Journal of Housing For the Elderly

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The Physical Housing Environment and Subjective

Well-Being Among Older People Using Long-Term
Care Services in Japan

Rumiko Tsuchiya-Ito, Björn Slaug & Tomoaki Ishibashi

To cite this article: Rumiko Tsuchiya-Ito, Björn Slaug & Tomoaki Ishibashi (2019): The Physical
Housing Environment and Subjective Well-Being Among Older People Using Long-Term Care
Services in Japan, Journal of Housing For the Elderly, DOI: 10.1080/02763893.2019.1597803

To link to this article: https://doi.org/10.1080/02763893.2019.1597803

Published online: 22 Apr 2019.

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JOURNAL OF HOUSING FOR THE ELDERLY
https://doi.org/10.1080/02763893.2019.1597803

The Physical Housing Environment and Subjective

Well-Being Among Older People Using Long-Term Care
Services in Japan
Rumiko Tsuchiya-Itoa €rn Slaugb
, Bjo , and Tomoaki Ishibashia
a
Dia Foundation for Research on Aging Societies, Tokyo, Japan; bDepartment of Health Sciences,
Faculty of Medicine, Lund University, Lund, Sweden

ABSTRACT KEYWORDS
For older people using long-term care services, the conditions Aged; physical housing
of their life-space may be critical. The relationships between environment; subjective
the physical housing environment and aspects of health were well-being; environment
docility hypothesis;
examined among older people in Japan (aged 65þ years, activities of daily living
N ¼ 1,928) by multivariable logistic regression analysis, adjust-
ing for sociodemographic characteristics. Lack of safety, low
access to emergency assistance, low or high indoor tempera-
ture, poor sanitary conditions, and state of home disrepair
were significantly associated with negative aspects of health
among people with low activities of daily living (ADL) inde-
pendence. Home care service providers and policymakers
need to consider the importance of appropriate environmen-
tal conditions for the most vulnerable groups.

Introduction
The population aging progress worldwide and the number of older people
living in their home with functional limitations is increasing. For older
people with functional limitations, the characteristics of the housing envi-
ronments are particularly important, as the home is the place where older
people spend most of their time (Baltes, Maas, Wilms, Borchelt, & Little,
1999). However, there is limited evidence about the potential impact of the
housing environments from Asian countries, including Japan (Ahrentzen &
Tural, 2015). Asian countries have distinctive features of housing construc-
tion and culture, and there is a need for more evidence from these coun-
tries. The present study focuses on two subjective well-being measures,
self-rated health (SRH) and life satisfaction (LS), and how these may be
related to physical housing environments in Japan.

CONTACT Rumiko Tsuchiya-Ito rumikot-tky@umin.ac.jp Dia Foundation for Research on Aging Societies,
3F Verde Vista Shinjukugyoen, 1-34-5, Shinjuku, Shinjuku-ku, Tokyo 160-0022, Japan.
ß 2019 Taylor & Francis Group, LLC
2 R. TSUCHIYA-ITO ET AL.

Physical housing environment

For older people with limitations in functional capacity, such as balance
problems and reduced fine motor skills, the design of the physical housing
environment becomes increasingly critical (Gitlin, Mann, Tomit, & Marcus,
2001; Lawton, 1986). One of the 17 goals of the Sustainable Development
Action (United Nations, 2015a) is “sustainable cities and communities.”
With special attention to the needs of older people, a concrete target is to
ensure safe, affordable, and accessible housing and public transportation
until 2030. It is also crucial, for current aging in place policies to be sus-
tainable, that ordinary housing is adequately designed to accommodate the
growing proportion of older people.
In Western parts of the world such as Europe, the United States, and
Oceania, the influence of physical housing environments has been assessed
from an urban environmental planning and public health perspective. In
1961, the World Health Organization (WHO) presented a report by an
expert committee on the public health aspects of housing environments
(WHO, 1961). Based on this report, Higasa and Hibata (1993) presented the
concept of “healthy housing environment,” distinguishing between four cate-
gories: safety, health, amenity, and convenience. As a support for older peo-
ple to remain in their present homes, “safety” was defined as “protection of
life and property of older people from disasters and problems,” while
“convenience” was defined as “ensuring the convenience of daily life.” In
previous studies it was shown that several environmental aspects of the
home impeded both safety and independence among community-living older
people (Gitlin, Corcoran, Winter, Boyce, & Hauck, 2001), that the impact of
physical barriers of the built environment differed depending on the level of
activities of daily living (ADL) (Iwarsson & Isacsson, 1998a), and that a large
magnitude of accessibility problems affected quality of life negatively
(Iwarsson & Isacsson, 1998b). Moreover, among very old people living in
ordinary housing, increased mortality was found to be associated with cer-
tain physical housing barriers, such as lack of hand rails in entrance stairs
(Rantakokko, T€ orm€akangas, Rantanen, Haak, & Iwarsson, 2013). In
Australia, the HIPI study focused mainly on decreasing fall injuries by
removing barriers in the housing environment (Keall et al., 2015). The HIPI
study showed a 26% reduction of fall injuries if an adequate housing adapta-
tion was conducted. In all these studies, aspects of “safety” and
“convenience” were major outcomes, related to physical housing environ-
ments. The category of “health” was defined by Higasa and Hibata (1993) as
the role of the housing environment that protects people’s physical and men-
tal health. That includes, for example, thermal conditions, and earlier studies
have found that installing well-insulated windows increased physical activity
among older people (Mori, Tsuzuki, Yasuoka, Sakamoto, & Takahashi,
 JOURNAL OF HOUSING FOR THE ELDERLY 3

