“You Don`t Go Out If You Don’t See Anyone” – Reconsidering the Interplay of Personal, Social and Environmental Resources for Life-Space Mobility in Old Age”

doi:10.21203/rs.3.rs-2955739/v1

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“You Don`t Go Out If You Don’t See Anyone” – Reconsidering the Interplay of Personal, Social and Environmental Resources for Life-Space Mobility in Old Age”

https://doi.org/10.21203/rs.3.rs-2955739/v1

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Maintaining mobility with increasing age depends on personal, social and environmental factors, but the understanding of their complex interplay remains limited. Considering the comprehensive concept of Life-space mobility (LSM), we aim to illustrate the synergistic or antagonistic interplay of personal, social and environmental factors for life-space mobility (LSM) of older adults living in rural areas. Semi-structured interviews with twelve older adults (74–95 years) from a particularly rural area in Germany were conducted alongside the validation study of the German version of the Life-Space Assessment (DRKS00019023). To analyze interview transcripts methods of qualitative content analysis were applied using MAXQDA 2020. Participants were additionally characterized with assessments of LSM, everyday functioning, quality of life and balance confidence were carried out. Eight participants reported restricted LSM. Qualitative analysis displayed that difficulties visiting healthcare services were related to accessible information and dependence on being driven there. Additionally, factors cancelled each other out, e.g., the motivation to go out was facilitated by modernized sidewalks but subverted by the absence of social contacts. Findings related to social and environmental factors turned out to be ambivalent. For instance, the spouse who helped his wife to be mobile outdoors also undermined her motivation to go out. Results reveal various forms of interplay of personal, social and environmental factors providing an enriched understanding of emerging barriers to LSM as well as resource allocation to maintain LSM in old age.

Life-Space mobility

Barriers and resources for mobility

Rural area

Qualitative content analysis

Community-dwelling older adults

Mobility, a concept with diverse definitions, is closely connected with social participation, physical activity, independence and quality of life (Musselwhite and Haddad 2010; Portegijs et al. 2015). Thereby mobility incorporates more than the functional capacity to complete a defined task in a certain time and quality; this is one reason why single laboratory measures such as gait speed or stride length fail to adequately predict the performed mobility outside one´s home in real-life (Giannouli et al. 2016). Especially in older age when functional and cognitive limitations increase, mobility outside one’s home (e.g. shopping, gardening and walking) becomes important to replace structured exercise and induce positive effects on quality of life and healthy ageing (Bangsbo et al. 2019). Besides the physical benefits of mobility, a meta-synthesis of qualitative studies additionally described mobility as an integral part of older adults’ self-perception and emphasized the significance of assisted mobility and adaptability to cope with mobility decline (Goins et al. 2014)

One of the most comprehensive mobility frameworks is the one proposed by Webber et al. (2010). It outlines the importance of social factors (e.g. availability of personal assistance), personal factors (e.g. physical functioning, cognition, self-efficacy) next to factors of the physical environment (e.g. stairs, outdoor terrain) and points out the impact of their interplay on a person’s mobility (Webber et al. 2010). Further, it defines mobility as the “[…] ability to move oneself (either independently or by using assistive devices or transportation) within environments that expand from one’s home to the neighbourhood and regions beyond.”(Webber et al. 2010).

The environments described by Webber et al. (2010) can be divided into theoretical zones that expand in a circular pattern from inside one’s home to the borders of the city/village lived in and beyond, so-called “life-spaces”, and travel between these specified geographical zones is named life-space mobility (May et al. 1985). As an empirical mobility concept, LSM is gaining increased attention. Restrictions in LSM have been found to be associated with negative health outcomes like incidence of frailty, reduced social participation, higher risk of depressive symptoms and fear of falling (Tsunoda et al. 2021; Polku et al. 2015; Portegijs et al. 2016; Auais et al. 2017).

Against this background, the importance of single mobility factors like gait speed or walkability of one´s neighbourhood has been highlighted, but it remains unclear how the synergistic or antagonistic interplay of personal, social and environmental factors can function as a resource or barrier for LSM (Kuspinar et al. 2020; Miyashita et al. 2021). The life-space constriction model (Xue et al. 2008) assumes direct effects of named factors whereas the mobility framework by Webber et al. (2010) or ecological models propose interactions between them (Oswald et al. 2005; Lawton and Nahemow 1973). A more fluid perspective on how social and physical environments are connected and related to personal views was introduced by Andrews et al. (2013) where space and place are recognized as relationally configured and performed and can thus scarcely be differentiated (Andrews et al. 2013).

