The Gerontologist
Vol. 45, No. 3, 327–336
A Long-Term Perspective on Person–
Environment Fit and ADL Dependence
Among Older Swedish Adults
Purpose: This study described person–environment
(P–E) fit and activities of daily living (ADLs) among
older adults, and it explored the relationship between
P–E fit and ADL dependence, testing Lawton’s docility
hypothesis at two points in time. Design and
Methods: From a random sample of individuals
aged 75–84 living in a Swedish municipality, 72
persons were available for baseline and follow-up
interviews over a 6-year period. Interviews and
observations were used for data collection at home
visits. Results: P–E fit problems as well as ADL
dependence increased from baseline to follow-up.
Functional limitations and dependence on mobility
devices increased; few changes were found concern-
ing environmental barriers. At follow-up, ADL de-
pendence and P–E fit correlated significantly in the
frailest subsample. Implications: In advanced age,
P–E fit problems in housing are related to ADL
dependence. The increase of P–E fit problems mostly
results from functional decline, although to some
extent it is from environmental changes as well. The
methodology used demonstrates the potential to
increase our understanding of how the main com-
ponents of Lawton’s model change and interact
over time.
Key Words: Accessibility, Docility hypothesis,
Functional limitations, Home assessment,
Occupational therapy
This research was supported by grants from the Kristianstad County
Council, the Swedish Federation of County Councils, the Council for
Medical Health Care Research in South Sweden, the Swedish Council for
Working Life and Social Research, and the Swedish Research Council.
I am grateful to G. Wilson for data collection and to B. Slaug for
computing the analyses.
Address correspondence to Professor Susanne Iwarsson, Division of
Gerontology and Caring Science, Lund University, Box 157, SE-221 00
Lund, Sweden. E-mail: Susanne.iwarsson@med.lu.se
1
Division of Gerontology and Caring Sciences, Faculty of Medicine,
Lund University, Sweden.
Vol. 45, No. 3, 2005 327
Copyright 2005 by The Gerontological Society of America
Susanne Iwarsson, PhD1
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The home environment is central to healthy aging
and well-being in old age, and the study of home
environments has long been an important research
domain within the field of environmental gerontol-
ogy. However, there is a paucity of adequate
theoretical foundations and appropriate methodol-
ogy for this kind of research (Gitlin, 2003).
Environmental gerontology represents pluralism
in regard to theoretical approaches (Wahl & Wies-
man, 2003), and placing the study of home environ-
ments within a theoretical framework is a major
challenge (Gitlin, 2003). However, the frequently
cited idea of person–environment (P–E) fit (Lawton,
1980) is applicable to research concerning older
adults’ housing situation (Steinfeld & Danford,
1999). When it comes to theoretical foundations,
Lewin’s early definition (1951) of behavior as
a function of the person and the environment is
often referred to as the basis for P–E fit research.
One important aspect of behavior of high relevance
for P–E fit research is the performance of activities
of daily living (ADLs; Iwarsson, 2004).
The model most often referred to in many different
disciplines is Lawton’s ecological model (Lawton &
Nahemow, 1973; Lawton & Simon, 1968), which
represents a landmark in environmental gerontology
(Golant, 2003; Scheidt & Norris-Baker, 2003; Wahl
& Wiesman, 2003) and which ‘‘explores the interplay
between individuals and their environments’’ (Nahe-
mow, 2000, p. 23). The person is defined in terms of
a set of competencies, and the environment is defined
in terms of demands. P–E fit comprises two in-
teractive components, the personal component and
the environmental component. As defined in the
original model, the personal component, denoting
‘‘competence,’’ includes biological health, sensory
and motor skills, and cognitive function. Adopting
Scheidt and Norris-Baker’s recent interpretation of
competence in the context of the ecological model, we
can say that competence is equivalent to functional
capacity. The environmental component, denoting
‘‘press,’’ is described in terms of five broad classes: the
physical environment, the personal environment, the
small-group environment, the suprapersonal envi-
ronment, and the social or megasocial environment
(Lawton & Nahemow). The surface of the model
labeled ‘‘adaptation’’ is intended to reflect the
matching between competence (personal component)
and press (environmental component). Interpreting
adaptation as manifested in real-life situations, we
can see that one important aspect of adaptation
relevant for gerontological research is ADL perfor-
mance (Iwarsson, 2004). Further, this kind of in-
terpretation is in line with current terminology for the
definition of functioning and disability widely used in
health care contexts (World Health Organization
[WHO], 2001), supporting the idea that positive
outcomes in environmental gerontological research
can reasonably be expressed as independence in
ADLs (Iwarsson, Isacsson, & Lanke, 1998).