2014), while a cold environment negatively impacted their physical perform-

ance (Hayashi, Schmidt, Malmgren F€ange, Hoshi, & Ikaga, 2017). The cat-
egory of “amenity” refers to the pleasantness of the environment as a place
in which to live, work, and spend one’s leisure time (Chopin & Kaiser,
1979). It was defined by Higasa and Hibata (1993) to include both a beauti-
ful appearance and satisfying conditions for recreation, and up till now there
is limited evidence of potential effects on population health. Moreover, there
is a paucity of studies attempting to capture the physical housing environ-
ment from multiple aspects and how it may impact older people’s health. By
considering the housing environment from a more comprehensive perspec-
tive, the possibilities to examine important aspects of older people’s health
such as subjective well-being are strengthened.

Significance of subjective well-being

In order to evaluate the potential impact of the housing environment on
older people’s health, subjective well-being is a factor of major significance.
According to Steptoe et al. (Steptoe, Deaton, & Stone, 2015), the concept of
subjective well-being includes the dimensions of (a) life evaluation, such as
life satisfaction, (b) feeling of happiness, and (c) eudemonic well-being. In
the current study, LS is focused as it is part of the Organization for
Economic Cooperation and Development (OECD) better life index (OECD,
2017), and is used as a major outcome to evaluate well-being among older
people. SRH is also prioritized in the current study, simply because it is
commonly used as a major health outcome and predictor for mortality
(see, e.g., DeSalvo, Bloser, Reynolds, He, & Muntner, 2006; Idler, Kasl, &
Lemke, 1990; Kaplan & Camacho, 1983; Mossey & Shapiro, 1982; Yasuda
& Ohara, 1989). According to the Person–Environment fit model (P-E fit
model), which is a conceptual model to illustrate the relationship between
personal competence and environmental press (Lawton & Nahemow,
1973), older people with functional decline are more vulnerable to environ-
mental pressure, such as various deficiencies in the housing environments,
and this could negatively influence SRH and LS. Therefore, examining
these relationships is important from a public health perspective.

Limited evidence from Asian countries

The aging rate in Asian countries was comparatively low in 2015, except
for Japan (United Nations, 2015b); the aging rate is increasing considerably
more quickly in Japan compared to European countries (United Nations,
2015b). Therefore, how to manage the issue of demographic aging is an
important challenge. In Japan, the aging rate has already reached 27.3%
4 R. TSUCHIYA-ITO ET AL.

(Ministry of Health, Labor and Welfare, 2017), and it is predicted that the
rate will keep raising rapidly. However, research on the relationships
between housing environments and subjective well-being has largely been
neglected in Japan, and evidence is therefore limited. Studies of housing
environment in Asian countries often focus on fall prevention (see, e.g.,
Huang & Acton, 2004; Kamei et al., 2015; Lee et al., 2013;
Sophonratanapokin, Sawangdee, & Soonthorndhada, 2012; Yoo, 2011),
mainly with attention to older people’s physical and mental functioning.
However, falls and other threats to health may also be affected by different
aspects of the housing environment, not only older people’s physical and
mental functioning. Accordingly, more comprehensive research is needed,
taking different aspects into account. Recently, a systematic literature
review pointed to evidence of negative influence by conditions of the hous-
ing environment on several health-related outcomes such as mortality,
SRH, quality of life, and activity participation in Europe and North
America (Ahrentzen & Tural, 2015). Therefore, there is a need to investi-
gate the evidence for such relationships also in Asian countries.
In Japan, traditional housing construction and housing environments
have culturally dependent characteristics such as a high level difference at
the entrance, and seating on the floor (tatami seating); Japanese culture
also has specific customs such as taking a bath as a daily activity
(Hayasaka, Shibata, Noda, Goto, & Ojima, 2011; Owa, Bao, Choi, &
Takahashi, 2008). The traditional Japanese style of housing is sometimes
hard for older people with limitations in functional capacity (Ichihara,
2010). Additionally, in Japan it is unusual for older people to move; as a
result, older people remain living in traditional housing even if the condi-
tions are no longer optimal for them. In earlier research, it was shown that
housing adaptations for long-term care users contributed to lower mortality
in Japan (Mitoku & Shimanouchi, 2014). A recent study, however, focusing
on symptoms of depression, did not find evidence of positive effects by
specific housing environments (Haseda et al., 2018). Overall, there is a
need for research in order to identify aspects of the housing environments
that could support older people in maintaining health and well-being. The
aim of the present study was to examine the relationships between the
physical housing environment and subjective well-being among older peo-
ple in Japan using home care services.

