The Contribution of Sense of Community to the Association Between Age-Friendly Built Environment and Health in a High-Density City: A Cross-Sectional Study of Middle-Aged and Older Adults in Hong Kong

Abstract

Sense of community may be shaped by the quality of the physical environment and has potential health implications. Based on a survey of 2,247 community-dwelling middle-aged and older adults living in Hong Kong, we tested the mediation effect of sense of community on the relationship between the quality of the built environment and physical and mental health using path analysis. The quality of the built environment was indicated by the age-friendliness of outdoor spaces and buildings. No direct association was found between the built environment and health outcomes, although age-friendly outdoor spaces were associated with better mental health. Sense of community mediated 14% of the total effect between outdoor spaces and mental health and 44.8% of the total effect between buildings and physical health, underscoring the importance of accommodating the social needs of middle-aged and older people in urban development in high-density cities.

Keywords

Introduction

The Built Environment and Older Adults’ Health

The characteristics of the built environment are tied to many aspects of older adults’ everyday life. The built environment generally refers to a multi-faceted man-made environment, including the distribution of space, building design, physical infrastructure, and the arrangement and appearance of the physical elements in a community (Handy et al., 2002). Such an environment is not merely a result of its design and physical attributes but also the extent to which residents feel it to be clean, walkable, accessible, and safe to live in. The built environment influences physical and mental health and quality of life in many ways (Brossoie & Burns, 2020; Kerr et al., 2012; van den Berg et al., 2015). For instance, the availability of green space is associated with mental well-being (Houlden et al., 2018; Wu et al., 2015) and self-rated health (de Vries et al., 2003; Maas et al., 2006). A study in rural Manitoba, Canada, identified a positive association between an age-friendly physical environment and self-perceived health (Menec & Nowicki, 2014). Understanding the impact of the built environment on the health of older people may provide necessary information for community design and planning.

Several prevailing hypotheses explain the micro- and macro-level impacts of the built environment on older people’s health. The harm reduction model describes the prevention of adverse health outcomes and injury by avoiding environmental hazards, such as inadequate lighting, slippery floor surfaces, and the lack of bathroom fixtures, all of which are known to increase the risk of falls (Hosseini & Hosseini, 2008). Accessible and user-friendly cooking, bathing, and toileting facilities are health-protective because they are essential for fulfilling basic human needs and reducing domestic injuries (Dogan et al., 2010). The activity model predicts that features of the built environment facilitate health-promoting behaviors, such as walking and a range of physical and social activities. A high degree of walkability in the built environment increases levels of physical activity. A walkable neighborhood characterized by greater residential density, street connectivity, and mixed land use is associated with greater levels of physical activity, especially walking and cycling (McCormack & Shiell, 2011). Leyden (2003) also found that a walkable neighborhood consistently predicts higher levels of social engagement. The third model points to the stress-reducing effect of a positive built environment. People exposed to nature and green space often report less self-reported stress (Ulrich et al., 1991) and flattening of cortisol circadian rhythm, a biological marker of chronic stress (Thompson et al., 2012). This theory is similar to the harm reduction approach that focuses on the negative consequences (i.e., stress) of environmental risk factors. However, little discussion has been devoted to understanding psychological resources that promote positive health outcomes.

Lawton and Nahemow (1973) used the Competence–Environmental Press model, which depicts the interaction between older adults’ competence and environmental press (demands), to study the ecology of aging framework. An older person is considered adaptive to aging when they can cope with the environmental challenges. A prime example is purpose-built senior housing that minimizes environmental barriers and enables older adults with lower competence levels to better adapt. The health impacts of the built environment are believed to be greater among older adults with increased functional limitations.

Sense of Community

Sense of community is a concept closely related to sense of place and sense of belonging but, unlike these, it reflects how a person feels connected with other people in the environment (Putnam, 2000). That is, place simply provides a physical context where people gather because of their family, social, or economic ties, or acts as a physical context for people to develop these ties. The sense of community in this case also reflects a person’s subjective appraisal of their social networks and connectedness. Research also supports the positive association between sense of community and social networks, social support and social engagement (Tang et al., 2017). Stedman (2003) argued that sense of place is a social construct encompassing meaning, attachment, and satisfaction.

Wahl and colleagues (2012) followed the principles of Lawton’s model to propose a developmental model of aging well as a function of person–environment interchange. One of the core processes that drives the interchange dynamic is the sense of belonging, the feeling of positive connection with a place or group, that is often regarded as a complex product of cognitive and emotional processes. Negative features of the urban environment, such as crowding, reduced public open space, and unsafe sidewalks deter the development of sense of community. Conversely, vernacular architecture that preserves the traditional way of life through rehabilitation of old buildings and recreation of communal spaces and buildings resembling old neighborhoods, is considered a means of maintaining people’s sense of community, cultural continuity, and cultural identity (Sharifi & Murayama, 2013).