The original ecological model is decidedly inter-
actionist in that the personal and environmental
components are assumed to be conceptually and
empirically distinguishable, and in this perspective
adaptation is viewed as the outcome domain. Accord-
ing to Diehl and Willis (2003), competent behavior
resides neither within the person nor within the
environment, but in the P–E interaction. That is, one
outcome of P–E interaction is ADL performance. The
original ecological model was very comprehensive,
but over the years Lawton (1989) elaborated it to
encompass several additional dimensions (e.g., dis-
tinctions between objective and subjective aspects of
the components, proactivity). Even though the model
and its different versions are widely cited and underlie
practical efforts in planning environments that sup-
port healthy aging, empirical testing of the model is
relatively sparse (for an overview, see Nahemow,
2000). Given the model’s complexity, research to test it
in its entirety is beyond the reach of current methodol-
ogy. As advised by Scheidt and Norris-Baker (2003),
research on P–E fit issues could well be based on
variables representing the original ecological model’s
major components. The present study is principally
focused on P–E fit in terms of functional capacity in
the person (personal component), the physical hous-
ing environment (environmental component), and in-
dependence or dependence in ADLs (adaptation level).
When Lawton’s ecological model is applied to the
physical dimension of the home environment, physical
barriers in the environment are not necessarily pro-
blems per se. Instead, they cause different magnitudes
of problems for different people, depending on each
person’s functional capacity (Iwarsson, 1997; Iwars-
son & Ståhl, 2003). According to the docility hypothe-
sis (Lawton & Nahemow, 1973; Lawton & Simon,
1968), individuals with lower competence are more
sensitive to the demands of the environment than
those with higher competence. Individuals with lower
competence spend so much of their energy over-
coming and adapting to environmental demand that
they have a reduced ability to change their situation on
their own. Negative environmental changes have
328
a greater impact on them, but also minor improve-
ments result in a more positive outcome in regard to
activity than in those with higher functional capacity.
When the personal and environmental components
are matched, adaptation is achieved; this is manifested
in real life, for example, in terms of independent ADL
performance (Iwarsson et al., 1998).
In many studies the physical home environment
has mainly been targeted in terms of risks of falling,
focusing on fall prevention in different patient groups
(e.g., El-Faizy & Reinsch, 1994; Gill, Robison,
Williams, & Tinetti, 1999; Steinfeld & Shea, 1993).
Moreover, P–E interactions have been studied in the
context of care units and sheltered housing (e.g.,
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Wahl, 2001), whereas far less research has targeted
ordinary housing in the community (Diehl & Willis,
2003). Among the few studies focusing on P–E fit in
community housing, some evidence from investiga-
tions in Germany that analyzed relationships be-
tween objective housing conditions and patterns of
capacity confirmed that reduced ADL ability was due
to unfavorable conditions in the physical home
environment (Schmitt, Kruse, & Olbrich, 1994).
Wahl, Oswald, and Zimprich (1999) demonstrated
that, in contrast to that for older adults without
visual impairments, unfavorable P–E fit negatively
affected individuals with impairments. Applying
novel methodology capturing P–E fit in great detail,
in prior studies, Iwarsson and colleagues explored
and identified relationships between functional ca-
pacity, environmental factors, and ADL dependence
among older adults (Iwarsson & Isacsson, 1997b;
Iwarsson et al., 1998). These studies also showed that
disability rates are affected by environmental factors
(Iwarsson & Isacsson, 1997a). That is, prior results
demonstrated that dependence on assistance from
others in more complex activities (e.g., shopping and
transportation) is affected by whether environmental
factors such as the design of the home entrance and
the availability of public transportation meet the
needs of individuals with functional limitations. The
results also demonstrated that the relationship
between P–E fit problems and ADL dependence was
significant only among the frailest half of the sample
investigated, lending some empirical support for the
docility hypothesis (Iwarsson et al.).
One of the greatest challenges for use of Lawton’s
general ecological model is incorporating temporal
dimensions. Hence, in the current study I incorpo-
rate time and focus on activity as recently suggested
by Golant (2003), investigating how the home
environment affects healthy aging over time.
A New Approach to Conceptualizing
and Measuring P–E Fit
In general, research targeting home environments
lacks psychometrically sound measures (Gitlin,
2003). Methods for assessing P–E fit problems should
The Gerontologist
provide evidence of the degree to which a particular
physical environment prevents or supports daily
activity (Steinfeld & Danford, 1999). In most prior
studies, however, measures used are study specific,
with unknown reliability and validity.
The Enabler Concept is an American idea,
originally published to serve as a basis for the design
of accessible housing and public environments
(Steinfeld et al., 1979). It was developed in connection
with research into issues of accessibility that gradu-
ally led to the housing standards of the American
National Standards Institute (ANSI, 1980). Because
the purpose of the Enabler Concept is to predict the
extent of P–E fit problems arising as a consequence of
the combination of a person’s functional limitations
and barriers in the physical environment, it agrees
well with Lawton’s ecological model (Iwarsson &
Slaug, 2001). More specifically, in the Enabler
Concept (Steinfeld et al.), P–E fit is operationalized
in terms of functional capacity (personal component)
and environmental demands (environmental compo-
nent; see Iwarsson & Ståhl, 2003). Iwarsson and
colleagues have developed a methodology for the
assessment and analysis of P–E fit in housing that is
based on the Enabler Concept, rendering predictive,
objective, and norm-based assessments and analyses
of P–E fit problems in the physical home environment
possible (Iwarsson & Slaug).