Methods
Data source
We utilized survey data from 2014 to 2017, assessing the quality of home
care services by means of the Japanese version of the interRAI Home Care
 JOURNAL OF HOUSING FOR THE ELDERLY 5

(HC) assessment, which has been tested for reliability including in Japan
(Hirdes et al., 2008). The interRAI HC assessment tool was developed in
1994, and is used in North America (Canada and multiple states in the
United States), Europe (Italy, Switzerland, Finland, Estonia, etc.), and Asia/
Pacific Rim (Hong Kong, Singapore, Japan, Australia, New Zealand) (The
interRAI Organization, 2018). This is a comprehensive geriatric assessment
tool, feasible for use among older people using home care services. The
study participants were 2,225 older people (aged 65þ years) using home
care services from 27 facilities managed by five corporations located in the
western and central part of Japan. After excluding the data of subjects
whose information on housing environments (n ¼ 91), ADL (n ¼ 26), SRH
(n ¼ 144), or LS (n ¼ 36) was missing, we used the data of 1,928 individuals
(86.7%). Data was collected by care managers, who specialize in making
long-term care plans and coordinating service use, and they visited their
clients every 90 days. The care managers used the assessment manual,
which was translated into Japanese, to guide their data collection (Morris,
Belleville-Taylor, Berg, Bernabei, & Bjorkgren, 2011).

Measurements
Subjective well-being
SRH and LS were rated by the older people themselves and were used as
measurements of subjective well-being. SRH consists of the single question
“In general, how would you rate your health?” which is answered by the
respondent on a scale from 0 to 3 (0 ¼ excellent, 1 ¼ good, 2 ¼ fair,
3 ¼ poor). In the current study the answers were dichotomized into 0 ¼ not
poor (excellent/good/fair) and 1 ¼ poor (poor). To capture LS, the question
“How would you rate your life satisfaction in the last 3 days?” was used.
The respondents answered on a scale from 0 to 5 (from totally satisfied to
totally unsatisfied). The answers were dichotomized into 0 ¼ satisfied (0 to
2) and 1 ¼ unsatisfied (3 to 5).

Physical housing environment

The physical home environment was rated by the care managers. As a basis
for the measurements of the physical housing environment, the present
study used the concept of “healthy housing environment” (Higasa &
Hibata, 1993), which was based on WHO classification of housing (WHO,
1961), that is, in terms of safety, health, amenity, and convenience. To cap-
ture these four categories, six items were used, each assessed by the raters
by means of observation and answered Yes or No. To capture safety the
items were 1, “lack of safety,” for example, evidence of violent crimes in
the area, heavy traffic in the street, and 2, “low access to emergency
6 R. TSUCHIYA-ITO ET AL.

Table 1. Rationale for associating the items included with the four categories of the physical
housing environment (Higasa & Hibata, 1993).
Examples of characteristics the
Category Item rater observed Rationale for inclusion
Safety 1. Lack of Safety Evidence of violent crimes in the Aspects of the physical
area, heavy traffic in the street housing environment that
2. Low access to Lack of usable telephone, lack of could be threatening to life
emergency alarm response system and property
assistance
Health 3. Low or high indoor Too hot in summer or too cold in Aspects of the physical
temperature winter and not controllable by housing environment that
the person could negatively impact
4. Poor sanitary Extremely dirty, infestation by rats physical or mental health
conditions or bugs
Amenity 5. State of home Hazardous, clutter, inadequate or Aspects of the physical
disrepair no lighting in life space housing environment that
could make it an unpleas-
ant place to live, work, and
spend leisure time
Convenience 6. Limited access to Barriers making it difficult to enter Aspects of the physical
housing and rooms or leave home, stairs difficult to housing environment that
climb, insufficient maneuvering could impede the conveni-
space within rooms, lack of rail- ence of everyday life
ings although needed

assistance,” for example, usable telephone, alarm response system; to cap-

ture health the items were:3, “low or high indoor temperature,” for
example, too hot in summer or too cold in winter (not controllable by the
person), and 4, “poor sanitary conditions,” for example, extremely dirty,
infestation by rats or bugs; to capture amenity the item was 5, “state of
home disrepair,” for example, hazardous, clutter, inadequate or no lighting
in life space; to capture convenience the item was “limited access to housing
and rooms,” for example, difficulty entering or leaving home, unable to
climb stairs, difficulty maneuvering within rooms, no railings although
needed. For an overview of the items, and the rationale for inclusion in the
four categories, see Table 1. Usually the care managers assessed the indoor
housing environment by on-site inspection of the client house; only if dir-
ect inspection was hindered for reasons out of the care managers’ control
did they make the assessment based on asking the clients, family, and allied
professionals for information.