Additionally, urban versus rural environments provide specific resources as well as barriers like the amount of available green space or distances to healthcare services, but more investigations that focus on LSM of older adults living in rural areas are needed (John and Gunter 2016; Mümken et al. 2021). In sum, although personal, social and environmental resources have been related to each other conceptually, a more finely graded understanding of their interaction and interrelation is needed.

To gain deeper insight into the role of personal, social and environmental factors, their synergistic or antagonistic interplay and their relation with LSM in older people living in rural areas, we draw on the perceptions of older adults. A qualitative research approach was chosen to answer the following two research aims: First, to describe how known personal, social and environmental factors derived from the literature emerge as resources or barriers for everyday LSM of community-dwelling older adults living in rural areas. Second, to gain a better understanding of how personal, social and environmental factors interrelate with each other and foster or hinder LSM in the narratives of community-dwelling older adults.

Study Design and Setting

This qualitative study is associated with the MOBILE trial (DRKS00025230), a randomized controlled trial designed to investigate the effectiveness of a motivational counseling intervention incorporating personal, social and environmental resources to improve out-of-home mobility of older adults living in rural areas (Haeger et al. 2022). The interviews were conducted alongside the validation study of the German Life-Space Assessment (LSA-D) for which approval was given by the local Ethics Committee of the Charité – Universitätsmedizin Berlin (EA2/124/19) and which was prospectively registered at the German Clinical Trials Register (DRKS00019023) (Mümken et al. 2021). The study took place in an ambulant geriatric rehabilitation clinic in the Havelland, an area classified as rural (Küpper 2016). Participants residential areas can be described as small villages (850 - 1,200 inhabitants), small towns (up to 18,000 inhabitants) or one bigger town (44,000 inhabitants) without services for upscale daily needs. Face-to-face interviews were administered between November and December 2019 by the main author and a trained research assistant.

Participants

All included participants were community-dwelling older adults that spend 6-8 hours on weekdays in the ambulant geriatric rehabilitation clinic to participate in general rehabilitation programs. Inclusion criteria were an age of at least 70 years, no severe cognitive limitations, ability to understand the study information and give written informed consent. Exclusion criteria included acute incidences that limited LSM within the previous four weeks (e.g. falls, operations), severe cognitive limitations or mental conditions, need of acute care and insufficient understanding of the German language. All identified older persons who fulfilled the inclusion and exclusion criteria in November and December 2019 were asked to participate in the interviews, hence a convenient sample of 14 participants could be recruited. Due to health reasons, two participants dropped out (one male 86 years old and one female 77 years old) so that 12 participants could be included in the study. In the remaining sample, only two older persons identified themselves as men. Concerning the residential area, living situation, and use of walking aids for LSM outdoors, a more balanced sample that reflected the research aim was achieved

Data collection

In order to stimulate narratives while staying focused on LSM during the face-to-face semi-structured interviews, an interview guide including four open-ended questions was developed and pre-tested beforehand (supplement 1). Follow-up questions for elaboration and clarification were generated ad hoc. Face-to-face interviews took 30 minutes to 1 hour and were conducted by the main author and a trained research assistant. To facilitate trust and rapport during the interviews, the two researchers took part in activities (e.g., sports groups and handicrafts) to integrate themselves into the daily routines of the ambulant rehabilitation clinic (DeJonckheere and Vaughn 2019).

In order to place the interview content in the context of functional abilities, standardized assessments were carried out. To administer self-reported LSM the German version of the life-space assessment (LSA-D) was used (Mümken et al. 2021). The LSA composite score (LS-C; range 0-120) is composed of the frequency of visits of five life-space levels within the past four weeks (life-space levels extend from the bedroom, house and nearby living environment over one’s perceived neighbourhood to the regions outside the town/city lived in), equipment needed and personal support. LS-C scores below 60 points reflect restricted LSM to one’s neighbourhood (Sawyer et al. 2010). Self-rated health was assessed using the visual rating scale (range 0-100%) of the EQ-5D-5L (Ludwig et al. 2018). Number of imitations in 14 activities and instrumental activities of daily living (ADL/iADL) was captured with an assessment of the Survey of Health Aging and Retirement in Europe (Borsch-Supan et al. 2013). Balance confidence was obtained with the short version of the activity-specific balance confidence scale (0-100%) (Schott 2014).

