Introduction
The organisation of health-care services and housing policies in Sweden and many other countries is guided by the policy ideal that home is the best place for people to be while ageing with functional limitations (Clemens et al. Reference Clemens, Wetle, Feltes, Crabtree and Dubitzky1994; Cutchin Reference Cutchin2003; Means, Richards and Smith Reference Means, Richards and Smith2003; National Board of Health and Welfare 2001). At the same time, the country has experienced an ageing population (Statistics Sweden 2005; US Census Bureau 2008). Consequently, the number of older people with functional limitations living in their homes is increasing and it is a challenge for society to provide services that meet the diverse place-specific needs and experiences of this group (Andrews Reference Andrews2002).
The concept ‘ageing in place’ is often used to denote the policy ideal of being able to remain at home while ageing (Cutchin Reference Cutchin2003). However, the need for an understanding of ageing in place as a progressive process has emerged among researchers in the field of environmental gerontology (Golant Reference Golant2003; Scheidt and Norris-Baker Reference Scheidt, Norris-Baker, Wahl, Scheidt and Windley2003; Wahl and Lang Reference Wahl, Lang, Wahl, Scheidt and Windley2003). The everyday reality for an individual who is ageing in place can be understood as a continuum of changing situations (Cutchin Reference Cutchin2003). Changes might be long-term, such as functional decline, in bodily or physical features, relocation, and moves away or deaths, of friends and close kin. Changes might also be day-to-day, such as variations in health conditions, mood, weather or in life itself (Golant Reference Golant2003; Rowles, Oswald and Hunter Reference Rowles, Oswald, Hunter, Wahl, Scheidt and Windley2003; Vik Reference Vik2008). A service process that fails to appreciate the complexity of such variations and to detect and harness older people's preferences, needs and efforts at problem-solving might result in confusion and frustration for older people and wasted efforts and resources for the service-providing organisation (Heywood Reference Heywood2004a; Richards Reference Richards2000). There is sparse theoretical and empirical knowledge about the changing everyday lives of older people, their efforts at problem-solving and how service provision interacts with those processes.
People ageing in place often face barriers in their physical home environments, such as placement of sinks and bath tubs, heavy doors and lack of handrails (Gitlin et al. Reference Gitlin, Hauck, Winter, Dennis and Schulz2006; Gitlin et al. Reference Gitlin, Mann, Tomit and Marcus2001; Iwarsson Reference Iwarsson2005; Lilja and Borell Reference Lilja and Borell1997). One strategy for managing the activities of daily life in such situations is to modify the physical home environment. Home modification services are provided by the community in Sweden and many other countries (Duncan Reference Duncan1998; Heywood, Oldman and Means Reference Heywood, Oldman and Means2002; Ministry of Health and Social Affairs 1992) with the general aim to enhance ageing in place. However, there is a lack of systematic knowledge about how to design appropriate services to meet these needs (Gitlin Reference Gitlin2003; Heywood Reference Heywood2004b).
Recognising older people as agents in the service process and enhancing their own efforts and problem-solving has been identified as a tool of empowerment (Richards Reference Richards2000). To this end we need to improve our knowledge of the dynamics of older people's preferences, needs, agency and efforts at problem-solving in their changing everyday lives. Such knowledge can be a basis for the design of empowering services. The ambition of this study was therefore to contribute to the theoretical and empirical understanding of such dynamics by applying the concept of place integration to experiences of older people in Sweden who have received home modification services (Cutchin Reference Cutchin1999, Reference Cutchin2003).
Theoretical framework
The concept of place integration was developed by Cutchin (Reference Cutchin1999, Reference Cutchin2003) as a philosophical and conceptual tool. It added important dimensions to the theoretical and empirical understanding of the dynamics of people in context, a central theme in environmental gerontology and occupational therapy (Canadian Association of Occupational Therapists 2002; Kielhofner Reference Kielhofner2002; Lawton and Nahemov Reference Lawton, Nahemov, Eisdorfer and Lawton1973; Wahl, Scheidt and Windley Reference Wahl, Scheidt and Windley2003). Theories have not managed to capture the dynamics of this interaction, as the focus has been on the interaction between separate entities. In both disciplines a need has been identified for theories and research methods that recognise the active relation that interconnect the individual and context over time (Golant Reference Golant2003; Kielhofner Reference Kielhofner2002; Law et al. Reference Law, Cooper, Strong, Stewart, Rigby and Letts1996; Scheidt and Norris-Baker Reference Scheidt, Norris-Baker, Wahl, Scheidt and Windley2003; Wahl and Lang Reference Wahl, Lang, Wahl, Scheidt and Windley2003).
