Effects of the Built Environment on the Elderly, Research Paper Example

Introduction

The psychological literature on environmental building (EB) factors and its impact on the elderly ranks amongst the smallest in the social sciences. Much of the subject research deals with confluences of BE with physical mobility or disability, or housing design, but other factors such as aesthetics and ageism have been little addressed. And yet it is a perennially topical subject, particularly important because the world’s elderly population is rapidly becoming one of the largest, and life expectation is extending one’s years on this earth.  Consequently, understanding the effects of the BE on the quality of life of the elderly population is necessary to help it develop in a more sustainable manner as well as saving significant costs in National Health Care.  The effect that the environment has on the elderly in so many ways impacts the world. After all, the elderly will be us one day, aside from which concerns affecting the elderly have a trickle down-effect spilling over to all aspects of society. If money were spent thwarting these concerns, our society would be a healthier and more content place to live in. Billions of dollars are spent annually on building and roads aimed at better environment in places, neighborhoods, and regions.  Given these practical objectives, it is natural for us to ask what has been learned about the most effective ways to improve the environment.

Our aim with this review is to highlight areas of research that will combine urban and suburban/ rural planning with public health concepts. We aim to identify and design key concepts from the literature in order to make these concepts acceptable to health researcher and practitioners and to identify the most common elements of BE that have been measured and correlate to physical activity and improved health in seniors.

Scope of the Review

We reviewed all articles, whether theoretical, experimental, or quasi-experimental, that was aimed at improving the environment for the elderly. Our purview, therefore, includes historical analysis, propositions, and reviews.

By “built environment” we mean the designed environment, whether urban or rural, in which the individuals(s) live. This includes suburbia, city, or town. Our concern with reliability and authenticity naturally leads us to place special emphasis on studies that use experimental, random assignment to evaluate, but our review also encompasses the large literature that uses non-experimental methods, review literature on particular associated topics, historical analysis, and the theoretical approach.

Methods

We searched Scopus, Academic Search Premier, PubMed, CinahL, and Web of science databases for published and unpublished reports dealing with understanding the effect of the built environment on the quality of life of the elderly population. We combed online databases of research literatures in psychology, sociology, education, medicine, policy studies, and architecture, pairing primary search words “older adults”, “geriatrics” “elderly” and “senior citizens” and:”built environment” with operative terms like  “residence characteristics,” “”rural built environment, “urban built environment”, “physical environment”, “sidewalks’, “street lighting”, “recreational facilities”, “parks”, “malls”,  “aesthetics”, “safety and crime”, “traffic”, “access to the environment”, “land use”, “community design”  and ‘infrastructure”. Also used were other terms such as “physical; activity”, “walking”, “exercise”, and “leisure time”.  Our research was confined to English-based material alone and sourced from 1990.  There were 130 citations at this level.

Using manual abstract screening, our inclusion/ exclusion criteria were that they must preferably be a quantitative or qualitative study and they must cite “elderly” or “older adults” or “senior citizens.” Studies were excluded if they did not measure the BE, or reported associations that were not applicable to recommendations for elderly improvement. We finally culminated with a database of thirty published reports.

This body of research could be organized in many different ways. In order to focus attention on what kinds of valid conclusions may be drawn from this literature, we divide studies according to research design.  This categorization scheme generates two groups: non-experimental studies in the field, and experimental studies.  The first group included case reviews, theoretical analyses, assessment of measures, and pure qualitative analyses, whilst the second focused on experimental or quasi-experimental studies. Within the experimental category, we grouped studies according to their   theme, assessing findings in light of the research setting, participants, and outcome measurement. A narrative rather than a meta-analytic review suits this purpose, in the interest of presenting a richer description of the environmental engineering literature. Moreover, the methods, experiments, and dependent variables are so diverse that meta-analysis is potentially meaningless, especially given that some of the research designs might be prone to bias, rendering their findings unsuitable for meta-analysis.

Our review of non-experimental and experimental research literature is concluded with a summary during which contrasts between studies and recommendations are discussed.  We then provide general recommendations for future research; discuss the strength and limitations of some of the mentioned research and the various ideas before concluding the review with a summary of implications for health promotion practitioners and researchers.