Qualitative analysis

Interviews were transcribed by a professional office and analyzed using category-based content analysis, a qualitative approach open to including quantitative analytical steps (Mayring 2019). First, an in-depth literature review on general mobility in older age, LSM and influencing personal, social and environmental factors as well as on theories about resources and barriers was conducted to deductively derive a category-system (table 1) (Webber et al. 2010; Xue et al. 2008; Hobfoll 2002; Oswald et al. 2005; Mollenkopf et al. 2004). Then the defined category system was applied on the interview transcripts. The smallest text element that could be assigned via code to one category was a part of sentence with an identified meaning and the biggest element was a complete text section. The main author and research assistant carried out the coding. To ensure consistency a coding manual including an anchor example extracted from the interview for each category was developed. Unclear text passages and their assignment to the categories were discussed.

Table 1: Overview of deductive category system

Main categories	Resources for life-space mobility
Main categories	Personal Factors	Social Factors	Environmental Factors
Sub-categories	Autonomy	Society	Nature
	Time	Partner	Garden
	Financial situation	Family	Buildings / architecture
	Knowledge / find Information	Friends	Physical distance
	Goals / goal setting	Neighbors	Weather / season
	Attitudes :	Loneliness (emotional feeling)	Public transport
Sub-sub-categories	• Self-confidence	Being alone (chosen situation)	Driving services (including taxi)
	• Acceptance of help	Being with others (chosen company)	Walking aids
	• Give help to others		Technical assistance
	• Reject help from others
	• Motivation / interest
	• Fear / worries
	• Attitudes towards aging
	Health:
	• Physical health
	• Mental health
	Emotions:
	• Positive emotions
	• Negative emotions

To illuminate the nature of resources and barriers for LSM, further analytical steps were performed including quantitative visualization techniques, as suggested for category-based content analysis (Mayring 2019). Thereby the integration of visual elements such as displaying text elements of specific categories can be seen as an analytical step to organize and structure the interview data and to identify text passages for further interpretative approaches (Berg 2004). Concerning the combination of visual approaches within the category-based content analysis, it is necessary that at least 50% of the interview text is coded (Gläser and Laudel 2009).

First, the distribution of coded categories among the interviews was visualized with a tool named “document portrays” of MAXQDA 2020 (figure 1). In a second step, text segments in which codes of resources and barriers to LSM overlapped were identified as important text elements to further analyze the synergistic and antagonistic interplay of personal, social and environmental factors with inductive theme development. Within this process, discussion and agreement between the main author and the research assistant were important to archive analyzability, reliability and transparency. All interviews were conducted, transcribed and analyzed in German. To guarantee a correct understanding of selected quotations that appear in publications, a professional translator was hired.

Participants were between 74 and 95 years old. Of all participants, ten identified as women and two identified as men (Table 2). Their living situations varied: Three participants lived in villages, six in small towns and three in one bigger town. Five participants lived together with their partner, two lived with their children and grandchildren and five lived alone. Eight participants used walking aids and seven of them were assigned to a care level of the German care insurance.

Table 2

Sample characteristic
ID	Age	Gender	Location (rural)	Living situation	Walking aids	Care level (1–5)	Life-Space mobility (LSM 0–120.)	ADL/ iADL Limitations (0–14)	Self-rated health (0–10 %)	Balance confidence (0–100%)
003	78	female	town	partner	walker / e-mobile	3	res. (24)	9	30	8
057	82	female	small town	alone	walker	2	res. (38)	6	50	12
145	74	female	village	partner	walker	2	res (45)	5	5	13
005	82	female	small town	alone	walker	2	res. (47)	5	50	10
074	82	female	small town	alone	cane / walker	none	res. (49)	9	30	8
131	81	female	small town	alone	none	1	res. (49)	4	70	61
114	83	male	town	partner	none	none	res. (54)	0	80	72
059	84	male	village	alone	cane / walker	2	res. (56)	5	50	13
080	83	female	town	partner	none	none	> 60 (63)	0	80	65
147	95	female	village	grandchildren	cane / walker	2	> 60 (80)	11	48	5
055	77	female	small town	children / grandchildren	none	none	> 60 (100)	0	55	73
104	77	female	small town	partner	none	none	> 60 (100)	0	80	70

