Psychosocial Well-Being of the Elderly and Their Perception of Matured Estate in Singapore

Journal of Housing For the Elderly

ISSN: 0276-3893 (Print) 1540-353X (Online) Journal homepage: http://www.tandfonline.com/loi/wjhe20

Keng Hua Chong, Wei Quin Yow, Debbie Loo & Ferninda Patrycia

To cite this article: Keng Hua Chong, Wei Quin Yow, Debbie Loo & Ferninda Patrycia (2015) Psychosocial Well-Being of the Elderly and Their Perception of Matured Estate in Singapore, Journal of Housing For the Elderly, 29:3, 259-297, DOI: 10.1080/02763893.2015.1055025

To link to this article: http://dx.doi.org/10.1080/02763893.2015.1055025

Published online: 15 Sep 2015.

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Download by: [Keng Hua Chong] Date: 16 September 2015, At: 20:20 Journal of Housing for the Elderly, 29:259–297, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0276-3893 print / 1540-353X online DOI: 10.1080/02763893.2015.1055025

Psychosocial Well-Being of the Elderly and Their Perception of Matured Estate in Singapore

KENG HUA CHONG, WEI QUIN YOW, DEBBIE LOO, and FERNINDA PATRYCIA Singapore University of Technology and Design, Singapore

This article explores various relationships between the elderly’s psychosocial well-being and components of aging-friendly community (continuity, compensation, connection, challenge, and contribution), in order to understand their perception of a matured estate and to discuss implications in housing neighborhood urban design. Interviews with elderly residents living in Bukit Merah (Red- hill), one of the matured housing estates in Singapore with a high percentage of elderly residents, were conducted to understand how eldercare infrastructure and social spaces developed within the fabric of a high-rise, high-density public housing estate can support or inhibit their psychosocial well-being, as indicated by the Geri- atric Depression Scale (GDS). Our results postulate that different groups of elderly form friendships and participate in activities in both formal social service centers and informal public spaces. The friendships formed in these places and the convenience of amenities around their houses may affect their perception of their current residences. While the elderly residents are generally satisﬁed with physical infrastructure, a comprehensive, integrated urban design

Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 is further needed to facilitate physical activities, social interactions, and active aging in the elderly in order to enhance their psychosocial well-being.

KEYWORDS psychosocial well-being, matured estate, housing neighborhood urban design, aging-friendly community, senior activity center, Singapore

Address correspondence to Keng Hua Chong, Singapore University of Technology and Design, 20 Dover Drive, Singapore 138682. E-mail: [email protected] Color versions of one or more of the ﬁgures in the article can be found online at www.tandfonline.com/wjhe.

259 260 K. H. Chong et al.

INTRODUCTION

The built environment and the aging phenomenon are intrinsically related, especially in this present-day high-density urbanity. The concept of aging in place, as promoted by various state governments of countries facing an aging population, would have to deal with issues of not only a larger proportion of elderly living in the city, but also a large percentage of those living in old housing neighborhoods since their youth. Over the decades, the process of aging spares neither humans nor their built environment. To continue living in these estates as one ages thus requires necessary interventions, both to adapt to the changing needs of the elderly and improve the deteriorating environment for better liveability. It will require not only housing modifica- tions to compensate for and assist in the elderly’s adaptation to a declining functional capacity in their daily life (Iwarsson, 2005), but also a thorough planning of social infrastructure that can help them maintain their quality of life. According to Person-Environment (P-E) fit theory (Carp, 1987), which highlights the importance of environment on quality of life, the predictors of P-E fit interaction are not only personal competencies or environmental conditions, but also the goodness of fit between person and environment, for example, the congruency between the individual’s environment and his or her physical and cognitive abilities and emotional needs (Wheeler, 1995). It is under this premise that the research on Singapore elderly’s perception of their matured estate was carried out to assess their psychosocial well-being in relation to their physical housing environment and provision of social infrastructure. Singapore is currently undergoing a tremendous shift in its demogra- phy. Twenty-five percent of the current citizen population will be 65 years and older by 2030 (National Population and Talent Division [NPTD], 2013). This number will have more than doubled from 9.9% of its resident population (Department of Statistics [DOS], 2012). The concept of aging in place is highly relevant to Singapore’s urban environment due to its highly structured urban housing landscape, i.e., the provision of high-rise public housing

Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 by the Housing and Development Board (HDB) since 1960. Many of these housing estates have been refurbished or demolished and redeveloped since the 1990s. However, as some matured estates house a much higher percentage of elderly than others, relocation of elderly residents and redevelop- ment of these estates become challenging and often undesirable. Several initiatives have been implemented by the state to provide eldercare services and improve physical accessibility in these estates. The outcomes of these implementations, however, have yet to be systematically studied. Therefore, our research investigates whether the social-psychological well-being of the elderly within the matured estate is dependent on their perception of their home and larger urban environments, as one’s sphere of mobility and interaction tends to be reduced with age. Psychosocial Well-Being of the Elderly 261

In this article, we will focus on the housing estate of Bukit Merah Plan- ning Area in Singapore. Bukit Merah was selected for this study because of its visible dissemination of eldercare infrastructure within the fabric of the high-rise, high-density public housing estate, to cater for a relatively high percentage of elderly residents. Interviews with the elderly who live within Bukit Merah were conducted to understand how housing and neighborhood design can support or inhibit their psychosocial well-being, as indicated by the Geriatric Depression Scale (GDS). These quantitative surveys as well as qualitative interviews were used to collect the elderly’s perceptions and needs in ﬁve aspects of “aging-friendliness”: Continuity, Compensation, Con- nection, Contribution, and Challenge (Scharlach, 2012). Through the analysis of these results, alongside a study of provision of eldercare facilities and other social spaces, relationships are drawn between key factors that impact and affect the seniors’ perception and experience of their housing environment.

LITERATURE REVIEW

Various studies have shown that many aspects of housing are associated with the elderly’s psychosocial well-being (Addae-Dapaah, 2008; Lam & Boey, 2005; Oswald et al., 2007; Oswald, Wahl, Mollenkopf, & Schilling, 2003; Rioux, 2005; Stark, 2004). In a study on 16 older adults with functional limitations, Stark (2004) found that removing the environmental barriers from the homes signiﬁcantly enhanced the older adults’ occupational performance and their satisfaction with their ability to perform daily activities. In Hong Kong, respondents’ scores on the Geriatric Depression Scale-15 (GDS-15; Sheikh & Yesavage, 1986) were correlated with type of housing, availability of helpers, ﬁnancial status, and family support (Lam & Boey, 2005). In their study, 397 elderly aged 75 to 89 living in urban areas were asked whether they reside in private housing with independent tenancy, private housing with shared tenancy (e.g., cubicles), or public housing. Those living in private housing with independent tenancy (a better living condition) scored lower on

Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 the GDS than those living in private housing with shared tenancy. Moreover, another study showed that the elderly’s perceptions of their well-being are not only associated with objective aspects of housing (e.g., the magnitude of accessibility problems), but also with their perceptions of the home’s meaning and usefulness (Oswald et al., 2007). Nevertheless, as we learn from P-E ﬁt theory that what matters is the match between environment and individuals’ needs and abilities, merely good housing and a well-perceived home are inadequate to enable the elderly to cope with various changes in their life. There is an increasing need to shift the discourse of improving the well-being of the elderly from being compartmentalized into either psychological or physiological aspects within the speciﬁc house-unit, to a broader and more inclusive, multidisciplinary 262 K. H. Chong et al.

