nature to walk in
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The reasons for the presence of nature or green space to be a facilitator of the physical environment
for active ageing were confirmed by the answers provided by the questionnaire respondents. These
were also both natives and non-natives.
Identified facilitator: park or forest
Parks and forests were identified as facilitators of nature or green space by both native and non-native
participants. The combination of being physically active while being enabled to relax without cars
zooming by was specifically mentioned as an advantage of having a park or forest in one’s
environment. The availability of seating was reported to contribute to this feeling of relaxation, as this
enables one to sit down and enjoy. Non-native participants were found to be more likely to make use
of seating in a park or forest. Furthermore, the building or presence of artificial green space seemed
to be more relevant to people living in a city, as it is harder to find natural green space there.
“This is a memorial park. And there are very old trees.
Absolutely fascinating, those trees. And I also find it
a beautiful place where you can abate. You can walk
there, it is not too long, but it is possible, especially
with regards to elderly it is a nice distance, through
the park. And there is a bench were you can sit down
to relax and enjoy the sun.” (P13, Image 15)
Identified facilitator: garden
To have a house with a garden so that participants could go outside was also mentioned several times
as facilitator. It were mostly native participants who mentioned this.
“Having a garden simply forces you to do something. That is hard work sometimes, like pruning. So I
makes me very active, physically. It is also a nice stretch exercise sometimes because you do not want
to be standing on plants, or when you have to prune high up. So you are physically active, outside. And
with nature. And I like that a lot. You do it with your whole body, and it is also some kind of training. I
am better able to keep my balance now than I was five years ago, so it helps you to get stronger.” (P4)
Although agreeing on the wish to live in a house where one can go outside, a couple of these native
participants mentioned to also be satisfied with a balcony, in case a garden is not possible to have.
Image 15 Park
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“At least a house where you can go outside. It does not necessarily have to be a garden, because you
also need to maintain a garden. So it can also be a balcony. But you need to be able to sit outside if the
weather is nice, to me that is a requirement.” (P1)
5.4.6 Social contact
Both native and non-native photovoice participants and questionnaire respondents repeatedly
mentioned that an age-friendly environment needs to facilitate social contact, as social activity was
perceived to contribute to active ageing. However, this need was found to be higher for non-native
participants. This could be related to the finding from chapter 5.3.2 that non-native participants
stressed the importance of social contact for active ageing more than natives did.
“An environment that invites you to make social contact.” (western, male, 60-64)
Also, non-native participants reported to be more likely or willing to join organised activities in order
to have social contact than their native peers.
“If there were more activities organised, like social meetings, I would like to go there, but now there is
nothing and I cannot meet people.” (P10)
“I do not like forced social meetings, or other things like that. Just let me do my own thing.” (P7)
Next to that, non-native participants generally reported to like being involved in social contact with
other elderly, whereas native participants generally preferred to be in mixed company while enjoying
social contact. This could be related to the finding from chapter 5.3.2 that native participants were
more likely to describe active ageing as having social contact with younger generations.
Identified facilitator: social meeting places
Different social meeting places were identified by photovoice participants as facilitators of the physical
environment for social contact. These social meeting places were preferred to be present in the direct
neighbourhood of one’s home. Community centres were mentioned most often. More non-native than
native photovoice participants reported to be interested in joining activities in a community centre in
order to have social contact. In addition, cafés and restaurant were mentioned as social meeting
places. Also, a few social meeting places that were more ‘out of the box’ were identified: a city beach
and a shopping street.
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“If you choose to go to a shopping street like this,
then you are triggered to have more social contact.
Because when you walk here, you meet all kinds of
people on the street, or in the shops, so social
contact arises there. And that is different than just
saying hello to the one that delivers your online
ordered groceries at home. And shopping malls also
do not trigger activity in me.” (P6, Image 16)
5.4.7 Organised activities
Having the opportunity to join organised activities was also identified as a need that an age-friendly
environment should facilitate, by both native and non-native participants. As the participants who
touched upon this topic did not mentioned that they wished to join activities in order to have social
contact, but instead because they just wanted to be occupied in activities that have their interest, this
separate theme was identified. This theme could also be identified from the questionnaire data.
Several activities were mentioned by respondents, both native and non-native, varying from knitting,
to wood crafting, to dancing.
“That there are courses or activities in the field of computers and other things that I am interested in.”
(native, female, 65-69)
Moreover, several questionnaire respondents perceived an age-friendly environment to be one in
which people have the opportunity to do voluntary work, or more generally: to be of meaning to
others. These kind of desirable activities were also coded under this theme.
5.4.8 Cultural activity
Several participants considered an environment where cultural activity can be found to be age-friendly.
The facilitation of cultural activity in an environment was mentioned to contribute to mental
stimulation and to enable outings and activities, which both contribute to staying active. It were mostly
native participants who mentioned cultural activity. This can be related to the finding that natives
perceived active ageing more than non-natives as mental activity, which was linked to cultural
activities, as described in chapter 5.3.3.
Image 16 Shopping street
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Identified facilitator: cultural places
A couple of cultural places were identified as facilitators of cultural activity and hence, of active ageing.
These included a theatre, cinema, concert-room and cultural centre.
“This is a square in Rotterdam, where you are
absorbed with culture, so to say. A theatre,
cinema. That keeps you vigorous and young in your
head, so for your mind. And next to physical
activity, I find that very important.” (P6, Image 17)
5.4.9 Close by
To have things in the close neighbourhood of one’s home was found to be important to a significant
amount of photovoice participants for an age-friendly environment. This applied to both native and
non-native participants. The presence of certain features like nature or social meeting places in an
environment was considered to be one thing, but to be able to find these close to your home as
another. Therefore, ‘close by’ was identified as an overarching theme for an age-friendly environment.
Social services, medical services, and public transport (e.g. bus stops) were desired to be close by, next
to nature and social meeting places. The same applied to ‘less essential’ services like a library,
hairdresser or pedicure.
“That there is a health centre in the neighbourhood, next to a shop and pedicure or hairdresser and
pharmacy, so that it is doable to go there with regards to the distance.” (P2)
Moreover, participants would like to be able to find activities and cultural places close by for an
environment to be age-friendly. The wish to have shops close by was expressed more by non-native
than by native participants.
To have these things close by makes it easier for people to go somewhere, as the barrier to move is
lower. Being able to find what you want close by makes it within reach. Consequently, it is easier for
people who cannot walk or cycle a large distance anymore, or who cannot drive a car, to stay active.
Hence, most preferably, services and other features were desired to be found within walking distance.
Image 17 Cultural square
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Moreover, if people only have to cover a short distance to reach their destination, this can contribute
to their level of independence and mobility, as participants reported. In addition, it was perceived to
be important for an age-friendly environment to have relatives or family living close by, but mainly to
non-native participants.
“I find it important that family and friends live close by and hence can come by often.” (P14)
The questionnaire data confirmed elderly’s need to be able to find services, shops or activities close
by, and that this could be due to the fact that some elderly are not able to drive a car anymore.
Moreover, it showed that being able to find activities close by can improve one’s level of physical
activity.
“An environment where moving activities are within reach for seniors (I do not drive a car).” (native,
female, 70-74)
5.4.10 Support
An age-friendly environment is considered to be a supportive environment (WHO, 2007). Therefore,
all identified themes for an age-friendly environment could be considered to contribute to support.
For example, the extent to which accessibility, mobility and safety are facilitated in an environment
were found to be of influence on the extent to which one is supported and can live independently, so
without or with as little help from others as possible. As a few photovoice participants and some
questionnaire respondents specifically mentioned that an age-friendly environment is one that offers
support, or in which you can get help if that is necessary, this separate theme was identified. When
the right amount and type of help is provided, this can support elderly to stay as independently as
possible for the rest. Hence, the facilitation of independency was coded under the theme of support
too. This was specifically mentioned by a few native questionnaire respondents to be desired from an
age-friendly environment.
“An environment that offers me as on older person all opportunities to live independently and in the
way I want it.” (native, male, 70-74)
Not only facilitating ‘general needs’ like independence, but also more specific help for people in need
was found to be important to some for an environment to be age-friendly. For example, a contact
point to support people who experience technical issues in their house. An environment that offers
support was also interpreted in a more broad and general sense, namely by taking seniors into account,
by being a stimulating environment, and by being an environment in which elderly can have fun too.
If an environment responds to the need for support and facilitates this support, people can live in an
59
environment in which it is possible to have limitations, which was also mentioned to be age-friendly.
The theme of support was mainly touched upon by natives.
Identified facilitator: clear and accurate direction signs in public space and buildings
This facilitator was mentioned by one non-native photovoice participant, and further identified from
the questionnaire answers provided by native respondents. Clear direction signs were reported to
support people to find services or things that could help them to stay active. Also, these were
mentioned to be of support to experienced discomfort related to the ageing process, such as having a
weaker bladder and being more often in need of public toilets because of that.
“In many public buildings, like hospitals, stairways are hard to find. For people like me, who want to
make use of the stairs for as long as possible, this often causes a long search. Therefore, clear directions
signs are desired!” (native, male, 65-69)
“This is in the centre. It says public toilets. But there are no
public toilets, I have looked everywhere. That is very
misleading. The only toilets you can use are in a restaurant.
This sign should be off from there. Signs should be accurate
in order to support people.” (P10, Image 18)
5.4.11 Neighbourhood characteristics
The population composition of the neighbourhood in which one lives also appeared to be of influence
on the extent to which participants perceived an environment to be age-friendly. It were almost only
native participants who mentioned this. Whereas some participants preferred to live together with
other older people, the majority of participants who touched upon this topic preferred to be living in
a neighbourhood where there is diversity of age. Some participants interpreted this diversity in a
broader way and mentioned to even prefer living in a neighbourhood that has diversity of age, but also
of different cultures and that has both rented houses and owner-occupied houses. Diversity in the
population composition was mentioned to keep one more young, vigorous and alert. Also, living
together with not just seniors but also with younger generations was mentioned to contribute to the
ageing process as it facilitates (mutual) serving.
Image 18 Direction signs in public space
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“If there are only seniors living, it is a homogeneous community, and that does not sparkle. So not only
seniors, just because age-friendly means that there are also younger people and children living there,
so that you can mutually serve each other. A child can go grocery shopping for you, but you can help a
child with doing homework. Or babysit for a young family. Yes, that seems very appealing to me.” (P2)
On the other hand, participants who preferred to live with other older people did this because they
enjoyed the contact with peers, or because they valued the social control that they considered to be a
result of living with other elderly.
The preference to either live together with other elderly or with young and old mixed was also found
in the questionnaire data. Except for one non-western migrant (female, 60-64) who mentioned willing
to live with other elderly, it were also only natives who touched upon this topic.
From the questionnaire data it also appeared that the bustle of a neighbourhood was perceived to be
related to the age-friendliness of an environment. Some respondents perceived a calm neighbourhood
to be age-friendly, whereas others mentioned that an age-friendly environment is one in which
excitement can be found. This was reported to trigger their minds and helped them to stay active as
such. Except for one western migrant who expressed to wish to live in a lively neighbourhood, it were
only native respondents who expressed their preference for this topic.
“An environment that is calm.” (native, male, 75-79)
“I also like it when there is a bit of excitement to be found in my surrounding, because I need stimuli in
order to stay active.” (native, mail, 60-64)
5.4.12 Non-native participants’ perception of influence migrant background
Non-native photovoice participants were also asked whether they themselves thought that their
migrant background was of influence on their perception of an age-friendly environment. Six
participants did not think so, of which two did think their migrant background was of influence on their
perception of active ageing. Two participants thought their migrant background was both of influence
on their perception of active ageing and an age-friendly environment.
“Yes. I think that culture is also very much, with ageing, that when you live together with people from
your own culture, I think that is much better.” (P8)
“Yes, because my social environment or contacts have different daily activities than people with a Dutch
background. For example, the older generation of Turkish people is less involved in activities concerning
sports.” (P14)
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5.4.13 Interim conclusion environment
Both natives and non-natives were found to perceive an age-friendly environment as an environment
that enables older people to remain functioning in their daily life and in society, and to stay active,
despite possible physical limitations experienced due to the ageing process. In total, 11 themes
were identified, which were found to be needs that an environment should facilitate in order to be
age-friendly. Within these, a distinction could be made between 1) basic needs, which are necessary
for elderly to function in their daily life, and which also contribute to staying active; 2) needs that are
mainly related to being able to stay active, or that contribute to well-being.
1) accessibility, safety, mobility, close by, support
2) social contact, opportunity to be physically active, presence of nature or green space, organised
activities, neighbourhood characteristics (population composition and bustle)
Many of these needs were found to be interrelated or to be of influence on each other. For example,
safety was found to influence mobility and accessibility, while accessibility was also found to influence
mobility. Accessibility was found to influence active ageing via the pathway of perception and
behaviour, just as safety and close by. Mobility, opportunity to be physically active, social contact and
organised activities were found to influence active ageing via the pathway of behaviour. For the 7
needs mentioned so far, behaviour mostly included physical or social activity. The presence of nature
or green space was found to influence active ageing directly (by contributing to well-being) and via
behaviour (physical activity). Cultural activity was also found to influence active ageing directly (by
mental stimulation) and via behaviour (outings/activities). Support was found to influence active
ageing via perception, and via perception and behaviour. Neighbourhood characteristics were found
to influence active ageing directly, via perception, or via behaviour. So, most characteristics for the
environmental condition age-friendly were found to influence active ageing via the pathway of
behaviour and the pathway of perception and behaviour.
For multiple themes, differences between native and non-native participants were found. Some of
these were small, others were more clearly present, like for safety, social contact and opportunity to
be physicaly active. The facilitation of safety was found to be more important to non-native
participants than to their native peers for an environment to be age-friendly. Also, the need for an age-
friendly environment to facilitate social contact was found to be higher for non-native participants.
Moreover, non-native participants were found to generally be more fine with being involved in social
contact with other elderly, whereas natives preferred to have social contact in a mixed setting, so with
people from younger generations too. Furthermore, it were mostly natives who mentioned mentioned
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the facilitation of opportunities to be physically active as their perception of an age-friendly
environment.