Note: Participants are listed in order from lowest to highest LSM-Score in ( )
ID = Pseudonym of participants; LSM = life-space mobility; LSM < 60 = restricted LSM (res); LSM > 60= unrestricted LSM; ADL = Activities of Daily Living; iADL= instrumental Activities of Daily Living; number of ADL/iADL limitations is given

Restricted LSM was reported by eight participants including the five who lived alone, and all participants with restricted LSM had four or more ADL/iADL limitations. Participants with balance confidence above 65% had unrestricted LSM except for participant 114. Another exception was participant 147 with the lowest balance confidence of 5% and unrestricted LSM.

We met the coding criterion by Gläser & Laudel as all in all 1045 codes were assigned to the twelve interviews (Gläser and Laudel 2009). Codes of the categories for barriers and resources for LSM overlapped 56 times. From the inductive analysis, a new theme about the ambivalence of social and environmental factors as resources or barriers for LSM emerged.

Resources and barriers for LSM

In total, we assigned more codes of barriers for LSM to six of the interviews whereas more codes of resources for LSM emerged from the other six interviews. Participant number 080, an 83-year-old woman who lives with her husband in a town, was identified as someone who spoke more about barriers than resources for LSM.

Analysis of her interview revealed that most of the barriers were worries about the future as she gave up driving one year ago. For some trips, e.g., visits to medical specialists, she is now dependent on her husband, but she worries about the time when he will have to quit driving too. Her thoughts about adaptive strategies reveal how the interplay of personal factors like knowing how to find information or environmental factors like distance inhibit LSM and the utilization of healthcare resources.

“I was at the station to get information about how the buses run, but they said I should go to the town hall and ask there and there […] you can´t get any information there either. […]. I don’t know where else you can get information about how the buses run. […] When my husband can’t drive a car anymore, […] then we’ll have to get a taxi, but the distance is too short for a taxi to take us there [to the dentist/urologist] […] and then we have to rely on the help of our neighbours.” (ID 080, ll. 43–46).

She is struggling to cope with a possible upcoming loss of independence and to accept the necessity to ask for help from others in the future. She cannot solve the problem of transportation by relying on her own personal abilities (i.e., personal resource) or on her husband (i.e., social resource) or use of public/private transportation services (i.e., environmental resource).

In contrast, participant 147, a 95-year-old woman living together with her grandchildren in a village, has eleven ADL/iADL limitations but an unrestricted LSM mainly speaks about resources for mobility. She sets a clear focus on the use of social and environmental resources like the help of her neighbours or the use of driving services from an association in her village where she is a long-term member. She said: “There are no barriers for me [to get to an event]. All the women who live further away […], they get picked up. […] I always get picked up. […] I just have to call [name of neighbour] in the morning and he says: Yes, I´ll pick you up, I´ll pick you up.” (ID 147, ll.134–137).

The interplay of personal, social and environmental factors for LSM

The following five examples highlight the synergistic interplay of personal, social and environmental factors that fosters LSM, but also how factors interfere, cancel each other out and emerge as a barrier for LSM. First, the importance of shopping as an essential task that also fulfils social needs synergistically is pointed out by participant 059, an 84-year-old man who lives alone in a village and uses a cane and a walker.“I often meet friends when I go out shopping, although there are fewer and fewer of them. We can talk a bit […]. That’s nice because nothing is worse than loneliness. I always need a little bit of companionship.” (ID 059, ll.43–47) His statement sheds light on how the synergistic interplay of his motivation, his environment (supermarket) and social contacts helps him to enhance his mobility outside his home and against loneliness. In a statement before he reveals a contrasting example of how personal attitudes can work as a barrier for LSM. “If necessary, I get into my car because I like to drive and I visit my friends. I built up new contacts after I was alone, and I go and visit them. Of course I don’t stay for too long, one cannot do that. Most of them are couples.” (ID 059, ll. 39–43). He is reluctant to spend too much time with befriended couples as he does not want to bother them, an attitude that hinders him from making longer visits although he can still drive a car to get there on his own as an important personal resource for his LSM.