understanding of aging populations vis-a-vis` their neighborhood’s environmental liveability. Since the 1990s, various urban planning reform movements have aimed to improve both the physical and mental health of residents. One of these movements is the Smart Growth Movement, which was initiated first by the American Planning Association, U.S. Department of Housing and Urban Development, and the Henry Jackson Foundation, and secondly from the Natural Resources Defense Council and the Surface Transportation Policy Project. The characteristics of this movement are mixed-land use, availability of open space, defined activity centers, walkable streets, and creating a greater sense of community (Ewing, Meakins, Bjarnson, & Hilton, 2011). Furthermore, recent design movement has emphasized the importance of creating informal social interaction, such as creating more opportunities for neighbors to meet each other. One way to do this is by locating public facilities near to each other or by grouping these facilities together, for example, by designing them in such a manner that someone who is walking toward a library will pass other facilities, such as an art center or post office, and have chance encounters with other people (Ball, 2012). The role of the elderly in making decisions about their communities has also been more recognized, for example, by including them in planning their own senior cohousing communities (Durrett, 2009). These changes in urban design imply that increasing the congruency between individuals and environment goes beyond barrier-free environment. Consistent with these movements in urban design, Scharlach (2012) has proposed that the “aging-friendliness” of a community can be explained in the following aspects based on various theories of lifespan developmen- tal psychology: Continuity (ability to maintain established patterns of social behaviors and social circumstances), Compensation (availability of prod- ucts and services to meet the basic health and social needs of individuals with age-related disabilities), Connection (opportunities for meaningful in- terpersonal interactions that foster reciprocal support and maintain social connectedness), Contribution (lifelong need to make a positive impact on

Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 one’s environment), and Challenge (age-appropriate opportunities for physical, intellectual, and social stimulation to ward off the physical and mental decline caused by lack of stimulation). Scharlach proposed that the physical and social infrastructure of a community should respond to elderly needs’ in these ﬁve aspects (abbreviated hereafter as “5 Cs”). One study that shows the example of the importance of Continuity is a qualitative study conducted by Aberg (2008) on 15 elderly, aged 80 to 94 years, who were undergoing geriatric rehabilitation in Sweden. It was found that the two common themes the elderly regard as important in their life satisfaction are (a), the ability to manage personal care and to carry out their hobbies, and (b) continuity in routine activities, especially keeping in touch with other people. Regarding Compensation, an empirical study Psychosocial Well-Being of the Elderly 263

that shows the importance of this aspect was a study conducted on 1,966 older adults in 50 neighborhoods in Bogota, Colombia (Parra et al., 2010). They found that those who resided in areas with more than 8% of land cov- ered by public parks tend to rate their health better. Regarding Connection, there have been many studies that show the importance of social interaction among the elderly (Gouda & Okamoto, 2012; Janevic, 2004). In fact, Lim and Kua (2011) found that loneliness is a better predictor of depression than one’s living arrangement (i.e., living alone). Thus, older adults who feel lonely tend to be more depressed, but older adults who live alone may not feel depressed if they do not feel lonely. These findings suggest that the three aspects of Continuity, Compensation, and Connection influence the social-psychological well-being of the elderly. Nevertheless, the perceptions of the elderly about their neighborhood in these three aspects, in relation to their psychosocial well-being, have not been investigated before. In the aspect of Contribution, according to the WHO Global Age- Friendly Cities guide (2007), social participation, civic participation, and employment are marked as important aspects of age-friendly cities, together with other aspects, such as transportation and housing. Furthermore, in a seven-year longitudinal study on 7,322 elderly respondents aged 70 and above, it was also found that volunteering slows the increase in depression level (Lum & Lightfoot, 2005). In a study conducted in Singapore, it was found that more frequent engagement in different types of activities is associated more with lower risk of cognitive decline, which shows the importance of aspect Challenge (Niti, Yap, Kua, Tan, & Ng, 2008). How- ever, little is known on how Contribution and Challenge aspects as what people understand as “active-aging” are related to neighborhood design and aging-friendly community. Based on this concept of “aging-friendliness” of a community in these five aspects, our research posits that active aging and good neighborhood design are actually two sides of the same coin. This area of study has largely been unexplored in Singapore’s context in recent years. Teo (1997) exam- ined the provision of facilities and services for elderly persons in urban

Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 Singapore, and posited that policies concerning this group are socially con- structed spatial forms that may not adequately meet their needs, emphasizing the signiﬁcance of subjectivity in environmental strategies of designing for older people—especially in land-scarce Singapore. In particular, Teo conducted surveys on 148 elderly living in Tampines and Bukit Merah to investigate their use of public space and various designated elderly corners and services provided by the state (e.g., community centers). She found that almost one third of them did not use any state-initiated services, and those who did use these services did so for health-related reasons (e.g., to exercise or to go to physiotherapy). Since then, there have been various new initiatives in improving the built environment for elderly, for example, the development of studio apartments and the new Accessibility Codes 264 K. H. Chong et al.

(Building and Construction Authority [BCA], 2013). However, there is still lack of understanding about the relationship between neighborhood design and active aging. Addae-Dappah (2008) administered a questionnaire to 390 elderly respondents living in studio apartments in Singapore that addressed various aspects of housing (i.e., size of apartment, noise level, transportation network, and ease of maintenance). It was found that even though residents were satisﬁed with the housing quality of their studio apartments, 49.9% of the residents were dissatisﬁed with the concept of age segregation in studio apartments. However, compared to other studies, Addae-Dappah did not assess psychosocial well-being using any standardized assessment. Further- more, the relationship between the housing design and active aging lifestyle has not been investigated in Singapore.

THE CASE OF BUKIT MERAH (REDHILL)

Singapore’s unique condition of an urban city-state is both a boon and bane in the face of its growing elderly population. The increasing pressure of the aging urban population of Singapore impresses upon the scarcity of land in the 715 square kilometers that make up this island city-state, especially so for housing and health-care provision. Nevertheless, its efﬁciency in policy making, coupled with its highly dense urban condition and pervasive public housing landscape, empowers it to address this aging situation in a swift manner. As 82% of the population lives in public housing, we look to the highly dense and largely mature region of the Bukit Merah Planning Area, situated just off Singapore’s Centre Business District, for our study. Bukit Merah, which literally means ‘Red Hill’ in the local Malay language, presently has the second highest percentage of elderly population (16.7%) among the public housing estates in Singapore, only after Marine Parade (DOS, 2012) (Figure 1). Bukit Merah is also ranked second in terms of the number of elderly residents who are 65 years old and over (25,600), after another matured estate Bedok (35,300) (DOS, 2012). In addition, most of the residents

Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 (94.6%) in Bukit Merah stay in HDB public housing (DOS, 2012) (Figure 2). Owing to its large elderly population, Bukit Merah boasts a relatively large number of social services catering to the elderly (Figure 3). These centers occupy the previously empty space on the ground ﬂoor of the housing blocks, which are referred to locally as “void decks.” The void decks are public communal spaces that emerged from the modern housing planning and served to enhance cross-ventilation, visibility, and community surveillance (Liu, 1975). Designed as an empty, ﬂexible expanse of sheltered ground-level space, it was used variously by the community as play areas for children, spaces for male elderly to hang bird cages, conversation areas for female elderly, and for events like funerals and weddings. Due to the ubiquitous void decks prevalent in every public housing estate, the state began in the 1980s Downloaded by [Keng Hua Chong] at 20:20 16 September 2015

265 FIGURE 1 Map of Singapore showing proportion of resident population aged 65 years and over by planning area, June 2012. Source: DOS, 2012. Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 266

FIGURE 2 Map of Singapore showing proportion of resident population staying in HDB ﬂats by planning area, June 2012. Source: DOS, 2012. Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 267

FIGURE 3 Map showing locations of various eldercare services located within the Bukit Merah Planning Area. Source: Authors. 268 K. H. Chong et al.

and 1990s to insert a wide variety of services ranging from child care to elder care. Managed and run by various volunteer welfare organizations (VWOs), these facilities sprung up specifically in response to the needs of the aging population, and filled the increasing need for planned activity spaces for the elderly. Some of these eldercare facilities found in Bukit Merah include senior activity centers (SACs)—spaces for social and recreational activities for elderly living in one-room rental flats and studio apartments—that are run by several VWOs (e.g., NTUC Silver Ace, Thye Hua Kwan, and Redhill Moral). One SAC usually serves one or two flats nearby. There are also numer- ous other program-centric eldercare institutions such as the Senior-Connect Plus Center at Bukit Merah Community Center and the Befriender Service that reach out to elderly who live alone through home visits, the Day Care Center for elderly with medical or neurological conditions (e.g., dementia, stroke, or Parkinson’s Disease), and the Day Rehabilitation Center for elderly who require post-hospitalization care (Figure 4). One such program is the Apex Day Rehabilitation Centre for the Elderly located at Bukit Merah View, which was one of the first eldercare and rehabilitation centers in Singapore. It was set up here as a pilot project by the National Council of Social Ser- vice (NCSS) in 1980. These formal and regulated private social services are separated from the public realm, being designated community zones for the aged. On the other hand, social spaces that are more public in nature are also provided in the estate, such as exercise corners (including those particularly designed for the elderly), pavilions, pocket gardens, neighborhood parks (including Tiong Bahru Park in the north and Telok Blangah Hill Park in the south), as well as the new Park Connector Network (PCN) that links up the various parks and gardens in SingaporeElderly are also seen in other public spaces such as children’s playgrounds, void decks (those that are not occupied by service facilities), eating outlets such as “hawker centers” (food centers housing multiple food stalls under one roof), coffeeshops, and public institutions like the Bukit Merah Public Library (Figure 5).

Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 With the insertion of all these eldercare facilities and the provision of social spaces, the matured estate of Bukit Merah offers a unique case of studying the elderly’s perceptions of their housing environment in relation to their psychosocial well-being. Both quantitative surveys as well as qualitative interviews with the elderly who live in Bukit Merah were conducted. Speciﬁcally, two groups of elderly were identiﬁed—those interviewed at various social service centers and those interviewed on the streets—in order to investigate their attitudes toward the planning and provisions of different social spaces. Through the analysis of these results, along with the study of provision of eldercare facilities and other social spaces, broader relationships were also drawn between key factors that affect the elderly’s perception and experience of their housing environment. It is with such understanding that Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 269

FIGURE 4 Photographs of various eldercare facilities in Bukit Merah as designated social spaces for the elderly. Source: Authors. Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 270

FIGURE 5 Photographs of various public spaces in Bukit Merah frequented by the elderly. Source: Authors. Psychosocial Well-Being of the Elderly 271

this article discusses and proposes recommendations for neighborhood urban design and social service provision in matured housing estates.

METHODS Participants We interviewed 33 healthy participants aged 55 or older who live in Bukit Merah. Of the 33 participants, 17 were males and 16 were females. Twenty of the 33 participants were recruited from senior activity centers (SACs) and day rehabilitation centers, while 13 participants were recruited through street interviews at places in Bukit Merah where elderly congregated, such as the Redhill Market and Food Center, Tiong Bahru Park, and pavilions.

Materials Demographic Questionnaire. This questionnaire requested basic demographic information from participants, such as gender, age, health status, marital status, education level, employment status, language(s) spoken, and information about the participants’ house and neighborhood (number of rooms, type of housing, composition of neighbors, preferred living arrangement, etc.). The ﬁrst section consisted of 12 questions on basic demographic data (adapted from Addae-Dappah, 2008, and Yow & Markman, 2011). The second section consisted of 8 questions about the participant’s house and neighborhood, as well as the individual’s opinions on various living arrange- ments (adapted from Elderly Accommodation Counsel, 2002). Subjective physical health questionnaire. This questionnaire consisted of 12 questions (adapted from Freedman et al., 2012) about whether participants have been diagnosed with any serious medical conditions (e.g., asthma, heart attack) and how this physical discomfort has affected their activities using a 4-point rating scale (from Not at all to Limited a lot). This measure is used to

Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 examine whether physical well-being might affect participants’ psychological well-being and perception of their living environment. Montreal Cognitive Assessment (MOCA) (Nasreddine et al., 2005). This instrument screens for mild cognitive impairment. It consists of 11 questions and assesses visuospatial ability, executive functioning, picture naming, memory, attention, language, abstraction, delayed recall, and orientation. We used the MoCA Singapore versions (English-, Chinese-, and Malay-language versions) in this study, which were developed and modiﬁed from the original MoCA by the Memory Aging and Cognition Center in Singapore (Dong et al., 2010). The original MoCA cutoff score is 26, which implies that individuals who score below 26 are at risk of cognitive impairment. However, there were no normative studies to identify the recommended cutoff score in 272 K. H. Chong et al.

using the MoCA Singapore versions, although Dong et al. (2010) suggested an optimal cutoff score of 21 to 22 to screen high-risk and low-risk cognitive impairment based on 118 patients in Singapore. Geriatric Depression Scale-15 (GDS-15; Sheikh & Yesavage, 1986).This aspect of psychological well-being measures an individual’s risk of depression. This questionnaire consists of 15 questions that ask people about their feelings in the past week; participants answer yes or no to questions such as “Do you often get bored?”.This questionnaire is commonly used as a measure of psychological well-being (Lam & Boey, 2005; Ng et al., 2009). The Chinese and Malay versions that we used were developed by the Geronto- logical Research Programme (Broekman et al., 2008; Nyunt, Fones, Niti, & Ng, 2009). Scores of 10 points or higher almost always indicate depression. Scores that are more than 5 points suggest depression and in clinical diagno- sis. It is recommended that individuals with these scores undergo follow-up interviews (Sheikh & Yesavage, 1986). The 5Cs Questionnaire: Psychological Well-Being of Seniors, Physical En- vironment, and Social Infrastructure in Housing Estate questionnaire. This questionnaire consists of five sections (Continuity, Compensation, Connec- tion, Contribution, and Challenge)–each section has a quantitative survey and a qualitative interview component (adapted from Scharlach, 2012). The sections Continuity, Compensation, and Connection ask about subjective experience using a 5-point rating scale (from strongly disagree to strongly agree). The Contribution and Challenge sections ask about frequency of engagement in various activities (1 = never/less than once a month,2= sometimes/once a month or more but less than once a week, 3 = once a week or more). The open-ended questions further investigate the availability of the services and the factual information about the participants’ house, neighborhood, and community in relation to these five components (Appendix A). These components were chosen based on various studies that investigate the relationship between elderly psychosocial well-being and various aspects of housing (Appendix B). Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 Procedure This study was approved by the Singapore University of Technology and Design Institutional Review Board. The survey was conducted via one-to-one interviews at SAC, The Apex Day Rehabilitation Centre, or in public places. All participants were informed about the study and given consent forms in one of three languages: English, Mandarin, or Malay. The interview lasted 60 to 90 minutes and was administered by research assistants who were fluent in at least two of the three languages. The interview was based on the five questionnaires mentioned above, and the questionnaires were administered in no particular order. Participants could choose whether they wanted to be Psychosocial Well-Being of the Elderly 273

audio-recorded during the interview. Four additional participants’ data were not included in the analysis either because they withdrew in the middle of the study or because they could not understand the instructions or questions in the questionnaire.

RESULTS Demographics and Physical and Mental Health Profiles of Participants A detailed demographic table is presented in Appendix C. Participants came from diverse backgrounds in terms of household size, marital status, and housing size (Appendix D). The majority of the participants were Chinese, and most reported themselves as mobile and healthy. The highest education level was mostly secondary school and below, and the average monthly income was $1,000 and less. Only five of the participants were currently working: one of them worked to support family members, and another one worked to interact with other people, while the rest did not explain the reason they worked. More than half of the participants had lived in their current house for more than 10 years, and most of them were satisfied with their living arrangement. Twenty-five of them (76%) preferred to stay in their current residence in the future. Overall, the participants were healthy in terms of their physical and psychological well-being. Most of them did not have serious medical conditions (Appendix E). Across all participants and various medical conditions, only four participants indicated that these medical conditions limited their activities a little, while the rest of the participants perceived that their medical conditions did not limit their activities at all. Our participants were also generally not depressed (Appendix F). Slightly more than half of the participants scored above the suggested cutoff score in MoCA based on Dong et al. 2010 (Appendix G). Of those who scored less than 22, one was visually im- paired and the majority of the remaining 11 participants expressed difficulty in understanding the tasks. Downloaded by [Keng Hua Chong] at 20:20 16 September 2015

Responses to the 5Cs Questionnaire The 5-point Likert scale from the Continuity, Compensation, and Connection sections were recoded to a 3-point scale (1 = strongly disagree/disagree, 2 = neither agree nor disagree,3= strongly agree/agree) for ease of comparison with Contribution and Challenge. It should be noted, however, that the 3-point scale for Contribution and Challenge referred to frequency of engagement instead (1 = never or less than once a month,2= sometimes or once a month or more but less than once a week,3= oftenoronceaweek or more). 274 K. H. Chong et al.