When it comes to the assessment of ADLs,
substantial bodies of assessment instruments as
well as ADL research literature are available,
representing different instrument administration
procedures, measurement levels, and scaling ap-
proaches (Wade, 1994). For example, note that there
is a distinction between performance potential and
actual performance (Diehl & Willis, 2003). Further,
self-reports and assessments based on observations
yield different results in the same study sample (Jette,
1994). Finally, far from all ADL instruments are
conceptually pure; in several instruments, for
example, basic functional capacities such as body
functions are included together with activities.
For a reliable and valid assessment of P–E fit in
housing and of ADL dependence to be made possible,
methods meeting basic methodological requirements
are needed. Further, the assessment tools must reflect
the targeted theoretical constructs. In order to
differentiate between the personal component of P–
E fit and the adaptation level of the general ecological
model, physical capacity as well as ADL dependence
must be validly operationalized. When it comes to
testing relationships between different variables, all
variables involved should reflect the same perspec-
tive; that is, if P–E fit is based on objective
observations of actual circumstances, ADL depen-
dence should be assessed likewise.
Applying the new approach to conceptualizing
and measuring P–E fit as described, based on
Lawton’s ecological model and the Enabler Concept,
my objective in this study was twofold. My first aim
Vol. 45, No. 3, 2005 329
was to give a long-term description of P–E fit
problems in housing and ADL dependence among
older adults living in the community. My second aim
was to study the relationship between P–E fit
problems in housing and ADL dependence and to
test the docility hypothesis at two points in time.
Design and Methods
I chose a longitudinal design, collecting interview
and observation data at home visits with older adults
who lived in their own households, at baseline and 6
years later. Because my ambition was to capture
long-term changes in old age, I chose a rather long
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time span between baseline and follow-up. The
study was approved by the Ethics Committee at
Lund University, Sweden.
Study Sample
The study district was a rural municipality
situated in the south of Sweden. At baseline, the
municipality had 49,458 inhabitants. Those aged 75–
84 years numbered 3,504 (i.e., 7% of the population).
I performed a random sampling procedure, using the
Swedish national population register. The baseline
sample comprised all individuals born on Days 15 or
16 of any month of the years between 1910 and 1919,
resulting in 222 individuals. Of these, I excluded 12
elders who were living in sheltered housing facilities
or staying at an address outside the district, leaving
210 possible participants. Four of those died before
the study began, and another 8 people moved to
sheltered housing or out of the district, resulting in
198 individuals. Among these, 133 (68%) agreed to
participate (Iwarsson, 1997; Iwarsson et al., 1998).
For the follow-up 6 years later, I identified the
survivors by means of the Swedish national pop-
ulation register. Since baseline, 42 individuals (32%)
were deceased and 2 had moved out of the study
district. Out of the 89 participants possible to reach,
72 (81%) agreed to participate. That is, at baseline as
well as at follow-up, the current study was based on
the 72 participants possible to follow at two points in
time (Figure 1). The study sample is further de-
scribed in Table 1.
Among those who did not agree to a home visit at
baseline, 40 agreed to a telephone interview that
included basic descriptive data and questions on
ADL dependence, using part of the ADL instrument
administered with the study participants (see the
subsequent description). The only significant differ-
ence (the chi-square test or Fisher’s exact test)
between the dropouts and the study participants
was that the latter, to a higher extent, lived in
privately owned houses, whereas more of the
dropouts lived in rented or privately owned apart-
ments (Iwarsson, 1997; Iwarsson et al., 1998). At
follow-up, 16 of the 17 dropouts did not want to

Figure 1. Overview of sampling from baseline to follow up.
participate because of reported illness; the other
person was impossible to reach (Figure 1).
Procedures
At baseline as well as follow-up, we sent in-
formation letters to intended participants, followed
by telephone calls in order to ask for informed
consent and confirm an appointment. Data collec-
tion was performed during home visits by one of two
experienced occupational therapists, trained to
administer a study-specific interview questionnaire
as well as two previously established instruments
(subsequently described) for interview and observa-
tion. Besides descriptive data, the data collection
comprised information on functional limitations in
the person, use of assistive devices for mobility,
eventual home modifications accomplished or
planned, environmental barriers in the home and
its close surroundings, and dependence in personal
(ADL) and instrumental (IADL) activities of daily
living. Therapists recorded the actual situation at
each data-collection occasion.
Measures
To assess P–E fit, I had therapists administer the
Housing Enabler instrument (Iwarsson & Slaug,
2001). Reliable administration requires the use of
330
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trained interviewers or observers who are able to
collect valid information on the personal component
of P–E fit during interviews, as well as to validate
interview responses by means of observations as
respondents move around and act in different parts
of their home environments. In addition, inter-
viewers or observers have to be trained for reliable
assessment of the presence of environmental barriers,
on the basis of national norms and regulations.