Second, participant 057, a woman from a small town who lives alone and uses a walker, also highlights the value of shopping as an incentive for LSM outside the house. Her personal strategy to use an attractive environment as a goal for outdoor mobility is undermined by her personal financial situation.“Outside? Oh well, I don´t like that anymore. I need a [defined] goal. And there is a store nearby, where I can go by bus. But some things there are too expensive and I can´t afford to go there that often.” (ID 057, ll. 292–295).

Third, participant 145, a woman, 74 years old, living in a village, with a clearly restricted LSM, low quality of life, low balance confidence and five ADL/iADL limitations, gives the following response to the interviewer’s question about the quality of sidewalks in her village. “Yes, there are sidewalks [in the village]. They modernized the drains and will modernize the sidewalks too. But that is not exactly brilliant. You don´t go out if you don’t see anyone. […] Or you must have someone in mind […] I go out and visit Ms. [Name] to drink coffee and talk a bit, but that rarely happens.” (ID 145, ll. 56–65). This highlights how even a sufficient infrastructure does not automatically facilitate LSM, and social and environmental factors cancel each other out. If the need for social interaction in the form of seeing other people out on the street or visiting a specific person is not fulfilled, there is no other personal motivation to leave the house. Here the social element is the key component in the interplay of factors that foster the decision to stay home or go out and use the existing resource of modernized sidewalks.

Forth participant 005, an 82-year-old woman who lives in a town, is mobile with a walker, has low balance confidence and a highly restricted LSM describes, how her dependency on her care service limits her opportunities to go out: “You know…from breakfast, until the care service gets here the time is too short for me [to go out], it passes quickly […] and until they come back at noon [to take off the compression socks], the time is also too short, because I am busy preparing my lunch. There is always too little time.” (ID 005, ll. 29–32). The care service enables LSM outside the home as they assist the participant to get on her compression socks in the morning. Conversely, the time between the visit of the care service in the morning and the visit in the early afternoon is too short to get active outside her home, especially because the participant sets her personal priorities on preparing lunch.

Fifth, participant 080 demonstrates how a huge garden that needs a lot of care functions as a resource for activities and LSM in the near living environment, but on the other hand limits LSM because the couple is too lazy to extend LSM towards locations within the neighbourhood or town due to physical activities in their garden. “Why don’t we go out? Well sometimes it is the weather or we have something else to do […]. For example in the garden. When we have worked all day in the garden we think that we have spent enough time outside and we can relax.” (ID 080, ll. 138–140).

Ambivalence within social and environmental factors

Within the process of inductive analysis, one new theme about the ambivalence of social and environmental factors was derived. This theme of ambivalence comprises how the same factor can foster LSM as a resource and, at the same time, hinder LSM as a barrier. The following two examples reveal the found ambivalent perceptions within social and environmental factors for LSM.

First, participant 003 is a 78-year-old woman who lives together with her partner in a rural town and uses a walker and an e-mobile. She describes how her partner, who helps her to be mobile with her walker and assists in other ADLs, simultaneously undermines her motivation to go out shopping. “My husband scolds me. “Do you really have to go there?” Yes, sometimes I want to go out and buy some things on my own at [name of drugstore] or somewhere else, shampoo or body lotion or […]. But then I ask my husband to bring it along. [...] I don´t want to talk about it anymore.”

Another example of ambivalent social factors influencing LSM negatively and positively at once is the example of participant number 005, an 82-year-old woman. She stopped riding a bike after she fell once and broke her shoulder two years ago, although she recovered from the fall. She used to go shopping by bike before the fall, and it was a huge source of independence and well-being for her. Her son refuses to help her to ride a bike again. Instead, he takes his mother to the supermarket by car: “I always used go by bike […], but then I fell and broke my right shoulder [...] and then, I was not allowed to ride a bike anymore, but that was two years ago. […] It has no impact anymore. […] But when I ask my son to help me to get my bike ready again he says: “What do you want [with your bike]? Do you want to fall again?”. [...] Yes my son keeps me from riding my bike.” […]. I had a huge basket on my bike where I could put everything […]. And now, when we both go shopping [together] he always tells me to put the groceries in this huge bag. […] I envy everyone who rides a bike.” (ID 005, ll. 55–70). The son’s reaction might be understandable due to safety reasons, but on the other hand, alternatives like using a tricycle to address impaired balance seem not to be discussed, while at the same time, he is a resource for his mother’s LSM as he helps her to visit the supermarket and buy groceries.