Differences were also found for accessibility. In general, natives seemed to be more concerned with
accessibility. Furthermore, an environment that facilitates the opportunity to be physically active was
perceived to be more important to native participants. Smaller differences were found for the theme
of close by. Non-natives were found to attach more value to the availability of shops close by than
natives did. The same applied to having family or friends living close by, which can be related to social
contact. The facilitation of cultural activity, support, and neighbourhood characteristics such as
population composition and bustle were mainly mentioned by native participants to be related to the
age-friendliness of an environment. No specific differences between western and non-western
migrants were found. Table 7 provides a summary of the results for the perception of native versus
non-native elderly’s perception of an age-friendly environment.
Table 7 Summary natives’ versus non-natives’ perception of age-friendly environment
All identified needs that an age-friendly environment should facilitate:
Accessibility
Safety
Mobility
Opportunity to be physically active
Presence of nature or green space
Social contact
Organised activities
Cultural activity
Close by
Support
Neighbourhood characteristics
More important to natives: Accessibility
Opportunity to be physically active
Cultural activity
Support
Neighbourhood characteristics
More important to non-natives: Safety
Social contact
Friends/family living close by, shops close by
An age-friendly environment aims to enable active ageing. When comparing the results for
participants’ perception of an age-friendly environment to the results for their perception of active
ageing, it is found that the active ageing themes of physical activity, social activity, mental activity,
staying active otherwise, health, mobility, independence and autonomy, and participation were
touched upon. That an age-friendly environment should facilitate social contact was mentioned more
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often by non-natives, which is in line with the finding that non-natives stressed the importance of social
activity for active ageing more than natives did. Furthermore, the facilitation of cultural activity, and
independence and autonomy were found to be more important for an age-friendly environment to
natives, which is in line with the finding that non-natives described active ageing more often as mental
activity, and independence and autonomy. In addition, the wish of natives to live in a neighbourhood
with people of other ages can be linked to the active ageing theme of keeping up, which was almost
only touched upon by natives. As such, only the active ageing theme of mindset, more important to
non-natives, was not touched upon in participants’ description of an age-friendly environment.
Therefore it is questionable if the physical environment can influence active ageing via one’s mindset.
5.4.14 Interim conclusion facilitators and barriers
The majority of identified facilitators were found to contribute to ‘accessibility’, ‘opportunity to be
physically active’, ‘presence of nature or green space’ and ‘mobility’ in an environment, whereas the
majority of identified barriers were found to hinder ‘accessibility’ OR ‘safety’ to be present in an
environment. Most of these needs were found to influence active ageing via the pathway of behaviour,
or the pathway perception and behaviour, as described in chapter 5.4.13. Likewise, most identified
facilitators and barriers of the physical environment for active ageing were found to either positively
or negatively influence active ageing via the pathway of behaviour, and the pathway of perception and
behaviour. This referred to activity related behaviour, mostly physical or social.
Many identified facilitators were found to have multiple purposes with regards to enabling active
ageing, for example both enabling accessibility as well as mobility. Likewise, several identified barriers
were found to have a negative influence on more than just one identified theme for an age-friendly
environment. This is in line with the interrelatedness and interinfluence that was found for the themes
identified for active ageing and an age-friendly environment.
A number of differences were found between native and non-native elderly’s perception of facilitators
and barriers of the physical environment for active ageing. Non-natives were found to be more willing
or likely to join organised activities for the purpose of having social contact and to join such activities
in a community centre. This is in line with the finding that the facilitation of social contact is more
important for an age-friendly environment to non-natives than to natives. Furthermore, non-natives
were found to attach more value to public seating and public transport, related to the theme of
mobility. Hence, they perceived the availability and quality of these features to be more important for
an age-friendly environment than natives did. This can be considered as a striking findings, since not
many non-natives did perceive active ageing to be about mobility. The availability of sports clubs, cycle
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paths and footpaths were found to be a more important facilitator of the physical environment to
active ageing to native participants. This is in line with the finding that natives perceived it to be more
important than non-natives that an age-friendly environment facilitates opportunity to be physically
active. Also, living in a house with a garden or other possibility to go outside was more important to
native people. Furthermore, for non-natives, the availability of footpaths appeared to be more
important than that of cycle paths, whereas for natives these were equally important. Non-native
participants were also found to perceive the accessibility of public buildings, shops and pavements to
be more important for an age-friendly environment, whereas for natives this was mainly the
accessibility of housing. Findings are summarised in Table 8.
Table 8 Summary native versus non-native elderly’s perception of facilitators of the physical environment for active ageing
All discussed identified facilitators of the physical environment for active ageing:
Accessible housing
Accessible public buildings, shops, pavements (public space)
Keeping public space free from ‘natural material’
Public transport
Availability of seating
Sports club
Cycle paths, footpaths
Park or forest
Garden
Social meeting places like community centre
Cultural places
Clear and accurate direction signs in public space and buildings
All discussed identified barriers of the physical environment for active ageing:
Stairs in public space
Surface of footpaths
Lack of street lighting
Dangerous traffic situations
More important to natives: Accessible housing
Availibility of sports clubs
Availibility of cycle paths
Availibility of foothpaths
Cultural places
A house with a garden or balcony
More important to non-natives: Accessible public space > accessible housing
Availibility of foothpaths > cycle paths
Public transport
Availibility of seating
Joining organised activities (in community centre)
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5.5 Characteristics of an age-friendly environment as identified by the WHO
5.5.1 Active ageing
In order to put the results that were produced for the fourth sub-question into the perspective of
active ageing, questionnaire respondents were first asked to assess the importance of certain aspects
for being able to actively age. These concerned aspects that were considered by the WHO to be part
of active ageing, as discussed in chapter 2.4, and included mobility, autonomy, independence,
inclusion, participation, and safety (security). To make sure that all respondents could understand what
was meant with these aspects, a short explanation was provided for every aspects. Mean scores of
natives were compared to means scores of non-natives. The results are shown in Table 9.
Table 9 Assessment of characteristics active ageing as defined by the WHO
* p-value<0.05 ** p-value<0.01
Mean scores of natives versus non-natives were found to significantly differ from each other for
autonomy (p<0.05) and independence (p<0.01). So, on average, native participants assessed both
autonomy and independence to be more important for active ageing than non-native participants did.
For autonomy, the biggest difference was found between native participants (µ=4,746) and
participants with a western migrant background (µ=4,489). For independence, the biggest difference
was found between native participants (µ=4,556) and participants with a non-western migrant
background (µ=4,021).
The finding that autonomy and independence are more important for active ageing to natives than to
non-natives is in line with the finding from chapter 5.3, which showed that autonomy and
independence were both mainly touched upon by natives with regards to participants’ perception of
active ageing. As such, the quantitative data validated the qualitative data for this finding.
Total N=113
Background
Native N=92 Non-native N=21
Mean St. Error Mean St. Error Mean St. Error p-value
Mobility 4.714 0.452 4.679 0.052 4.738 0.113 0.646
Autonomy 4.476 0.499 4.746 0.048 4.494 0.105 0.035*
Independence 4.048 0.785 4.556 0.063 4.042 0.139 0.001**
Inclusion 4.143 0.774 4.407 0.063 4.123 0.138 0.071
Participation 4.048 0.722 4.278 0.064 4.02 0.141 0.106
Safety 4.476 0.499 4.57 0.097 4.599 0.214 0.903
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5.5.1 Assessment of domains without context
‘Outdoor environments’, ‘Transport and mobility’, and ‘Housing’ were to be assessed on importance
for active ageing. These are the three domains of an age-friendly physical environment according to
the WHO, as described in chapter 2.5.1 of the current research. Participants were solely provided with
the names of these domains, so no description or specific characteristics of these domains were given.
Results are shown in Table 10.
Table 10 Assessment of domains without context
* p-value<0.05
The mean scores for the domain of Outdoor environments were found to significantly differ (p<0.05)
between natives and non-natives. The biggest difference was found between native (µ=4.134) and
non-western participants (µ=3.512). So, Dutch elderly with a non-western migrant background were
found to assess Outdoor environments significantly less important than native Dutch elderly. Overall,
the highest mean scores for both natives and non-natives were yielded for the domain of Transport
and mobility. So, on average, both natives and non-native respondents considered this domain to be
the most important for active ageing of the three domains of an age-friendly physical environment as
established by the WHO.
5.5.2 Outdoor environments
For the domain of Outdoor environments, 14 characteristics were to be assessed on importance for
active ageing. Of these, the first 10 were illustrated with a picture, which can be found in Appendix 4.
Results are provided in Table 11.
Total N=113
Background
Native N=92 Non-native N=21 Mean St. Error Mean St. Error Mean St. Error p-value
Outdoor environments 3.714 0.765 4.133 0.074 3.749 0.162
0.037*
Transport and mobility 4.524 0.587 4.624 0.057 4.600 0.124 0.864
Housing 4.286 0.765 4.539 0.072 4.303 0.159 0.189
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Table 11 Assessment of Outdoor environments
Total N=113
Background
Native N=92 Non-native N=21 Mean St. Error Mean St. Error Mean St. Error p-value
Safe pedestrian crossing with nonslip markings
4.286 0.547 4.156 0.070 4.268 0.154 0.518
Cycle paths are separate from pavements and other pedestrian walkways 4.286 0.628 4.241 0.068 4.324 0.148 0.621
Outdoor safety is promoted by good street lighting 4.667 0.471 4.423 0.063 4.716 0.138 0.063
Outdoor safety is promoted by police surveillance 4.095 0.750 3.966 0.076 4.102 0.166 0.468
There are sufficient public toilets, both indoors and outdoors, and they are clean and well-maintained 3.952 1.174 4.040 0.099 3.920 0.217 0.622
Public toilets are accessible for elderly 4.000 0.976 4.173 0.088 3.958 0.193 0.325
Public space is clean and pleasant 4.000 0.756 4.093 0.076 3.972 0.168 0.522
There is sufficient safe green space 4.333 0.642 4.311 0.064 4.306 0.141 0.976
Benches and other public seats are well-maintained 4.429 0.495 4.097 0.070 4.431 0.155 0.058
Pavements have dropped curbs to road level 4.095 0.683 4.091 0.077 4.127 0.169 0.849
Special customer service arrangements are provided, such as separate queues or service counters for older people 3.238 0.921 3.006 0.092 3.306 0.202 0.190
Services are located close to each other 3.905 0.683 3.896 0.070 3.981 0.154 0.624
...table continues on the next page...
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Total N=113
Background
Native N=92 Non-native N=21 Mean St. Error Mean St. Error Mean St. Error p-value
Public space and buildings provide opportunity for social contact 3.857 0.774 3.747 0.081 3.773 0.179 0.898
Average Outdoor environments 4.088 0.473 4.019 0.045 4.091 0.099 0.514
No significant results were found for the difference between the mean scores of natives versus non-
natives. This contradicts the finding from Table 10, which showed that the domain of Outdoor
environments was assessed to be significantly more important by native participants. This suggests
that when a domain is questioned in more detail, so when specific characteristics or underlying
constructs are provided, different results are obtained.
Although not significant, a notable difference (p<0.058) between the scores of natives versus non-
natives for the importance of benches and other public seats being well-maintained was found. This
finding can be related to the finding described in chapter 5.4.3 that non-native participants considered
the availability of seating to be more important for an age-friendly environment than natives did. The
statistical analysis also showed somewhat contradictory findings between the qualitative and
quantitative data for this domain. No significant difference was found between the mean scores of
natives versus non-natives for the importance of ‘public space and buildings provide opportunity for
social contact’, while non-natives were found to perceive the facilitation of social contact in an
environment to be more important than natives according to the qualitative data. However, non-
natives were found to be more likely to search for social contact in a community centre, and not
necessarily generally in public space or buildings as was stated in the questionnaire. This might explain
the difference in obtained results.
What can furthermore be concluded from the results related to Outdoor environments is that safety
being promoted by good street lighting had the highest mean for the total population (µ=4.667), and
also the highest mean for the three background groups separately (native µ=4.424, western µ=4.752,
non-western µ=4.668). Therefore, the promotion of outdoor safety by good street lighting can be
considered to be the most important surveyed characteristic of Outdoor environments for enabling
active ageing. The provision of special customer service arrangements such as separate queues or
service counters for older people, on the other hand, was assessed to be the least important surveyed
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characteristic for the total population (µ=3.238), and for the three background groups separately
(native µ=3.006, western µ=3.059, non-western µ=3.640).
5.5.3 Transport and mobility
The assessment of the characteristics belonging to the domain of Transport and mobility appeared to
be the most influential to background, as is shown in Table 12.
Table 12 Assessment of Transport and mobility
Total N=113
Background
Native N=92 Non-native N=21
p-value Mean St. Error Mean St. Error Mean St. Error
All districts in a city or village can be reached with public transport 4.333 0.713 3.975 0.089 4.251 0.196 0.213
Doctors and other services can be reached with public transport 4.619 0.575 4.106 0.086 4.585 0.189 0.027*
Public transport is affordable 4.714 0.547 4.143 0.080 4.658 0.175 0.010*
Public transport is reliable and frequent, also at night and in the weekend 4.476 0.587 4.054 0.083 4.477 0.181 0.040*
Average Transport and mobility 4.536 0.452 4.070 0.074 4.493 0.163 0.023*
* p-value<0.05
Mean scores for that doctors and other services can be reached with public transport, that public
transport is affordable and that public transport is reliable and frequent, also at night and in the
weekend, were all found to significantly differ for natives versus non-natives. The means of the average
scores for the domain of Transport and mobility were also found to be significantly different for natives
versus non-natives. Like was the case for Outdoor environments described in chapter 5.5.2, this too
contradicts the finding from Table 10. Hence, it can be stated that different results are obtained when
context is provided or specific characteristics of a domain are surveyed. Affordable public transport
was found to be the most important characteristic, both overall (µ=4,714), for the total group of non-
natives (µ=4.658), and for all background groups separately (native µ=4.143, western µ=4.465, non-
western µ=4920).