The concept of ‘place integration’ is based on the geographical concept of place and the philosophy of pragmatism. In contemporary cultural geography, place is understood as a continuously changing integrated socio-cultural and physically experienced setting that cannot be separated into parts (Cutchin Reference Cutchin2004; Wiles Reference Wiles2005). Pragmatism focuses on the ever-changing and integrated character of human experiences and action. The objects of inquiry are the time-specific contexts in which experiences and actions occur, which have been conceptualised by the philosopher of pragmatism, John Dewey, as unique situations that can never be repeated (Cutchin Reference Cutchin1999, Reference Cutchin2007). In line with those concepts, the place integration process is understood as a process of continuous transactions into new situations.
Changes in the person-place whole lead to a disintegration of the person-place relationship, and an undetermined situation from which problems and possibilities emerge and stimulate creative thoughts and actions to restore the integration (Cutchin Reference Cutchin2003). The place integration process can be described as a spiral of transactions into new situations rather than as a linear process in which causes and consequences follow an unidirectional path or alternatively a circular process of repeated and predictable situations. An understanding of ageing in place as a spiral of place integration can be used as a tool to increase the understanding of the dynamics of ageing in place and its relationships to service delivery (Cutchin Reference Cutchin2003). This reasoning has implications for the understanding of agency in the process of ageing in place. Traditionally, agency is understood as the autonomous individual's power to act on a situation (Wray Reference Wray2004; Christiansen and Townsend Reference Christiansen and Townsend2004). However, in line with the reasoning on place integration, agency can be understood as one aspect involved in the active relation that interconnects the individual and context over time. This leads to a need for conceptualising agency as creative and generative and autonomy as relational as has been suggested by Wray (Reference Wray2004).
Home modifications
Recent research suggests that modifying the home environment can enhance accessibility and usability of the environment (Fänge and Iwarsson Reference Fänge and Iwarsson2005a, Reference Fänge and Iwarsson2005b), increase satisfaction with activity performance (Stark Reference Stark2004), increase safety and reduce difficulties in activity performance (Petersson et al. Reference Petersson, Lilja, Hammel and Kottorp2007) and restore dignity and decrease feelings of insecurity (Heywood Reference Heywood2004a). None of those studies has taken a process perspective, and the authors have all addressed a need for developing theories and methods the better to understand the complexity of the interaction between the home environment and activity performance. Characters and effects of home modifications depend largely on the socio-cultural and organisational contexts in which they are provided, but the complexity of the interaction between people and the environment is a shared feature. Research on home modifications can therefore provide theoretical knowledge about the interactions relevant to various socio-cultural and organisational contexts.
In Sweden, home modification grants are provided for adaptation of permanent physical features in the indoor or immediate outdoor environment, including installation of stair lifts, ramps, rails, automatic door openers and remodelling of bathrooms (Ministry of Health and Social Affairs 1992). The grant is provided irrespective of the financial situation of the applicant, and it is not dependent on whether the home is rented or owned or if it is an apartment or single house (Ministry of Health and Social Affairs 1992). An application for home modification grants is often done in collaboration between the applicant and a health-care professional. Normally, a referral from a health-care professional is required. Eligibility for grants is assessed by home modification officers at the local municipal administration based on the application, the referral and sometimes a home visit (Arman and Lindahl Reference Arman and Lindahl2005). If the home is rented, the installation of the modification is subject to approval by the landlord (Ministry of Health and Social Affairs 1992).
The aim of the study
The literature review above shows that there is a need to understand ageing in place and its relation to service delivery as a process. However, we have found limited empirical research on this process. The aim of this study, therefore, was to explore the process of ageing in place, in relation to home modification services. More specifically, the study aimed to increase the understanding of the transaction in everyday life relating to service delivery among some older individuals who have got an application for home modification services approved.
Method
Design
The study was part of a research project focusing on home modification services for older adults in one Swedish urban municipality. To meet the aim of this specific study, four individuals were selected from a larger sample (N=114) of applicants for home modification grants participating in the research project. Participants were recruited through the municipal department that handles all applications for home modification grants in the municipality where the study was conducted. The ethical committee at the Karolinska Institutet approved the research project.