Concerning environmental factors, participant 104, a woman with unrestricted LSM, describes how difficult it is to get a taxi in the small town where she lives. There are three different taxi companies in her small town and a taxi can be used as a resource for LSM, but it is almost impossible to get a taxi with only a few days of advanced planning, which makes them unavailable for spontaneous enterprises. “And it is difficult to get a taxi. If […] a woman wants to go to the hairdresser, for example […] you need to schedule it at least four weeks in advance. And then you have to ask them to see if they can fit you in between [other appointments]. […] Well, it is difficult because they [taxis] have a fixed schedule to drive patients to go to [name of two cities] for dialysis. Sometimes they also have to wait for the patient to return.” (ID 104, ll. 61–70).

In our study, we used the qualitative research approach of category-based content analysis to extend our knowledge about resources and barriers for LSM of older adults living in rural areas. Further, we integrated individual assessments of LSM and indicators of health and functioning to gain an enriched picture of each participants’ situation. This approach allowed the identification and extraction of text units that reveal real-life examples of the synergistic and antagonistic interplay of personal, social and environmental factors and display how this interplay emerges as a resource or barrier for LSM in different ways.

The interplay of factors constituted whether an existing resource is used to facilitate LSM or not. This was shown in the non-use of modernized sidewalks due to a lack of fulfillment of social needs and low intrinsic motivation. In addition, barriers or resources for LSM emerged as a result of the interplay of personal, social and environmental factors. This interplay displayed in a synergistic manner when the importance of shopping was highlighted by a participant as an essential task that also fulfills social needs. The interplay was antagonistic, however, in the example of the care service that created a barrier to outdoor LSM by setting too little time between appointments and a lack of personal abilities to adapt. These findings extend beyond the simple direct effect of early mobility concepts and coincide in general with the assumptions of interacting personal, social, and environmental factors within Webber’s framework or models of healthy ageing, but add a meaningful, more interrelated perspective (Webber et al. 2010; Oswald et al. 2005).

Further, we observed that barriers and resources for LSM can be ambivalent in themselves, as the same factor can be both a resource and a barrier for LSM for the old person. One example is the husband who on the one hand enables LSM by providing personal assistance outdoors but also limits LSM on the other hand by creating fears and worries about going shopping, and who is angry about his wife’s wish to go shopping. These results give an insight into how social support can undermine LSM by inducing negative emotions and restrictions. The ambivalent role of social exchange processes was clearly described by Tracy Revenson as “social support as a double-edged sword” (Revenson et al. 1991). Another example of ambivalent resources and barriers for LSM is the use of taxis as a mobility resource in a rural area which also constitutes a barrier. There are taxi companies available, but using them requires careful and advanced planning. The taxi companies are following a completely booked schedule, which makes the fulfillment of spontaneous mobility needs impossible.

Our findings of ambivalent resources and barriers for LSM and the synergistic/antagonistic interplay of personal, environmental and social factors call for a more fluid view on factors influencing mobility to reflect their complex interactions (Andrews et al. 2013). In that regard, a more dialectical approach would be needed to understand personal, social and environmental factors as mutually constituting, as relativizing, and even as interfering. The absence of negative or ambivalent resource-mobility constellations could be explained by the concept of adaptability, a key theme to move forward that was found in one meta-synthesis of qualitative studies (Goins et al. 2014). As Goins et al. (2014) understand adaptability, it requires the integration of different resources and we could demonstrate how the interplay of personal, social and environmental factors can be utilized as a resource to facilitate LSM.

