The basic Activities of daily
living (ADL) are the repetitive activities that people do every day without
assistance like eating, grooming, toileting and transferring(1).
When the elder person suffers from a health problem which affects his ADLs
independency, his/her family is advised to bring a personal assistant in home
or reallocate him/her in a nursery home.

Despite some of the elderly are
physically fit, they can’t do their ADLs independently due to low self-esteem
or fear of fall (FOF) to avoid possible problems like fractures.  An estimated 30–55% of older persons are
afraid of falling, and approximately one third of them report restrictions in
their ADLs independency (2).

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The determinants of healthy life
are not only depending on the biological well-being, but also on the
surrounding physical and social environment (3).Physical environment
includes-but not limited to- the air quality(temperature/humidity level),
illumination, floor friction, stairs design and surrounding space. Safe and
accessible physical environment can preserve the elderly independency to do
their ADLs, so the WHO has reported that the physical environment is an
important component of quality of life (QoL) (4). Moreover, these
physical environmental factors are the cause of one-third to one-half of self-reported
fall accidents among elderly (5) (6).

Aim and research questions

Aim: To describe the effect of
the surrounding physical environment on the Activities of Daily Living (ADLs)
independency among the elderly

Research questions:

1- To what extent the surrounding
environment affect the elder from doing your ADLs properly?

2- How do they express the role
of the surrounding environment as a factor helping/restricting their ADLs

Previous research

Many studies had studied the
effect of the outdoor physical environment and the neighborhoods planning as a
factor affecting the elders’ health in general(7,8) here it is discussing the
effect of the surrounding public space, administrative boundaries, how crowded
it is and public services accessibility on the elders’ health.

Other study concentrated on a
comparison between the design of the physical environment in rural and urban
areas(9) and its health outcomes. Here, they discussed the effect of shade
trees presence, public benches, public art, safe public transportation,
side-walks, bike lanes and average block length as factors affecting the
physical and mental health of the elders.

Studies had concentrated on the
effect of the indoor physical environment, not only the outdoor physical environment.
Most of these studies (10, 11, 12, 13, 14, 15) concentrated of the role of
indoor air quality (temperature and humidity level) and respiratory diseases
among the elders as a leading cause of disabilities and death, according to
report published by the CDC at the USA, chronic respiratory diseases are the 3rd
cause of death among the population over 65 years old after the cardiovascular
diseases and cancer (16).

Other studies (17, 18, 19) had
established a relation between the indoor physical environment and the level of
physical activity among elderly. These studies discussed how the design of the
indoor physical environment may be a leading factor causing a sedentary life
style which may lead to health problems. (19) has recommended more qualitative
in-depth multidisciplinary studies to describe the role of the surrounding
environment and the elderly well-being. 

Thus, at least to the level of my
knowledge, there is not any study described in-details the relation between the
indoor physical environment and the level of the ADLs independency as an
important factor for physical and mental well-being among elderly at nursing


Ethnography qualitative research at
3 nursing homes in Gothenburg for the elderly (Male +Female aged more than 50
YO and free from any diseases which may cause physical impairment limiting his
ADLs activities  ), triangulated by using
observation and interview for 10 patients/nursing home (n=30), using the
purposive sampling technique(which is a selective method to reach samples quickly
depending upon the inclusion criteria), starting with 30 participants for
interview till I find and generate the themes which will sufficiently answer my
research questions.

Observation (Structured participants observation):

I have selected observation as a
tool for data collection because I want to observe and see how they are dealing
normally in their actual physical surroundings without any interference from me
(that is why the observation will be 1
hours/day (3days/week) for 6 months, using a paper-based observation sheet at 3
different hours (morning/afternoon/evening)) to decrease the effect of changing
elders habits/behaviors when they know that they are being observed, moreover if I used interview data only, it may be inaccurate as
some of the elderly may have some recalling memory problems.

The observation sheet will
include observation of the elders’ ADLs behavior at the activities room, common
rooms, dining areas and halls. Also, description for the surrounding indoor
physical environment; like handrails position, corridor and hallway
length/widths, illumination
intensity and glare, floor material, emergency call-buttons distribution and
accessibility, humidity level, temperature level, air quality and doors
design(weight, lock position and opening direction).

After getting the acceptance of
the Institutional Review Board (IRB), I will be asking the permission of the 3
gatekeepers (3 private nursing homes in Gothenburg). Firstly, I will find the
best way to reach and contact them by one or a combination between the
following: telephone, postal mail and email to save time. Secondly, I will be
explaining my request briefly to them, the aim/nature of my research, why I
have selected them, the proposed hours needed for my observation/interview and
ask for a meeting with them to elaborate more and explain the importance of my
study for their organization too for better planning/rearrangement/modification
of their current physical environment.

Interview (semi-structured interviews):

I have selected the
semi-structured interview method as a tool for data collection because I will
be using many open-ended questions to get more detailed description from the
elderly and it will allow me to follow many conversations routes when the
elders want to add something important away from my interview guide. As I do
not have access for observation in their residence rooms and bathrooms, so
Interview will be the ideal method for data collection about their ADLs
independency at these areas.

My interview-by 2 trained
interviewers-will be individually not a group interview because It will be more
easier to handle and direct the interview, to prevent any affection of the
answers by other one’s answer, easy to ask follow –up questions if I need more
clarification and some people may be shy to express some points in their ADLs
in public.

It will be a paper-based and tape-recorded
interview (when some elderly want to add more details and to be easy accessible
for me to analysis afterwards).

After considering the inclusion
criteria for the interview (Based on the elders medical history sheet), the
interviewer will go with the company of the nurse/social worker directly to
their resident rooms and ask for a prospective meeting for the interview.

Example of interview questions:

1- Could
you please describe a typical day from getting up till sleeping?

2- What
is your favorite room to stay during the day? Why?

3- What
is your opinion about the illumination degree? Is it sufficient?

4- What
do you want to add/remove for better mobility freedom at the nursing home?


My data are
unstructured text because I will generate transcribed word-by-word data from
the observation and interview transcripts. NVivo11 will be used with two steps
of coding. The first basic coding step to generate overall themes and the
second step is the interpretative coding to in-depth details and understanding
of themes. Thematic (content) analysis will be performed by two researchers
with good knowledge of coding to decrease the chance of coding errors and enhance
the reliability of my data.


1- For the
protection of their personal data: the patients’ identifications will be coded
with numbers.

2- As my study
includes participants’ observation in selected areas like (the activity and common rooms, dining areas and halls), their
privacy should not be violated: a written voluntary informed consent should be
signed to declare their acceptance to be observed during their daily

3- As my study includes
interview: some of them may be shy to express of their personal
habits/information in front of others, so interviews will be managed at whether
their rooms or any other place they prefer.  



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