Confounding factors
As confounding factors, the following items were used: age, sex (men/
women), hospital admission in last 90 days, living arrangement, economic
status, chronic diseases, cognitive function, and ADL. Age was calculated at
the assessment date and used as a continuous variable. To assess hospital
admission in last 90 days, it was checked whether the time since last hospital
stay was within 90 days from the assessment date (yes/no). Living arrange-
ment comprised a question if the participant was alone or living with
 JOURNAL OF HOUSING FOR THE ELDERLY 7

someone else (including spouse, partner, child, parents, guardians, siblings

and other relatives). Economic status was captured by the question “Because
of limited economic resources, did you have to make trade-offs during the
last 30 days regarding any of the following: adequate food, shelter, clothing;
prescribed medications; sufficient home heat or cooling; necessary health
care,” which was answered by yes or no. In terms of chronic diseases, three
conditions were checked and answered by yes or no: fracture/fall, dementia,
and cerebrovascular disease. These three conditions are the main causes for
certification in long-term care insurance (Ministry of Health Labour and
Welfare, 2016). ADL was captured by the Activities of Daily Living self-
performance hierarchy scale (ADL-H) (J. N. Morris, Fries, & Morris, 1999),
covering the four activities of personal hygiene, locomotion, toilet use, and
eating on a scale from 0 to 6 (from independent in all four activities to
dependent in all four activities). Cognitive function was captured by the
Cognitive Performance scale (CPS) (B€ ula & Wietlisbach, 2009; Hartmaier
et al., 1995), which also consists of a scale from 0 to 6 (from intact to very
severe impairment). The scale covers these four items related to cognitive
function: cognitive skills for daily decision making, making self understood,
short-term memory, and eating performance.

Statistical analysis
In a first step, associations of confounding factors and measurements of the
physical housing environment with SRH and LS were examined, using a v2
test and t-test. In a second step, variables that came out as significantly asso-
ciated with SRH and LS, respectively, were selected for multivariable logistic
regression analyses, using SRH and LS as dependent variables. As the ADL
level was considered to potentially affect the associations between housing
environments and subjective well-being, the multivariable logistic regression
analyses were conducted stratifying the sample into two groups based on
ADL level: high ADL independence (ADL-H ¼ 0 to 3) and low ADL inde-
pendence (ADL-H ¼ 4 to 6). The cutoff point of between the two groups
was chosen because a person with 3 points or lower can still eat with limited
support, which is a core marker of late-loss ADL performance (Morris et al.,
1999). The p values <0.05 were considered statistically significant.

Results
Among those with high ADL independence 22.0% rated SRH poor, while
among those with low ADL independence 35.6% rated SRH poor.
Comparison of sociodemographic characteristics between those with poor
and not poor SRH, stratified by ADL level, is shown in Table 2. In the high
 8

Table 2. Sociodemographic characteristics and self-rated health (SRH) among older people using long-term care, stratified by ADL level (n ¼ 1,928).
High ADL independence (ADL-H  3) Low ADL independence (ADL-H  4)
Total SRH ¼ Not poor SRH ¼ Poor p Value Total SRH ¼ Not poor SRH ¼ Poor p Value
Total 1439 (100.0) 1122 (78.0) 317 (22.0) 489 (100.0) 315 (64.4) 174 (35.6)
Age 82.3 ± 7.5 82.6 ± 7.5 81.2 ± 7.6 0.005 82.2 ± 8.4 82.5 ± 8.3 81.8 ± 8.6 0.336
Sex
R. TSUCHIYA-ITO ET AL.

Men 553 (38.4) 430 (38.3) 123 (38.8) 0.878 204 (41.7) 117 (37.1) 87 (50.0) 0.006
Women 886 (61.6) 692 (61.7) 194 (61.2) 285 (58.3) 198 (62.9) 87 (50.0)
Hospital admission in 90 days
No 1111 (78.2) 897 (81.0) 214 (68.2) <0.001 325 (67.1) 226 (72.7) 99 (57.2) 0.001
Yes 310 (21.8) 210 (19.0) 100 (31.8) 159 (32.9) 85 (27.3) 74 (42.8)
Living arrangement
Alone 452 (31.5) 333 (29.8) 119 (37.7) 0.008 68 (14.0) 33 (10.5) 35 (20.2) 0.003
Living with someone 981 (68.5) 784 (70.2) 197 (62.3) 418 (86.0) 280 (89.5) 138 (79.8)
Economic status
No problem 1377 (96.7) 1076 (97.0) 301 (95.6) 0.198 459 (94.3) 299 (94.9) 160 (93.0) 0.390
Problem 47 (3.3) 33 (3.0) 14 (4.4) 28 (5.7) 16 (5.1) 12 (7.0)
Disease
Fracture/fall: no 1270 (88.3) 995 (88.7) 275 (86.8) 0.346 410 (83.8) 264 (83.8) 146 (83.9) 0.977
Fracture/fall: yes 169 (11.7) 127 (11.3) 42 (13.2) 79 (16.2) 51 (16.2) 28 (16.1)
Dementia: no 889 (61.8) 638 (56.9) 251 (79.2) <0.001 325 (66.5) 206 (65.4) 119 (68.4) 0.502
Dementia: yes 550 (38.2) 484 (43.1) 66 (20.8) 164 (33.5) 109 (34.6) 55 (31.6)
Cerebrovascular disease: no 1119 (77.9) 863 (77.1) 256 (80.8) 0.161 339 (69.5) 200 (63.5) 139 (80.3) <0.001
Cerebrovascular disease: yes 318 (22.1) 257 (22.9) 61 (19.2) 149 (30.5) 115 (36.5) 34 (19.7)
Cognitive function (CPS) 1.85 ± 1.35 1.93 ± 1.35 1.55 ± 1.29 <0.001 2.31 ± 1.57 2.41 ± 1.61 2.13 ± 1.49 0.060
ADL (ADL-H) 1.23 ± 1.11 1.19 ± 1.08 1.35 ± 1.18 0.037 4.54 ± 0.65 4.56 ± 0.65 4.50 ± 0.63 0.363
Note. v2 test and t-test (p < 0.05). CPS: cognitive performance scale. ADL-H: activities of daily living self-performance hierarchy scale. For age, CPS, and ADL the figures in the table indi-
cate mean and standard deviation; for all other variables in the table, the figures indicate n (%).
 JOURNAL OF HOUSING FOR THE ELDERLY 9