Results

Description of Studies

Thirty studies met the inclusion criteria, none published prior to 1990.  The studies were categorized based on study design; eight were cross-sectional, and two were longitudinal. Three studies employed only qualitative methods; two were reviews (one on mobility; the other on programs for the elderly); two assessed either a measure or tools instrumental for benefiting elderly; another was a theoretical, case history based discussion on ageism; whilst the rest used quantitative methods.  Study objectives emphasized degrees and manners in which the environment could be better facilitated to help the elderly in physical, emotional and social factors.

Rural populations were the focus of two studies whilst the others devolved around an urban environment or rural/ suburban/ urban sample. Most studies were based in the United States; four occurred in other countries. Random sampling techniques were used in ten studies, four used convenience samples.  Sample sizes ranged from twenty-two participants to 1966 participants in the quantitative research.  Three studies used focus groups; most of the quantitative studies employed a survey approach.

Instruments used in each of the quantitative studies included one or more of the following measures: disability and construction measure, a restorativeness scale, Quality Functional deployment, and the Walkability index. In all cases, reliability and authenticity of instrument was specified. One study also used the American Changing Lives Study (1986-2001) as its database

Table 1: Summary of Literature on Built Environment and Elderly

Non-Experimental Research in the Field

Whereas experimental study provides the advantage of being (or attempting to be) as objective as possible, its conditions, arguably, best apply to the physical sciences where situations and characteristics are constant, homogenous, and more predicable. In a field as diverse and as unpredictable as the human sciences, critics of the experimental approach insist that study has to be conducted in the field, preferably on a one-to-one basis where the participant is not evaluated as some laboratory material but rather for the human that he or she is. The following sources were theoretical, thematic reviews, or case-history based; all of them qualitative in orientation.

Historical analysis and narrative

A narrative study focused around a case history of a community in Denmark was material for Blokland’s (2001) assertion that a sense of personal history and belonging ranked amongst the most important categories of a BE. Engineers should consider and recreate these constructs when designing neighborhoods for the elderly.

Reviews

A review by Satariano and McAuley (2003) uses an ecologic model of physical ability promotion programs developed and structured towards the elderly demonstrating that programs focusing on the individual and others focusing on the community are actually complementary in outcome. Older adults need social and emotional experiences in their environments as well as motivational structures that are conducive to encouraging them to use these faculties.  Better measures are needed to address the interaction of the individual and the environment that capture social interaction more directly.

Another review, this time on vulnerability (accidents and disaster) in the BE (Sime, 2002) reviewed building use and safety in terms of the elderly population.  Recent examples of major crowd disasters in Britain were cited as instances where poor safety management, inappropriate communications, and design of the settings negatively affected the elderly residents.  Attention, concluded Sime (2002), needs to be focused on that equation People, Actions, and Environment (P*A*E) for appropriate safety principles to be considered   In another review that caters to planning for aging populations (Harrison & Parker, 1998), it is recognized that elderly populations will be the fastest growing segments of a countries population in the coming decades.  Integration, rather than segregation, is therefore recommended in planning relevant housing, health, and social services; and that these be understood within the broader socio-economic and legal contexts in which the planning occurs.

Theories and propositions

Laws  (1994; 1993) theorized that the American construct of ageism is reflected in the environment. Old age, says Laws (1994; 1993), is a socially defined category and it is, unjustifiably, reflected in the geography of the urban built environments.  This can be seen in three ways: firstly by the integration of young and old in household level, suggesting that the elderly must be dependent on the young for their welfare; secondly, by the small-scale separation of the generations such as specific features like playgrounds and schools for children, and separately residential care facilities for elderly, which makes a clear distinction between the two, and finally multifarious ways in which the environment is built in a manner that suggests that younger and older people choose to separate themselves  and be freed from apparently incompatible lifestyles. This may be unconscious stereotyping on the part of American people, but the impact of these on manner towards elderly and the consequent manner in which elderly people respond to these stereotypes cannot be ignored. Environmental engineers, argues Laws, have a responsibility and the ability in changing and restructuring these stereotypes.