TABLE 1 Mean, Median, and Standard Deviation of 5Cs Scores

Variables Median Mean Standard Deviation (SD)

Continuity∗ 2.78 2.72 .33 Compensation∗ 2.86 2.81 .24 Connection 2.33 2.19 .56 Contribution∗ 1.24 1.28 .21 Challenge∗ 1.42 1.40 .22

Note.∗Scores signiﬁcantly differ from midpoint (score of 2), p < .05.

As most of the scores are not normally distributed (Appendix H), one- sample Wilcoxon signed-rank tests were used. Results show that, out of a maximum score of 3, median scores of Continuity and Compensation scores were signiﬁcantly above 2, and median scores of Contribution and Chal- lenge are signiﬁcantly below 2 (ps < .05) (Table 1). Our results imply that participants generally felt that they were able to make decisions about their house and manage themselves and their house, and were positive about the location of the amenities around their house and the availability of outdoor facilities (high Continuity and Compensation scores). They were marginally agreeable with the overall cohesiveness of their community (Connection score, p = .077). However, participants rarely engaged in the various activities listed in the Challenge and Contribution sections.

Relationships Between the Different Measures Employed in the Study Similarly, Spearman’s correlation analysis was used since most of the scores are not normally distributed. Those who had a lower risk of cognitive impairment (higher MoCA score) tended to have a lower risk of depression and a higher monthly personal disposable income (Table 2), suggesting a protective effect of cognitive functioning on psychological well-being that is

Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 correlated with an individual’s income level. Depression scores are also negatively correlated with Compensation and Connection scores: Participants who were more satisﬁed with the location of the amenities around their house and with the availability of outdoor facilities (higher Compensation score) and who perceived their community to be more cohesive (higher Connection score) tended to have lower GDS scores. Participants who have a higher education background also tended to contribute more to their family and community (higher Contribution scores) and were more engaged in stimulating activities (higher Challenge scores). The frequency of going to SACs is positively related to Continuity, Compensation, Contribution, and Challenge scores and negatively related to monthly personal disposable income. Our results suggest that active participation in senior-related activities Psychosocial Well-Being of the Elderly 275

TABLE 2 Summary of Signiﬁcant Correlations Between 5C Components and Other Variables

Spearman’s Variable 1 Variable 2 rho (rs) Np MoCA GDS –.391∗ 29 .036 MoCA Monthly .402∗ 27 .038 personal disposable income GDS Compensation –.357∗ 31 .049 GDS Connection –.379∗ 31 .036 Education level Contribution .390∗ 32 .028 Education level Challenge .381∗ 32 .031 Frequency of going to SAC Monthly –.393∗ 28 .038 personal disposable income Frequency of going to SAC Continuity .496∗∗ 32 .004 Frequency of going to SAC Compensation .357∗ 32 .045 Frequency of going to SAC Contribution .440∗ 31 .013 Frequency of going to SAC Challenge .583∗∗ 32 .001

∗p < .05, two-tailed. ∗∗p < .01, two-tailed.

is related to a greater level of satisfaction in various aspects of housing, but participants with higher income were less likely to be involved in activity centers. Correlation analysis among the 5Cs revealed that the more satisﬁed the participants were with the facilities around them (higher Compensation scores), the more cohesive they perceived their neighborhood (higher Con- nection scores), and the more often they were engaged in various activities (high Challenge scores) (Table 3). The relationship between Compensation and Challenge is reﬂected in some of our participants. For example, a man who goes to SAC regularly commented: Downloaded by [Keng Hua Chong] at 20:20 16 September 2015

TABLE 3 Correlations Between 5Cs Components (Spearman’s rho (rs)) Continuity Compensation Connection Contribution Challenge

Continuity Compensation .164 Connection –.143 .356∗ Contribution .505∗∗ .082 –.195 Challenge .333 .427∗ –.011 .591∗∗

∗p < .05, two-tailed. ∗∗p < .01, two-tailed. 276 K. H. Chong et al.

It’s important to have exercise corners, especially special ﬁtness corners for the elderly. Preferably not too far from home, 5 to 10 minutes is ideal. Currently walking to SAC takes more or less 10 minutes, but SAC is constrained by operating hours. It would be nice to have integrated park with library (like Tampines). I like Chinatown Point Library because it has very nice Chinese books. Here I would like to grow my own vegetables, herbs, plants that are edible.

Furthermore, the more the participants were engaged in various activities (high Challenge scores), the more they tended to contribute to their family and community (high Contribution scores). Continuity, in turn, is positively associated with Contribution, such that the more participants perceived they were able to make decisions about their house and manage themselves and their house (high Continuity scores), the more often they contributed to their family and community (high Contribution scores) (Please see Appendix I for signiﬁcant correlations among various subscales). In summary, the results suggest that satisfaction with the facilities around housing neighborhoods contributes positively to how frequently an elderly engages in various activities, which could lead to a greater sense of cohesiveness with their community, a greater sense of self-efﬁcacy, and a lower risk of depression.

Comparison Between Subgroups of Participants Twenty participants were recruited from centers and 13 participants were recruited from the streets. While Mann-Whitney U tests showed that these two groups of participants did not differ in their risk of cognitive impairment and depression (U = 104.5 and U = 104.5, respectively, ps > .10), participants recruited from the centers scored higher than participants recruited from the streets in three of the components: Continuity, Contribution, and Challenge (U = 66.5, U = 63.5, U = 41, respectively, ps < .05) (Table 4). Compared to

Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 participants recruited through street interviews, participants from the centers were able to make decisions about their house and manage themselves and their house (Continuity), tended to participate more in stimulating activities (Challenge), and do more activities for people living around them (Contribu- tion)However, both groups tended to have similar scores for Compensation (U = 108, p = .402) and Connection (U = 98.5, p = .243), suggesting that both groups have similar views toward the facilities, housing conditions, and social cohesiveness of their neighborhood (Please see Appendix J for more detailed comparison of scores between participants recruited through street interviews and interviews conducted at activity centers). In general, participants were rarely engaged in structured voluntary work, but they often mentioned their spontaneous contribution to peo- Psychosocial Well-Being of the Elderly 277

TABLE 4 Medians and Means (Standard Deviations in Parentheses) of Scores Between Par- ticipants Recruited Through Street Interviews and Interviews Conducted at Activity Centers

Center-Based Street Interviews Interviews p Variables Median Mean (SD) Median Mean (SD)Value

MoCA 23.00 21.55 (4.97) 22.00 21.15 (5.21) .000∗∗ GDS 2.00 3.17 (3.44) 2.00 2.39 (2.25) .819 Continuity 2.75 2.61 (0.35) 2.89 2.79 (0.30) .018∗ Compensation 2.79 2.80 (0.19) 2.93 2.82 (0.27) .402 Connection 2.33 2.32 (0.50) 2.17 2.11 (0.60) .243 Contribution 1.11 1.20 (0.22) 1.35 1.34 (0.19) .021∗ Challenge 1.26 1.25 (0.19) 1.50 1.50 (0.17) .002∗∗ Frequency going to 1.00 1.17 (0.58) 3.00 2.80 (0.62) .000∗∗ SAC (including day care)

∗∗Signiﬁcant difference between the two groups of participants (p < .01); see Appendix J for more detailed descriptive statistics.