The Housing Enabler is administered in three
steps.
The first step is the assessment of functional
limitations and dependence on mobility devices
(personal component of P–E fit). This is a combina-
tion of interview and observation, used to assess
the presence or absence of functional limitations
(13 items) and dependence on mobility devices
(2 items). The majority of the functional limitation
items concern physical capacity, whereas 1 item
touches on cognitive capacity and 3 concern
perception (vision and hearing; see Table 2).
The second step is the assessment of physical
environmental barriers (environmental component
of P–E fit). This is a detailed observation assessing
environmental barriers in the home and the imme-
diate outdoor environment (188 items) as present or
absent. Nearly 70% of the items in the Housing
Enabler have been defined according to official
Swedish norms and guidelines, whereas the remainder
of the items are assessed on the basis of professional
The Gerontologist
Table 1. Sample Characteristics at Baseline and Follow Up Table 2. The Personal Component of P–E Fit

Baseline Follow-Up Drop Outs at Functional Limitations

Sample Sample Follow Upa and Dependence Baseline Follow
on Mobility Devicesa (%) Up (%) p
Variable n % n % n
A. Difficulty interpreting
Men 31 41 31 41 5 information 0 3 ns
Women 41 59 41 59 12 B1. Severe loss of sight 18 24 ns
Age, (M) 79 — 85 — 84 B2. Complete loss of sight 0 0 ns
Married 34 47 26 36 — C. Severe loss of hearing 15 42 , .0001
Living Alone 38 53 46 64 — D. Prevalence of poor
Housing condition balance 15 28 ns
E. Incoordination 3 11 ns
Ordinary housing 72 100 66 91 14
F. Limitations of stamina 31 33 ns
Sheltered housing 0 0 6 9 3
One-family house 38 53 35 47 — G. Difficulty in moving

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Multidwelling block 34 47 31 43 —
Time in present
dwelling (M) 28 — 30 — —
Home modification — — 13 18 — J. Loss of upper extremity
Relocation
No — — 62 86 11
Yes — — 10 14 6
Relocation to
sheltered housing — — 6 8 3 N. Extremes of size and weight
Notes: For the table, N = 72. A dash indicates that the
value was not applicable or not measured.
a
N = 17, with a target sample of N = 89.
experience. The housing environment is divided into
four sections: outdoor environment (33 items),
entrances (49 items), indoor environment (100
items), and communication features (6 items).
The third step is the calculation of the P–E fit
score. For each environmental barrier item, the
instrument comprises predefined severity ratings
(Steinfeld et al., 1979), operationalized as points
quantifying the severity of the problems predicted to
arise in each case. The accessibility severity scale is
scored from 1 (potential accessibility problem) to 4
(very severe accessibility problem or impossibility).
On the basis of the assessments accomplished in Steps
1 and 2 and with the use of a complex matrix
comprising the predefined severity ratings from 1 to
4, the profile of functional limitations identified in
each person is juxtaposed with the environmental
barriers found present in the home environment. This
analysis is run item by item, and each P–E fit
incongruency is quantified by means of the scale. The
sum of all the predefined points yields a score
outlining the problems anticipated. Thus, the mag-
nitude of problems caused by a particular combina-
tion of functional limitations and environmental
barriers (i.e., the degree of objective, norm-based P–E
fit problems in the home) can be calculated. In cases
in which no functional limitations or dependence on
mobility devices are present, the score is always zero.
In cases in which the person has functional limi-
tations or is dependent on mobility devices, higher
scores mean more P–E fit problems. For reliable and
valid computations, the Housing Enabler software is
head 1 4 ns
H. Difficulty in reaching
with arms 17 18 ns
I. Difficulty in handling–fingering 11 14 ns
skills 0 7 .025
K. Difficulty bending,
kneeling, etc. 43 46 ns
L. Reliance on walking aids 8 47 , .0001
M. Reliance on wheelchair 0 3 ns
0 0 ns
Notes: P–E = person–environment; ns = not significant.
For the table, N = 72. At baseline, 24% of the participants
had no functional limitations and were not dependent on mo-
bility devices. At follow up, the corresponding proportion was
12% (p , .0001). A considerable proportion of the partici-
pants had more than one functional limitation and/or depen-
dence on mobility aids.
a
Assessed by means of the Housing Enabler (Iwarsson &
Slaug, 2001).
recommended (Slaug & Iwarsson, 2001; demo
version available at http//:www.enabler.nu).
Content validity and interrater reliability have
been established for functional limitations and
mobility devices, j  = 0.87, as well as for environ-
mental barriers, j  = 0.68 (Iwarsson & Isacsson,
1996a). The instrument has been used in different
studies, and based on accumulated empirical experi-
ences, it subsequently has been revised for improved
reliability and validity (Iwarsson & Slaug, 2001).