Laws (1994) illustrates her argument with a case study from Toronto.

Gerotechnology is concerned with fundamental and applied research on the complex interaction of elderly people with technological products and the BE. Technology has the potential to improve the capability of people confronted by the challenges of aging, Pinto et al. (2006) suggest that gerotechnology may be particularly helpful in facilitating attempts to overcome disability, and can improve the comfort and safety of older people. Environmental engineers, when planning housing and environmental designs of elderly, could benefit by taking this into account. This was the opinion too of Harrison and Parker (1998) of the school of Architecture in Singapore who presented several alternatives – including allowing elderly occupant’s greater integration into fuller community – by which elderly-friendly housing might be better realized in the future.

In an integrative theory that actually paraphrases all, Demirbilek and Demirkan (2004) proposed a prescriptive model where elderly residents are actively involved in the design process of the environment through collaboration sessions.  A tool, Quality Function Deployment created and then implemented in a consequent case study (2004) in order to apply and test the proposed model. Conclusions indicated that participatory design sessions were also advantageous in the aspect that they increased elderly people’s awareness of the consequences of the decisions that were taken, as well as the fact that they gained satisfaction by having contributed to these decisions.

Conclusion of Non-Experimental Research

Through a mixture of qualitative studies, reviews, propositions, and historical analysis, a diversity of conclusions was formulated regarding improving the designed environment for the elderly. In a practical sense, gerotechnology was suggested as a useful tool for enhancing many aspects of day-to-day existence. Gerotechnology can be specifically useful when applied to improving environmental safety. Several additional topics seemed to fuse into one: elderly people need social and emotional support as well as a familiar and communally integrated and interactive environment that gives them a sense of familiarity, well-being, and contentment. Ageism, negative stereotypes towards the elderly seem to, albeit unconsciously, permeate the BE in various ways. Awareness of this issue could help engineers in undercutting these problems and in designing a more socially friendly environment that would, also incidentally, be more true to spirit of the constitution. Inter-generational conflict would be undercut, and the elderly better allowed to integrate and contribute to society as a whole. Finally, and perhaps most significantly, it is recommended that the elderly population themselves have a say in designing their own population. Their opinions should be solicited and their recommendations welcomed. They could have a lot to teach us.

Quantitative Study Findings

The experimental method, otherwise known as quantitative research or laboratory study, (although not always strictly conducted in a laboratory) uses strict scientific methodology to achieve its results. The researcher’s intent is to formulate hypotheses, to collect the data, and test this hypothesis according to scientific principles that obstruct, as carefully as possible, bias, and then to analyze this data using statistical measures. As some of the qualitative studies demonstrated, their limitations were that they studied only a certain population, sometimes who were biased.  Experimental studies, on the other hand, because they screen bias so carefully, offer a degree of reliability and accuracy that qualitative lacks.  Quasi-experimental studies (illustrated by several cases here) are based on non-random sampling, usually employing convenience samples.

PE/ Mobility

Several studies – urban, suburban, rural, and a mixture of all three examined effect of the environment on elderly mobility. The geography of environment differs. Suburbs are generally built with design layout demanding a vehicle; facilities are far in distance one from the other, and some suburbs even lack sidewalks for pedestrians to walk. There comes an age when the elderly are no longer able to drive. What happens then? Are they able to survive in such surroundings, or does it affect them? On the other hand, urban environments might be less conducive to mobility due to possible non-restorativeness of environment (e.g. bustling sidewalks, smog, traffic, fear of crime and so forth). Which conditions, researchers wondered, would augment walking activity and physical exercise in older adults?

A majority of Americans hope to grow old in the suburbs, but Lord, Despres and Ramadier (2010) found that this would often be to the disadvantage of their mobility. Since car mobility in the suburbs is essential for daily trips, and since the elderly become increasingly unable to drive independently, elderly suburbanites, even if they succeed in increasing their mobility, are headed for inevitable immobility. This was demonstrated by a qualitative and longitudinal perspective that surveyed a group of 22 American suburbanites aged from 62 to 89 in 1999 and in 2006.  Suburbia demands more independence and provides less support, as well as   offering less in terms of its social existence. All of this may be detrimental for the mobility (and health) of the elderly.