Strengths and limitations

The present study has strengths and limitations. First, one strength is the use of visual elements to structure and organize qualitative interview transcripts in order to identify the synergistic and antagonistic interplay of known factors that can foster or hinder LSM. Second, the ambivalence of resources and barriers was displayed as can be seen in the example of a worried husband or son. Third, it was possible to identify the synergistic and antagonistic interplay of factors for LSM that predominantly occur in areas that can be classified as rural. Examples are the huge garden that creates a lot of work and limits mobility in a synergistic interplay with the personal attitude to reward oneself for the work done with laziness and limits LSM to the house and garden. Further the regular lack of spontaneously available taxis might be a specific theme of LSM in rural areas. Fourth, the combination of qualitative interviews with standardized assessment tools helps to gain a complete picture of the personal context and physical abilities of each participant.

A limitation of the present study is that the twelve study participants were recruited in only one rehabilitation clinic and therefore the study sample solely consists of people over 70 years living in [name of area] and results reflect their LSM experiences. On the other hand [name of area] is a particular rural area in Germany and results can help to forward new research about older adults LSM outdoors in different rural settings. Concerning the composition of the sample only two men could be included and women are overrepresented. Regarding the residential area, living situation, and use of walking aids for LSM outdoors, a more balanced sample was achieved and multiple perspectives could be included. A further limitation refers to the date of the interviews shortly before the Covid-19 pandemic started in 2020. For this reason, no statement can be provided about the consequences of this environmental threat or the importance of social factors during this time of directed mobility restrictions. Otherwise, we found examples referring to basic activities and daily routines in the lives of older adults (e.g. shopping, use of transportation, gardening). In that sense, our findings about the interplay of personal, social and environmental factors are still of great relevance today for the understanding and improvement of older adults’ LSM.

Implications

Policymakers and practitioners should be aware of the interplay of personal, social and environmental factors, as these work in concert. A policy measure of improving neighbourhood walkability may only be beneficial in terms of mobility performance if the social structure and practices of the people are considered. Therefore, it is important to provide possibilities and activities that facilitate social encounters and fit local people’s diverse personal needs. Further, healthcare providers may incorporate these findings to offer not only barrier-free entrances and architecture but also understandable and easily accessible information about public transportation and other available environmental resources. This could facilitate access to healthcare services, especially for those with physical limitations or low health literacy. Additionally, a differentiated understanding of how LSM can be influenced by the interplay of personal, social and environmental factors might be useful to enhance preventive programs that target fostering LSM outside the house or for programs after rehabilitation.

Our research reveals that most of the resources and barriers for LSM emerge out of an interplay between personal, social and environmental factors that is often antagonistic and sometimes even ambivalent. Our finding helped to shed light on these complex interrelations, but further studies should examine the synergistic/antagonistic interplay of personal, social and environmental factors and the ambivalence of mobility barriers and resources in other social contexts such as diverse neighbourhoods or within the context of health-care services and hospitals. Therefore approaches that enable the increased inclusion of social and environmental factors beyond person-centred views, such as map-based or walk-along interviews while travelling through different life-spaces or GPS-derived data about LSM should be used.

Acknowledgments: We sincerely thank Justina Buchcik (JB) for assisting in the conduct of the interviews and their qualitative analysis and Bridget Schäfer for translating the quotes taken from the interviews and proofreading the manuscript. We also thank all participants involved in the study for their time and openly shared experiences.

Ethical approval and registration: Ethics approval for the study was provided bythe Ethics Committee of Charité – Universitätsmedizin Berlin (EA2/124/19). The study was pre-registered. at the German Clinical Trials Register (DRKS00019023).

Conflict of Interests: None declared.

Funding: This work was supported by the MOBILE project funded by the Federal Ministry of Education and Research (BMBF; ID 01GY1803) and the Institute of Medical Sociology and Rehabilitation Science, Charité – Universitätsmedizin Berlin.

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Supplement 1: Interview guide

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“You Don`t Go Out If You Don’t See Anyone” – Reconsidering the Interplay of Personal, Social and Environmental Resources for Life-Space Mobility in Old Age”

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Abstract

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Introduction

Methods

Study Design and Setting

Participants

Data collection

Qualitative analysis

Results

Resources and barriers for LSM

The interplay of personal, social and environmental factors for LSM

Ambivalence within social and environmental factors

Discussion

Strengths and limitations

Implications

Conclusion

Declarations

References

Additional Declarations

Supplementary Files

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