ple around them, such as helping neighbors to buy necessities, pushing wheelchairs, or assisting other elderly to board the bus. Participants recruited from both street interviews and centers enjoyed doing exercise and engaging in socially stimulating activities. The most common intellectually stimulating activity that they did was reading the newspaper. However, the nature of the social activities that they were engaged in was slightly different as participants who go to senior activity centers were more aware of available courses, such as SCOPE (Self-Care for Older Persons in Singapore) and various outings organized by the SAC in collaboration with companies or schools. Among the participants, only two did not know about SAC or Community Center, or how to join these activities.The rest of the street interview group were aware of the activities, but they did not have time for or the interest in attending the activities (Table 5). Participants recruited from centers also consisted of signiﬁcantly more females than the street interview group (U = 42.5, p < .001). In fact, only one female participant was recruited through a street interview, while 15

Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 out of 20 participants recruited from centers were females. Female participants visited and used the facilities at SACs more frequently than males (U = 72, p < .05) (Table 6). Hence, it is not surprising that males scored significantly lower than females in Continuity, Contribution, Challenge, and frequency of going to SACs. This difference is consistent with the difference between participants recruited through street interviews and participants recruited from SACs (compare Tables 4 and 6). However, despite the fact that males did not visit SACs as often as females and their GDS scores did not differ significantly from the female participants, they perceived greater social cohesiveness of their neighborhood (U = 69, p < .05). On the other hand, there is no significant difference in Connection between participants recruited from centers and those recruited via street 278 K. H. Chong et al.

TABLE 5 Excerpts of Participants’ Comments in 5Cs Questionnaires

Center-Based Interviews Male Female

Mr. CH, 71 Mrs. AX, 72 “I would like to teach if possible/ there is “Sometimes SAC organizes outing to the zoo chance, but it’s not necessary to my or parks (e.g., Alexandra). At SAC, I join well-being. Even if I share my stories with Angklung (musical instrument ensemble) young people or try to teach them, some of and yoga. I also often help calling the people the places that I remember do not exist (at SAC) according to numbers when they anymore. Areas or buildings are all gone conduct regular blood-pressure checks at and this makes communicating with the SAC. young people hard. Other than the activities listed in the Challenge sections, I watch YouTube and go to Expo. I go to Residents’ Committee (RC), CC, SAC regularly; I see Mrs. LM, 64 activities depend on schedule of the centers. “I go to SAC every day. I don’t become I exercise at SAC every day and at volunteer, only if people ask for help, I’d like Henderson Wave parks.” to help. My husband said what if I sign up as a volunteer, but then I don’t have time when they need me? So I don’t sign up. I like to go to Geylang Serai once in two to three months. I also like to go to Woodlands, to Causeway Point. Sometimes there’s outings at SAC, but sometimes I don’t know the details.” Street Interviews Male Female

Mr. TZ, 73 Mrs. JH, 70 “I used to go fishing, but now no place to fish. I walk to Henderson Park to exercise 15 minutes “I have never gone to CC because I don’t every morning. I don’t have education, know how to join CC.” don’t know reading/writing. I organize own grouptogoout.IliketogoPulauUbinand go sightseeing, eating, drinking coffee. I sometimes go to Buddha Tooth Temple. I don’tliketogotoSAC,Idon’tliketomix with those older folks with different Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 behaviors (70s to 80s). They are too old, troublesome, selfish, no image. I only joined dinner at CC once. I don’t like to join these people. I prefer to be with friends staying around Block 19.” Mr. YT, 67 “There is GRC (Group Representation Constituency) activity center. I volunteer English-Chinese translation at lawyer friend’s place, but not too often. I think the activities organized by CC are good, but sometimes I don’t have time. I used to do tai chi in the past.” Psychosocial Well-Being of the Elderly 279

TABLE 6 Medians and Means (Standard Deviations in Parentheses) of Scores Between Male and Female Participants

Male Female Variables Median Mean (SD) Median Mean (SD) p value

MoCA 23.00 22.4(4.85) 21.00 20.25 (5.16) .170 GDS 2.00 2.78 (3.14) 3.00 2.64 (2.41) .936 Continuity∗∗ 2.75 2.62 (0.31) 2.95 2.82 (0.33) .002∗∗ Compensation 2.86 2.84 (0.18) 2.86 2.78 (0.29) .576 Connection∗ 2.50 2.42 (0.47) 1.82 1.95 (0.56) .015∗ Contribution∗∗ 1.11 1.19 (0.20) 1.39 1.38 (0.18) .003∗∗ Challenge∗ 1.29 1.31 (0.21) 1.52 1.50 (0.18) .012∗ Frequency of going to SAC∗ 1.00 1.75 (1.00) 3.00 2.63 (0.81) .013∗

∗Signiﬁcant difference at p < .05. ∗∗Signiﬁcant difference at p < .01.

interview (Please see Appendix K for more detailed comparison of scores between male and female participants).

DISCUSSION Well-Being of Elderly in Relation to Independence, Neighborliness, and Cohesiveness The participants generally had high satisfaction in their ability to be independent in making decisions about their house and to manage themselves and their house. They were also satisfied with the location of their house and the outdoor support, services, and facilities around their house. For example, almost all participants felt that they had enough time to cross at traffic inter- sections and that the location of their house was convenient to shops, clinics, and activity centers. These reflect positive feedback on all the elder-friendly infrastructure and facilities provided in the matured estate of Bukit Merah.

Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 Our results also show that participants who were more satisﬁed with the location and availability of outdoor support around their house tended to feel less depressed. Furthermore, those who perceived themselves as independent and able to manage themselves and their house tend to contribute more to their family and community. On the other hand, the participants did not have any strong opinions in evaluating the cohesiveness of their neighborhood. Nevertheless, the more positive they valued the cohesiveness of their neighborhood, the less prone they were to depression. It is understandable that participants who have closer friends around the neighborhood might tend to perceive their neighborhood as more cohesive, and therefore tend to be less depressed. One of the participants who scored 2 in the GDS commented: 280 K. H. Chong et al.

Mine is a close-knit neighborhood because it’s a common corridor. I have good neighbors, but neighbors keep things to themselves.

Thus, more could be done in neighborhood planning and design to encourage social connectedness among elderly and between elderly and others in the matured estate.

Well-Being of Elderly in Relation to Active Aging and Volunteerism Despite the general trend of extremely high perceived independence and neighborliness in this sample, most participants were not engaged in various activities frequently—neither in stimulating activities as listed in the Challenge section, nor in other activities that require interaction with family and community as listed in the Contribution section. Interestingly, the Chal- lenge score was also found positively associated with Compensation, despite the low Challenge scores and high Compensation scores in the present study. The result implies that improvements in neighborhood design could help; more speciﬁcally, there is still room to improve neighborhood design and planning in matured estates that could intrinsically encourage the elderly to participate in various physical activities and social activities in the community.

Provision and Planning of Formal and Informal Social Spaces Participants who attended activities at SAC enjoy outing activities organized by the center. As shown earlier, SACs tended to attract more females than males, as women tend to establish friendships at activity centers. For example, Mrs. LM (64 years old), who attended SAC activities every day, shared that she “meets up with SAC friends and goes shopping.” This aligns well with the ﬁndings that elderly women who live alone felt that they have formed close friendships since they came to senior centers (Aday, Kehoe, & Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 Farney, 2006). Furthermore, women also perceived greater health beneﬁts from attending senior centers compared to men (Fitzpatrick, McCabe, Gitel- son, & Andereck, 2006), and women with higher levels of education and better subjective physical health assessments tended to be frequent users of senior centers (Yoo & Kim, 2005). On the other hand, one of the reasons indicated by male participants for not going to activity centers was that their friends did not go to these centers. Two of the male participants who were recruited through street interview commented:

I don’t go to SAC because (I) work part time and meet friends at the park. I don’t have friends there so I don’t go. Psychosocial Well-Being of the Elderly 281

It is not surprising that most male participants who did not visit activity centers scored lower in Continuity (noting that the result could be skewed by men generally being less active in managing households), Contribution, and Challenge. Based on open interviews, in addition to meeting their friends regularly at SACs, female participants also meet their SAC friends at coffeeshops or hawker centers nearby. For example, Mrs. KN (72 years old) commented:

I visit my son once in two weeks (he lives in Woodlands). I go shopping with friends; eat together (we leave from SAC). Twice a month go to temple at Toa Payoh then eat there.