Selection of participants
Four participants were purposefully selected (Patton Reference Patton2002) from the larger sample of participants in the research project to include different onset of functional limitations and a variation in changes in activity performance expected from the applied home modification. With a few exceptions, the participants included in the research project lived in rented apartments, owned apartments or owned houses, with rented apartments being the most common. This reflected housing conditions in the studied municipality. Participants in the research project met the inclusion criteria of being aged 40 or more years, being able to speak and understand Swedish, living in their own homes and having applied for, but not received, home modifications. Individuals with health conditions that prevented them from participating in study interviews, such as cognitive problems, depression or fatigue, were excluded (see Johansson et al. Reference Johansson, Lilja, Petersson and Borell2007 for a more detailed description). In addition the four participants included in this study met the inclusion criteria of living in rented apartments, having shown an interest in sharing their experiences related to home modification services, and having had their application of home modification grants approved. Once we had reached a total of four participants, we concluded that we had in-depth data that was rich enough to explore the issues on which the study was focused.
Description of the participants
The names and some facts about the participants were changed to ensure integrity and anonymity.
Anders was a man about 60 years of age. He had been on disability pension since one year before being included in the study because of a stroke. At the time of discharge from a rehabilitation clinic he was not able to walk long distances, could not manage the stairs to his apartment and had great difficulties getting into the bathtub. By the time he was included in the study Anders' physical capacity had increased, but he still had difficulties getting into the bathtub and felt unsafe going out using a walking stick. He had been prescribed an electric wheelchair to facilitate mobility outdoors. He had applied for grants for modifications that were necessary for using the wheelchair, such as arranging a storage place, automatic door openers, and reshaping of a path to access the storage room. In addition, he had applied for grants for remodelling the bathroom to facilitate taking a shower.
Gustav was a man about 70 years old. His second leg had recently been amputated. He used a wheelchair since he could no longer manage with prostheses (crutches). To get into and out of his home he used a transport service, which carried him and his wheelchair up and down the three stairs to his apartment. He had applied for grants for installation of a stair lift and an automatic door opener to be able to get into and out of his home on his own. He managed to move about with a manual wheelchair, but had been prescribed an electric wheelchair to facilitate moving outdoors. He had applied for home modification grants for construction of a storage room for the electric wheelchair.
Maria was a woman about 80 years old. She had had back problems for most of her life, but some months before inclusion in the study her health condition had deteriorated markedly. Since then she could no longer manage stairs, with the consequence that she could not get out unless transport services carried her up and down the stairs to her apartment. Furthermore, she could not manage to get into the bathtub. She had applied for grants for installation of a stair lift in order to be able to get out on her own to continue participating in her many social activities. She had also applied for grants for remodelling the bathroom to be able to take a shower without help.
Anna was about 70 years old. Because of mobility problems she used a walker both indoors and outdoors. She had applied for home modification grants for ramps over thresholds and over differences in levels between the apartment and the balcony to facilitate mobility. She had problems getting into the bathtub and she had applied for grants for remodelling of the bathroom to facilitate taking a shower. Furthermore, she had problems getting through the entrance door with the walker, but had not taken any actions to reduce this problem.
Data collection
In order to achieve rich in-depth data about the process of ageing in place in relation to home modification services, data were collected with open interviews (Patton Reference Patton2002) in the participants' home environments from before the modification had been installed until there was judged to be some stability in the situation relating to the home modification service process. The periods varied from eight to 17 months. Data for the research project were collected with structured interviews two and six months after the planned installation of a home modification. On those occasions data for this study were collected with an open interview when the structured interview was ended. In addition, the four participants were contacted by telephone at intervals of one or two months. If they described a change related to home modification services or activity performance, an open interview was arranged. Altogether 16 interviews were conducted, with a minimum of three with each participant. Each interview lasted between one and two hours and all interviews were conducted by the first author.
An unstructured interview guide was used to allow for the interviews to unfold in accordance with individual participants' processes. The interview guide covered the following areas: (a) how the participants managed everyday life and what problems they experienced; (b) expected or experienced changes in the everyday life situation related to the applied or installed modifications, and (c) actions taken to handle the situations and experiences of those actions. The interviews were audio-taped and transcribed verbatim. In addition, the participants were asked to demonstrate how activities relating to the applied or installed home modification were performed, which provided a situation where questions about immediate experiences and actions could be asked. For practical reasons a tape recorder was not used in those situations. Notes about the participants' experiences and actions were written immediately after the demonstrations.
