PROFESSIONAL ASSIGNMENT PROJECT Community dwelling elderly’s perception of the environment is the missing link in understanding the dynamics of outdoor falls and fear of falling in falls prevention A Professional Assignment Project on behalf of Gertrud Pijnenburg Msc, PT EUROPEAN SCHOOL OF PHYSIOTHERAPY 2016-2017 ESP coach: Jan-Jaap Voigt, MSc, PT ESP Students: Karlijn Musch, 500702655 Gwendolyn Wregar, 500702237 Monica Iulisca, 500702835 Date of submission: May 16th, 2017 “Older persons should be able to live in environments that are safe and adaptable to personal preferences and changing capacities” (United Nations 2017) II! List of Abbreviations and codes Abbreviations ADL Activities of daily living AH Albert Heijn FES-I Fall Efficacy Scale International FOF Fear of falling GP General practitioner Codes FG Focus Group QUAL Qualitative data QUAN Quantitative data or descriptive statistics III! List of Definitions Adaptation: the act or process of being able to change or be changed in order to fit or work better in some situation or for some purpose (Merriam-Webster's online dictionary 2016). Age-friendly city: An age-friendly city encourages active ageing by optimising opportunities for health, participation, transport and security in order to enhance quality of life as people age. There are eight domains which are the key focus of age-friendly cities in adapting structures and services to be accessible and inclusive of older people with varying needs and capacities (WHO 2007). Albert Heijn (AH): The Albert Heijn is the largest Dutch supermarket chain named after its founder. Avoidance: the act or practice of keeping away from or withdrawing from something undesirable (Merriam-Webster's online dictionary 2016). Boomspijker: A local community center at the Recht Boomsloot 52, 1011EC, Amsterdam Buurtschouw: “neighbourhood inspection” during which a specific walking route is taken to illustrate certain aspects of a neighbourhood. Case study: is an in depth study of a case (an event, an activity, an individual), studied over time using multiple sources of information (e.g. observations, documents, interviews) (KCL 2017). Community dwelling elderly: Community dwelling elderly are defined as elderly living independently in the community, as opposed to those who are institutionalised in nursing homes. Elderly: A person aged 65 years or older (WHO 2007). Environment: “the circumstances, objects or conditions by which one is surrounded” (Merriam- Webster's online dictionary 2016). Expert interview: is a semi-structured interview, but with deliberate choice of the interviewee, which is an expert in his/hers area of study. Fall: “an unexpected event in which the person comes to rest on the ground, floor or other lower level, excluding intentional change in position to rest in furniture, wall or other objects” (WHO 2007; Lamb et al. 2005). Fear of Falling (FOF): “an ongoing concern about falling, which ultimately limits the performance of activities of daily living” (Tinetti and Powell 1993). Focus group: is a group of people brought together in an informal setting to talk about a particular topic that has been set by the researcher acting as a facilitator (Longhurst 2003). HEMA: Popular Dutch discount retail chain selling household items, clothing and food. Independence: not dependent, not requiring or relying on others (Merriam-Webster's online dictionary 2016). Interpretative: exploration of the human experiential interpretation of any observed phenomena. Enables researchers to gain a better understanding of the underlying processes that may influence behaviour (KCL 2017). Interpretative theme finding: is a process in which themes (explanatory ideas) are identified from the data collected in the first stages of analysis. It is interpretative, because it is the researchers’ common interpretation of the themes that are the missing links between the participants answers and behaviour. IV! Iteration (an iterative process): relates to the process of repeatedly returning to the source of the data to ensure that the understandings are truly coming from the data. In practice this means a constant process of collecting data, carrying out a preliminary analysis, and using that to guide the next piece of data collection and continuing this pattern until the data collection is complete (KCL 2017). Interview survey: is a one-on-one interview during which an interviewer asks direct questions to a participant in order to explore the responses of the participants are gather in-deep information about a topic. Narrative: “A narrative can be understood to organise a sequence of events into a whole so that the significance of each event can be understood through its relation to that whole“ (Elliott 2005). “Narratives (stories) in the human sciences should be defined provisionally as discourses with a clear sequential order that connect events in a meaningful