Mrs. HM, age 63, also explained:

My relatives stay in Chua Chu Kang, Ang Mo Kio, and Sengkang, but most of my friends live nearby. We usually go to the market and drink coffee.

While many studies have focused on improving accessibility in houses and around the houses, our results posit that improving lives for elderly should also take into account the provision of public spaces to gather. Our results also reveal that while services provided by various activity centers provide opportunities for elderly residents to engage in stimulating activities, not all people are attracted to activities at such centers. There are other people who do not join these activities and choose to gather in informal public spaces, yet they have similar (low) scores in GDS. For example, participants recruited from street interviews indicated the importance of pavilions and public parks. This aligns with the previous study conducted by Teo (1997) on 148 elderly living in Bukit Merah and Tampines, which also showed that elderly meet up not only at structured social spaces like SACs, but also at informal public spaces such as coffeeshops and void decks. In addition, male participants, who were mostly recruited through street

Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 interviews, perceived social cohesiveness signiﬁcantly higher than female participants. Although it was found that male participants were less likely to express their dissatisfaction about their neighbors as compared to female participants, the result still suggests the positive values of open public spaces in enhancing perceived social cohesiveness in matured estates. When asked about activities that they thought were most important for their well-being, most participants replied that exercise or walking was an important activity for them. They also considered eating out and going to various places as important activities. As for activities that they usually did with their friends, the participants often mentioned drinking coffee, going to the market, and going to shopping malls. Exercising together was also a common activity between the participants and their friends, especially 282 K. H. Chong et al.

those who went to activity centers regularly. The results imply that a strong connectivity between formal and informal public spaces is very important for the elderly. While the elderly formed friendships in activity centers, their activities often extended beyond the centers to places like parks, markets, and hawker centers. Even elderly who did not visit activity centers often had an unspoken but speciﬁc meeting place with their friends, for example, at a designated pavilion where they would play chess, talk, smoke, or simply take a nap. Therefore, with regard to urban design in matured estate, the connectivity among activity centers, markets, hawker centers, coffeeshops, and parks can still be improved to encourage more active participation from elderly in ways that do not require them to change their lifestyle abruptly. Ball (2012) proposed that it is not sufﬁcient to have facilities that are near to each other, yet isolated from each other. To create more possibility of having chance encounters with each other and to enhanced perceived cohesiveness, thereby improving the elderly’s psychosocial well-being, our results posit a more integrated planning and urban design of all these social spaces, improving their connectivity, blurring their boundaries, and offering a wider array of formal and informal public spaces to cater to diverse groups of elderly.

LIMITATIONS

Nevertheless, the limitations of this study are the small sample size and the unbalanced gender composition in our sample, as most participants who volunteered to participate in surveys or interviews at activity centers were females—a trend that also occurred in previous studies (Fitzpatrick et al., 2006; Kim et al., 2011; Yoo & Kim, 2005). Further studies on the elderly with a wider range of health status, education background, and income level can be conducted in the future. As most of the participants were mostly healthy elderly who were able to move around independently, which explains the positively skewed scores of Compensation, Continuity, and GDS, further studies on the elderly with various health and mobility Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 status are needed. The relatively low education status of our sample (mostly secondary school education and incomplete primary school education) may also explain the low Challenge and Contribution scores. As our results show a signiﬁcant positive relationship between education status and Challenge and Contribution scores, further studies are also needed to include elderly with higher education status to explore future trends.

CONCLUSIONS

This article has explored various relationships between the elderly’s psychosocial well-being and components of aging-friendly community as mea- Psychosocial Well-Being of the Elderly 283

sured by the 5Cs Questionnaire (Continuity, Compensation, Connection, Challenge, and Contribution), in order to understand their perception of a matured estate and to discuss implications in housing neighborhood urban design. Our results postulate that different groups of elderly form friendships and participate in activities in both formal social service centers and informal public spaces. The friendships formed in these places and the convenience of amenities around their houses may affect their perception of their current residences. Our results have also indicated that elderly residents are generally satisﬁed with the physical infrastructure in matured estate of Singapore, particularly in Bukit Merah. However, the social infrastructure and urban design of the housing estate can still be further improved to help the elderly maintain their connections with other people and encourage more contribution to the community.A comprehensive, integrated urban design is also needed to facilitate physical activities, social interactions, and active aging in the elderly in order to enhance their psychosocial well-being.

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APPENDIX A

Table A1 Description and Examples of the 5C Components

5Cs Description Format

Continuity Independence Ability to make decisions about the 3 questions using (2 aspects) house 5-point Likert scale Examples: and 3 open-ended 1. I am free to make decision about questions my house and live in it as I please. (Likert scale: strongly agree/agree / neither agree nor disagree / disagree / strongly disagree) 2. Do you wish to be more independent? What are the things youwishtodobyyourselfand what are the things you wish others to help? (Open-ended) Managing Ability to manage oneself and the 6 questions using house (e.g., preparing daily meal, 5-point Likert scale gardening) and 4 open-ended Examples: questions 1. I am able to manage keeping my house clean. (Likert scale) 2. Is there anything you used to be able to do, but you cannot manage now? Why? (Open-ended) Continuity Location How convenient it is to go to the 9 questions using (2 aspects) clinic, to buy food, and to go to 5-point Likert scale activity centers and other service and 4 open-ended providers? questions Examples: 1. My home is convenient to shops. (Likert scale) 2. How often do you visit a senior activity center or integrated day facilities around your home (if there are any)? Why? (Open-ended) Outdoor Ability to cross trafﬁc intersection in 5 questions using Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 Support time, availability of shaded 5-point Likert scale outdoor spaces, community and 5 open-ended garden, etc. questions Examples: 1. I am satisﬁed with the availability of well-lit seating areas around my residence. (Likert-scale) 2. Five years from now, do you think your house and neighborhood will still be suitable for you? Why? (Open-ended) (Continued on next page) Psychosocial Well-Being of the Elderly 287

Table A1 Description and Examples of the 5C Components (Continued)

5Cs Description Format

Connection Social Self-assessment on how much they 6 questions using (2 aspects) Cohesiveness trust their neighbors 5-point Likert scale Examples: and 4 open-ended 1. People here are willing to help questions their neighbors. (Likert scale) 2. What is your ideal frequency in meeting up with your good friends? Do you get to do this? (Open-ended) Proﬁle of Frequency of meeting up with 11 open-ended Interaction family and friends, activities that questions they do during this interaction, andperceptiononwhathinders or helps this interaction Examples: 1. What activities do you usually do when you meet up? (Do you visit them? Do they visit you? Do you go out together? What do you do during the visit or when you go out with them?) Contribution Family Frequency of their contribution to 6 questions using (4 aspects) Contribution the family, such as cooking, taking 3-point frequency care of grandchildren, etc. scale Examples: 1. How often are you engaged in preparing meals? Frequency scale: • never or less than once a month • sometimes or once a month or more, but less than once a week • often or once a week or more Social/ Frequency of their contribution to 6 questions using Volunteer their community, such as 3-point frequency Work attending fundraising events, scale befriending other elderly with physical or mental disabilities, etc. Examples: Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 1. How often are you engaged in teaching a class, e.g., line dancing, calligraphy, cooking, etc.? (Frequency scale) Expertise Frequency of their contribution to 6 questions using Volunteer their community in their speciﬁc 3-point frequency Work skills, such as mentoring young scale professionals, teaching IT skills, etc. Examples: 1. How often are you engaged in organizing fundraising events? (Frequency scale) (Continued on next page) 288 K. H. Chong et al.