Participants were also asked for what kind of activities they would make use of public transport, for
which they could choose from 1) Visiting family or friends; 2) Visiting a doctor or other care provider;
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3) Groceries; 4) Nice outings; and 5) Differently, namely… (to be filled in by participant). For native
participants, nice outings was chosen the most, representing 36,9% of the provided answers for this
background group, closely followed by visiting family or friends (34.8%). The same applied to non-
native participants, except that nice outings represented 31.0% of the provided answers and visiting
family or friends 24.1%. Moreover, 20.7% of the non-native participants reported to use public
transport to visit a doctor or other care provider, compared to 21.7% for native participants.
5.5.4 Housing
For the assessed characteristics belonging to the domain of Housing, no significant differences
between the mean scores of natives and non-natives were found, as is shown in Table 13.
Table 13 Assessment of Housing
Total N=113
Background
Native N=92 Non-native N=21 Mean St. Error Mean St. Error Mean St. Error p-value
Houses have even surfaces 4.048 0.722 4.051 0.092 4.110 0.203 0.795
Houses have passages that are wide enough for wheelchairs 4.000 0.690 4.268 0.077 4.113 0.169 0.416
Bathrooms, toilets and kitchens are adjusted to older people, or have this opportunity 4.286 0.700 4.365 0.069 4.402 0.151 0.826
There is sufficient affordable housing in safe areas 4.095 0.750 4.383 0.069 4.178 0.151 0.227
Houses are available close to services and other houses 4.333 0.563 4.386 0.073 4.356 0.057 0.864
Average Housing 4.152 0.478 4.291 0.057 4.232 0.125 0.675
The availability of sufficient affordable housing in safe areas showed the lowest p-value (0.227). So
although not significant, this was the biggest observed difference for the surveyed characteristics
belonging to the domain of Housing. For the total population, the highest mean score was found for
that houses were available close to services and other houses (µ=4.333). This too applied to the highest
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mean score of native participants (µ=4.386), but the highest mean score for non-native participants
was found for the characteristic of bathrooms, toilets and kitchens being adjusted for older people, or
to have this opportunity (µ=4.402). This implies that houses being available close to services and other
houses is the most important of the assessed characteristics to natives, whereas to non-natives this is
that bathrooms, toilets and kitchens are adjusted for older people or have the opportunity to.
5.5.5 Significant findings for covariates
From the included covariates, the most significant findings in terms of quantity were yielded for sex
(8), education (7), living situation (5), and age-interval (4). Of these findings, most concerned the
domain of Outdoor environments. Besides, education and living situation were also found to be
significant for Housing characteristics. As variety of these covariates was present within both groups,
no conclusions can be drawn upon these findings. Occupational status, income, composition of the
household, years living in the neighbourhood, and self-rated health, mobility, social activity, physical
activity and limitation were found to produce no or only a very few significant results.
5.5.6 Interim conclusion
First of all, native participants were found to consider both autonomy and independence to be
significantly more important for active ageing than non-native participants. Second, Dutch elderly with
a non-western migrant background were found to assess Outdoor environments less important than
Dutch elderly with a western migrant background, and significantly less important than native Dutch
elderly. However, this assessment was done without being provided with a description or being asked
for specific characteristics of the three domains of concern. Third, the domain of Transport and
mobility was on average found to be significantly more important for being able to actively age to non-
native participants than to their native peers. This validates the finding from chapter 5.4, which stated
that non-natives attach more value to the availability of public transport for an environment to be age-
friendly. Fourth, notable difference was also found for the availability of seating, assessed to be more
important by non-natives. This finding can be related to the qualitative finding that the availability of
seating is more important to non-natives, as described in chapter 5.4. However, the observed
quantitative difference was not significant (p<0.058). Consequently, the influence of having a native
or non-native background on the assessment of this aspect cannot be confirmed and hence, the
qualitative finding cannot be validated. Findings from chapter 5.5 are summarised in Table 14. This
table also includes the characteristics for which the highest overall mean scores were obtained.
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Table 14 Summary native versus non-native elderly’s assessment of importance of characteristics age-friendly environment as identified by the WHO
Autonomy and independence are significantly more important for active ageing to natives than to non-natives
The domain of Outdoor environments, without context or specific surveyed characteristics, is significantly more important to natives
The domain of Transport and mobility, including specific surveyed characteristics, is significantly more important for active ageing to non-natives
For Outdoor environments, the promotion of outdoor safety by good street lighting can be considered to be the most important surveyed characteristic for enabling active ageing for both natives and non-natives
The provision of special customer service arrangements such as separate queues or service counters for older people was assessed to be the least important surveyed characteristic for both natives and non-natives
For the domain of Transport and mobility, affordable public transport was found to be the most important surveyed characteristic, for both natives and non-natives
For the domain of Housing, houses being available close to services and other houses is the most important of the surveyed characteristics to natives, whereas to non-natives this is that bathrooms, toilets and kitchens are adjusted for older people, or to have this opportunity
No significant differences between non-western and western-migrants were found
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Chapter 6 - Discussion
In this chapter, the main findings of the research will be discussed in relation to the theoretical
framework, after which the strengths and limitations of the research will be discussed and
recommendations for future research will be made. Lastly, a translation into practice is provided.
6.1 Interpretation of main findings
This research aimed to find an answer to the question ‘What are differences between the perception
and wishes of native versus non-native Dutch elderly regarding the contribution of the physical
environment to active ageing?’. To be able to answer this main research question, four sub-questions
were formulated. These were:
1. What do native versus non-native Dutch elderly perceive to be ‘active ageing’?
2. What do native versus non-native Dutch elderly perceive to be an ‘age-friendly environment’?
3. What do native versus non-native Dutch elderly perceive to be facilitators and barriers of the
physical environment for active ageing?
4. How important are the characteristics of an age-friendly physical environment as identified by
the WHO to native versus non-native Dutch elderly for being able to actively age?
The conclusion to the main research question is provided in Chapter 7.
6.1.1 Native versus non-native Dutch elderly’s perception of ‘active ageing’
Comparing the results for native and non-native participants’ perception of active ageing to the
existing knowledge on active ageing provided in chapter 2.4, shows first of all that the identified
themes of health, participation, and autonomy and independence correspond to the WHO’s definition
of active ageing (2002). Also, as in the WHO’s definition of health (1978), both the physical, mental and
social domain were addressed by the participants of the current research. However, in contrast to the
WHO’s definition, participants addressed these domains with a specific focus on activity instead of on
well-being. Still, although participants did not explicitly mention this, physical, mental and social
activity might be considered to contribute to well-being. Nevertheless, the perception of the
participants of the current research appeared to be more about staying active than about staying
healthy. Although activity and health were found to be related to each other, it suggests a different
focus than that of the current definition of active ageing as established by the WHO. Also, the finding
from the current research that active ageing is perceived to be about mobility, keeping up and mindset,
complements the existing definition or description of active ageing.
Moreover, non-natives appeared to be less likely to perceive active ageing as health, while health is a
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central aspect in the definition of active ageing as established by the WHO. This finding suggests that
health is a less central aspect of active ageing to non-natives, which would therefore ask for a focus on
activity more than a focus on health for policy makers building an age-friendly environment. However,
this must be put in perspective, as the choice to ask for participants’ perception of active ageing and
not of healthy ageing was made for the current research, while an age-friendly environment aims to
encourage active ánd healthy ageing as is defined by the WHO. If the perception of healthy ageing was
asked for, it is more likely that participants would have mentioned health, as that word is part of the
concept. So, the focus on the word health or on the word active in relation to ageing well could be
considered to make a difference for the perception of at least non-natives.
When comparing the results from the current research to the study conducted by Bowling (2009), the
most notable general similarity is that of active ageing being defined as social activities and as attitude,
which in the current research was coded as mindset. Moreover, both the participants in Bowling’s
research and participants in the current research provided a more dynamic and more multidimensional
view of active ageing than is provided by the WHO. Bowling (2009) also found that non-natives
associated active ageing with physical health and fitness less than native participants did. However,
this was different for the current research. Non-natives did not associate active ageing with physical
activity less than natives, but instead stressed the importance of also being social active more than
natives did.
A general side note for this sub-question needs to be made. The fact that non-native participants on
average provided shorter descriptions of active ageing, containing not as many different aspects and
a less in-depth reasoning compared to native participants, generally made it harder to draw
conclusions. Although one can discuss to what extent this observation is objective, it seemed to the
researcher as if natives had a clearer picture in mind of what active ageing looked like and as such, had
less difficulties to give a clear description of the term. This could first of all be due to the fact that some
participants had issues with the Dutch language, which could have affected the extent to which they
were able to give a clear description of active ageing. Next to that, it could be due to the fact that
natives are more familiar with the term active ageing, or that ageing actively is more of a concrete life
goal for natives than it is for non-natives. This can be related to the finding that mindset was mentioned
more often to be part of active ageing for non-natives than for natives, which might indicate that
according to non-natives one just needs to keep going in order to stay active, instead of to specifically
think about how one can actively age. However, these are suggestions and can therefore not be
considered as conclusive results. Besides, the on average shorter explanations of active ageing
provided by non-natives could also simply indicate that active ageing is generally less multidimensional
75
to non-native participants than it is to native participants, but that too cannot be proven with this
research.
6.1.2 Native versus non-native Dutch elderly’s perception of an ‘age-friendly environment’
Native and non-native participants were found to agree on the general concept of an age-friendly
environment: an environment that enables older people to remain functioning in their daily life and in
society, and to stay active, despite possible physical limitations experienced due to the ageing process.
So, native and non-native participants’ perception of the aim of an age-friendly environment can be
considered to be the same. This aim is to some extent similar to the aim of an age-friendly environment
as established the WHO: “to encourage active and healthy ageing by optimizing health, stimulating
inclusion and enabling well-being in older age” (WHO, 2016, p.12). However, participants of the current
research did not directly mention inclusion to be important for an age-friendly environment. In fact,
they did not even mention this aspect at all. Nevertheless, participants did mention to find it important
to be enabled to keep functioning and moving around in the environment despite the fact that they
get older and experience limitations due to that. So, one can argue that the aspect of inclusion was in
fact touched upon, but more indirectly. What can be stated more clearly is that the aim of an age-
friendly environment as identified by the participants of the current research is in line with the more
detailed aim as provided by the WHO (2016) and Michel et al. (2017), which describes that an age-
friendly environment can contribute to enabling and improving people’s functional ability, in order to
ensure that people with different capacity levels can keep doing the things that they consider to be
valuable.
With regards to the conceptual framework, an age-friendly environment was found to influence active
ageing mostly via the pathways of behaviour, and perception and behaviour. This applied to both
natives and non-natives. Direct influence or influence via the pathway of perception solely were found
less often. Still, it can be concluded that all four pathways of environmental health etiology as
identified by Commers et al. (2006) are valuable and can hence be applied for understanding the
contribution of the physical environment to active ageing for both natives and non-natives. An addition
to that is then that the pathways of behaviour, and of perception and behaviour are found to be most
important, or at least apply to the majority of identified needs that an age-friendly environment should
facilitate according to natives and non-natives, and could therefore be focussed on best. However, it
is debatable whether or not all identified themes are to some extent sensitive to perception. For
example, an environment that facilitates opportunity to be physically active was considered to
contribute to active ageing via behaviour. However, what is perceived by one person as an opportunity
76
to move might not necessarily be perceived in the same sense by another person. The same principle
could be applied to support. Nevertheless, the conclusions drawn in this research are based on what
was mentioned by participants. Therefore corresponding pathways were identified based on the input
of participants and not based on what could be possible as well.
Furthermore, to the researcher it seemed like more non-native participants had difficulties with
imagining what an age-friendly environment would or should look like than native participants. This
could have influenced the extent to which clear differences could be examined. Short questionnaire
answers from non-natives, but also difficulties with giving a description of an age-friendly environment
during interviews, underlie this observation. This could be due to problems with expressing oneself in
the Dutch language. Also, it could indicate that the concept of an age-friendly environment is simply
not familiar to non-native people. Furthermore, some non-native participants were found to focus
more on the social aspect of an environment than the physical aspect. This might indicate that the
social environment is more important for active ageing to non-natives than the physical environment
is. Although this too is an insight obtained from this research, it was a limitation to obtaining an answer
to this sub-question as the physical aspect of the environment was the focus and interest of this
research. However, this does suggest a more holistic approach when building an age-friendly
environment.
6.1.3 Native versus non-native Dutch elderly’s perception of facilitators and barriers of the physical
environment for active ageing
Many facilitators and barriers of the physical environment for active ageing were identified by the
participants of this research. Some were mentioned by one person only, others were mentioned with
a certain repetition and were therefore presented in chapter 5.4. With regards to the conceptual
model, most of the identified facilitators and barriers of the physical environment for active ageing
were found to either positively or negatively influence active ageing via the pathway of behaviour, or
the pathway of perception and behaviour (activity related, mostly physical or social). This applied both
to the facilitators and barriers that were found to be more important to natives as well as those more
important to non-natives.
When comparing the facilitators and barriers identified in the current research to the characteristics
of an age-friendly physical environment as established in the checklist of the WHO, it first needs to be
mentioned that the checklist only describes facilitators of the physical environment for active ageing.
Still, as all barriers identified in the current research could be translated into facilitators by making
them positive (lack of street lighting sufficient street lighting), it was well possible to compare the
77
results with the established characteristics. First of all, it was found that most of the identified
facilitators and barriers could be categorised according to the three domains of a physical age-friendly
environment as established by the WHO. These are Outdoor environments, Transport and mobility
and Housing. However, this did not apply for the identified facilitators ‘cultural places’ and ‘social
meeting places’. According to the WHO, the availability of social meeting places is a feature that
belongs to the dimension of the Social environment and to the domain of Social participation.
However, participants of the current research specifically mentioned to perceive this feature to be
related to an age-friendly physical environment. This is illustrative for the interdependentness of the
three dimensions of an age-friendly environment as established by the WHO. Also, it confirms that the
dividing line between the social and the physical dimension of an age-friendly environment is relative,
which is shown in Figure 5. Therefore, in the creation of an age-friendly physical environment, the
interface between the social and the physical dimension should also be taken into account. This would
particularly be the case for an age-friendly environment that aims to be sensitive to migrant elderly,
as especially non-natives were found to be more willing to visit social meeting places like a community
centre.