Analysis
The analysis was undertaken by all the authors, based on a hermeneutic approach. This meant that dialectics between experience-near and experience-distant perspectives were interpreted, aiming to achieve a theoretical understanding of the participants' everyday experiences and actions (Geertz Reference Geertz1983; Gustavsson Reference Gustavsson2000).
First of all, the transcripts were read to get an overall understanding of the material. In an early phase of analysis the concept of place integration (Cutchin Reference Cutchin2003) was identified as a useful tool for analysing the connections between the participants' experiences and problem-solving in everyday life and the home modification service process. In line with this concept, we identified sections of the texts including descriptions of what constituted problematic situations, motives for and choices of action and the new situation resulting from this action. The identified sections served as data for further analysis and were organised to describe a spiral of place integration for each individual. The four individual spirals were compared and analysed with the intent of answering the following questions: What constitutes the problematic situation, and how is this problem defined? What motivates the choice of action to be used to reintegrate the person-place? What constitutes the new situation in relation to choices of actions taken?
Further interpretation shows that the answers to those questions related to four overlapping and interacting phases associated with concepts in the place integration process according to Cutchin (Reference Cutchin2003), and with the organisation of services. Those phases were understood as ongoing courses of events. The identified courses of events were: (a) an undetermined situation constituted by problems in activity performance relating to barriers in the home environment; (b) creative thoughts and actions resulting in an application for home modification services as an action to solve the problematic situation; (c) actions taken to handle everyday activity performance while waiting for home modifications; and (d) a new situation that was handled with or without home modifications. The material was reorganised, based on those courses of events to describe a spiral of place integration that was valid for all four participants. With the aim of reaching a theoretical understanding of the transaction in everyday life relating to home modification services, this spiral was interpreted to explore the meaning of the identified courses of events, and the transactions between them.
Findings
One overall finding expressed through the different courses of events in the participants' spiral of place integration was their aspiration to regain or increase possibilities for action. Possibilities for action were identified as an undetermined situation in which the participants experienced possibilities to perform activities in accordance with their values and preferences.
Four identified courses of events are presented in the following section. Even though presented as a chronology, the findings show that the different courses of events were overlapping and individual participants moved between them over time in different orders and directions.
Experiencing threatened possibilities for action in everyday situations
This course of event was characterised by the participants' experiences of restricted possibilities to execute spontaneous choices about when and how to perform an activity, which in the analysis was interpreted as an experienced threat to their possibilities for action. As a consequence of the design and focus of the study, this experienced problematic situation was related to barriers in the physical home environment barrier.
In their problematic situations, the participants were, or thought they soon would be, dependent on help from other individuals to perform everyday activities. Adjusting activity performance to schedules and preferences of a service organisation, relatives or friends was experienced as threatening possibilities for action, as expressed by Anders:
They [the home help service] come, well, they come today around 10:30. Somebody comes with the newspapers, but drat it, who wants to wait half the day to shower? Showering, that's something you do in the morning.
Maria described how performing activities became very complicated because of her dependency on transport services. For example, she wanted to take some flowers to a funeral. To make this possible she had to pay for the flowers to be delivered to her home. She also had to co-ordinate the time of this delivery with her order for transport services, instead of being able to ‘just roll down the road [to the flower shop] with the walker’ and take the transport service from there. This was interpreted as experiencing threatened possibilities for action.
Having the possibility to make spontaneous choices about what to buy and what to eat, based on quality, price and availability of groceries in different stores was of high value to participants. Using home help for grocery shopping reduced this possibility as all grocery shopping was done in one particular store and service users were not allowed to accompany the home helper to the store.
Because of the problematic situation constituted by physical barriers in the home environment some activities could not be performed either with the participants' own physical efforts or by leaving them to somebody else. The participants experienced this as a threat to their possibilities to execute their everyday spontaneous choices of what activities to perform. For example, both Maria and Gustav had given up a large repertoire of social and practical activities outside the home, such as taking courses, participating in social activities in their neighbourhood or doing errands. In contrast, Anders had created possibilities for a life with much time spent at home by renovating his apartment and buying new furniture. He stated, ‘You have done so much in life. Now it's time to take it a bit easy’. The experience of threatened possibilities for action related to activities outside the home varied with the seasons of the year. For example, Gustav had no possibility to get out spontaneously which we interpreted as experiencing threatened possibilities for action, but still he said:
It is not too bad now, because it is not summer. Then it becomes much worse. Then I really long for [getting out].