For assessment of dependence in ADL and IADL
performance, I used the ADL Staircase (Sonn &
Hulter-Åsberg, 1991), revised version (Iwarsson,
1998; Iwarsson & Isacsson, 1997a). The nine-item
ADL Staircase was based on Katz’s ADL index
(Katz, Ford, Moskowitz, Jackson, & Jaffe, 1963)
and Swedish studies adding IADL items to the
original Katz instrument (Sonn & Hulter-Åsberg).
The ADL Staircase comprises the following activi-
ties: feeding, transfer, going to the toilet, dressing,
bathing, cooking, shopping, cleaning, and using
transportation. In the original version the trans-
portation item was defined for use in urban areas,
whereas in the revised version there was an alter-
native item intended for use in rural areas. The
measurement level of the instrument is the level of
dependence a person has on other people. I ensured

Vol. 45, No. 3, 2005 331

that the assessment was administered by means of
a combination of interview and observation (Sonn &
Hulter-Åsberg) as originally recommended by Katz
and associates and that the results were scored on
a three-graded scale: dependent, partly dependent, or
independent.
Reliable administration of the ADL Staircase
requires trained interviewers or observers, who are
able to collect valid information on actual ADL
dependence during interviews as well as to validate
interview responses by means of observations of
basic mobility as respondents move through different
parts of their home environments. In line with earlier
studies (Iwarsson, 1998; Iwarsson & Isacsson,
1997a), the ADL Staircase data collected for the
current study fulfilled internal validity requirements
(coefficient of scalability, baseline = 0.68, follow-
up = 0.76; coefficient of reproducibility, baseline =
0.95, follow-up = 0.96).
Data Analyses
For functional limitations and dependence on
mobility devices (personal component of The P–E fit)
as well as environmental barriers in the home
(environmental component of the P–E fit), I analyzed
changes by means of McNemar’s test. I analyzed
magnitudes of P–E fit problems by means of the
Housing Enabler software (Slaug & Iwarsson, 2001).
Based on the raw data collected and the predefined
severity ratings in the complex instrument, the
software generates total P–E fit problem scores.
Thereafter, I analyzed changes in magnitudes of P–E
fit problems from baseline to follow-up by means of
the sign test.
For ADL dependence, I investigated changes from
baseline to follow-up on the basis of the three-graded
scale of the ADL Staircase (Fänge, Lanke &
Iwarsson, 2004), computing ADL ranks (Iwarsson
et al., 1998, Iwarsson & Lanke, 2004). The ranking
approach represents an alternative data-treatment
principle respecting ordinal scale properties. The
raw data outcome of an ADL Staircase assessment is
a nine-item variable describing response patterns
resulting from the three-graded scale. For analysis of
changes between two assessment occasions using
ADL ranks, all data from both assessments should be
considered simultaneously. The rank of all nine
items is computed by comparing one assessment
with all other assessments in the 2n sample, one by
one, and then counting the number of times that the
first assessment is higher than the second, and the
number of times the two assessments are equal. That
is, the assignment of ranks is based on an itemwise
comparison of response patterns. If one response
pattern has every item coded at least as high as that
of the response pattern with which it is compared,
with strict inequality for at least one item, then the
former should be considered to be more dependent
332
than the latter. In all other cases, the two response
patterns are considered to be noncomparable and
treated as tied. After computation of ADL ranks, I
used the sign test for the investigation of changes
between baseline and follow-up.
I computed the correlation between P–E fit
problems in housing and ADL dependence by use
of Spearman’s rank correlation. Thereafter, in order
to test the docility hypothesis, I performed separate
correlation analyses of participants with higher or
lower P–E fit problem scores. My rationale for this
approach to analysis was that the total Housing
Enabler score is an estimation of the P–E fit, in
congruence with how the relation between com-
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petence and environmental press is expressed in
Lawton’s general ecological model (Lawton, 1980;
Lawton & Nahemow, 1973). As outlined in the
introduction, in this study ADL dependence repre-
sents the adaptive level in the Lawton model
(Iwarsson et al., 1998). Thus, I used the median
P–E fit problem scores at baseline and follow-up as
cutoffs for dichotomization, and thereafter I calcu-
lated the correlation between ADL dependence and
P–E fit problem scores in each of the subgroups of
participants at baseline and at follow-up. I consid-
ered results to be significant at p , .05.
Results
Person-Environment Fit (P–E Fit) in Housing
In regard to overall P–E fit, the most common
value at baseline for the total P–E fit problem score
was zero (total score range = 0–319, Mdn = 36,
interquartile range = 75.5). At follow-up, the most
common value was still zero (total score range =
0–418, Mdn = 85, interquartile range = 115.5).
The overall magnitude of P–E fit problems in the
home increased significantly from baseline to
follow-up (p = .0043).