Furthermore, several facilitators and barriers were identified in the current research which were not
described in the WHO’s checklist. This shows that the checklist is not exhaustive and confirms the
statement from chapter 1.1.4 (Menec et al., 2011; Keating, Eagles, & Philips, 2013) that different
groups of people might indeed have different needs. Some of the identified facilitators and barriers in
this research were not described at all in the WHO’s checklist, such as the availability of houses at
street level, footpaths, parks or forest, cultural places, and a contact point for (technical) assistance.
Others were touched upon, but not described as detailed as the participants of the current research
did. So, findings from the current research were considered to supplement the existing knowledge, as
new characteristics and more detailed information about the already identified characteristics was
yielded. This is useful as the WHO’s characteristics are now only described very broadly or generally.
For example, public space needs to be clean and pleasant, but it is not defined what clean and pleasant
include. As such, the checklist as established can be considered to be subjective to the perception of
the person working with it, because what is considered clean, and what as pleasant, depends on
perception. So, although it is questionable to what extent it is desirable to have a very detailed
checklist, the results from the current research can provide policy makers with more concrete
information to interpret and work with the WHO’s checklist. This can be useful as public resources
might be too limited to facilitate all the characteristics as identified by the WHO. Therefore, it could be
more effective to focus on a few of them based on a concrete description as provided in this research
78
instead.
This research has also gained more understanding of what non-native elderly perceive to be facilitators
and barriers of an age-friendly environment. Although these appeared not to differ too much from
those identified by natives, it did become clear that non-natives attach more value to certain specific
characteristics than natives do. As this is not described in the WHO documents related to age-friendly
environments, the current findings can help policy makers in deciding which of the established
characteristics deserve more attention when they want to take migrant elderly into account. Also,
some additional facilitators and barriers that were found to be more important to non-natives were
identified. The translation of the current research into practice is provided in chapter 6.5.
6.1.4 Importance of the characteristics of an age-friendly environment as identified by the WHO for
being able to actively age
Like for sub-question 3, the obtained results for sub-question 4 are considered to supplement the
existing knowledge on the characteristics of an age-friendly environment as established by the WHO.
Not because new characteristics were identified, but because established characteristics that should
be paid specific attention to when building an age-friendly environment that is sensitive to migrant
elderly were identified.
The main finding for this sub-question is that non-natives find it significantly more important than
natives that public transport is affordable, reliable, frequent (also at night and in the weekend) and
that doctor and services can be reached with public transport. Hence, the average score for Transport
and mobility was found to be significantly higher for non-natives. Therefore, this domain of an age-
friendly physical environment was found to deserve most attention when attempting to take into
account the specific needs of migrant elderly. As such, this result can support policy makers to set
priorities when building an age-friendly environment that is based on the prescribed key features of
the WHO. However, with regards to this finding and the other findings for this sub-question, it must
be considered that in the realisation of these findings, subjective terms were used. Consequently,
participants have assessed characteristics based on their perception of those subjective terms, while
it remained unknown to the researcher what participants’ perception included. Hence, it is debatable
to what extent findings are completely comparable. Moreover, it is now known that affordable public
transport is more important for being able to actively age to non-natives than it is to native
participants, but it remains unknown what ‘affordable’ exactly means. As this may be different for
every person or for a group of persons, no concrete recommendations for the price of public transport
for it to contribute to active ageing can be formulated. This subjective interpretation too applies to
79
used terms like ‘safe’, ‘clean’ or ‘close to each other’.
By accompanying statements or questions with pictures, so that every respondent had the same point
of reference, this issue could partly be overcome, but not completely. This was also due to the fact
that for some characteristics no representative pictures could be found or taken, as was assessed by
the researcher. An example of such a characteristics is ‘services are located close to each other’.
However, as these characteristics were based on the checklist established by the WHO, this is not only
a drawback of the current research, but can also be considered as a lack in the documents provided by
the WHO. Nevertheless, as a result of this procedure, conclusions can only be drawn upon the surveyed
characteristics out of the all the characteristics included in the checklist. Still, translation into practice
could be made, which is provided in chapter 6.5.
Furthermore, it should be taken into account in the interpretation of the results for sub-question 4
that about four times as much natives as non-natives were included in the sample. This was a limitation
to the extent to which it was possible to prove significant difference between the mean scores of both
groups. Also, the bigger the sample size, the more reliable the results are. As such, the results obtained
for non-natives could be considered to be less reliable than the results obtained for natives.
6.2 Strengths of the research
Making use of a mixed methods design was a major strength of the research, as in this way it was
possible to compare findings from both methods, to supplement these findings, and to integrate and
validate data. Consequently, more rich and complete results concerning participants’ perception of
active ageing, an age-friendly environment, and how such an environment contributes to active ageing
could be produced. Hence, the applied triangulation contributed to the internal validity of this
research. Also, a larger total sample size could be achieved by not only making use of a qualitative
method, but by making use of a quantitative method too. This was of positive influence on the external
validity of this research, as the larger the sample is, the more representative for the theoretical
population the findings are.
Furthermore, by making use of the photovoice method, the research process was not structured
around the pre-determined characteristics of what constitutes an age-friendly environment according
to the WHO. Instead, the perspectives of older people served to identify enablers, barriers, and wishes
related to how the physical environment can contribute to active ageing. Consequently, new insights
could be gathered and possible additional characteristics could be identified. With regards to the
conducted interviews, using an interview guideline can considered to be a strength, as this reduced
the bias that could possibly have been caused by what kind of questions were asked and in what way.
80
Another strength of this research was the variety of participants included. Both the youngest old and
the oldest-old were included, people came from different places in the Netherlands, and also differed
on other socio-demographic variables like income and education. Consequently, the sample was
representative for the older population in the Netherlands, which contributes to the generalizability
of the results.
6.3 Limitations of the research
Several limitations of this research can be identified, which should be taken into account when
interpreting the results and conclusion of this research. First of all, the sample size of both the
qualitative as well as the quantitative part of this research is not representative for the theoretical
population. However, to obtain a representative sample was simply not feasible with regards to the
limited time span in which this research needed to be conducted and the researcher’s limited
resources for attracting people to participate. As a result however, the extent to which results can be
extrapolated to the theoretical population is limited, which negatively influences the external validity
of this research.
Moreover, native participants were overrepresented in the sample of questionnaire respondents.
Although that too is the case in the theoretical population, it is a limitation to the research as this
research specifically aimed to gain insight in the perception of native versus non-native participants.
This could to a large extent be achieved as the photovoice sample included 8 non-natives versus 7
natives, but the small amount of non-native respondents compared to native respondents at least
influenced the answer to sub-question four. In addition, many non-native participants of this research
did not consider themselves to be non-native. This particularly applied to non-natives who lived in the
Netherlands for twenty years or longer already, or who were second generation migrants. This
observation might have influenced the internal validity of the research, as gaining understanding in
the specific perception of non-natives was part of the research aim. However, according to the
categorisation of Statistics Netherlands these people were in fact migrants, so this could not be known
by the researcher beforehand. Nevertheless, this variety between non-natives who actually considered
themselves to be non-natives and those who did not, generally made it harder to draw conclusions for
the total group of non-natives. Also, an age-friendly environment was found to have the potential to
be of specific contribution to diminishing ethnic and culture related health inequalities experienced by
migrant elderly. However, to the researcher’s knowledge, at least the included non-native photovoice
participants did not or barely experience these health inequalities, except for a language barrier that
81
was reported by two participants. So, the people to which an age-friendly environment can be of most
benefit were not or barely included in this research, which can be considered as a limitation. Also, this
and the other observed variety within the group of included non-natives shows that it is questionable
to what extent migrant elderly can be considered as one specific group of people and should be treated
as such.
Another drawback of the current research was that many questionnaire respondents did not provide
an explanation for their given answers to qualitative questions. As such, context often lacked and
provided information was not in-depth, which made it harder to draw conclusions on the relationship
between e.g. the provided characteristics of an age-friendly environment and why and how these
could contribute to active ageing. This could possibly have been overcome by adding extra explanatory
questions. However, on the other hand, this would have made the questionnaire even longer than it
already was, increasing the risk on a higher dropout rate. Also, it is not necessarily the aim of a
quantitative research method like a questionnaire to obtain in-depth information. However, it must
be considered that the quantitative findings mainly supplemented and validated the qualitative
findings in terms of prevalence of themes/codes than in terms of obtained in-depth information. Also,
with regards to the used questionnaire, it is questionable to what extent non-native participants that
do not have sufficient Dutch language skills were able to complete this survey while fully understanding
all questions asked. One respondent with a non-western migrant background actually mentioned that
a particular question was too difficult to understand. So, as a result of language issues, it could have
occurred that respondents filled in answers without full awareness. Although the researcher
attempted to make the questionnaire as understandable as possible, for example by doing a pilot and
providing descriptions of used terms, false answers do to a language barrier experienced by the
respondent cannot be excluded.
Furthermore, it could be a limitation of the research that all of the interviews were conducted by one
person, as this can possibly have led to biased reporting since the coding and interpretation was also
only done by the same one person. This bias was attempted to be reduced by the feedback of the
supervisor. The fact that all interviews were conducted by one person also had an advantage, as
interview bias was excluded in this way.
6.4 Recommendations for future research
Based on the main findings and the limitations of this research, recommendations for future research
can be done. First, it is recommended to include non-native participants who actually experience
ethnic and culture related health inequalities, as an age-friendly environment can be of specific benefit
82
to those migrant elderly. Also, including more non-natives who also consider themselves to be non-
native is recommended. By doing so, the specific perceptions and experiences of the population group
that can contribute most of an age-friendly environment can be better examined, which might yield
other results than the current research did. This could be achieved by finding people who are less well-
integrated in the Dutch society than the participants of the current research were, for example people
that either established in the Netherlands for less years ago than the participants of the current
research.
Moreover, a considerable amount of participants of the current research mentioned that one only
observes the barriers of an environment as one starts to have limitations, or even that an age-friendly
environment would only become relevant once one start to experience physical limitations or health
problems. Most of the participants in the current research still perceived themselves to be healthy and
active, and experienced no or very few physical limitations. Therefore, including more participants who
experience physical limitations that are due to the ageing process might produce different results than
the current research did. To include more older-old people in the sample might be a way to achieve
this, as physical limitations usually come with age. So, to assure the inclusion of more non-natives that
consider themselves to be non-native and more people who experience physical limitations, sampling
is recommended to be less random than in the current research. In addition, it is recommended to
include a higher sample size so that the results are more representative for the theoretical population.
To achieve this, it is necessary to collaborate with organisations for (migrant) elderly, boards of places
of worship, and service providers like general practitioners, as was experienced in the current research.
6.5 Translation into practice
Results from this research can be translated into practice in order to support governments, policy
makers and spatial planners in building age-friendly physical environments that take into account the
perception and wishes of both native and non-native Dutch elderly. Based on this research, it is
recommended to use the WHO’s checklist for an age-friendly environment as exit point in this
designing process, but to hereby pay specific attention to, or prioritise, the features that were found
to be more important for active ageing to migrant elderly. These features are portrayed in Table 15.
83
Table 15 Specific recommendations for building an age-friendly environment that takes migrant elderly into account
Pay specific attention to:
Public transport, as part of the domain of Transport & mobility, with affordability being the most important feature
The availability of seating in public space in order to facilitate mobility
Ensuring safety, which can be achieved by the presence of sufficient street lighting and paying attention to traffic situations regarding speed limits, interaction with other traffic like cyclists, and safe crossovers
Creating social meeting places, preferably in every neighbourhood so that these are easy to reach
Organising activities, both for social contact purposes as well as for satisfying the interests of people
The accessibility of public space which concerns the absence stairs, or at least placing grips and offering an alternative like a slope, equal pavements with curbs dropped to road level, pavements free of cars, snow and leaves
The accessibility of public buildings, which refers to entrances with slopes and without steps, elevators in building
The availability of both footpaths and cycle paths, with footpaths being the main priority
Furthermore, based on this research it is advised that certain characteristics should in any case be
taken into account when building a generally age-friendly physical environment is the aim. These
aspects are portrayed in Table 16. Some of these are also included in the WHO’s checklist for age-
friendly environments, others are not. Also, attention should be paid to the finding that many
characteristics of an age-friendly environment are interrelated. Therefore, the influence of certain
characteristics on the bigger picture should be considered in the decision-making or designing process.
By doing so, priorities can be set. Also, it can be determined which characteristic is most effective to
focus on, depending on its influence on the bigger picture.
84
Table 16 General recommendations for building an age-friendly environment
What? How?
Enable accessibility Pavements with dropped curbs to road level
Alternatives next to stairs in public space, like a slope
Houses at street level, or that can be adjusted with e.g. stair lifts
Slops and elevators for public buildings
Prevent cars from being parked over the pavement
Keep footpaths, cycle paths, pavements, roads etc. free from natural rest material
Consider the surface of footpaths
Enable safety Sufficient street lighting
Safe crossroads
Consider dangerous traffic situations (infrastructure)
Clean environment
Limit speed of cars in residential areas
Enable mobility Public transport
Bicycle roads and pedestrian areas
Sufficient parking places
Sufficient seating
Facilitate oppportunity to be physically active
Well-maintained (separated) cycle paths, including separate cycle paths
Well-maintained footpaths
Sports or moving activities, both inside and outside
Facilitate social contact
Social meeting places (community centre, café, restaurant)
Organised activites
Facilitate presence of nature or green space
Parks, forests
To walk in, to cycle in, to sit in
(Senior) Houses with gardens or at least balcony’s
Facilitate cultural activity
Theatre, cinema, concerts
Cultural centres and activities
Facilitate support Provide public toilets, that are clean, safe and accessible
Provide clear and accurate directions signs in public space and buildings
Provide a contact point for technical assistance
Take elderly into account or let them participate in the designing process
Direction signs
Enable participation Opportunities for voluntary work
Close by Especially medical services
Shops
Activities
85
Chapter 7 - Conclusion
This research gained understanding in the differences between the perception and wishes of native
versus non-native Dutch elderly regarding the contribution of the physical environment to active
ageing. A conceptual model was used for this purpose, which was based on existing knowledge about
active ageing (WHO, 2002), an age-friendly environment (WHO, 2007, 2016) and the Pathways of
environmental health etiology as described by Commers et al. (2006). The pathways through which
the physical environment is most likely to influence active ageing do not differ for native versus non-
native Dutch elderly. For both groups, this happens mostly either via behaviour, or via perception and
behaviour. However, differences were found between the perception of natives and non-natives
regarding the needs that an environment should facilitate in order to be of positive influence on active
ageing. Being able to find cultural activity, opportunity to move and support was found to be more
important to natives, as well as that the physical environment is accessible and that the neighbourhood
one lives in has certain characteristics. More specific, natives perceived the availability of sports clubs,
cycle paths, footpaths and houses with a garden or balcony to be more important than non-natives for
an environment to contribute to active ageing. On the other hand, the facilitation of safety and social
contact were found to be more important to non-natives. Also, the availability of public seating and
public transport were found to be more important to non-natives. If these needs can be met, an
environment has the potential to be perceived as age-friendly.