ADL independence group, younger age, having hospital admission in

90 days, living alone, not having dementia diagnosis, better cognitive func-
tion, and lower ADL level were significantly associated with poor SRH. In
the low ADL independence group, being a man, having hospital admission
in 90 days, living alone, and not having diagnosis of cerebrovascular disease
were significantly associated with poor SRH.
With regard to LS, 33.4% in the high ADL independence group were not
satisfied, compared to 45.2% among those with low ADL independence.
Comparison of sociodemographic characteristics between those rating LS
satisfied and those rating LS not satisfied, stratified by ADL level, is shown
in Table 3. In the high ADL independence group, younger age, having hos-
pital admission in 90 days, having economic status problems, and low cog-
nitive function were significantly associated with not satisfied LS. In the
low ADL independence group, being a man, having hospital admission in
90 days, having economic status problems, not having diagnosis of cerebro-
vascular disease, and low cognitive function were significantly associated
with not satisfied LS.
The most common housing barrier overall was low access to emergency
assistance. In the high ADL independence group, low access to emergency
assistance and poor sanitary conditions were significantly associated with
poor SRH. For the low ADL independence group, lack of safety, low or
high indoor temperature, poor sanitary conditions, and state of home disre-
pair were significantly associated with poor SRH. Low or high indoor tem-
perature, poor sanitary conditions, and state of home disrepair were
associated with not satisfied LS in the group with high ADL independence.
In the low ADL independence group, with the addition of lack of safety,
the same aspects of the physical housing environment were significantly
associated with not satisfied LS. For further details on the associations
between physical housing environments and SRH and LS, respectively, see
Tables 4 and 5.
After adjusting for age, sex, hospital admission in 90 days, living arrange-
ment, economic status, chronic diseases, cognitive function, and ADL level,
multivariable logistic regression analysis showed that low access to emer-
gency assistance and poor sanitary conditions were significantly associated
with poor SRH in the high ADL independence group. For the low ADL
independence group, lack of safety, low or high indoor temperature, poor
sanitary conditions, and state of home disrepair were significantly associ-
ated with poor SRH. For the high ADL independence group no indoor
housing environment was associated with not satisfied LS. On the other
hand, in the group with low ADL independence, lack of safety, low access
to emergency assistance, and poor sanitary conditions were significantly
associated with not satisfied LS. For further details, see Table 6.
 10

Table 3. Sociodemographic characteristics and life satisfaction (LS) among older people using long-term care, stratified by ADL level (n ¼ 1,928).
High ADL independence (ADL-H  3) Low ADL independence (ADL-H  4)
Total LS ¼ Satisfied LS ¼ Unsatisfied p Value Total LS ¼ Satisfied LS ¼ Unsatisfied p Value
Total 1439 (100.0) 958 (66.6) 481 (33.4) 489 (100.0) 268 (54.8) 221 (45.2)
Age 82.3 ± 7.5 82.7 ± 7.4 81.4 ± 7.5 0.002 82.2 ± 8.4 82.4 ± 8.7 82.1 ± 8.2 0.641
Sex
R. TSUCHIYA-ITO ET AL.