To examine the relation between BE in an urban setting and walking activity in an older adult sample between both neighborhoods and residencies, Li, Fisher, Brownson, and Bosworth (2004) surveyed 577 residents (mean age, 73 years) from 5 neighborhoods in Portland, Oregon, USA.  Geographic information systems were used to define neighborhood level variables, whilst resident level variables consisted of a mix of self-reports and geocoded data on the BE.  This cross sectional, multilevel survey involved self-reports about neighborhood walking. Li et al (2004) found a positive relation between BE factors  (density of public buildings, green and open spaces for recreation, the number of street interactions) and walking activity at the neighborhood level. At the resident level, Perceptions of safety for walking and the number of nearby recreational facilities encouraged higher levels of walking activity. In both cases, a significant interaction was found between the number of street intersections and perceptions of safety from traffic.  These findings were replicated by Gomez et al. (2010) in a 2007 study conducted in Bogotá, Spain, where 1966 participants (60 years and older) of 50 neighborhoods were measured in a multilevel cross-sectional study and surveyed. Participants who reported feeling safe from traffic were more likely to report walking for at least 60 minutes, whilst the presence of a recreational program inspired extended walking (for at least 150 minutes in an average week).

In a further 2001 study that Nagel et al. (2007) conducted in the same place  (Portland, Oregon) measuring characteristics of the local neighborhoods and walking activity among a sample of 546 community dwelling older adults, a geographic information system was used to derive measures of the BE within a quarter-mile and a half-mile radius around each participants’ residence.  Multilevel regression analysis was then used to examine the association of BE with walking behavior. No association between BE and walking behavior was observed in the cohort of older adults.  However, it was discovered that the average time spent walking depended on amount of automobile traffic and a number of commercial establishments in the area. In 2006, a similar study conducted in the same area  (Michael, Beard, Choi, Faraqhuar, & Carlson) found that the presence of a mall was positively associated with neighborhood walking. This observation was elicited by questioning 105 older adults on self-reported frequency of walking in the neighborhood and perceived measures of neighborhood environment.

Presence of a mall however, was not so encouraging in all aspects. Suburban development patterns, Frank et al (2010) discovered, may impede not only physical activity and mobility but also affect healthy aging. Neighborhood design was measured using a walkability index (residential density, street connectivity, retail density, and land use mix), reinforced by chi-square and regression to evaluate possible relationships. Of the groups of 142 adults over 65 years old studied it was found that increased walkability correlated with better health and decreased obesity. On the other hand, visiting a fast food outlet was associated with increased odds of obesity.  Frank et al recommended that engineers include healthy food outlets in close geographic range to where elderly Americans live in order to encourage regular walking and healthy body weight.

Indeed, in another study, this time done in North California in 2003 (Cao, Mokhtarain, & Handy, 2010) evaluating effects of land use policies that designated more space for walking, it was found that enhanced accessibility had a great effect on the elderly (in fact significantly more so than it had on a control group comprised of a younger population).

Older people often have disabilities. How do elements in BE correlate with disabilities?  Do prospective contributions of the environment lead to changes in PE and is this helpful fro those with disability? To answer that question, Morris, McAuley, and Motl (2000) assessed a cross-sectional sample of 136 older women who were diagnosed with multiple sclerosis. Individuals completed a battery of questionnaires and wore an activity monitor for seven days. Correlational analyses indicated that self-efficacy, functional limitations, and street connectivity were significantly related to physical activity. Self-efficacy and functional limitations seemed to be the greatest factor in impeding mobility with MS individuals. The question then remains how environmental engineers can better structure environments so as to engender improved mobility in the case of those who are disability-ridden.