Table A.1 Description and Examples of the 5C Components (Continued)

5Cs Description Format

Work Current job/last job and amount of 2 multiple-choice Contribution last salary questions Examples: Employment characteristics: a. work full-time, industry ______b. work part-time, industry ______c. retired, industry of the last job ______Challenge Physical Frequency of their physical 5 questions using (4 aspects) activities, such as jogging, tai chi, 3-point frequency etc. scale 1. How often are you engaged in walking/ jogging? (Frequency scale) Examples: Intellectual Frequency of their intellectually 6 questions using stimulating activities, such as 3-point frequency reading newspaper, taking scale courses, etc. Examples: 1. How often are you engaged in browsing news on the Internet? (Frequency scale) Social Frequency of their social activities, 8 questions using such as playing mahjong, going to 3-point frequency activity centers, etc. scale Examples: 1. How often are you engaged in attending church/ mosque/temple? (Frequency scale) Technology Frequency of their usage of Internet, 4 questions using such as browsing Internet, using 3-point frequency Facebook, etc. scale and 4 Open-ended questions on the usage open-ended of smartphone (e.g., reason, questions beneﬁts of the device in their daily activities) and their use of Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 social networking sites. Examples: 1. How often are you engaged in using social networking sites (Facebook/Twitter, etc.)? (Frequency scale) 2. Do you use a smartphone/smart device? Why? (Open-ended) (Continued on next page) Psychosocial Well-Being of the Elderly 289

Table A1 Description and Examples of the 5C Components (Continued)

5Cs Description Format

General Remarks About Summary of their perspectives on 2 questions using Psychological Well-Being their activities and the facilities 5-point Likert scale and Housing around them and 2 open-ended Examples: questions 1. Please list 5 activities that are most important to your well-being. (Open-ended) 2. How satisfied are you with the facilities around your home to support your activities? (very satisfied/ satisfied/ neither satisfied nor dissatisfied/ dissatisfied/ very dissatisfied)

APPENDIX B TABLE B1 Sources of Each Component of the 5Cs Questionnaire

5Cs Sources

Continuity Housing Options for Older People (Elderly Accommodation Counsel, 2002) Compensation Global Age-Friendly Cities: A Guide (WHO, 2007) Housing Options for Older People (Elderly Accommodation Counsel, 2002) Connection Social Cohesion/Trust Questionnaire (Sampson et al., 1997) Contribution Leisure Activities Questionnaire (Niti et al., 2008) Challenge Leisure Activities Questionnaire (Niti et al., 2008) Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 290 K. H. Chong et al.

APPENDIX C TABLE C1 Demographic Details of Participants (N = 33)

Variables N (%)

Language of Questionnaire Completion English 11 (33.33%) Mandarin 16 (48.48%) Malay 6 (18.18%) Age 55–70 12 (36.36%) More than 70 21 (63.64%) Health Status Mobile/healthy 30 (90.91%) Immobile/Has disabilities 3 (9.09%) Employment Status Work full-time 1 (3.03%) Work part-time 4 (12.12%) Retired 25 (75.76%) Unemployed 3 (9.09%) Marital Status Single 6 (18.18%) Married 15 (45.45%) Divorced/Separated 3 (9.09%) Widowed 8 (24.24%) Missing 1 (3.03%) Ethnicity Malay 4 (12.12%) Chinese 28 (84.84%) Other 1 (3.03%) Highest education No formal education 10 (30.30%) Primary school 7 (21.21%) Secondary school 12 (36.36%) A level/Diploma 3 (9.09%) Bachelor’s degree 1 (3.03%) Monthly income in Singapore dollars Less than 500 14 (42.42%) 500–1,000 11 (33.33) 1,001–2,500 4 (12.12%) Missing 4 (12.12%) Source of income∗ Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 Earnings from work 3 (9.09%) CPF/Government pension/Retirement beneﬁts 10 (30.30%) Children 16 (48.48%) Savings 5 (15.15%) Other 9 (27.27%) Number of languages the respondent is exposed to 1 4 (12.12%) 2–3 20 (60.61%) More than 3 5 (15.15%) Missing 4 (12.12%) ∗∗ English language exposure None 17 (51.52%) Less than 30% 5 (15.15%) (Continued on next page) Psychosocial Well-Being of the Elderly 291

Table C1 Demographic Details of Participants (N = 33) (Continued)

Variables N (%) 30% or more 6 (18.18%) Missing 5 (15.15%) Malay language exposure∗∗ None 22 (66.67%) Less than 30% 1 (3.03%) 30% or more 5 (15.15%) Missing 5 (15.15%) Mandarin language exposure∗∗ None 10 (30.30%) < 30% 8 (24.24%) > 30% 7 (21.21%) Missing 8 (24.24%) Chinese dialects exposure∗∗ None 8 (24.24%) < 30% 3 (9.09%) > 30% 18 (54.55%) Missing 4 (12.12%)

Note. ∗Participants could choose more than one source of income. ∗∗Participants listed all languages to which they were exposed. Central Provident Fund (CPF) Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 292 K. H. Chong et al.

APPENDIX D TABLE D1 Housing Information of Participants (N = 33)

Variables N (%)

Number of people living with respondent No one 6 (18.18%) 1person 13(39.39%) 2–3 persons 11 (33.33%) 4 or more persons 3 (9.09%) House type HDB 31 (93.94%) Condominium 1 (3.03%) Missing 1 (3.03%) Housing size 1 room 11 (33.33%) 2–3 rooms 4 (12.12%) 3 or more rooms 17 (51.52%) Missing 1 (3.03%) Tenure Paid 18 (54.55%) Leasehold 4 (12.12%) Rented from HDB 7 (21.21%) Missing 4 (12.12%) Satisfaction with current living arrangement Yes 27 (81.82%) No 3(9.09%) Missing 3 (9.09%) Length of residence Less than 10 years 9 (27.27%) 10–19 years 9 (27.27%) 20 or more years 12 (36.36%) Missing 3 (9.09%) House preference Staying in the current residence 25 (75.76%) Moving out 2 (6.06%) Missing 6 (18.18%) Preferred neighbors on the same ﬂoor Mostly senior citizens 7 (21.21%) Mostly young families 0 Balanced number of senior citizens and 11 (33.33%) young families Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 No preference 10 (30.30%) Missing 5 (15.15%) Will you consider staying in a studio apartment? Yes 2(6.06%) No 10 (30.30%) Missing 21 (63.64%) (Continued on next page) Psychosocial Well-Being of the Elderly 293

APPENDIX D TABLE D1 Housing Information of Participants (N = 33)(Continued)

Will you consider staying at a nursing home? Yes 3(9.09%) No 14 (42.42%) Missing 16 (48.48%) Will you consider staying at a retirement village? Yes 6(18.18%) No 6(18.18%) Missing 21 (63.64%)

Housing Development Board (HDB) APPENDIX E TABLE E1 Number and Percentage of Participants with the Following Medical Conditions

Medical Condition n %

Stroke 0 0 Heart attack 3 9.09 Coronary heart disease 1 3.03 Angina 0 0.00 High blood pressure 13 39.39 Asthma 2 6.06 Lung disease 1 3.03 Diabetes 5 15.15 Arthritis 6 18.18 Learning disorder 0 0.00 Cancer 0 0.00 Psychiatric problem 1 3.03

APPENDIX F TABLE F1 Summary of GDS Scores

Scores of Scores of Scores of Mean N < 5 5–10 > 10 (SD) Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 GDS∗ 31 24 7 0 2.72 (2.79)

∗ Note. Scores ≥ 5 indicate risk to depression; scores >10 almost always indicate depression.

APPENDIX G TABLE G1 Summary of MoCA Scores

Scores of Scores of Scores of Scores of Mean N < 8 8–14 15–21 22–28 (SD)

MoCA∗ 31 0 4 8 19 21.29 (5.05)

∗ Note. Original MoCA cutoff score is 26. Suggested cutoff score in Singapore version is 21–22. 294 K. H. Chong et al.