Men 553 (38.4) 369 (38.5) 184 (38.3) 0.923 204 (41.7) 101 (37.7) 103 (46.6) 0.046
Women 886 (61.6) 589 (61.5) 297 (61.7) 285 (58.3) 167 (62.3) 118 (53.4)
Hospital admission in 90 days
No 1111 (78.2) 759 (80.3) 352 (73.9) 0.006 325 (67.1) 199 (75.1) 126 (57.5) <0.001
Yes 310 (21.8) 186 (19.7) 124 (26.1) 159 (32.9) 66 (24.9) 93 (42.5)
Living arrangement
Alone 452 (31.5) 290 (30.4) 162 (33.8) 0.188 68 (14.0) 31 (11.7) 37 (16.7) 0.110
Living with someone 981 (68.5) 664 (69.6) 317 (66.2) 418 (86.0) 234 (88.3) 184 (83.3)
Economic status
No problem 1377 (96.7) 924 (97.5) 453 (95.2) 0.022 459 (94.3) 258 (96.3) 201 (91.8) 0.034
Problem 47 (3.3) 24 (2.5) 23 (4.8) 28 (5.7) 10 (3.7) 18 (8.2)
Disease
Fracture/fall: no 1270 (88.3) 852 (88.9) 418 (86.9) 0.258 410 (83.8) 225 (84.0) 185 (83.7) 0.942
Fracture/fall: yes 169 (11.7) 106 (11.1) 63 (13.1) 79 (16.2) 43 (16.0) 36 (16.3)
Dementia: no 889 (61.8) 589 (61.5) 300 (62.4) 0.744 325 (66.5) 182 (67.9) 143 (64.7) 0.455
Dementia: yes 550 (38.2) 369 (38.5) 181 (47.6) 164 (33.5) 86 (32.1) 78 (35.3)
Cerebrovascular disease: no 1119 (77.9) 745 (77.8) 374 (77.9) 0.976 339 (69.5) 173 (64.6) 166 (75.5) 0.009
Cerebrovascular disease: yes 318 (22.1) 212 (22.2) 106 (22.1) 149 (30.5) 95 (35.4) 54 (24.5)
Cognitive function (CPS) 1.85 ± 1.35 1.79 ± 1.32 1.95 ± 1.39 0.034 2.31 ± 1.57 2.17 ± 1.51 2.48 ± 1.63 0.031
ADL (ADL-H) 1.23 ± 1.11 1.20 ± 1.09 1.28 ± 1.14 0.169 4.54 ± 0.65 4.52 ± 0.62 4.55 ± 0.68 0.614
Note. v2 test and t-test (p < 0.05). CPS: Cognitive performance scale. ADL-H: activities of daily living self-performance hierarchy scale. For age, CPS, and ADL the figures in the table indi-
cate mean and standard deviation; for all other variables in the table the figures indicate n (%).
Table 4. Physical housing environments and Self-rated health (SRH) among older people using long-term care, stratified by ADL function level (n ¼ 1,928).
High ADL independence (ADL-H  3) Low ADL independence (ADL-H  4)
Total SRH ¼ Not poor SRH ¼ Poor p Value Total SRH ¼ Not poor SRH ¼ Poor p Value
Total 1439 (100.0) 1122 (78.0) 317 (22.0) 489 (100.0) 315 (64.4) 174 (35.6)
Safety
Lack of safety
No 1337 (92.9) 1050 (93.6) 287 (90.5) 0.062 452 (92.4) 302 (95.9) 150 (86.2) <0.001
Yes 102 (7.1) 72 (6.4) 30 (9.5) 37 (7.6) 13 (4.1) 24 (13.8)
Low access to emergency assistance
No 573 (39.8) 471 (42.0) 102 (32.2) 0.002 163 (33.3) 106 (33.7) 57 (32.8) 0.841
Yes 866 (60.2) 651 (58.0) 215 (67.8) 326 (66.7) 209 (66.3) 117 (67.2)
Health
Low or high indoor temperature
No 1363 (94.7) 1066 (95.0) 297 (93.7) 0.354 455 (93.0) 301 (95.6) 154 (88.5) 0.003
Yes 76 (5.3) 56 (5.0) 20 (6.3) 34 (7.0) 14 (4.4) 20 (11.5)
Poor sanitary conditions
No 1351 (93.9) 1061 (94.6) 290 (91.5) 0.043 458 (93.7) 302 (95.9) 156 (89.7) 0.007
Yes 88 (6.1) 61 (5.4) 27 (8.5) 31 (6.3) 13 (4.1) 18 (10.3)
Amenity
State of home disrepair
No 1379 (95.8) 1079 (96.2) 300 (94.6) 0.229 469 (95.9) 308 (97.8) 161 (92.5) 0.005
Yes 60 (4.2) 43 (3.8) 17 (5.4) 20 (4.1) 7 (2.2) 13 (7.5)
Convenience
Limited access to housing and rooms
No 1314 (91.3) 1033 (92.1) 281 (88.6) 0.056 405 (82.8) 266 (84.4) 139 (79.9) 0.201
Yes 125 (8.7) 89 (7.9) 36 (11.4) 84 (17.2) 49 (15.6) 35 (20.1)
Note. v2 test (p < 0.05). The figures in the table indicate n (%).
JOURNAL OF HOUSING FOR THE ELDERLY
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 12

Table 5. Physical housing environments and life satisfaction (LS) among older people using long-term care, stratified by ADL level (n ¼ 1,928).
High ADL independence (ADL-H  3) Low ADL independence (ADL-H  4)
Total LS ¼ Satisfied LS ¼ Unsatisfied p Value Total LS ¼ Satisfied LS ¼ Unsatisfied p Value
Total 1439 (100.0) 958 (66.6) 481 (33.4) 489 (100.0) 268 (54.8) 221 (45.2)
Safety
Lack of safety
R. TSUCHIYA-ITO ET AL.