Negotiating technical solutions to regain possibilities for action
This course of events was characterised by a process of negotiation between the participants and different professional actors, including translations of experiences of threatened possibilities of action into technical solutions such as home modifications. The negotiation was initiated by the participants themselves or by a health-care professional, but other actors were also involved in the process. In the negotiating process, the problematic situation first had to be defined in order to get an agreement about the problem that should be translated. Secondly, an agreement about the correct translation into a solution was needed. The character of this negotiation differed between the participants, and was to a large extent determined by behaviour and actions taken by the professional actors. The negotiations could be performed without disagreement. Gustav described how an occupational therapist from a rehabilitation clinic made a home visit and asked many questions about what activities he used to perform, resulting in an agreement on a stair lift and an electric wheelchair as solutions to Gustav's experienced problems.
There could also be a discrepancy in the definition of problems and solutions in the negotiation process as exemplified by Anders' description:
And they had the idea that I would not remain in my home because I could not manage the stairs, and I could not manage to get to the toilet, and I could hardly manage to get between the rooms, and then of course, if you have that attitude it is not possible. … They had to give up because I, I was the one who was going to make the decision. … No, there's got to be a limit to this nonsense.
Discrepancies were also exemplified in Maria's description of when her landlord was involved in the process of negotiation. The landlord refused the installation of the modifications, stating that there was no need for Maria to get down the stairs as she could get fresh air on the balcony. He also said that there was no need for her to remodel the bathroom as she could wash her hair in the sink. Great efforts were made by Maria, her relatives and officers at the home modification agency, using humanistic, economic and legal arguments to reach an agreement. Eventually they found this fruitless and Maria gave up her expectation of receiving a stair lift or getting the bathroom remodelled. Instead she applied for, and was given, grants for an automatic door opener to at least facilitate getting through the entrance door. The landlord was reluctant to accept this modification, but when another individual in the house applied for the same modification he eventually agreed to have it installed.
Anna's difficulties with managing the entrance door were never addressed in the negotiation with professional actors, which meant that a difference in definitions had never been acknowledged and Anna did not expect any solution to her experienced problem.
The installation of a home modification could lead to a situation where possibilities for action were still threatened, leading to new negotiations. Anna had received a metal ramp over the bathroom threshold, but could still not get into the bathroom in accordance with her values and preferences:
Now I take a big step over the threshold because it sinks down and then makes a cracking sound and I think it, I mean, disturbs the neighbours.
A new negotiation with a home-modification officer led to an agreed solution of installing a ramp made from a material that would not make any noise. In the end Anna chose not to order the new ramp. Thus she no longer expected her problems with the bathroom threshold to be solved through a technical solution.
When Anders received his electric wheelchair, a disagreement arose about problems and solutions between him and the home-help officer. Anders was no longer allowed to get his ready-made lunch delivered, but he experienced it as unsafe and unpleasant to use the electric wheelchair in wintertime. After he had slipped once with the wheelchair outside the place where he went for lunch he initiated a new negotiation about his need for a delivered, which was successful and the lunch was delivered to Anders' home during the winter.
Struggling through performance of daily activities to regain possibilities for action
This course of events was characterised by the participants' struggle to regain their possibilities for action in the presence of environmental barriers. The waiting time for a home modification installation was determined by a routine waiting time and by unplanned delays in the service process. During this time, the participants struggled to develop strategies to perform activities without adjusting to the schedule of a formal or informal helper, which was interpreted as a strategy to regain possibilities for action. This was accomplished with great effort, resulting in new problematic situations.
Anders, Maria and Anna all had access to assistance from home help or relatives in taking showers but had developed techniques to manage their hygiene on their own. Using those techniques was experienced as difficult and unsafe. Anna described how she developed the courage to shower by herself to regain the possibility to choose when to have a shower:
I get help [from the home helps] with taking a shower if I need it. But I'm stubborn and want to get along by myself. [laughing] Maybe it's silly at times but I want to be able to do it, I don't want to wait. I'm allowed to shower once a week. I want to take a shower two, three times a week. … In the beginning I was afraid, I didn't dare, but after a while I thought, Oh, I am going to sit down on the stool and just do it. I felt like, well, I will manage this, and I did.
When the participants accepted help, it was done in such a way that their possibilities for action were preserved as much as possible, but this demanded planning and organisation that hindered spontaneity. Both Maria and Gustav co-ordinated spontaneous activities with scheduled health-care activities for which transport services were already organised, for example, by ordering the return trip so that there was time to ‘roll around for a while’ (Gustav).