Although the perception of an age-friendly environment differs somewhat between natives and non-
natives based on the above-mentioned preferences, the general concept of an age-friendly
environment turned out to be broadly the same for both population groups. Both natives and non-
natives perceived an age-friendly environment as an environment that enables older people to remain
functioning in their daily life and in society, and to stay active, despite possible physical limitations
experienced due to the ageing process. Hence, it can be concluded that the pathways through which
the physical environment can influence active ageing do not differ for natives versus non-natives, but
that the environmental conditions related to age-friendliness do and that these depend on perception.
Nevertheless, a one-size-fits-all age-friendly environment cannot be designed based on the results of
this research, not for the total population, nor for natives or non-natives separately. The sample size
was too small and the variety within the group of migrants too wide to be able to do so. Future research
has the potential to obtain more complete results if more targeted sampling of participants is applied.
However, based on this research, it is debatable to what extent non-native elderly can be considered
as one specific group of people and should be treated as such.
86
References
Abbott, P., & Sapsford, R. (2005). Living on the margins: Older people, place and social exclusion. Policy
Studies, 26(1), 29-46.
Alley, D., Liebig, P., Pynoos, J., Banerjee, T., & Choi, I. H. (2007). Creating elder-friendly communities:
Preparations for an aging society. Journal of Gerontological Social Work, 49(1-2), 1-18.
Bacsu, J., Jeffery, B., Novik, N., Abonyi, S., Oosman, S., Johnson, S., & Martz, D. (2014). Policy,
community and kin: Interventions that support rural healthy aging. Activities, Adaptation &
Aging, 38(2), 138-155.
Bakker, I. C. (2014). Uncovering the secrets of a productive environment, A journey through the impact
of plants and colour (Doctoral dissertation, TU Delft, Delft University of Technology).
Beard, H. P. J. R., & Bloom, D. E. (2015). Towards a comprehensive public health response to population
ageing. Lancet (London, England), 385(9968), 658.
Beard, J. R., & Petitot, C. (2010). Ageing and urbanization: Can cities be designed to foster active
ageing?. Public Health Reviews, 32(2), 427.
Biggs, S., & Haapala, I. (2015). Age friendly environments. Journal of Social Work Practice, 29(1), 1-3.
Boudiny, K., & Mortelmans, D. (2011). A critical perspective: towards a broader understanding of'active
ageing'. E-Journal of Applied Psychology, 7(1), 8-14.
Bowling, A. (2009). Perceptions of active ageing in Britain: divergences between minority ethnic and
whole population samples. Age and Ageing, 38(6), 703-710.
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative research in
psychology, 3(2), 77-101.
Buffel, T. (2015). Ageing migrants and the creation of home: Mobility and the maintenance of
transnational ties. Population, Space and Place.
Buffel, T., Phillipson, C., & Scharf, T. (2012). Ageing in urban environments: Developing ‘age-
friendly’cities. Critical Social Policy, 32(4), 597-617.
Ciobanu, R. O., Fokkema, T., & Nedelcu, M. (2017). Ageing as a migrant: Vulnerabilities, agency and
policy implications. Journal of Ethnic and Migration Studies, 43(2), 164-181.
Collings, P. (2001). “If you got everything, it's good enough”: perspectives on successful aging in a
Canadian Inuit community. Journal of cross-cultural gerontology, 16(2), 127-155.
Commers, M. J., Gottlieb, N., & Kok, G. (2006). How to change environmental conditions for
health. Health Promotion International, 22(1), 80-87.
87
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.
Deeming, C. (2009). 'Active ageing' in practice: a case study in East London, UK. Policy & Politics, 37(1),
93-111.
Dempsey, J. V., & Tucker, S. A. (1991). Using Photo-Interviewing as Tool for Research and Evaluation.
Deregowski, J. B. (1972). Pictorial perception and culture. Scientific American, 227(5), 82-89.
De Winter, J. C., & Dodou, D. (2010). Five-Point Likert Items&58; t Test versus Mann-Whitney-
Wilcoxon. Practical Assessment, 15(11), 1-16.
Emlet, C. A., & Moceri, J. T. (2012). The importance of social connectedness in building age-friendly
communities. Journal of aging research, 2012.
Eurostat (2016). Population structure and ageing. Retrieved on 12-9-2017 via
http://ec.europa.eu/eurostat/statistics-explained/index.php/Population_structure_and_ageing
Fernández-Ballesteros, R., Robine, J. M., Walker, A., & Kalache, A. (2013). Active aging: a global
goal. Current gerontology and geriatrics research, 2013.
Fitzgerald, K. G., & Caro, F. G. (2014). An overview of age-friendly cities and communities around the
world. Journal of Aging & Social Policy, 26(1-2), 1-18.
Fokkema, T., & Naderi, R. (2013). Differences in late-life loneliness: a comparison between Turkish and
native-born older adults in Germany. European Journal of Ageing, 10(4), 289-300.
Foster, L., & Walker, A. (2014). Active and successful aging: A European policy perspective. The
Gerontologist, 55(1), 83-90.
Fry, C. L., Dickerson-Putman, J., Draper, P., Ikels, C., Keith, J., Glascock, A. P., & Harpending, H. C. (1997).
Culture and the meaning of a good old age. The cultural context of aging: Worldwide perspectives, 3,
99-123.
Gabriel, Z., & Bowling, A. (2004). Quality of life from the perspectives of older people. Ageing &
Society, 24(5), 675-691.
Gifford, R., Steg, L., & Reser, J. P. (2011). Environmental psychology. IAAP handbook of applied
psychology, 440-470.
Given, L. M., Opryshko, A., Julien, H., & Smith, J. (2011). Photovoice: A participatory method for
information science. Proceedings of the Association for Information Science and Technology, 48(1),
1-3.
Goldstein, E. (2009). Sensation and Perception. Belmont (CA): Cengage Learning.
Golledge, R. G., & Stimson, R. J. (1987). Analytical behavioural geography. London: Routledge Kegan &
Paul
88
Ittelson, W. H. (1978). Environmental perception and urban experience. Environment and behavior,
10(2), 193-213.
Jacobs, M. H. (2006). The production of mindscapes: a comprehensive theory of landscape experience
Julien, H., Given, L. M., & Opryshko, A. (2013). Photovoice: A promising method for studies of
individuals' information practices. Library & information science research, 35(4), 257-263.
Keating, N., Eales, J., & Phillips, J. E. (2013). Age-friendly rural communities: Conceptualizing ‘best-
fit’. Canadian Journal on Aging/La Revue canadienne du vieillissement, 32(4), 319-332.
Keith, J., Fry, C. L., & Ikels, C. (1990). Community as context for successful aging. The cultural context
of aging: Worldwide perspectives, 245-261.
Kerr, J., Rosenberg, D., & Frank, L. (2012). The role of the built environment in healthy aging:
community design, physical activity, and health among older adults. Journal of Planning
Literature, 27(1), 43-60.
Kowal, P., & Dowd, J. E. (2001). Definition of an older person. Proposed working definition of an older
person in Africa for the MDS Project. Geneva: World Health Organization.
Kristiansen, M., Razum, O., Tezcan-Güntekin, H., & Krasnik, A. (2016). Aging and health among migrants
in a European perspective. Public Health Reviews, 37(1), 20.
Lassen, A. J., & Moreira, T. (2014). Unmaking old age: Political and cognitive formats of active
ageing. Journal of Aging Studies, 30, 33-46.
Lawton, M.P. (1983) Environment and other determinants of well-being in older people. The
Gerontologist, 23(4), 349-57.
Lawton, M. P., & Nahemow, L. (1973). Ecology and the aging process.
Lindheim, R., & Syme, S. L. (1983). Environments, people, and health. Annual review of public
health, 4(1), 335-359.
Löckenhoff, C. E., De Fruyt, F., Terracciano, A., McCrae, R. R., De Bolle, M., Costa, P. T., ... & Allik, J.
(2009). Perceptions of aging across 26 cultures and their culture-level associates. Psychology and
aging, 24(4), 941.
Lowry, K. A., Vallejo, A. N., & Studenski, S. A. (2012). Successful aging as a continuum of functional
independence: lessons from physical disability models of aging. Aging and disease, 3(1), 5.
Lui, C. W., Everingham, J. A., Warburton, J., Cuthill, M., & Bartlett, H. (2009). What makes a community
age‐friendly: A review of international literature. Australasian journal on ageing, 28(3), 116-121.
Martin, W. (2012). Visualizing risk: Health, gender and the ageing body. Critical social policy, 32(1), 51-
68.
Mattila, A. S., & Wirtz, J. (2001). Congruency of scent and music as a driver of in-store evaluations and
behavior. Journal of retailing, 77(2), 273-289.
89
Matsumoto, D. (1996). Culture and Psychology. Pacific Grove, CA: Brooks/Cole Publishing Company.
Means, R. (2007). Safe as houses? Ageing in place and vulnerable older people in the UK. Social Policy
& Administration, 41(1), 65-85.
Mehrabian, A., & Russell, J. A. (1974). An approach to environmental psychology. Cambridge, MA: the
MIT Press.
Menec, V. H., & Nowicki, S. (2014). Examining the relationship between communities’‘age-friendliness’
and life satisfaction and self-perceived health in rural Manitoba, Canada. Rural and Remote
Health, 14(2594).
Menec, V. H., Means, R., Keating, N., Parkhurst, G., & Eales, J. (2011). Conceptualizing age-friendly
communities. Canadian Journal on Aging/La Revue canadienne du vieillissement, 30(3), 479-493.
Michel, J. P., Beattie, B. L., Walston, J. D., & Martin, F. C. (Eds.). (2017). Oxford Textbook of Geriatric
Medicine. Oxford University Press.
Naaldenberg, J., Vaandrager, L., Koelen, M., & Leeuwis, C. (2012). Aging populations’ everyday life
perspectives on healthy aging: New insights for policy and strategies at the local level. Journal of
Applied Gerontology, 31(6), 711-733.
Nosraty, L., Jylhä, M., Raittila, T., & Lumme-Sandt, K. (2015). Perceptions by the oldest old of successful
aging, Vitality 90+ Study. Journal of aging studies, 32, 50-58.
Novek, S., & Menec, V. H. (2014). Older adults' perceptions of age-friendly communities in Canada: a
photovoice study. Ageing & Society, 34(6), 1052-1072.
OECD (2011), Pensions at a Glance 2011: Retirement-income Systems in OECD and G20 Countries.
Paris: OECD Publishing, http://dx.doi.org/10.1787/pension_glance-2011-en.
O’Neill, G., Morrow-Howell, N., & Wilson, S. F. (2011). Volunteering in later life: From disengagement
to civic engagement. In Handbook of sociology of aging (pp. 333-350). New York, NY: Springer.
Paúl, C., Ribeiro, O., & Teixeira, L. (2012). Active ageing: an empirical approach to the WHO
model. Current gerontology and geriatrics research, 2012.
Phillipson, C. (2004). Urbanisation and ageing: Towards a new environmental gerontology. Ageing &
Society, 24(6), 963-972.
Phillipson, C. (2007). The ‘elected’and the ‘excluded’: sociological perspectives on the experience of
place and community in old age. Ageing & Society, 27(3), 321-342.
Phillipson, C. (2012). Developing age-friendly cities: policy challenges & options. Housing Learning &
Improvement Network, London.
Plouffe, L., & Kalache, A. (2010). Towards global age-friendly cities: Determining urban features that
promote active aging. Journal of Urban Health, 87(5), 733–739.
90
Plouffe, L., Kalache, A., & Voelcker, I. (2016). A critical review of the WHO age-friendly cities
methodology and its implementation. In Age-friendly cities and communities in international
comparison (pp. 19-36).
Ranzijn, R. (2010). Active ageing—Another way to oppress marginalized and disadvantaged elders?
Aboriginal elders as a case study. Journal of Health Psychology, 15(5), 716-723.
Scharf, T., Phillipson, C., & Smith, A. (2007). Aging in a difficult place: assessing the impact of urban
deprivation on older people. New dynamics in old age: Individual, environmental and societal
perspectives, 153-73.
Scharf, T., Phillipson, C., Smith, A., Wahl, H., Tesch-Romer, C., & Hoff, A. (2007). New Dynamics in Old
Age: Individual, Environmental and Societal Perspectives. London: Routledge.
Wahl, H. W., Tesch-Romer, C., Hoff, A., & Hendricks, J. (2017). New dynamics in old age: Individual,
environmental and societal perspectives. London: Routledge.
Sidorenko, A., & Zaidi, A. (2013). Active ageing in CIS countries: semantics, challenges, and
responses. Current gerontology and geriatrics research, 2013.
Statistics Netherlands (2016). Afbakening generaties met migratieachtergrond. Retrieved on 3-10-
2017 via
https://www.cbs.nl/nl-nl/achtergrond/2016/47/afbakening-generaties-met-
migratieachtergrond
Statistics Netherlands (2017). Bevolking met migratieachtergrond; geslacht, leeftijd, 1 januari.