Personal Component of P–E Fit
At baseline, 24% of the individuals in the sample
had none of the functional limitations assessed, and
they were not dependent on mobility devices; at
follow-up, this percentage had decreased to 12%
(p , .0001). On both occasions, the most prevalent
functional limitations were difficulty in bending and
kneeling (baseline = 43%, follow-up = 46%) and
limitations of stamina (baseline = 31%, follow-up =
33%). From baseline to follow-up, the prevalence of
severe loss of hearing (p , .0001) and loss of upper
extremity skills (p = .025) increased. At baseline,
none of the participants used a wheelchair, whereas
3 participants did at follow-up. Reliance on walking
aids increased between the two data collection
waves, from 8% at baseline to 47% at follow-up
(p , .0001; see Table 2).
The Gerontologist
Environmental Component of P–E Fit
Most participants lived in homes with high
housing standards, but I identified environmental
barriers in every home assessed. To exemplify, in at
least 90% of the homes’ kitchens, no work surface at
a height suitable for sitting was available, the
bathroom sinks were placed at a height for use
only when standing, with pipes causing obstruction
under them, and telephones with amplified sound
were lacking. At baseline as well as follow-up, in
virtually all bath and laundry rooms as well as in the
dwelling in general, control and hardware use
required hand function.
At follow-up, 13 participants (18%) had taken
concrete measures for making it possible to continue
living in their present home, and 11 of those had
applied for and been granted economic support for
their home modifications. The most common
measures concerned bathrooms (corner shower in-
stead of a bathtub), the removal of thresholds, and
changes at entrances. Eleven percent of the partic-
ipants reported that they had taken some security
measures, for example, removing loose carpets, and
7% had rearranged furniture so that they now slept
on the ground floor instead of upstairs. Despite the
fact that some participants had undertaken concrete
measures, the prevalence of single environmental
barriers was stable between baseline and follow-up;
that is, in 158 of the 188 barriers assessed (84%), I
identified no significant changes. Among the 30
barriers changing significantly in prevalence between
baseline and follow-up, 15 were significantly more
prevalent at follow-up, whereas for the remaining 15
barriers the prevalence decreased. For example, in
82% of the cases at baseline but in 71% at follow-up,
there were stairs at the entrance, without an
accessible alternative way (p = .001). Further details
are presented in Table 3.
ADL and IADL Dependence
At baseline, 31% of the participants were in-
dependent in both ADL and IADL tasks, whereas 65%
were dependent in IADL tasks only. The remaining
4% were dependent in IADL as well as in ADL tasks.
At follow-up, 21% of the participants were indepen-
dent in both ADL and IADL tasks, whereas 57% were
dependent in IADL tasks only. The remaining 12%
were dependent in IADL as well as in ADL tasks.
Overall, functional dependence increased signifi-
cantly (p = .0017) over the study period.
Relationships Between P–E Fit
and Functional Dependence
At baseline, the correlation between ADL–IADL
dependence and P–E fit in housing was nonsignifi-
cant, whereas at follow-up it reached significance at
Vol. 45, No. 3, 2005 333
rs = 0.52 (p , .0001). At baseline, the analyses on
the subsamples (based on dichotomization of the
total sample) resulted in very low, nonsignificant
correlation coefficients. At follow-up, rs = 0.45 (p =
.0059) in the subsample with more P–E fit problems
in housing, whereas among those individuals with
fewer P–E fit problems, the correlation was non-
significant (rs = 0.30).
Discussion
The results of this study demonstrate that P–E fit
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problems in housing as well as ADL and IALD
dependence among older adults living in the
community increase with advancing age. When it
comes to the personal component of P–E fit, the
prevalence of functional limitations as well as
dependence on mobility devices increased from
baseline to follow-up. In line with previous research
on environmental hazards in the homes of older
adults (Gill, Williams, Robison, & Tinetti, 1999), in
this research I recorded many environmental bar-
riers. Noteworthy, however, was that the follow-up
of the environmental component of P–E fit demon-
strated only little change over time, even if significant
changes were found in some environmental barriers.
In summary, the increase of P–E fit problems in
housing among older adults over time results, to
a considerable extent, from functional decline.