No 1337 (92.9) 896 (93.5) 441 (91.7) 0.198 452 (92.4) 257 (95.9) 195 (88.2) 0.001
Yes 102 (7.1) 62 (6.5) 40 (8.3) 37 (7.6) 11 (4.1) 26 (11.8)
Low access to emergency assistance
No 573 (39.8) 383 (40.0) 190 (39.5) 0.861 163 (33.3) 81 (30.2) 82 (37.1) 0.108
Yes 866 (60.2) 575 (60.0) 291 (60.5) 326 (66.7) 187 (69.8) 139 (62.9)
Health
Low or high indoor temperature
No 1363 (94.7) 918 (95.8) 445 (92.5) 0.008 455 (93.0) 258 (96.3) 197 (89.1) 0.002
Yes 76 (5.3) 40 (4.2) 36 (7.5) 34 (7.0) 10 (3.7) 24 (10.9)
Poor sanitary conditions
No 1351 (93.9) 910 (95.0) 441 (91.7) 0.014 458 (93.7) 259 (96.6) 199 (90.0) 0.003
Yes 88 (6.1) 48 (5.0) 40 (8.3) 31 (6.3) 9 (3.4) 22 (10.0)
Amenity
State of home disrepair
No 1379 (95.8) 927 (96.8) 452 (94.0) 0.012 459 (95.9) 263 (98.1) 206 (93.2) 0.006
Yes 60 (4.2) 31 (3.2) 29 (6.0) 20 (4.1) 5 (1.9) 15 (6.8)
Convenience
Limited access to housing and rooms
No 1314 (91.3) 878 (91.6) 436 (90.6) 0.523 405 (82.8) 227 (84.7) 178 (80.5) 0.225
Yes 125 (8.7) 80 (8.4) 45 (9.4) 84 (17.2) 41 (15.3) 43 (19.5)
Note. v2 test (p < 0.05). The figures in the table indicate n (%).
Table 6. Physical housing environments and associations with self-rated health (SRH)/life satisfaction (LS) among older people using long-term care serv-
ices: multivariable logistic regression analysis.
Self-rated health (0 ¼ not poor, 1 ¼ poor) Life satisfaction (0 ¼ satisfied, 1 ¼ unsatisfied)
High ADL independence Low ADL independence High ADL independence Low ADL independence
95% CI 95% CI 95% CI 95% CI
AOR Lower Upper AOR Lower Upper AOR Lower Upper AOR Lower Upper
Safety
Lack of Safety 1.323 0.812 2.157 3.143 1.435 6.885 0.994 0.639 1.545 2.335 1.049 5.202
Low access to emergency assistance 1.500 1.130 1.990 0.984 0.643 1.506 0.958 0.757 1.212 0.604 0.401 0.910
Health
Low or high indoor temperature 1.222 0.690 2.163 2.526 1.143 5.581 1.515 0.926 2.480 2.277 0.995 5.211
Poor sanitary conditions 1.711 1.028 2.850 2.301 1.032 5.130 1.572 0.996 2.481 2.359 1.010 5.511
Amenity
State of home disrepair 1.302 0.706 2.403 2.957 1.049 8.332 1.602 0.938 2.735 2.750 0.908 8.322
Convenience
Limited access to housing and rooms 1.395 0.908 2.144 1.455 0.853 2.482 1.077 0.726 1.599 1.295 0.774 2.165
Note. AOR: adjusted odds ratio; 95% CI: 95% confidence interval. Statistically significant results are boldfaced. Each physical housing environment item was assessed in each model after
adjusting for age, sex, hospital admission in 90 days, living arrangement, economic status, chronic diseases (fracture/fall, dementia, and cerebrovascular disease), cognitive function,
and ADL level.
JOURNAL OF HOUSING FOR THE ELDERLY
13
14 R. TSUCHIYA-ITO ET AL.

Discussion
In this study the relationships between physical housing environments and
subjective well-being among older people using home care services in Japan
were examined. As a main result, shortcomings in three of four categories
of the physical housing environment (i.e., safety, health, and amenity) were
found to be significantly associated with negative aspects of subjective well-
being; however, the association differed depending on the ADL independ-
ence level and was more pronounced among those with low ADL
independence.

Physical housing environment, self-rated health and life satisfaction

Safety is a major issue for older people living in ordinary housing, and
many housing adaptation interventions are conducted to improve safety, in
particular to decrease fall accidents (Chang et al., 2004; Gillespie et al.,
2012). In this study lack of safety was associated with both poor SRH and
not satisfied LS among those with low ADL independence, but not among
those with high ADL independence. A recent study among older commu-
nity-living people in China found similar results, though that study focused
on the neighborhood rather than the housing environment (Wong et al.,
2017). However, low access to emergency assistance was only associated
with poor SRH in the high ADL independence group, while in the low
ADL independence group it was associated with satisfied LS. An explan-
ation for this somewhat surprising result could be that people with high
ADL independence are only prone to ask for help in case of emergencies
and therefore find access to emergency assistance more important, while
among those in the low ADL independence group, who need caregiving
from others much of the time, it may have signified a substitute for the
presence of caregivers. As the presence of family caregivers or other care-
givers has been found in previous studies to be related to a high degree of
life satisfaction (Lu, Lum, & Lou, 2016; Yeung & Fung, 2007), it seemed
that the presence of a caregiver could be a confounding factor that would
need to be taken into account in the analysis. In the present study however,
we did not have access to such data, and further studies are needed to
explore this finding.
The results of the present study also suggest that health aspects of the
physical housing environment (i.e., indoor temperature and sanitary condi-
tions) were important for subjective well-being among older people. Among
those with low ADL independence, indoor temperature was associated with
poor SRH, while sanitary conditions were associated with both poor SRH
and not satisfied LS. However, in the high ADL independence group, the
only significant association was between sanitary conditions and poor SRH.
 JOURNAL OF HOUSING FOR THE ELDERLY 15