Anna paid for home help services to do the grocery shopping, but as long as there was no snow or ice she did the grocery shopping by herself. She felt that this increased her possibilities for action as it worked as a motivation for her to get out. It also gave her a possibility to make spontaneous choices of what to buy. However, the authorities could not accept that she only paid for the seasons when she used home help. She paid for home help for the full year and, consequently, her strategy to increase possibilities for action included economic considerations.
As shown in the description of Anders' negotiation of technical solutions, he strived not to receive help that he experienced as intruding on his possibilities for action, but he also struggled to receive the help he considered to support such possibilities, as, for example, the delivery of a ready-made lunch. This was interpreted as developing strategies to increase possibilities for action.
For Maria the extended waiting time became permanent as her landlord refused installation of the home modifications. Applying for home modifications was shown to be an action that could not support her possibilities for action. She stated that ‘I have always managed difficulties in my life’, which motivated her to challenge her physical capacity and struggle to develop techniques to shower and get in and out of the house on her own in order to have the opportunity to choose when to perform those activities.
Gustav expected the installation of the home modifications to help him regain his possibilities for action and he kept those expectations even though the installation of the stair-lift was delayed repeatedly. His expectations even increased, partly because he shared other people's positive experiences of using stair-lifts and electric wheelchairs. It can be said that through his expectations he experienced a potential to regain opportunities for action. When he was contacted by the company installing the modification he believed the modifications as more or less installed already, stating that ‘this was really worth waiting for’.
Anders received all home modifications as scheduled, but the electric wheelchair was delivered much later. Consequently, the installed storage room did not change his situation. He struggled with restricted possibilities to choose when to get out because he felt unsafe without the wheelchair and did not get out as often as he wanted. As time passed, his frustration increased and he stressed that ‘I must have it’, indicating that the electric wheelchair was a prerequisite for his opportunities for action.
Mediated possibilities for action in everyday life
This course of events can be understood as the outcome of the actions for place integration taken by the participants. It describes a situation with temporary stability, but also undetermined situations from which actions for place integration that are not included in this study can be assumed to emerge.
The participants' spiral of place integration was guided by their aspirations to regain opportunities for action. In this process they mediated their values and preferences with their functional capacity, social support and physical home environments. To a large extent, opportunities for action were created through the installation of home modifications. This is exemplified in Gustav's description of how the home modification increased his scope for action in different aspects:
It's so nice, I've been out with the rubbish and then with the newspapers. You get so much advertising, so there's a lot of paper trash. So I can roll out with it myself. I don't have to ask, and it's the same when they're here cleaning. Then I don't need to ask them to take out the rubbish bag. … Well, I can wheel myself down on my own, whenever I want. The same if I want to go out in the morning, then I can wheel myself down to the tube station and get the free newspaper and things like that. It's nice, and then I can go shopping for what I want to have, spontaneously, so to speak.
When the applied-for home modifications were not granted or could not be used in a satisfactory way, the participants experienced problematic situations where their opportunities for action were restricted. For example, Anna described how she mediated her values, physical capacity and home environment, resulting in restricted possibilities to choose how to get into her bathroom:
First I take a step over the threshold. Then I take the walker in backwards, but of course this is not always good, walking backwards I mean. Well, I think something could happen. It has happened, I have fallen.
Maria had to some extent regained opportunities for action through mediating her physical capacity, her remaining environmental barriers and her strong preference for performing the two activities of going out and managing her hygiene. She had developed techniques for managing the stairs and her hygiene on her own. However, using those techniques involved great physical efforts and pain, which restricted her possibilities to choose when and how to perform the activities. Furthermore, she could only carry very light things up and down the stairs and she was still dependent on home help for most grocery shopping. At the last interview, Maria could no longer manage personal hygiene on her own, and she only took showers on the two days a week when she was allowed home help. She experienced this as a restriction, saying: ‘I can never take a spontaneous shower as I did earlier’.
Even when modifications were experienced as successful, the mediating process could result in restricted possibilities for action in comparison with the participants' expectations. Taking a shower had become less difficult and safer for Anna when the bathroom was remodelled, but she still experienced showering as unsafe if she was tired, and therefore only took showers in the morning. It appeared that she had no possibility to choose when to take a shower because all mornings except Sundays were scheduled for home help to put on her support stockings. She did not want to get up early and take a shower before the home help came, giving her no options to shower except on Sundays.