Retrieved on 1-10-2017 via
http://statline.cbs.nl/StatWeb/publication/?VW=T&DM=SLNL&PA=70787ned&LA=NL
Stegeman, I., Otte-Trojel, T., Costongs, C., & Considine, J. (2012). Healthy and active ageing. Brussels:
EuroHealthNet and Bundeszentrale für gesundheitliche Aufklaerung (BZgA).
Torres, S. (2001). Understandings of successful ageing in the context of migration: The case of Iranian
immigrants in Sweden. Ageing & Society, 21(3), 333-355.
United Nations (personal communication with World Health Organization representative, 2001).
Retrieved on 9-10-2017 from http://www.who.int/healthinfo/survey/ageingdefnolder/en/
United Nations. (2015). World population prospects: The 2015 revision, key findings and advance
tables. Working Paper No. ESA/P/ WP.241 New York: UN DESA.
Victor, C. R., Burholt, V., & Martin, W. (2012). Loneliness and ethnic minority elders in Great Britain:
an exploratory study. Journal of cross-cultural gerontology, 27(1), 65-78.
Walker, A., & Maltby, T. (2012). Active ageing: A strategic policy solution to demographic ageing in the
European Union. International Journal of Social Welfare, 21(s1).
Wang, C. C., & Redwood-Jones, Y. A. (2001). Photovoice ethics: Perspectives from Flint
photovoice. Health education & behavior, 28(5), 560-572.
91
Wang, C., & Burris, M. A. (1997). Photovoice: Concept, methodology, and use for participatory needs
assessment. Health education & behavior, 24(3), 369-387.
Wieringen, Joke van (2014). Wie zorgt voor oudere migranten? De rol van mantelzorgers,
sleutelfiguren, professionals, gemeenten en ouderen zelf. Utrecht: Pharos.
Willcox, D. C., Willcox, B. J., Sokolovsky, J., & Sakihara, S. (2007). The cultural context of “successful
aging” among older women weavers in a Northern Okinawan village: The role of productive
activity. Journal of cross-cultural gerontology, 22(2), 137-165.
Wisdom, J., & Creswell, J. W. (2013). Mixed methods: integrating quantitative and qualitative data
collection and analysis while studying patient-centered medical home models. Rockville: Agency for
Healthcare Research and Quality.
World Health Organization (1978) Declaration of Alma-Ata: International Conference on Primary
Health Care, Alma-Ata, USSR, 6–12 September 1978. .
World Health Organization. Department of Noncommunicable Disease Prevention and Health
Promotion (2002). Active ageing : a policy framework. Geneva : World Health Organization
World Health Organization (2007). Global age-friendly cities: A guide. Geneva: World Health
Organization.
World Health Organization (2011). Global health and ageing. Retrieved on 16-9-2017 from
http://europepmc.org/articles/pmc4663973
World Health Organization (2015). World report on ageing and health. Geneva: World Health
Organization.
World Health Organization (2016). Creating age-friendly environments in Europe: A tool for local
policy-makers and planners. Geneva: World Health Organisation
World Health Organization (2018). Age-friendly environments. Retrieved on 5-2-2018 from
http://www.who.int/ageing/projects/age-friendly-environments/en/
Zaidi, A., Gasior, K., Zolyomi, E., Schmidt, A., Rodrigues, R., & Marin, B. (2017). Measuring active and
healthy ageing in Europe. Journal of European Social Policy, 27(2), 138-157.
Zimmer, Z. (2016). Global Ageing in the Twenty-First Century: Challenges, Opportunities and
Implications. London: Routledge.
Zonn, L. E. (1984). Landscape depiction and perception: A transactional approach. Landscape
Journal, 3(2), 144-150.
Zube, E. H., Sell, J. L., & Taylor, J. G. (1982). Landscape perception: research, application and theory.
Landscape planning, 9(1), 1-33.
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Appendices
Appendix 1 – Checklist of essential features of an age-friendly environment (WHO, 2007)
This checklist of essential age-friendly city features is based on the results of the WHO Global Age-
Friendly Cities project consultation in 33 cities in 22 countries. The checklist is a tool for a city’s self-
assessment and a map for charting progress. More detailed checklists of age-friendly city features are
to be found in the WHO Global Age-Friendly Cities Guide.
This checklist is intended to be used by individuals and groups interested in making their city more
age-friendly. For the checklist to be effective, older people must be involved as full partners. In
assessing a city’s strengths and deficiencies, older people will describe how the checklist of features
matches their own experience of the city’s positive characteristics and barriers. They should play a
role in suggesting changes and in implementing and monitoring improvements.
Outdoor spaces and buildings
☐ Public areas are clean and pleasant.
☐ Green spaces and outdoor seating are sufficient in number, well-maintained and safe.
☐ Pavements are well-maintained, free of obstructions and reserved for pedestrians.
☐ Pavements are non-slip, are wide enough for wheelchairs and have dropped curbs to road level.
☐ Pedestrian crossings are sufficient in number and safe for people with different levels and types of disability, with nonslip markings, visual and audio cues and adequate crossing times.
☐ Drivers give way to pedestrians at intersections and pedestrian crossings.
☐ Cycle paths are separate from pavements and other pedestrian walkways.
☐ Outdoor safety is promoted by good street lighting, police patrols and community education.
☐ Services are situated together and are accessible.
☐ Special customer service arrangements are provided, such as separate queues or service counters for older people.
☐ Buildings are well-signed outside and inside, with sufficient seating and toilets, accessible elevators, ramps, railings and stairs, and non-slip floors.
☐ Public toilets outdoors and indoors are sufficient in number, clean, well-maintained and accessible.
Transportation
☐ Public transportation costs are consistent, clearly displayed and affordable.
☐ Public transportation is reliable and frequent, including at night and on weekends and holidays.
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☐ All city areas and services are accessible by public transport, with good connections and well-marked routes and vehicles.
☐ Vehicles are clean, well-maintained, accessible, not overcrowded and have priority seating that is respected.
☐ Specialized transportation is available for disabled people.
☐ Drivers stop at designated stops and beside the curb to facilitate boarding and wait for passengers to be seated before driving off .
☐ Transport stops and stations are conveniently located, accessible, safe, clean, well-lit and well-marked, with adequate seating and shelter.
☐ Complete and accessible information is provided to users about routes, schedules and special needs facilities.
☐ A voluntary transport service is available where public transportation is too limited.
☐ Taxis are accessible and affordable, and drivers are courteous and helpful.
☐ Roads are well-maintained, with covered drains and good lighting.
☐ Traffic flow is well-regulated.
☐ Roadways are free of obstructions that block drivers’ vision.
☐ Traffic signs and intersections are visible and ell-placed.
☐ Driver education and refresher courses are promoted for all drivers.
☐ Parking and drop-off areas are safe, sufficient in number and conveniently located.
☐ Priority parking and drop-off spots for people with special needs are available and respected.
Housing
☐ Sufficient, affordable housing is available in areas that are safe and close to services and the rest of the community.
☐ Sufficient and affordable home maintenance and support services are available.
☐ Housing is well-constructed and provides safe and comfortable shelter from the weather.
☐ Interior spaces and level surfaces allow freedom of movement in all rooms and passageways.
☐ Home modification options and supplies are available and affordable, and providers understand the needs of older people.
☐ Public and commercial rental housing is clean, well-maintained and safe.
☐ Sufficient and affordable housing for frail and disabled older people, with appropriate services, is provided locally.
☐ Workplaces are adapted to meet the needs of disabled people.
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Appendix 2 – Photo journal
‘Fotodagboek’ Afstudeeronderzoek Saskia Nijland Bijdrage van de fysieke leefomgeving aan actief ouder worden
Hiervoor wordt van u gevraagd om:
Minimaal 3 foto’s en maximaal 10 foto’s te maken van plaatsen of dingen in de fysieke
leefomgeving (al het materiële in uw omgeving, zoals: gebouwen, winkels, wegen,
fietspaden, openbaar vervoer, parken, bossen, enz.) die voor u bijdragen aan actief ouder
kunnen worden. Dit hoeft niet per se in uw huidige eigen leefomgeving te zijn, de
foto’s mogen ook op een andere plek gemaakt worden dan in uw eigen buurt.
Minimaal 2 foto’s (meer mag eventueel ook) te maken van plaatsen of dingen in de fysieke
leefomgeving die voor u juist een barrière vormen om actief ouder te kunnen worden, of dit
bemoeilijken. Ook hiervoor geldt dat deze foto’s zowel in uw eigen buurt als in een andere
buurt gemaakt mogen worden.
Voor elke foto 4 vragen kort te beantwoorden. Deze antwoorden mag u typen, maar
geschreven is ook prima, net wat u fijn vindt. Mocht u meer dan de gegeven schrijfruimte
nodig hebben dan is dat geen probleem. Deze 4 vragen zijn:
o Waar heeft u deze foto gemaakt?
o Wat is er te zien op de foto?
o Wat betekent deze foto voor u? (Wat symboliseert het? Wat voor gevoelens of
gedachtes roept het bij u op?)
o Waarom heeft u deze foto gemaakt? (In relatie tot de bijdrage aan actief ouder
worden, of juist het bemoeilijken hiervan)
Mocht u nog vragen hebben dan kunt u mij altijd bellen via 06-14983224 of mailen naar
Deel 1 - Foto’s van dingen of plaatsen in de fysieke leefomgeving die voor u bijdragen aan actief
ouder kunnen worden (min. 3 en max. 10)
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1)
Deel 2 - Foto’s van dingen of plaatsen in de fysieke leefomgeving die voor u een barrière vormen
om actief ouder te kunnen worden, of dit bemoeilijken (min. 2, meer mag ook)
Voor elke foto 4 vragen kort te beantwoorden. Deze antwoorden mag u typen, maar
geschreven is ook prima, net wat u fijn vindt. Mocht u meer dan de gegeven schrijfruimte
nodig hebben dan is dat geen probleem. Deze 4 vragen zijn:
o Waar heeft u deze foto gemaakt?
o Wat is er te zien op de foto?
o Wat betekent deze foto voor u? (Wat symboliseert het? Wat voor gevoelens of
gedachtes roept het bij u op?)
o Waarom heeft u deze foto gemaakt? (In relatie tot de bijdrage aan actief ouder
worden, of juist het bemoeilijken hiervan)
Waar heeft u deze foto gemaakt?
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Wat is er te zien op de foto?
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Wat betekent deze foto voor u?
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Waarom heeft u deze foto gemaakt?
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1)
Waar heeft u deze foto gemaakt?
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Wat is er te zien op de foto?
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Wat betekent deze foto voor u?
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Waarom heeft u deze foto gemaakt?
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Appendix 3 – Interview guideline
Introductie
Het doel van dit onderzoek is dus om te begrijpen hoe 60-plussers denken over hoe de fysieke
leefomgeving bijdraagt aan actief ouder worden. De fysieke leefomgeving wil zeggen: al het materiële
in uw omgeving, zoals huizen, gebouwen, parken, bossen, wandel- en fietspaden. Ik onderzoek
specifiek of er verschillen zijn tussen 60-plussers met en zonder migratieachtergrond in hoe zij denken
over actief ouder worden en de bijdrage van de fysieke leefomgeving hieraan.
Inleidende interviewvragen
1. U hoeft niet uw naam te noemen, maar zou u kort iets over u zelf kunnen vertellen? Waar
houdt u zich bijvoorbeeld zoal mee bezig in het dagelijks leven? Heeft u hobby’s?
2. En mag ik vragen wat uw leeftijd is?
3. Indien geïnterviewde een migratieachtergrond heeft: wat is uw culturele of etnische
achtergrond?
4. Indien geïnterviewde een migratieachtergrond heeft: Als u uw eigen migratie- of culturele
achtergrond moest omschrijven, hoe zou u dat dan doen?
a. Als deelnemer niet weet hoe te antwoorden, dan inspiratie geven: bijvoorbeeld
autochtoon, westerse migrant, niet-westerse migrant, of bijvoorbeeld als Turk of
Nederlander, of Nederlandse Turk/Turkse Nederlander)
Interviewvragen (actief) ouder worden en seniorvriendelijke leefomgeving
1. Bent u bezig met het ouder worden (in het algemeen)?
a. Zo ja, wat merkt u ervan of waar loopt u tegenaan?
2. Wat is ‘actief ouder worden’ volgens u, zou u daar een omschrijving van kunnen geven?
a. Wat betekent actief ouder worden voor u? Hoe denkt u erover?
b. Bent u bezig met actief ouder worden?
c. Wat houdt de term ‘actief’ voor u in?
d. Hoe ziet u het actief ouder worden voor u in de toekomst? (Bijvoorbeeld: welke dingen
wilt u kunnen blijven doen, of wat houdt de term ‘actief’ voor u in over een aantal jaar
denkt u?)
e. Indien geïnterviewde een migratieachtergrond heeft: denkt u dat uw
migratieachtergrond, dus het feit dat u vanuit een ander land naar Nederland bent
gekomen, van invloed is op uw blik op/mening over actief ouder worden of hoe u dit
ervaart?
(Indien het antwoord nee is: En uw culturele achtergrond?)
3. Wat is een ‘seniorvriendelijke leefomgeving’ volgens u, kunt u daar een omschrijving van
geven, van hoe u dat voor u ziet?
a. Welke kenmerken vindt u hier bij passen? Wat vindt u belangrijk?
b. Hoe vindt u dat in uw huidige situatie? Zoals het nu is, vindt u dan dat de fysieke
leefomgeving seniorvriendelijk is? En wat zou er anders beter kunnen, of wat is het
ideaalplaatje voor u? (Het kan ook zijn dat iemand er nog niet mee bezig is en dus niet
98
echt een mening heeft over de huidige situatie, maar bijv. wel dingen kan bedenken
wat hij/zij fijn zou vinden in de toekomst als het ‘ouder worden’ meer opspeelt.)
c. Indien geïnterviewde een migratieachtergrond heeft: denkt u hierbij dat uw
migratieachtergrond (of anders culturele achtergrond) nog een rol speelt, bij uw idee
van een seniorvriendelijke leefomgeving?