Nevertheless, the changes I found in the environ-
mental component give detailed information on the
types of environmental barriers in housing contrib-
uting to P–E fit problems. The results demonstrate
highly significant relationships between P–E fit
problems and functional dependence at follow-up,
and the results of the subsample analyses lend
support to the docility hypothesis (Lawton &
Nahemow, 1973; Lawton & Simon, 1968). That is,
changes in one of the components of the ecological
model (e.g., personal competence) affect the adaptive
level, operationalized here as ADL–IADL depen-
dence. Further, individuals with more P–E fit
problems are more vulnerable, demonstrated by the
fact that the relationship between P–E fit problems in
housing and ADL–IADL dependence at follow-up
was significant only in the subsample of individuals
with more P–E fit problems. Because the operation-
alization of the docility hypothesis was limited in
terms of the variables covered by the instruments
used, these results are at best suggestive. Further, as
originally expressed by Lawton and Nahemow,
docility means that individuals with low compe-
tence are much more vulnerable to environmental
demands than those with high competence, and de-
tails are crucial as to what they can manage in every-
day life. As demonstrated by the current study, the
major reason for increasing P–E fit problems in hous-
ing was not changes in the environmental component
 Table 3. Environmental Barriers Demonstrating
Significantly Different Prevalence Between Baseline
and Follow Up in 72 Cases
Environmental Barrier Item
Increased prevalence at follow-up
Outdoor environment
No tactile cues of abrupt level changes
or other hazards
Passenger loading zones far from
entrance
No marked parking spaces for people
with disabilities within 10 m of the
entrance
Refuse bin and/or letterbox difficult
to reach
Entrances
Automatic opening on side-hung doors
Stairs with too short handrails
Ramps without handrails
Sitting-out place or balcony too narrow
Indoor environment
Complicated circulation routes
Insufficient maneuvering areas where
turning is necessary
Ceramic stove hobs or the like
Door swings (inner doors) impedes
accessibility to storage units
Controls in kitchen, utility kitchen, or
laundry room require turning motion
of wrist
Elevated toilet
Communication
Markings and signs poorly exposed,
illuminated, or placed
Decreased prevalence at follow up
Outdoor environment
Narrow parking spaces
Parking space far from entrance
Letterbox can only be reached via
steps or other difference in level.
Entrances
High thresholds and/or steps at the
entrance
Stairs the only route (no lift or ramp)
Stairs without handrails
No sitting-out place or balcony
Indoor environment
Stairs or differences in level between
rooms or floor spaces
High-pile, loose-weave, soft floor
coverings
Stove hobs with ordinary rings
Control use in kitchen, utility kitchen,
or laundry room requires isolated
finger grip
Storage cupboards, towel hooks, etc.
inaccessibly placed
High force required to activate controls
(dwelling in general)
Table 3. (Continued)
Environmental Barrier Item p
p Communication
No telephone with amplified sound .031
Small letters and numbers on signs .016
Notes: Environmental barriers were assessed by means of
the Housing Enabler (Iwarsson & Slaug, 2001).
.08
.02 but in the personal component, to some extent con-
tradicting the statement by Lawton and Nahemow.
In a previous article based only on baseline data
.008 from the current study (N = 133; Iwarsson et al.,
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.031 1998), subsample analyses revealed a significant rela-
tionship between P–E fit problems and ADL–IADL
dependence among participants with more P–E fit
.016 problems in housing, whereas among participants
.001
.008 with fewer problems no such relationship was found.
.016 Presumably because of the larger sample size and
more variation in terms of functional limitations and
ADL dependence earlier on in the aging process,
.008
those results already supported the docility hypoth-
.031 esis. Current results demonstrate that, to determine
.008 the kinds of changes in P–E fit that cause docility,
a follow-up design is required. However, the high
.031 mortality rates in old age reduced the possible
follow-up sample to approximately one third, and
.004
some of the dropouts declined follow-up because of
.031 ill health. The results of any longitudinal geronto-
logical study have to be interpreted bearing such
well-known facts in mind, and the participants at
.031
follow-up of course represented the proportion of
the aging population with overall higher health
status and less rapid functional decline. Our un-
derstanding of P-E fit relationships and how they are
.016 related to ADL/IADL dependence throughout the
.04 aging process is still insufficient, in particular when it
.008 comes to such relationships in sub-samples display-
ing different levels of health. Data collection for
a 10-year follow-up is in progress, and forthcoming
results will shed additional light on the complex
.031
.001 relationships targeted by the current study. The data
.001 also provide a basis for additional analysis, such as
.004 survival analysis, which could generate important
knowledge regarding P–E fit and mortality.
Given the impact Lawton’s general ecological
.004 model has had over the years (Scheidt & Norris-
Baker, 2003; Wahl & Wiesman, 2003), empirical
.001 results elucidating its mechanisms contribute to
.016 current knowledge. Even though the current study
demonstrated a significant relationship between P–E
.006
fit problems in housing and ADL–IADL dependence
at follow-up, the correlation coefficient was only
.02 moderate. Thus, this relationship only explains
a minor facet of the complex problem of functional
.02 dependence. In developing an integrated perspective
on how environmental variables affect human
functioning, it is important to consider the connec-
tion between physical environments and their social
334 The Gerontologist
and cultural implications (Iwarsson et al., 1998), as
well as many other dimensions.
Lawton’s general ecological model has been
criticized and further developed over the years,
because it deals neither with people’s needs, attitudes,
knowledge, preferences, and perceptions, nor with
the fact that the environment is characterized by
resources as well as demands (Scheidt & Norris-
Baker, 2003; Wister, 1989). For example, instrumen-
tal disabilities do put pressure on people to change
their living environments, but features of living
arrangements, such as with whom one lives, are
a vital part of the system of environmental support,
transcending the physical housing environment
(Jackson, Longino, Zimmerman, & Bradsher,
1991). It should be kept in mind that the assessment
of the environmental component used in this study
was limited to one of the five environmental classes as
defined by Lawton and Nahemow (1973), that is, the
physical environment. Thus, it was not possible to
distinguish between older adults who functioned at
their highest possible level because of a supportive
social environment and those whose functions could
have been increased if the physical environment were
modified. Even if there were differences in rates of
living alone versus living with others between baseline
and follow-up, given the limited sample size I did not
considered it valid to run subgroup analyses. Further,
it should be kept in mind that the current study was
based on the general ecological model, with no
ambitions to embrace the much more transactional
and dynamic perspectives of the complex, largely
taxonomic articulation that emerged from its revi-
sions. The results, however, serve as a guide for future
research involving a wider range of variables.