Anders's opportunities to choose when to get out increased when he received the electric wheelchair, as it made him feel safer outdoors. There was a constraint, however, because he felt it was unsafe to go out during wintertime. Gustav encountered barriers in the outdoor environment but they did not restrict his opportunities for action. He tried to find routes with as few barriers as possible and when he ran into difficulties he asked for help from people in the street. He stressed that people in general were very helpful.
Both Maria and Anna considered some activities, for example meeting people and getting out, to be very important. Performance of those activities demanded physical efforts, and overcoming their own resistance was used as a strategy to preserve their possibilities for action. However, their motivation did not always overcome the resistance.
Summary of findings
Through their spirals of place integration, the participants' creativity and efforts were directed towards creating future situations with possibilities for action. Whether the focus was on proximal or distal time was determined by how different actions and actors in the process were co-ordinated. The imagination of potential situations directing actions and expectations resulted partly from negotiations between participants and professional actors, but also from other sources, such as the individuals' own and others' experiences and expectations. Through the courses of events it was found that unpredictable events in the service process influenced the spiral of place integration. Overall the findings show that the installation of a home modification was not a question of just providing a solution to a problematic situation, but was only one component involved in the transactions over the courses of events in which problems and possibilities, as well as the need and use of a home modification, were continuously changing.
Discussion
This study has shown how the participants used their creativity and energy to direct future situations towards increased possibilities for action. Applying for home modification services was shown to be one component in this process of place integration, that interacted with other actions and events. The home modification service process, including unplanned events and unpredictable behaviour among involved actors, was shown to have a strong impact in the place integration process. Overall the findings show the interconnectedness between an individual's life, the delivery of services and home modifications in the process of place integration.
Using the argument that enhancing older people's own efforts and problem-solving is empowering (Richards Reference Richards2000), the findings indicate that home-modification services that support older people's creativity and efforts in creating possibilities for action has the potential to be empowering. The ability to act in a situation through thoughts, language and action has theoretically been defined as agency (Christiansen and Townsend Reference Christiansen and Townsend2004). In line with this conceptualisation, possibilities for action can be understood as an expression of agency. However, it should be noted that the findings of this study suggest that these possibilities emerge from complex place integration processes where individual agency is one component interacting with others.
The participants used great creativity and physical effort to regain or preserve opportunities for action, at the cost of difficulty, insecurity and loss of spontaneity. Parallels can be drawn with empirical research showing that the ability to adjust life to changing conditions with a preserved self-image and meaning in existence was experienced as the core aspect of quality of life among people aged over 80 years (Borglin Reference Borglin2005). Functional independence per se was not important to the participants, but was experienced as a prerequisite for executing everyday choices. Therefore, they developed strategies to perform activities without help from anyone else. Those findings have provided further insight about the dynamics underlying results in previous research showing older people applying for home modifications having high levels of functional independence, but also high levels of difficulties in activities of daily living (Johansson et al. Reference Johansson, Lilja, Petersson and Borell2007; Petersson et al. Reference Petersson, Lilja, Hammel and Kottorp2007), and that home modifications have little effect on independence (Fänge and Iwarsson Reference Fänge and Iwarsson2005b; Petersson et al. Reference Petersson, Lilja, Hammel and Kottorp2007) but can reduce difficulty and increase safety (Heywood Reference Heywood2004a; Petersson et al. Reference Petersson, Lilja, Hammel and Kottorp2007).
Other studies in the Nordic context have presented similar findings, showing how older people took action and struggled to their utmost limits to be able to perform activities without support as a means of being able to govern their daily lives, which was experienced as a basis for freedom and spontaneity (Dunér and Nordström Reference Dunér and Nordström2005; Haak et al. Reference Haak, Fänge, Iwarsson and Ivanoff2007; Vik Reference Vik2008). Independence and self-determinism have often been used as indicators of successful ageing and rehabilitation, stemming from an uncritical use of the individual liberalistic notion of choice and independence as expressions of autonomy and agency (Agich Reference Agich, McCullough and Wilson1995; Cardol, De Jong and Ward Reference Cardol, De Jong and Ward2002; Wray Reference Wray2004). This is in spite of a growing body of research showing that this culturally bound perspective is not conducive to understanding agency and autonomy in a broader cultural context, and in a broader spectrum of life situations (McCullough and Wilson Reference McCullough and Wilson1995; Torres Reference Torres2006; Wray Reference Wray2004). Findings from this study indicate that services that enhance older people's creative efforts at problem-solving, rather than services that only support functional independence, have the potential for supporting agency and being empowering (Richards Reference Richards2000).