way for a definite audience and thus offer insights about the world and/or people’s experiences of it.” (Hinchman & Hinchman 1997) Near Fall: “a stumble event or loss of balance that would result in a fall if sufficient recovery mechanism were not activated” (Maidan et al. 2014). Participant observation: spending time with people from the population under study while making careful observations of their behaviour and interactions with their environment. Perception: 1) a mental image, and 2) physical sensation interpreted in the light of experience (Merriam-Webster's online dictionary 2016). Pinto Huis: A library and cultural center at the Sint Antoniebreestraat, Amsterdam. Self-efficacy: One's belief in one's ability to succeed in specific situations or accomplish a task. One's sense of self-efficacy can play a major role in how one approaches goals, tasks, and challenges (Bandura 1986). Self-perception: perception of oneself and of his own capabilities. Slip (noun), to slip / slipping (verb): An act of falling or sliding. To slide without intending to (Cambridge Dictionary 2016). Trip (noun), to trip / tripping (verb): An occasion of knocking one’s foot against something and fall or lose one’s balance, or someone else causes this, when walking or running (Cambridge Dictionary 2016). Urban vitality: is the concept of positively influencing the life of people through urban planning at its core. A city is not static, embracing the changes that occur over time within the socio-economic, cultural and physical environment enables to maintain the vitality of a complex system (Selezneva 2011). V! Acknowledgements We would like to show our gratitude to G. Pijnenburg for this assignment, who gave us the opportunity to get in contact with the elderly of Nieuwmarkt, delve into the life of this neighbourhood and experience its environment through their eyes. This manuscript could not have been realized without her assistance, availability and guidance over the course of this study. We would also like to thank our mentor, J.J. Voigt (MSc) from the HvA for his guidance throughout the research process. Furthermore, we thank J. van Wijchen from the HAN (MSc), who provided additional insight and expertise in the field of conducting qualitative research which greatly assisted the study process and data analysis. We would like to thank R. Zijlstra (PhD) and M. Pijnappels (PhD) whose valuable research and expert opinion helped us contextualize our findings. We thank Mrs. C. Marsman from the Boomspijker for assistance with hosting the focus group meetings and Mrs. A. Ketel from the GGD Amsterdam for her availability to introduce us to the concept of “age-friendly city”. Furthermore, we thank Mrs. W. Daamen, from the Gemeente Amsterdam for her help in the preparatory phase of this study. We would also like to acknowledge Mr. I. Baardman, PhD, and Mr. J. van Rossum, PhD retired from the VU, as well as Mr. J. Sisselaar for their feedback and contribution to the development of the interview survey at the start of this research. Our appreciation and gratitude goes to all the people of the Nieuwmarkt who agreed to participate in this study, as they provided us with precious empirical insight of the role of the outdoor environment in falls and fear of falling. Finally, this project could have not been realised in its comprehensiveness without the intense collaboration and unconditional support from each other. There are no words to describe the quality of friendship and professionalism this project has fostered in us and we are immensely grateful to each other for this unique learning experience. VI! Table of contents List of Abbreviations and codes III List of Definitions IV Acknowledgements VI Table of contents VII Tables and Figures List X Abstract 1 1. Introduction 2 1.1. Introduction to the health problem 2 1.2. Question of the client: scope and relevance of this study 3 1.2.1. Characteristics of the Nieuwmarkt 3 1.2.2. Aim and products of the study 4 1.3. Research questions 4 1.4. Introduction to the study design 4 2. Research Design and Methods 5 2.1. Research design 5 2.1.1. The emergence of mixed methods designs 5 2.1.2. Mixed methods design of this study 5 2.2. Process 6 2.3. Methods 6 2.3.1. Participants 6 2.3.2. Literature Search and other data sources 7 2.3.3. Data collection procedures and timing 7 2.3.4. Selection of participants 8 2.3.5. Language and location 8 2.3.6. Screening, inclusion and exclusion criteria 8 2.4. Quantitative methods 9 2.4.1. The FES-I 9 2.4.2. The interview survey 9 2.4.3. Participant observation during the interview survey 10 2.4.4. Data analysis 10 2.4.5. Mapping 10 2.5. Interpretive theme finding 11 2.6. Qualitative methods 11 2.6.1. Focus group interviews and buurtschouw 11 2.6.2. Participant observation and case study 11 2.6.3. Narrative 12 2.6.4. Expert interview 12 VII! 2.7. Final data evaluation and synthesis 12 2.8.