In a very different mixed-methods study that was conducted to identify perceived physical ability (PA) enablers and barriers amongst an ethnically and geographically diverse group of older adults, data from 42 focus groups consisting of African Americans, American Indians, Latinos, Chinese, Vietnamese, and Caucasians was solicited. Constant-comparison methods were used to analyze the data.  Perceived fears in environment conditions were situations or elements that impinged on health problems, fear of falling, and inconvenience. Enablers included positive outcome expectations, social support, and PA program access. American Indians also mentioned a lack of knowledge about PA as a barrier. Both Whites and American Indians emphasized the importance of PA activities for older adults. These are some ways, suggest Mathews et al (2010) in which BE can promote PA among older people.

Aesthetics

Obviously the surrounding area greatly impact on inhabitants regardless of whether they are elderly or not.  Does the environment however have a significant impact on elderly? If so, what, if any are its resultant characteristics? And which elements of the environment may lead to this? More specifically, does a restorative, or natural, environment, have a greater restorative effect on the health and well-being of resident? Or do other factors, such as familiarity and sentimental attachment, counterbalance?

In order to investigate the effect of a restorative environment in later life, Scopelliti and Giuliani (2005) analyzed the restorative experience of 182 elderly persons living in Rome.  They examined the restorativeness of natural and urban BE, considering the influence of the social context of the environment and life activities performed in that environment.  Ultimately, however it was not the nature of the place that determined self-efficacy and improved health for the elderly but rather extraneous factors such as perceived self-efficacy, independence, character, and patterns of social interaction that individual shared with life.

A study with contradictory results, however, demonstrated that the elderly significantly preferred environments that granted them restorativeness and familiarity.  Nature concluded Berto (2007) is a useful resource for people when she found that a group of 50 elderly people (62-93 years old) preferred, and apparently did buttered in restorative as compared to urban BEs.  The sample were asked to rate the restorative value of ten pictures of environments ranging from a natural to built, covering five environmental categories: housing, industrial zone, city streets, hills, and a lake. The ‘Perceived Restorativeness scale was used. Three groups of elderly were sampled (those living in an urban environment, in their own homes, and in a natural environment). All preferred the natural environment to the BE.

Likewise, Stimson and McCrae’s (2004) push-pull framework for modeling the retirees to a retirement village in Australia discovered that although most older people prefer to age in place, many do relocate with a small proportion moving to retirement villages which provided a carefully designed and often restorative environment specifically for the elderly. Using factor analyses, path analyses and a push-pull framework, Stimson and McCrae employed data from a national survey of retirement village residents living in Australia and modeled their decision making process in order to identify relationships between push-pull factors and predictor variables. They found that the push factors, inevitably related to change in lifestyle, home maintenance, social isolation, and health and mobility, whereas the pull factors related to BE and affordability, the locational attributes of villages, and the desire to maintain an existing lifestyle. On the whole, apparently most residents were satisfied with their move.

Housing Conditions and Designs

A review of existing conditions in the United States showed Smith, Rayer, and Smith, (2008) that the elderly population is growing rapidly and that since disability increases with age, population aging will bring substantial increases in the number of disabled persons, consequently having a significant impact on housing availability and design.  Two alternative measures of disability and construct projections of household with at least one disabled resident were used.  Using data of the average lifespan of single-family detached units, authors developed and applied a technique for estimating the probability that a newly-built single-family detached unit will house at least one disabled resident.       Using medium assumptions, they projected that 21% of households will have at least one disabled resident in 2050. Since most people desire to live independently, this research indicates the necessity that housing units be built with features that make them accessible to the vulnerable population.  These conclusions were replicated by Demirkan (2007) who specified there should be a universal design theory that should be systematically and consistently developed during the design process, especially since many people age in the same house.

Land use diversity, or housing density, apparently also leads to reduction in disability according to a study conducted by Clarke and George (2005) who, using hierarchical Poisson regression analyzed on data of older adults from North Carolina to examine possible correlation between factors of BE and modifying factors in the pathways between lower extremity limitations and activities of daily living, found that, despite declining physical function, elderly who live in environments with more land-use reported greater independence in instrumental activities.  Substandard and inadequate housing, on the other hand, greatly contributed to declension in lower extremity function.