Interviewvragen gemaakte foto’s (facilitators en barriers)
Dan nu over naar de vragen over de foto’s die u gemaakt heeft. Zou u een top 3 kunnen maken van de
foto’s die voor u het belangrijkst zijn of het meest bijdragen aan actief ouder worden, of anders één
foto aanwijzen die u het belangrijkst vindt of waar u het meeste waarde aan hecht? Dan wil ik die graag
als eerste bespreken.
Vragen per foto
1. Kunt u vertellen wat er op de foto te zien is?
2. Waar heeft u deze foto gemaakt?
a. Wat voor soort activiteiten onderneemt u daar?
3. Waarom heeft u deze foto gemaakt?
a. Wat is uw gevoel hierbij?
4. Op welke manier draagt wat op de foto te zien is voor u bij aan actief ouder worden?
a. Doorvragen naar thema’s
b. Focussen op de plek, niet op de activiteit
Voor alle foto’s geldt: doorvragen, zodat (een deel van) de volgende onderwerpen aan bod komen:
c. Mobiliteit
d. Zelfstandigheid
e. Autonomie; zelf kunnen beslissen over doen en laten
f. Inclusie; er bij horen
g. Participatie; mee doen
h. Veiligheid
5. Ook de foto’s die u gemaakt heeft van dingen of plekken die juist een barrière vormen voor
actief ouder worden of dit bemoeilijken wil ik graag bespreken.
a. (In elk geval) Zelfde vier vragen stellen als hierboven genoemd.
6. Zijn er verder nog dingen in de fysieke leefomgeving dat echt bijdraagt aan actief ouder
worden, waar u geen foto van heeft gemaakt maar die u wel zou kunnen opnoemen? Als u
bijvoorbeeld denkt aan uw eigen woonplaats of andere plekken waar u graag komt. Of iets dat
juist een barrière vormt?
Interviewvragen ‘self-rated health’
1. Hoe zou u uw gezondheid beoordelen?
Heel goed – goed – neutraal – slecht – heel slecht
2. Hoe zou u uw mobiliteit beoordelen?
Heel goed – goed – neutraal – slecht – heel slecht
99
3. Hoe actief zou u zichzelf gemiddeld noemen op fysiek gebied?
Helemaal niet actief – niet actief – redelijk actief – actief – heel actief
4. En op sociaal gebied?
Helemaal niet actief – niet actief – redelijk actief – actief – heel actief
Wilt u verder nog iets toevoegen, of heeft u nog vragen?
Dan wil ik u heel erg bedanken voor het interview en uw bijdrage aan mijn afstudeeronderzoek, heel
fijn dat u mee wilde doen! En mocht u toch nog vragen of opmerkingen hebben dan kunt u altijd nog
contact met mij opnemen.
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Appendix 4 – Questionnaire
Vragenlijst fysieke leefomgeving en actief ouder worden
Start of Block: Default Question Block
Q1 Deze vragenlijst is onderdeel van het afstudeeronderzoek van Saskia Nijland, student Gezondheid & Maatschappij aan de Wageningen Universiteit. Het doel van dit onderzoek is om te begrijpen hoe 60-plussers denken over hoe de fysieke leefomgeving bijdraagt aan actief ouder worden. De fysieke leefomgeving wil zeggen: al het materiële in uw omgeving, zoals gebouwen, parken, wegen, stoepen en fietspaden. Ik onderzoek specifiek of er verschillen zijn tussen 60-plussers met en zonder migratieachtergrond, in hoe zij denken over actief ouder worden en de bijdrage van de fysieke leefomgeving hieraan. Bent u 60 jaar of ouder en woont u zelfstandig? Dan bent u van harte uitgenodigd om deel te nemen. Als u mee wilt doen aan het onderzoek wordt van u gevraagd om een vragenlijst in te vullen. Deze vragenlijst gaat over hoe belangrijk bepaalde kenmerken van de fysieke leefomgeving voor u zijn om actief ouder te kunnen worden.
Het invullen van de vragenlijst duurt ongeveer 15 minuten.
De vragenlijst bestaat voornamelijk uit meerkeuzevragen.
Aan het einde van de vragenlijst wordt gevraagd naar wat persoonlijke gegevens.
Het onderzoek is anoniem. Uw gegevens worden vertrouwelijk verwerkt.
Persoonlijke gegevens worden losgekoppeld van elkaar. Op deze manier is het niet meer te achterhalen van welke deelnemer deze gegevens komen. Zo wordt de anonimiteit gewaarborgd.
Deelname aan dit onderzoek is op vrijwillige basis. U kunt zich dus op elk gewenst moment terugtrekken. Als u niet meer wilt deel nemen is dat geen probleem. U zit nergens aan vast.
Ook achteraf kunt u dit nog aangeven.
Door mee te doen aan dit onderzoek levert u een bijdrage aan kennis over hoe de fysieke leefomgeving het beste ingericht kan worden om actief ouder te kunnen worden. Dit draagt bij aan de kwaliteit van leven en gezondheid van 60-plussers en daarmee aan de gezondheid van de maatschappij.
De resultaten worden verwerkt in een rapport. Als u dit rapport wilt ontvangen, dan kunt u contact opnemen met Saskia (zie onderstaande contactgegevens).
Mocht u vragen hebben voor, tijdens of na het onderzoek dan kunt u contact opnemen met Saskia Nijland. Dit kan via telefoonnummer 06-14983224 of e-mailadres [email protected]. Aan het einde van de vragenlijst worden deze contactgegevens nogmaals gegeven. Verklaart u bovenstaande te hebben gelezen en hiermee akkoord te gaan?
Ja (1)
101
Q2 Binnen welke categorie valt uw leeftijd?
60-64 jaar (1)
65-69 jaar (2)
70-74 jaar (3)
75-79 jaar (4)
80 jaar of ouder (5)
Q3 Wat is uw woonsituatie?
Zelfstandig wonend zonder zorgondersteuning door familie/bekenden of zorginstanties (1)
Zelfstandig wonend met zorgondersteuning van zorginstanties (2)
Zelfstandig wonend met zorgondersteuning van familie/bekenden (3)
Zelfstandig wonend met zorgondersteuning van familie/bekenden en zorginstanties (4)
Anders, namelijk (5) ________________________________________________
Q4 Hoe zou u uw gezondheid gemiddeld gezien beoordelen?
Heel slecht (1) Slecht (2) Matig (3) Goed (4) Heel goed (5)
Mijn gezondheid is
(1)
Q5 Hoe zou u uw mobilieit gemiddeld gezien beoordelen? Onder mobiliteit wordt verstaan: zich kunnen verplaatsen, het vermogen om zich te kunnen bewegen in de omgeving.
Heel slecht (1) Slecht (2) Matig (3) Goed (4) Heel goed (5)
Mijn mobiliteit is (1)
102
Q6 Hoe actief zou u zichzelf gemiddeld noemen?
Helemaal niet
actief (1) Niet actief (2)
Redelijk actief (3)
Actief (4) Heel actief (5)
Fysiek actief (1)
Sociaal actief (2)
Q7 In hoeverre wordt u door gezondheidsklachten beperkt in uw bewegen?
Niet beperkt (1)
Licht beperkt (2)
Sterk beperkt (3)
Q8 Vul de volgende zin naar eigen inzicht aan. Dit mag ook met steekwoorden en u mag er ook meerdere zinnen van maken. Er zijn geen goede of foute antwoorden. Ik ben geïnteresseerd in uw mening. Voor mij betekent actief ouder worden...
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103
Q9 Vul de volgende zin naar eigen inzicht aan. Dit mag ook met steekwoorden en u mag er ook meerdere zinnen van maken. Er zijn geen goede of foute antwoorden. Ik ben geïnteresseerd in uw mening. Een seniorvriendelijke leefomgeving is voor mij...
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Q10 In dit onderzoek betekent ‘actief ouder worden’ dat 60-plussers actief kunnen blijven deelnemen aan de samenleving. Het gaat dus niet alleen om fysieke activiteit (bewegen, sporten) of deelname aan de arbeidsmarkt, maar ook om het mee kunnen blijven doen aan sociale en culturele activiteiten. Hiervoor is het kunnen behouden van zowel de fysieke, mentale als sociale gezondheid erg belangrijk. Ook veiligheid speelt hierin een belangrijke rol. Actief ouder worden gaat dus om het stimuleren van activiteit, deelname, gezondheid en veiligheid, zodat de kwaliteit van leven behouden kan blijven als mensen ouder worden. Kunt u zich in deze definitie vinden?
Ja (1)
Nee, want (2) ________________________________________________
Q11 Houdt bij de volgende vragen de hiervoor gegeven definitie van actief ouder worden aan als uitgangspunt. Deze definitie is hieronder nogmaals kort weergegeven.
104
Hoe belangrijk zijn de volgende dingen voor u om actief ouder te kunnen worden?
Helemaal niet belangrijk (1)
Niet belangrijk (2)
Neutraal (3) Belangrijk (4) Heel erg
belangrijk (5)
Huisvesting (1)
Openbare ruimtes en
gebouwen (2)
Transport en mobiliteit
(onder mobiliteit
wordt verstaan: zich kunnen verplaatsen,
kunnen bewegen in de omgeving) (3)
Q12 Hoe belangrijk zijn de volgende dingen voor u om actief ouder te kunnen worden? Rangschik op volgorde van belangrijkheid, waarbij 1 het belangrijkste kenmerk is en 3 het minst belangrijke. Dit kunt u doen door de antwoorden te verslepen.
______ Huisvesting (1) ______ Openbare ruimtes en gebouwen (2) ______ Transport en mobiliteit (beweeglijkheid, zich kunnen verplaatsen) (3)
105
Q13 Hoe belangrijk zijn de volgende kernmerken voor u om actief ouder te kunnen worden?
Helemaal niet belangrijk (1)
Niet belangrijk (2)
Neutraal (3) Belangrijk (4) Heel erg
belangrijk (5)
Mobiliteit; beweeglijkheid,
zich kunnen verplaatsen (1)
Autonomie; zelf kunnen beslissen
over doen en laten (2)
Onafhankelijkheid; niet afhankelijk zijn van de hulp van anderen (3)
Inclusie; er bij horen, volwaardig
deel uit maken van de
samenleving (4)
Participatie; deelname, mee kunnen doen (5)
Veiligheid (6)
Zelfstandigheid; zelfredzaamheid
(7)
106
Q14 Hoe belangrijk is het volgende kenmerk voor u om actief ouder te kunnen worden?
Helemaal niet
belangrijk (1)
Niet belangrijk
(2) Neutraal (3)
Belangrijk (4)
Heel erg belangrijk
(5)
Veilige voetgangersoversteekplaatsen,
met slipvrije markeringen (1)
Q15 Hoe belangrijk is het volgende kenmerk voor u om actief ouder te kunnen worden?
Helemaal niet belangrijk (1)
Niet belangrijk (2)
Neutraal (3) Belangrijk (4) Heel erg
belangrijk (5)
Fietspaden zijn gescheiden van
stoepen en andere
voetpaden (1)
107
Q16 Hoe belangrijk is het volgende kenmerk voor u om actief ouder te kunnen worden?
Helemaal niet belangrijk (1)
Niet belangrijk (2)
Neutraal (3) Belangrijk (4) Heel belangrijk
(5)
De veiligheid op straat wordt
bevorderd door de aanwezigheid
van goede straatverlichting
(1)
Q17 Hoe belangrijk is het volgende kenmerk voor u om actief ouder te kunnen worden?
Helemaal niet belangrijk (1)
Niet belangrijk (2)
Neutraal (3) Belangrijk (4) Heel erg
belangrijk (5)
Er wordt gesurveilleerd door de politie
om de veiligheid te
bevorderen (1)
108
Q18 Hoe belangrijk is het volgende kenmerk voor u om actief ouder te kunnen worden?
Helemaal niet belangrijk (1)
Niet belangrijk (2)
Neutraal (3) Belangrijk (4) Heel belangrijk
(5)
Er zijn zowel binnen als
buiten voldoende openbare
toiletten en deze zijn
schoon en goed onderhouden
(1)
109
Q19 Hoe belangrijk is het volgende kenmerk voor u om actief ouder te kunnen worden?
Helemaal niet belangrijk (1)
Niet belangrijk (2)
Neutraal (3) Belangrijk (4) Heel belangrijk
(5)
Openbare toiletten zijn toegankelijk
voor ouderen (1)
Q20 Hoe belangrijk is het volgende kenmerk voor u om actief ouder te kunnen worden?
Helemaal niet belangrijk (1)
Niet belangrijk (2)
Neutraal (3) Belangrijk (4) Heel belangrijk
(5)
De openbare ruimte is
schoon en aangenaam (1)
110
Q21 Hoe belangrijk is het volgende kenmerk voor u om actief ouder te kunnen worden?
Helemaal niet belangrijk (1)
Niet belangrijk (2)
Neutraal (3) Belangrijk (4) Heel belangrijk
(5)
Er zijn voldoende veilige
groenvoorzieningen (1)
Q22 Hoe belangrijk is het volgende kenmerk voor u om actief ouder te kunnen worden?
Helemaal niet belangrijk (1)
Niet belangrijk (2)
Neutraal (3) Belangrijk (4) Heel belangrijk
(5)
Bankjes en andere
openbare zitplaatsen zijn
goed onderhouden
(1)
111
Q23 Hoe belangrijk is het volgende kenmerk voor u om actief ouder te kunnen worden?
Helemaal niet belangrijk (1)
Niet belangrijk (2)
Neutraal (3) Belangrijk (4) Heel belangrijk
(5)
Stoepen hebben schuine
stoepranden die aflopen
naar het wegdek (1)
Q24 Houdt ook bij de volgende vraag de gegeven definitie van actief ouder worden aan als uitgangspunt. Ter herinnering wordt deze hier nogmaals weergegeven.
112
Hoe belangrijk zijn de volgende kenmerken voor u om actief ouder te kunnen worden?