According to the Environment Docility hypothesis (Lawton & Simon, 1968),

people with lower functional capacity are more sensitive to influence from
the environment, which is consistent these findings. A recent study from
Japan showed that thermal conditions, especially cold temperature, negatively
impacted activities of older people (Hayashi et al., 2017), which could
account for the association with poor SRH found in the current study.
Traditional Japanese wooden houses, which comprise 57% of the Japanese
housing stock (Ministry of Internal Affairs and Communications, 2015), and
where many older people live, were often built with priority to decrease
indoor humidity; as a consequence, the temperature difference between
rooms can be considerable, which may cause heat stress among older people
(Hayasaka et al., 2011; Mori et al., 2014). Health aspects should be of pri-
mary concern when deciding housing adaptation interventions, as they have
the potential to improve both SRH and LS. However, in the Japanese system
of long-term care insurance, the housing adaptation policy is limited to five
types (installation of handrails, elimination of height differences, changes of
floor materials, changes of doors, changes of lavatory basins and other
accompanying housing adaptations) and does not support, for instance, the
installation of heat-insulating walls or heating devices. This hampers the pos-
sibilities of taking actions motivated by more long-term health promotion
goals, and a policy debate is therefore called for.
In this study, amenity (measured by the state of home disrepair) was
associated with poor SRH in the low ADL independence group. Amenity
has been considered a central concept of “self-neglect,” defined as “behavior
of a person that threatens his/her own health or safety” (The National
Center on Elder Abuse, 1998). Self-neglect generally manifests itself in an
older person’s refusal or failure to provide him- or herself with adequate
food, water, clothing, shelter, safety, personal hygiene, and medication,
which would explain the association with poor SRH. To improve the situ-
ation a comprehensive approach is needed, which in addition to improving
the housing environment also involves efforts by home care service pro-
viders and municipalities’ staffs.
The present study did not find evidence of convenience aspects being
associated with SRH or LS, in either of the ADL level groups. Limited
access to housing and rooms is related to housing accessibility, and there
are a large number of studies indicating housing accessibility to impact
older people’s performance of ADL activities and quality of life (Iwarsson
& Isacsson, 1998a, 1988b; Wahl, Fange, Oswald, Gitlin, & Iwarsson, 2009).
In the present study, however, the measurement of housing accessibility
was restricted to a single question, which is not sufficient to capture the
complexity of this concept. A more detailed measurement would be neces-
sary to examine a potential relationship with SRH or LS in depth.
16 R. TSUCHIYA-ITO ET AL.

Overall, among those with high ADL independence, none of the housing
environment aspects were related to LS. For this group the life-space
extends beyond the indoor housing environment, and it may therefore be
necessary to include more extensive aspects such as public transportations
and neighborhood environments to find an impact on LS. Still, safety and
health aspects appear to be important to maintain good SRH also in this
group. In the low ADL independence group however, safety and health
were related both to SRH and LS. Considering the conditions of the indoor
housing environment is therefore needed for sustainable “aging in place”
polices that protect the well-being of older people, especially among the
most vulnerable groups.

Limitations and strengths of the study

There are three main limitations of the present study. First, the study is of
cross-sectional design, and we cannot infer causal relationships from these
results. There is thus a need for longitudinal studies where changes over
time in subjective well-being and the relationships between objective and
subjective assessments of the physical housing environment can be ana-
lyzed. Second, the assessments were conducted by long-term care service
managers; as a result, the raters might have been influenced by the clients’
health status. For example, if the care manager recognized the client as par-
ticularly vulnerable, they could be more inclined to rate the indoor tem-
perature as too low/high. In this study, however, to minimize that risk the
assessment manual instructed the care managers to always ask health pro-
fessional colleagues for advice, if they were not sure how to assess an item.
Third, the study is based on a secondary data source, utilizing the interRAI
assessment tool, which primarily was developed to assess quality of care,
and is therefore not sufficient to fully assess the physical housing environ-
ments. For instance, the items to capture convenience and amenity are lim-
ited in scope and more complex instruments or checklists would be needed
to cover these categories. Notwithstanding these limitations, a significant
strength of the current study is that it covered four categories identified by
the WHO as important to capturing the public health aspects of housing
environments. A further strength is the Asian study setting, which is a wel-
come contribution to the growing literature on housing and health among
older people.

Conclusion
Addressing the relationships between the physical housing environment
and subjective well-being among older people in Japan, the present study
 JOURNAL OF HOUSING FOR THE ELDERLY 17

indicates the importance of a deepened knowledge of these matters for

future housing and public health policies. The results suggest that short-
comings in issues related to safety, health, and amenity of the physical
housing environment are associated with negative aspects of health and
most pronounced among those with low ADL independence. Home care
service providers and policymakers need to consider the importance of
appropriate environmental conditions for the most vulnerable groups, and
there is also a need for more detailed assessments, covering multiple
aspects of the physical housing environments.

Disclosure Statement
The authors have no conflicting interests.

Funding
No grants to be mentioned.

ORCID
Rumiko Tsuchiya-Ito http://orcid.org/0000-0002-6817-6817
Bj€
orn Slaug http://orcid.org/0000-0001-7386-2224

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