Similarly, environmental factors such as uneven or discontinuous sidewalks, heavy traffic, and inaccessible public transportation also seem to affect the health of elderly aside from dissuading mobility.  These were results of long-term studies on a national sample of American (age 45+) followed over a 15-year period.  Multilevel level logistic growth curve models together with data from the American Changing Lives Study (1986-2001) found that trajectories of mobility disability are steeper with older age groups.  Results of this study suggest that environment factors can contribute to this declension in mobility (Clarke, Aishire, & Lantz, 2009)

Ageing Stereotypes

Ageism, as Laws  (1994; 1993) indicated earlier may have a pervasive effect on the environment that the elderly live in. Should engineers challenge these debilitating stereotypes? Can they? And if by doing so would their modifications potentially improve the health and welfare of elderly citizens?

Ory et al. (2003) maintained that the myths of aging partially explain why older people have not been primary targets for health promotions and disease-prevention programs.  Conducting a qualitative review on current myths and reality of aging in the context of designing health promotion programs for older adults, they suggested strategies for combating ageism based on health and aging. Of those that are relevant to engineers, these include more opportunities for intergenerational linkage, the design of productive roles for older adults, a retrofit of the BE, and collaborative actions from both public and private sectors.

Conclusion: Experimental Research

Concepts that were studied here included: factors that effected mobility, physical activity, and safety of environment, disability, housing design, and ageism.

Elements that affected mobility included density of public buildings; green and open spaces for recreation; the number of street interactions; perceptions of safety for walking; and the number of nearby recreational facilities. At least two cases found significant correlation to exist between the number of street intersections and perceptions of safety from traffic (including the amount of automobile traffic).  The presence of a recreational program and the amount of commercial establishments in the area also contributed to walking activity. On the other hand, a nearby fast food outlet was associated with increased odds of overweight.  So whilst it was found that increased walkability correlated with better health and decreased obesity, the character of these nearby stores also had a contributing factor to the adult’s overall health. Situations or elements that impinged on health problems, fear of falling, and inconvenience discouraged mobility as well as uneven or discontinuous sidewalks, and inaccessible public transportation. All of these had a similar detrimental effect on general health.

Recreational centers contributed to more than mobility; they often contributed to better intellectual and emotional well ebbing, as well as fostering greater social visibility, self-efficacy, and sense of independence. In fact, self-efficacy, functional limitations, and street connectivity were all significantly related to physical activity, which was, in turn, enabled, by social support, and PA program access. It, therefore, seems that these social centers should also offer PA programs or, if not, that such amenities should be available in the close area.

In a related sense, when comparing restorative to urban environments, although studies were mixed, one study found that it was not the particular restorative nature of the place (namely rural or urban) that determined self-efficacy and improved health for the elderly but rather extraneous factors such as community. Familiarity and feeling an integral part of the community – contributing to its welfare – seemed to be the determining factors. This is where a community center is essential for elderly living.

Since most people desire to live independently and since population aging will bring substantial increases in the number of disabled persons, researchers indicate the necessity that housing units be built with features that make them accessible to the vulnerable population.  A universal design, was therefore, recommended.

Adequate housing and design of housing seems to be an essential element. In fact, substandard and inadequate housing may contribute to declension in lower extremity function. Finally, intergenerational linkage, the design of productive roles for older adults, a retrofit of the BE, and collaborative actions from both public and private sectors are recommended for dealing with problems of ageism.

Discussion

A total of thirty studies were included in this literature review.  Elements of the BE that were most frequently measured in the literature included physical mobility, physical activity, disability, health and traffic. This was succeeded by aesthetics of surroundings, perceptions of safety, housing design, and effect of negative stereotypes on elderly.   Restorativeness presented inconsistent findings in that, whilst one study indicated that elderly preferred other factors such as familiarity and social elements to restorativeness, two other studies seemed to show contradictory results. Whilst, too, on the one hand, presence of a mall encouraged mobility, on the other hand a fast food takeout seemed to denote negative correlations to health. These are not necessarily contradictory results; engineers should consider this data when designing the BE.