Helemaal niet
belangrijk (1)
Niet belangrijk
(2) Neutraal (3)
Belangrijk (4)
Heel belangrijk
(5)
Er zijn speciale voorzieningen voor ouderen, zoals een
aparte wachtrij of balie (1)
Dienstverleners/voorzieningen zijn dicht bij elkaar gevestigd
(2)
Openbare ruimte en gebouwen bieden de
mogelijkheid tot sociale ontmoetingen (3)
Q25 Zijn er nog andere dingen die te maken hebben met actief ouder kunnen worden die u belangrijk vindt aan openbare ruimte en gebouwen? U mag zo veel opnoemen als u wilt. Indien het antwoord nee is, hoeft u niets in te vullen.
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113
Q26 Houdt ook bij de volgende vraag de gegeven definitie van actief ouder worden aan als uitgangspunt. Hoe belangrijk zijn de volgende kenmerken voor u om actief ouder te kunnen worden?
Helemaal niet belangrijk (1)
Niet belangrijk (2)
Neutraal (3) Belangrijk (4) Heel erg
belangrijk (5)
Alle wijken en in de stad zijn met
het openbaar vervoer
bereikbaar (1)
Dokters en andere
dienstverleners zijn met het
openbaar vervoer
bereikbaar (2)
Het openbaar vervoer is
betaalbaar (3)
Het openbaar vervoer is
betrouwbaar en rijdt regelmatig, ook 's nachts en in het weekend
(4)
Q27 Zijn er nog andere dingen die u belangrijk vindt aan het openbaar vervoer die te maken hebben met actief ouder kunnen worden? U mag zo veel opnoemen als u wilt. Indien het antwoord nee is, hoeft u niets in te vullen.
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114
Q28 Houdt ook bij de volgende vraag de gegeven definitie van actief ouder worden aan als uitgangspunt. Hoe belangrijk zijn de volgende kenmerken voor u om actief ouder te kunnen worden?
Helemaal niet belangrijk (1)
Niet belangrijk (2)
Neutraal (3) Belangrijk (4) Heel erg
belangrijk (5)
Huizen zijn gelijkvloers (1)
Huizen hebben doorgangen die wijd genoeg zijn voor rolstoelen
(2)
Badkamers, toiletten en keukens zijn
aangepast (3)
Er is voldoende betaalbare
huisvesting in veilige gebieden
(4)
Huizen zijn beschikbaar in de nabijheid
van voorzieningen
en andere woningen (5)
115
Q29 Wat voor activiteiten zou u ondernemen in groene ruimte zoals een park of bos? U mag meerdere antwoorden kiezen.
▢ Wandelen (1)
▢ Picknicken (2)
▢ Zitten op een bankje (3)
▢ Sporten (4)
▢ Anders, namelijk (5) ________________________________________________
Q30 Wat voor activiteiten zou u ondernemen met het openbaar vervoer? U mag meerdere antwoorden kiezen.
▢ Op bezoek bij familie of vrienden (1)
▢ Een dokter of andere zorgverlener bezoeken (2)
▢ Boodschappen (3)
▢ Leuke uitstapjes (4)
▢ Anders, namelijk (5) ________________________________________________
116
Q31 Welke kenmerken moet huisvesting volgens u hebben, om actief ouder te kunnen worden? U mag meerdere antwoorden kiezen.
▢ Betaalbaar (1)
▢ Dichtbij zorgverleners en voorzieningen (2)
▢ Mogelijkheid tot aanpassingen, zoals een traplift (3)
▢ In een veilige omgeving (4)
▢ Anders, namelijk (5) ________________________________________________
Q32 Zijn er nog andere dingen in de fysieke leefomgeving die voor u kunnen bijdragen aan actief ouder worden? U mag zoveel opnoemen als u wilt. Indien het antwoord nee is, vul dan niets in.
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Q33 Zijn er nog dingen in de fysieke leefomgeving die voor u het actief ouder kunnen worden juist tegenhouden of vermoeilijken? U mag zoveel opnoemen als u wilt. Indien het antwoord nee is, vul dan niets in.
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117
Q34 Wat is uw geslacht?
Man (1)
Vrouw (2)
Q35 Wat zijn de cijfers van uw postcode?
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Q36 Wat is uw burgerlijke staat?
Getrouwd (1)
Samenwonend (2)
Alleenstaand (3)
Weduwe (4)
Gescheiden (5)
LAT-relatie (6)
Anders, namelijk (7) ________________________________________________
Q37 Wat is de samenstelling van uw huishouden?
Eenpersoonshuishouden (1)
Meerpersoonshuishouden zonder inwonende kinderen (2)
Meerpersoonshuishouden met inwonende kinderen (3)
118
Q38 Wat is uw hoogst voltooide opleiding?
Lagere school (1)
Middelbare school: vmbo, mavo, mulo (2)
Middelbare school: havo, vwo, atheneum (3)
Hogeschool of universiteit (4)
Q39 Wat is uw beroepsstatus? Als u bijvoorbeeld zowel betaald werk als vrijwilligers werk doet, kies dan de optie waar u het meeste tijd aan besteed.
Gepensioneerd (1)
Betaald werk (2)
Vrijwilligerswerk (3)
Gekozen werkloos (4)
Ongewenst werkloos (5)
Anders, namelijk (6) ________________________________________________
Q40 Het modale netto maandelijks inkomen in Nederland ligt in 2017 op €2152,00. Ligt uw netto maandinkomen hierboven, onder, of is deze hier gelijk aan?
Mijn inkomen is onder modaal (1)
Mijn inkomen is ongeveer modaal (2)
Mijn inkomen is boven modaal (3)
Q41 In welk land bent u geboren?
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119
Q42 In welk land is uw moeder geboren?
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Q43 In welk land is uw vader geboren?
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Q44 Hoe zou u uw (migratie)achtergrond omschrijven?
Autochtoon (1)
Niet-Westerse migrant (2)
Westerse migrant (3)
Anders, namelijk: (4) ________________________________________________
Q45 Als u niet in Nederland bent geboren, hoeveel jaar woont u al in Nederland?
Minder dan 10 jaar (1)
Tussen de 10 en de 20 jaar (2)
Tussen de 20 en de 30 jaar (3)
Meer dan 30 jaar (4)
Q46 Hoe lang woont u al in dezelfde buurt?
0-5 jaar (1)
6-10 jaar (2)
11-15 jaar (3)
16-20 jaar (4)
Meer dan 20 jaar (5)
120
Q47 Heeft u verder nog vragen of opmerkingen? Indien dit niet het geval is, dan kunt u deze vraag onbeantwoord laten.
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Q48 Mocht u nog vragen en/of opmerkingen hebben, dan kunt u contact opnemen met Saskia. Dit kan via telefoonnummer 06-14983224, of e-mailadres [email protected]
End of Block: Default Question Block
121
Appendix 5 – Identified themes and codes
Table 17 Identified themes for native versus non-native participants’ perception of active ageing
Identified themes Codes Sub-codes
Physical activity Sports o Sports club o Tennis o Jogging o Exercise/fitness
Moving o Walking, city walking o Cycling o Going outside o Gardening o Standing up o Dancing o Exercises from the tv o Housekeeping
Staying physically fit
Social activity To be in contact with others
o Contact with colleagues o Contact with family or friends o Contact via the church o Being among people, being with people
Contact with younger people
o Family o Relatives
Contact with other elderly
o 55+ appartment o Social control
Social outings/meetings
Mental activity Mental stimulation/fitness
o Reading o Board/committee work
Keep training oneself
o
Staying curious for new things
o Trying out new things o Being amazed
Cultural activities o Theatre o Museum o Concert
Staying active otherwise
Not sitting still o Doing two things at the same time
Doing hobbies o Woodcrafting o Singing in a choir
Travelling
Going on holidays
Other activities o Babysitting
Health Physical
Social
Health behaviour o Not smoking o Not drinking (too) much alcohol o Healthy eating/diet
Able-bodied o Both physical and mental/social
Mindset Positive attitude
122
Intention to stay active
o Keep being on the move o Keep trying
Continue doing what you always did
o Keep going o Keep doing things
Focus on possibilities, not on limitations
o Focus on what you still can do o Not accepting limitations due to age
To enjoy life o To enjoy
“Niet achter de geraniums zitten”
o Still fully alive/in life
Mobility Being able to move yourself
Being able to go to places
o Nice outings o Shops o City centre o Medical services
Being able to visit people
Independence and autonomy
To be independent o Not needing help from others
Able to make own choices
o Decide for yourself
To be self-reliant o To give substance to life o Remain living at home o Being able to drive a car
Keeping up With current times
With younger generations
o Music o Sports o Interests
With current developments
o Technology o Societal
Remaining interested in daily life
o Reading the newspaper daily
Participation Keep participating
Voluntary work o To be of meaning to others
Societal engagement o In the neighbourhood o In the church o In politics
Table 18 Identified themes and codes for natives versus non-native participants’ perception of an age-friendly environment and facilitators and barriers of the physical environment for active ageing
Identified themes Codes Sub-codes Identified facilitators/barriers
Accessibility Accessible housing o Accessible houses for wheelchairs
Houses at street level
Possibility for adjustments (stairlift, shower)
123
Accessible public space o Pavements o Enter buildings o Move around in buildings o Able to go everywhere
when having to use a rollator, mobility scooter or wheelchair
No loose paving stones
Equal pavements Dropped curbs to
road level No cars parked on
or over the pavement
No stairs in public space
Keeping public space snow-free, free of leaves, free of fallen branches
Surface of footpaths
An elevator in public buildings
Slopes to enter buildings
Financial accessibility o Affordable houses o Affordable activities o Affordable public
transport
Safety Danger/safety
o Traffic o Falling o Loitering o Bad people o (No) fear
Lack of street lighting
Dangerous traffic o Behaviour of other traffic users
o Infrastructure/design
Specific traffic situations
Cars driving too hard
Dangerous crossroad
Scooters and mopeds on cycle paths
Separate cycle paths
Clean o Air quality
Trusted surrounding
Mobility Move oneself from one place to another/being able to move around/go places
o Pedestrian areas o Bicycle roads o Public tansport
Availability of seating
Public transport (accessible, safe, affordable, close by)
Free travelling pass
Shelter at bus stop
124
Opportunity to be physically active
Opportunities to move, stimulates you to be moving
o Cycling o Walking o City walking
Cycle paths Separate cycle
paths Foot paths
Opportunities to play sports
o Sports club o Gymnastics o Indoor sports
Availability of sports clubs
Presence of nature or green space
That it is green/that there is nature
o Peace in nature o Enjoy the sun o Enjoy the seasons o Enjoy insects, trees
Park Forest Green space Garden
Social contact Social activity, contact with others
o Social meeting places Community centre
Shopping street Restaurant, café City beach Shopping street
Organised activities
Activities to join o Activities for things I am interested in
o Computers o Hobbies
A club Meetings
To do things for others o To be of meaning to others
o Voluntary work
Opportunities for voluntary work
Cultural activity Culture, to come in touch with culture
o Cultural activities o Cultural places
Theatre Concert room Cinema Cultural centre
Close by Within (walking) short distance
o Able to reach without car o Able to reach by foot
Close to home, not too far away, within reach
o In every neighbourhood
Services close by o Medical services o Shops o Public transport o Nature o Social meeting place o Library o Hairdresser, pedicure o Pharmacy o Activities o Cultural places
Family/friends/relatives living close by
Support Support
That support is provided, that help is provided
Contact point for (technical) assistance
Clear and accurate direction signs in public space
125
Facilitate independency o To be able to do things on your own
Taking seniors into account
o Senior heared and seen o To be able to have
limitations
Stimulating environment
o Challenging o To leave the house
Environment in which elderly can have fun too
Neighbourhood characteristics
Diversity o Cultures o Backgrounds o Rented houses o Owner-occupied houses
Population composition o Young o Old o Mixed
Bustle o Calm o Lively
126
Appendix 6 – Informed consent/permission form
Toestemmingsformulier afstudeeronderzoek Saskia Nijland
Het doel van dit onderzoek is om te begrijpen hoe 60-plussers denken over hoe de fysieke
leefomgeving bijdraagt aan actief ouder worden. De fysieke leefomgeving wil zeggen: al het materiële
in uw omgeving, zoals gebouwen, parken, bossen en wegen. Ik onderzoek specifiek of er verschillen
zijn tussen 60-plussers met en zonder migratieachtergrond in hoe zij denken over actief ouder worden
en de bijdrage van de fysieke leefomgeving hieraan.
Door mee te doen aan dit onderzoek levert u een bijdrage aan kennis over hoe de fysieke leefomgeving
het beste ingericht kan worden om actief ouder te kunnen worden. De verkregen resultaten kunnen
bijv. gemeentes hopelijk helpen om de wensen van zowel autochtone ouderen als ouderen met een
migratieachtergrond nog beter in acht te nemen bij het maken van hun beleid. Op deze manier zou
het beleid dus beter afgestemd kunnen worden op de specifieke bevolkingssamenstelling. Dit draagt
bij aan de kwaliteit van leven en gezondheid van 60-plussers en daarmee aan de gezondheid van de
maatschappij.
Deelname aan dit onderzoek is op vrijwillige basis. U kunt zich dus op elk gewenst moment
terugtrekken. Als u niet meer wilt deelnemen is dat geen probleem. U zit nergens aan vast. Ook
achteraf kunt u dit nog aangeven.
Het onderzoek is anoniem. Uw gegevens worden vertrouwelijk verwerkt. Persoonlijke gegevens
worden losgekoppeld van elkaar. Op deze manier is het niet meer te achterhalen van welke deelnemer
deze gegevens komen. Zo wordt de anonimiteit gewaarborgd.
Het interview wordt opgenomen, zodat wat besproken is uitgetypt kan worden. De resultaten worden
anoniem verwerkt in een rapport. Als u dit rapport wilt ontvangen, dan kunt u contact opnemen met
mij, Saskia Nijland, via 06-14983224 of [email protected]
Als u vragen heeft voor, tijdens, of na het onderzoek mag u deze altijd stellen.
Verklaart u hiermee akkoord te gaan?
Naam deelnemer: …………………………………………………………………………………….
Plaats: …………………………………………………………………………………….
Datum: …………………………………………………………………………………….
Handtekening deelnemer:
127
Appendix 7 – Ethical approval