The creativity shown in this study in the participants' efforts to generate opportunities for action can be understood as strategies for dealing with constraint and disempowering experiences in accordance with their values. Such strategies might be difficult to understand from the perspective of professionals involved in the home modification service process since they might be more focused on carrying out interventions. As has been shown elsewhere (Heywood Reference Heywood2004b), successful home modifications can be provided only if the individual's values are recognised in the assessment process. It has been suggested that agency should be conceptualised as creative and generative to allow for the recognition of strategies used to deal with constraint and disempowering experiences (Wray Reference Wray2004). In line with this suggestion, policy and practice of home modification services must recognise how experiences of constrained and disempowering situations and values of importance for older people interact with their efforts at problem-solving, in order to support older people's agency.
This study has shown that values and needs were negotiated in the meeting between the older individual and professionals. Such negotiating situations have been analysed in the field of institutional interaction (Olaison and Cedersund Reference Olaison and Cedersund2006; Seltzer et al. Reference Seltzer, Kullberg, Olesen and Rostila2001), but little attention has been paid to how those negotiations influence the life of the service users. The findings in this study show how the outcome of those negotiations influenced actions and expectations, and also determined the participants' experienced possibilities for action. Furthermore, the participants adjusted their actions and expectations to unpredicted events in the service process. It can be assumed that those events were expressions of the dynamics and complexities in a process of service organisation. It has been suggested that the service organisation process should be understood as an ongoing interaction between individual actors and political and organisational frameworks (Allen, Griffiths and Lyne Reference Allen, Griffiths and Lyne2004; Bleiklie Reference Bleiklie1997; Griffiths Reference Griffiths2001, Reference Griffiths2003; Vassy Reference Vassy2001). However, the unpredictable character of the service process has not been recognised and further studies are needed to address this issue.
Study limitations
The model of place integration was chosen as a tool for understanding the dynamics of ageing in place and its relationship to home modification services. This choice guided the analysis and strongly influenced the findings. This can be seen as a theoretical strength, but must also be recognised as a limitation, as it can be assumed to dismiss some aspects of the issues featured in the study.
The concept of place integration sees person and place as an integrated whole, with the ambition of avoiding an individualistic perspective of humans in context (Cutchin Reference Cutchin2003, Reference Cutchin2004). The importance of sociality was shown in this study, but still the results focus very much on actions taken by the four individuals studied. It is difficult to sort out whether this reflects the minds of the researchers and the research method, the perspectives of the participants or is a consequence of an individualistic design of the home modification services. All these exist within the context of a society dominated by a liberal individualistic ideology. Furthermore, the concept of place integration was used with the aim of taking a process perspective. However, it can be questioned whether this aim can be met when data are collected on different occasions, including retrospective descriptions of what happened in between. For the specific aim of this study, the method chosen was considered to be appropriate, but the practical, theoretical and ethical difficulties of following individuals continuously over long periods call for new methods for research on the process of human occupation and ageing.
In conclusion, more extensive studies are needed further to develop theoretical and empirical understanding of ageing in place and its relationship to service delivery. The theoretical perspective of place integration needs to be further explored, but findings in this study also need to be complemented with research that aims to understand ageing in a globally changing world (Phillipson Reference Phillipson2003; Wray Reference Wray2003). We accept that a much wider range of cultural variations and a greater diversity of participants' life histories call for study.
Conclusions
This study has shown how older people used creativity and efforts to direct their own futures in ways that increased their possibilities for action. Applying for home modifications was shown to be one possible action, and one that interacted with other actions and events. The findings imply that services aiming to support individuals who are ageing in place should be directed towards increasing possibilities for action, rather than just facilitating activity performance. Furthermore, the findings indicate that if service users' creativity and efforts are recognised as resources in the design and provision of services, a service that aims to support individuals who are ageing in place might have the potential of being empowering.
Acknowledgements
We thank the participants who shared their time and experience with us and the staff at the Home Modification Agency, who helped us contact individuals in need of home modification services. We also thank Malcolm Cutchin for creative comments on a late draft of the manuscript. Furthermore, we would like to thank the Health Care Sciences Postgraduate School at Karolinska Institute for financial support of this study.