Sense of community, whether positive or negative, may impact residents’ health, notably the elderly who are more homebound. Previous studies suggest that sense of community significantly predicts quality of life (Gattino et al., 2013), health-behavior change (Hystad & Carpiano, 2012), self-perceived health and mental health (Kitchen et al., 2012), and less severe depressive symptoms (Fowler et al., 2013). It is unclear whether sense of community shaped by environmental factors, such as public space, impacts on physical and mental health, especially the middled-aged and older population.

Research Objective and Hypotheses

Physical and mental health have been well researched, including their relationship with the perceived built environment and people’s sense of community. However, no research has investigated the respective roles of the age-friendliness of the built environment and sense of community on people’s physical and mental health-related quality of life. The research hypotheses of this study were therefore to examine whether age-friendliness of the built environment was associated with physical (H1) and mental health-related quality of life (H2), and whether sense of community mediated the relationship between the built environment and physical health-related (H3) and mental health-related quality of life (H4).

The Study Site

Data were collected in Hong Kong, a city known for high population density and prevalence of super-high-rise housing. Although Hong Kong’s population density is only moderately high by Asian standards, averaging 6,830 people per km², the bulk of its 7.48 million residents are concentrated in 24.3% of the total land area. As the city is characterized by steep and elevated natural terrain, there is limited open space within the built-up area. However, 42% of the natural land is earmarked as country parks and natural reserves, most of which are served by public transport. There are over 9,000 high-rise buildings in Hong Kong. The average public open space accounts for 2.3% of the total land area (9.3% of the developed area), or equivalent to 1.64 m² local open space per person in the neighborhood area and 1.07 m² per person at district level (Lai, 2017). Local open space is more accessible to older people, but usually comprises smaller sites such as small parks, gardens, and sitting-out areas that are suitable for passive recreation.

Hong Kong is undergoing rapid population aging. Currently, those aged 65 years or older comprise 17% of the population and expected to rise to 30% in 2040 (Census and Statistics Department, 2017b). Despite its high population density, Hong Kong is livable because of efficient public transport and relatively close proximity to green space, public amenities, facilities, commercial blocks, and economic activities. Nevertheless, Hong Kong has been criticized because the design and layout of transportation and the built environment tend to maximize effectiveness instead of inclusiveness (Chui et al., 2019).

In the face of the challenges brought by the aging population, the Hong Kong Council of Social Service (Chan et al., 2016) initiated the concept of age-friendly Hong Kong in 2008. The government’s 2016 Policy Address prioritized building Hong Kong as an age-friendly community (The Government of the Hong Kong Special Administrative Region, 2016). Means of increasing the supply of elderly facilities include supporting welfare organizations’ expansion and site redevelopment and imposing land sale conditions requiring private developers to provide premises for welfare facilities.

In parallel with the Government’s policy direction, a citywide cross-sectional survey was initiated in late 2015, one of whose objectives was to assess the age-friendliness of each district in Hong Kong. The assessment findings were used to guide the development of a three-year action plan to build an age-friendly city. The current study draws on data from this survey to test the mediating effect of sense of community on the relationship between perceptions of the built environment and physical and mental health. There has been limited study of sense of community in Hong Kong (Mak et al., 2009). The study’s findings are expected to inform the direction of strategic planning and design for a livable high-density city promoting older adults’ health.

Design and Method

Setting

This study was conducted in five districts in Hong Kong (Central & Western, Wan Chai, Eastern, Southern, and Wong Tai Sin), each of which are old towns developed before the 1970s, in which 16.0%–17.2% of residents are aged 65 or above, in contrast to 15.8% in the whole territory (Census and Statistics Department, 2017a). However, variations in population characteristics exist within each district. To gauge sample representativeness, we first divided the districts into meaningful and exclusive geographical clusters, some of which have very different profiles even located within the same district. These clusters were validated by stakeholders in each district. The five districts involved 46 clusters and 1,678,652 residents, representing 23% of Hong Kong’s total population.

Sample

We used quota sampling with stratification by geographical cluster and age group with the intention of recruiting approximately 500–700 participants in each district, at least 85% of whom would be aged 50 years or older. We recruited participants via public rental housing estates, nongovernment organizations’ elderly centers, civic organizations, and snowball referrals.

Data were collected through face-to-face interviews undertaken by trained research assistants in two phases: from November 2015 to February 2016 in two districts and from April 2017 to July 2017 in three districts. A total of 2,506 participants were recruited, of whom 2,247 (90%) completed the survey. Data were drawn from The Jockey Club Age-friendly City Project that was reviewed and approved by the Human Research Ethics Committee of the University of Hong Kong (reference number: EA1510033). All participants provided written informed consent.