Considering these findings, the elements of the environments that may be most relevant to the BE include recreation homes, street connectivity, safety from crime or traffic, lack of housing density, and presence of recreational facilities, trails, or parks.  The results may illustrate the needs to further examine where environmental aspects can alter ageism. Also, the counterintuitive findings within the studies assessing restorativeness may suggest that both aspects are needed: familiarity, social connectivity and certain element of nature in environmental design in regards to elderly. It is certainly recommended that the elderly themselves participate in designing their own environment.   If done in an organized, and peaceable manner this can be only beneficial and salutary and informative both to designers/ engineers and to elderly participants themselves.

Contradictions or, different opinions may be due to the different countries surveyed or to the different ways that rural versus urban residents view their communities or to socialization and different patterns of living in various communities and other variables. Interpretations of findings may also need to take into account that population sizes and sample differed greatly among studies in this review.

Future Research/ Recommendations

Findings from this literature review illustrate four areas in which improvements in research could be made. Firstly, it would be interesting to conduct further research amongst other populations and in diverse areas of the United States to see whether positive correlations exist between negative stereotypes of elderly and other factors such as self-efficacy of elderly, health, and intergeneration conduct.  Secondly, further research contributions from diverse cultures would be beneficial. Further Longitudinal studies would be helpful in assessing causality and in further establishing parental relationships.  Thirdly, research assessing BE and other factors in rural areas should be expanded to include subgroups such as racial/ ethnic minorities. More comparison groups (such as elderly with adolescents) should be involved in order to better assess possible contrast of environment on elderly as a specific group.  This would allow researchers to assess whether subgroups and/ or whether different ages interact differently with the environment. Such information would support the development of intervention strategies to promote mobility and general health of elderly.  Then again, studies should involve a more diverse geographic sample of communities and contrast environmental supports among residents in rural areas with high and low levels of various types of physical activity (e.g., hiking, horse-riding, sailing (or other sea activities), golfing, and bicycling).  By evaluating rural BES where a greater diversity of land and water sports are played and contrasting findings with those in areas where the scope for these sports are lower or virtually non-existent, researchers may gain advanced knowledge about elements of the BE that play a key role in mobility, physical activity.  Some self-reports may have contained participant and participation bias, and self-reported physical activity may be over-reported.

Finally, further studies should consider additional variables, such as neighborhood/ residential socio-economic status, employment status, and absorption in extra-curricular activities.

Strengths and Limitations

Limitations of this review include the fact that several samples used the same setting. Too many, too, focused on mobility in contrast to other themes making that topic top-heavy.  A limited number of studies focused on disability and health. More studies on obesity and on the possible effect of environment on disability (such as that cited on lower trunk extremity) would have been interesting.  The inclusion of reviews and propositions may have been distracting and extraneous to positioning of review.  A major strength of this review lies in the fact that it has the ability to benefit the growing field of BE research by highlighting ways to improve and advance our understanding of a wide range of elements of BE as regards impact on elderly in a wide diversity of manner.

Conclusion

This review seems to indicate that BE has a definite impact on mobility and general health of the elderly. The elderly population is growing and implementing a universal design would benefit all sectors of the population. Whilst proximity of stores and other amenities is advantageous to elderly, wisdom and forethought should be used into selecting those stores, including only that salutatory to the health of the population.  Social centers and recreational centers are shown to be of immeasurable value. These and similar institutes offering programs catering to enhancing physical activity should be encouraged and placed within a close neighborhood radius easy for elderly to walk to. Attention should be allocated to green places, and parks; traffic should be curtailed; in suburban areas greater positioning should be allocated to pedestrian areas; whilst in urban areas, safety of crime and refuge from traffic should be ensured.    Experimental programs devised to create greater intergenerational contact and other means to eliminate possible negative stereotypes and generating and transmission of these stereotypes could be tried. The results would be interesting. Similarly too it would be fascinating to involve elderly into environmental discussions on BE concerns in order to ensure that their unique perspectives are considered. Such efforts to study BE elements as impact elderly in all possible variables of their life is of the utmost importance, particularly at a time when life expectancy is expanding on the one hand, but when chronic disease and class gap widens on the other.

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