APPENDIX H TABLE H1 Mean, Standard Deviation, and Distribution of Scores (p < .05 indicates violation of normality assumption)

Shapiro-Wilk Variables N Mean (SD) Statistic df p

Continuity 33 2.72 (0.33) .773 33 .000 Continuity—Independence 33 2.87 (0.31) .495 33 .000 Continuity—Managing 33 2.64 (0.43) .779 33 .000 Compensation 33 2.81 (0.24) .769 33 .000 Compensation—Location 33 2.85 (0.23) .677 33 .000 Compensation—Outdoor 33 2.68 (0.58) .583 33 .000 Support Connection 33 2.19 (0.56) .945 33 .093 Contribution 32 1.28 (0.21) .948 32 .126 Family contribution 32 1.60 (0.43) .901 32 .007 Social/volunteer work 32 1.24 (0.34) .753 32 .000 Expertise volunteer work 32 1.01 (0.06) .172 32 .000 Challenge 33 1.36 (0.32) .799 33 .000 Physical challenge 33 1.53 (0.49) .898 33 .005 Intellectual challenge 33 1.28 (0.33) .837 33 .000 Social challenge 33 1.54 (0.44) .918 33 .016 Technology challenge 33 0.98 (0.20) .295 33 .000 MoCA 31 21.29 (5.05) .920 31 .024 Age 33 70.85 (7.48) .972 33 .549 GDS 31 2.72 (2.79) .863 31 .001 Highest education 33 2.33 (1.11) .875 33 .001 Size of house (HDB type) 32 2.38 (1.16) .828 32 .000 Monthly personal disposable 29 1.66 (0.72) .767 29 .000 income Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 Psychosocial Well-Being of the Elderly 295

APPENDIX I TABLE I1 Signiﬁcant Correlations Among Various Subscales

Spearman’s No. Variable 1 Variable 2 rho (rs) Np 1 Continuity—Managing Frequency of going to .422∗ 32 .016 SAC/IDF 2 Compensation—Location Compensation—Outdoor .455∗∗ 33 .008 Support 3 Compensation—Outdoor Frequency of going to .366∗ 32 .040 Support SAC/IDF 4 Compensation—Outdoor Connection .323 33 .067 Support 5 Contribution Continuity—Managing .524∗∗ 32 .002 6 Contribution Challenge—Physical .524∗∗ 32 .002 7 Contribution Challenge—Social .523∗∗ 32 .002 8 Contribution—Family Challenge—Physical .449∗∗ 32 .010 9 Contribution—Family Challenge .395∗ 32 .025 10 Contribution—Family Continuity—Managing .451∗∗ 32 .010 11 Contribution—Family Continuity .403∗ 32 .022 12 Contribution—Social Challenge—Intellectual .422∗ 32 .016 13 Contribution—Social Challenge—Social .567∗∗ 32 .001 14 Contribution—Social Frequency of going to .591∗∗ 31 .000 SAC/IDF 15 Contribution—Social Continuity—Managing .409∗ 32 .020 16 Contribution—Social Continuity .448∗ 32 .010 17 Challenge Continuity—Managing .361∗ 32 .042 18 Challenge Compensation—Location .447∗ 32 .010 19 Challenge Compensation—Outdoor .389∗ 32 .028 Support 20 Challenge—Physical Challenge—Intellectual .381∗ 32 .032 21 Challenge—Physical Challenge—Social .544∗∗ 32 .001 22 Challenge—Physical Compensation—Outdoor .357∗ 32 .045 Support 23 Challenge—Physical Compensation .352∗ 32 .048 24 Challenge—Intellectual Challenge—Social .422∗ 32 .016 25 Challenge—Intellectual Frequency of going to .573∗∗ 31 .001 SAC/IDF 26 Challenge—Intellectual Compensation—Outdoor .446∗ 32 .011 Support 27 Challenge—Social Frequency of going to .587∗∗ 31 .001 Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 SAC/IDF 28 Challenge—Social Compensation—Location .502∗ 32 .003 29 Challenge—Social Compensation .403∗∗ 32 .022

∗p < .05, two-tailed. ∗∗p < .01, two-tailed. Senior Activity Center (SAC); Integrated Day Facility (IDF) 296 K. H. Chong et al.

APPENDIX J TABLE J1 Comparison of Scores Between Participants Recruited Through Street Interviews and Interviews Conducted at Activity Centers

Street interviews Center-based interviews Variables Median Mean (SD) Median Mean (SD)

MoCA 23.00 21.55 (4.97) 22.00 21.15 (5.21) GDS 2.00 3.17 (3.44) 2.00 2.39 (2.25) Continuity∗ 2.75 2.61 (0.35) 2.89 2.79 (0.30) Continuity—Independence 3.00 2.87 (0.29) 3.00 2.87 (0.33) Continuity—Managing∗ 2.67 2.47 (0.52) 2.83 2.75 (0.33) Compensation 2.79 2.80 (0.19) 2.93 2.82 (0.27) Compensation—Location 2.88 2.84 (0.15) 3.00 2.86 (0.27) Compensation—Outdoor 2.80 2.74 (0.34) 3.00 2.65 (0.70) Support Connection 2.33 2.32 (0.50) 2.17 2.11 (0.60) Contribution∗ 1.11 1.20 (0.22) 1.35 1.34 (0.19) Family contribution 1.33 1.44 (3.45) 2.00 1.71 (0.46) Social/Volunteer work∗ 1.00 1.13 (0.37) 1.33 1.32 (0.29) Expertise volunteer work 1.00 1.03 (0.09) 1.00 1.00 (0) Challenge∗∗ 1.26 1.25 (0.19) 1.50 1.50 (0.17) Physical challenge 1.40 1.38 (0.40) 1.80 1.71 (0.38) Intellectual challenge∗∗ 1.17 1.19 (0.20) 1.33 1.41 (0.24) Social challenge∗∗ 1.38 1.36 (0.29) 1.75 1.74 (0.31) Technology challenge 1.00 1.04 (0.14) 1.00 1.00 (0) Frequency of going to 1.00 1.17 (0.58) 3.00 2.8 (0.62) SAC/IDF∗∗

∗Signiﬁcant difference at p < .05. ∗∗Signiﬁcant difference at p < .01. Senior Activity Center (SAC); Integrated Day Facility (IDF) Downloaded by [Keng Hua Chong] at 20:20 16 September 2015 Psychosocial Well-Being of the Elderly 297

APPENDIX K TABLE K1 Comparison of Scores Between Male and Female Participants

Male Female Variables Median Mean (SD) Median Mean (SD)

MoCA 23.00 22.4 (4.85) 21.00 20.25 (5.16) GDS 2.00 2.78 (3.14) 3.00 2.64 (2.41) Continuity∗∗ 2.75 2.62 (0.31) 2.95 2.82 (0.33) Continuity—Independence 3.00 2.90 (0.26) 3.00 2.83 (0.36) Continuity—Managing∗∗ 2.60 2.47 (0.45) 3.00 2.82 (0.35) Compensation 2.86 2.84 (0.18) 2.86 2.78 (0.29) Compensation—Location 2.89 2.86 (0.14) 3.00 2.84 (0.30) Compensation—Outdoor 3.00 2.81 (0.32) 2.90 2.55 (0.76) Support Connection∗ 2.50 2.42 (0.47) 1.82 1.95 (0.56) Contribution∗∗ 1.11 1.19 (0.20) 1.39 1.38 (0.18) Family contribution∗∗ 1.33 1.39 (0.31) 2.00 1.84 (0.43) Social/volunteer work∗ 1.00 1.17 (0.35) 1.33 1.32 (0.30) Expertise volunteer work 1.00 1.02 (0.08) 1.00 1 (0) Challenge∗ 1.29 1.31 (0.21) 1.52 1.50 (0.18) Physical challenge 1.40 1.46 (0.41) 1.80 1.71 (0.39) Intellectual challenge 1.33 1.28 (0.26) 1.33 1.37 (0.23) Social challenge∗ 1.43 1.44 (0.32) 1.75 1.75 (0.31) Technology challenge 1.00 1 (0) 1.00 1.03 (0.13) Frequency of going to 1.00 1.75 (1.00) 3.00 2.63 (0.81) SAC/IDF∗∗

∗Signiﬁcant difference at p < .05. ∗∗Signiﬁcant difference at p < .01. Senior Activity Center (SAC); Integrated Day Facility (IDF) Downloaded by [Keng Hua Chong] at 20:20 16 September 2015