The study of home life is necessarily time
intensive, requiring face-to-face contact with single
individuals, and the research efforts involved in
a study like this are substantial. Even if the sample
used for the current study was limited, the response
rate at follow-up was notably high, and the study
exemplifies Gitlin’s statement (2003) that the home
environment is a potential laboratory for developing
and testing constructs that may extend to environ-
mental gerontology as a whole.
When it comes to the methodology used in
the current study, according to Gitlin (2003), the
Housing Enabler (Iwarsson & Slaug, 2001) is the only
promising research tool available in this field.
Further, I thoroughly considered the choice of an
appropriate ADL–IADL instrument. Among patients
with considerable reduction in functional capacity,
instruments measuring ADL ability are sufficient. For
discriminative power among those with fewer
functional deficits, as for example in the current
general population study of older adults living in the
community, assessments comprising IADL are nec-
essary (Iwarsson, 1998; Iwarsson & Isacsson, 1997a;
Sonn & Hulter-Åsberg, 1991). Further, in order to
match the objective assessment of P–E fit problems, I
Vol. 45, No. 3, 2005 335
found it necessary to use an ADL instrument based on
interview and observation instead of self-reports.
Such an assessment tool must be reliable and valid,
and in longitudinal studies it is imperative that the
scale is sensitive enough to detect changes over time.
Even if a multitude of ADL and IADL assessments
exist (see, e.g., Wade, 1994), by applying these criteria
for choosing an instrument, one restricts the arsenal.
The ADL Staircase is not widespread outside of
Scandinavia, but as it stands the instrument un-
derwent successive application and testing of appro-
priate analysis methods (Iwarsson, 1998; Iwarsson &
Isacsson, 1997a; Iwarsson et al., 1998). The rank data
treatment principle applied in this study is novel and
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therefore scarcely known, but it optimally utilizes the
discriminative power of the three-graded scale of the
ADL Staircase. In addition, the ordinal properties as
well as the hierarchical order between items in each
sample are fully utilized, thus respecting the ordinal
character of the data (Iwarsson & Lanke, 2004).
Based on the notion that P–E fit is an interactive
construct (Iwarsson, 2004), the results of this study
demonstrate that P–E fit problems in housing are
related to older adults’ ADL–IADL dependence, and
the relationship grows stronger with advancing age.
The results indicate that the increase of P–E fit
problems in housing among older adults over time
mostly results from functional decline, although the
increase also to some extent results from changes in
the environmental component. The results are based
on detailed, reliable, objectively collected information
on the personal and environmental components of P–
E fit as well as on functional dependence, and they
lend support to the docility hypothesis. That is, the
study implies that P–E fit problems in housing have
a more negative impact on daily activity among older
adults with more functional limitations and depen-
dence on mobility devices. An important contribution
of this study is that it demonstrates that research
utilizing a methodology that allows for operational-
ization of aspects of Lawton’s ecological model, such
as the Housing Enabler, has the potential to increase
our understanding of how the ecological model’s
main components change and interact over time.
When it comes to practical implications, knowl-
edge on how housing accessibility problems in the
aging population increase with advancing age can be
used to reduce the need for relocation and sheltered
housing. Because the notion of P–E fit implies that the
relation of the personal and environmental compo-
nents can be influenced by interventions, the fact that
the increase of accessibility problems mainly is
caused by functional decline is a strong argument
for preventive measures targeting the environmental
component instead. A major advantage of the anal-
ysis of accessibility problems based on the Housing
Enabler is the possibility to identify which environ-
mental barriers cause the most accessibility problems
(Iwarsson & Isacsson, 1996b; Iwarsson & Slaug,
2001). Such analyses identify the environmental
barriers that, in relation to the prevalence of
functional limitations and dependence in an in-
dividual or a sample or population, generate the
highest accessibility scores. For example, based on
baseline data from this study (N = 133; Iwarsson &
Isacsson, 1996b), an analysis of weighted environ-
mental barriers demonstrated that among the single
items of the environmental component of the
Housing Enabler, the environmental barrier ‘‘no
grab bars at shower/bath and/or toilet’’ generated
the most accessibility problems. Such detailed in-
formation about the nature of the environmental
barriers causing accessibility problems is directly
applicable in the planning of housing for senior
citizens as well as in individual home-modification
cases, representing a concrete measure to reduce poor
P–E fit among older people living in the community.
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Received March 5, 2004
Accepted October 27, 2004
Decision Editor: Linda S. Noelker, PhD
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