Measures

Age-friendliness of the built environment

Participants rated the age-friendliness of the built environment in two domains: outdoor spaces and buildings (Supplemental Appendix 1), that were developed based on the World Health Organization’s (2007) age-friendly city framework and guidelines and subsequently confirmed by exploratory factor analysis. Each domain contained four items showing acceptable internal consistency (Cronbach’s alpha of .731 [outdoor spaces] and .675 [buildings]). The items in the outdoor spaces domain concerned environmental cleanliness, green spaces and outdoor seating, pavements, and pedestrian crossings. The buildings domain concerned the building design, accessible toilet facilities, accessible commercial services, and special customer service arrangements. Each item was rated on a 6-point Likert-type scale, ranging from 1 (strongly disagree) to 6 (strongly agree), with higher scores indicating greater age-friendliness.

Sense of community

We assessed sense of community using the eight-item Brief Sense of Community Scale, with four dimensions: needs fulfillment, group membership, influence, and emotional connection (Peterson et al., 2008). The eight items were rated on a 5-point Likert-type scale, ranging from 1 (strongly disagree) to 5 (strongly agree), with higher scores indicating greater sense of community. The scale has satisfactory internal consistency (Cronbach’s α = .836). The scale supported the hypothetical construct of sense of community and its overall score demonstrated moderate correlation with mental health and depression.

Physical and mental health-related quality of life

The locally validated, 12-item Short-Form Health Survey (SF-12) measuring health-related quality of life was used to measure participants’ physical and mental health (Lam et al., 2005). The items were drawn from the 36-item Short-form Health Survey (SF-36), in which two items were taken from each main concept: physical functioning, role-physical, role-emotional, and mental health; and one item from each of the other concepts: bodily pain, general health, vitality, and social functioning. Physical and mental health were expressed by the Physical Component Summary (PCS) scale and Mental Component Summary (MCS) scale, respectively, based on the summation of all item responses and their corresponding weights. The standard SF-12 items were used with standard PCS and MCS regression coefficients as the item weight. The correlation between PCS and MCS was weak at .07 (p < .01), implying that the two components had a very small shared variance and should be separately examined.

Individual characteristics

Individual characteristics were control variables: gender, age, marital status, educational attainment, living arrangement, monthly personal income, subjective financial sufficiency, and whether using a walking aid. Gender, monthly personal income, and whether using a walking aid were measured by a binary variable (0 = male, 1 = female; 0 = HK$0–5,999, 1 = HK$6,000 or above; 0 = not using a walking aid such as cane, walker, or wheelchair, 1 = using a walking aid). We categorized marital status into three groups: married, widowed, and never married/divorced/separated. Educational attainment was classified into four categories: no formal education/kindergarten, primary, secondary, and postsecondary. The three types of living arrangement were categorized as: living alone, living with spouse only, and other living arrangements. Finally, subjective financial sufficiency was measured by asking participants to rate whether they had sufficient money for their daily expenses on a 5-point Likert-type scale (1 = very insufficient; 2 = insufficient; 3 = sufficient; 4 = more than sufficient; 5 = abundant). These covariates were chosen based on their potential association with the perception of age-friendliness of built environment and health-related quality of life. People of different ages and genders had different health profiles and tended to have different benchmarks for the age-friendliness of environment (Black & Hyer, 2019). Marital status and living arrangements reflected a person’s familial support that helped adaptation to the built environment. Single people and those living alone tend to be at greater risk of poor mental health (Fukunaga et al., 2012; Stahl et al., 2017). The need to use walking aids, an important indicator of health status, poses greater challenge to adapt to the environment.

Analysis

Descriptive statistics were calculated for sample characteristics and ratings of age-friendly outdoor spaces and buildings. We used Pearson correlation to ascertain the relationship between the age-friendliness measures, sense of community, and health-related quality of life. We tested the mediation effect of sense of community using path analysis. Specific hypotheses were summarized as follows:

Hypothesis 1 (H1): Age-friendliness of the built environment was associated with physical health-related quality of life.

Hypothesis 2 (H2): Age-friendliness of the built environment was associated with mental health-related quality of life.

Hypothesis 3 (H3): Sense of community mediated the relationship between the built environment and physical health-related quality of life.

Hypothesis 4 (H4): Sense of community mediated the relationship between the built environment and mental health-related quality of life.

Noting the skewed distribution of the indirect effects, we determined their standard errors using 5,000 bootstrap samples. We ascertained a bias-corrected and accelerated confidence interval (BCa CI) for each specified indirect effect. A confidence interval that did not cross zero implied statistical significance. The independent variables of interest were outdoor spaces and buildings. We hypothesized that outdoor spaces and buildings (exogenous variables) influenced health-related quality of life (endogenous variables) through sense of community (mediator variable). Participants who live in an age-friendly environment will develop a stronger sense of connectedness with other community members, which subsequently promotes their quality of life. The model was tested with adjustments for covariates (see above) to calculate unstandardized path coefficients for direct, indirect, and total effect and standardized coefficients that indicated the strength of correlation between variables. The model was deemed to provide a good fit to the data if the comparative fit index (CFI) ≥ 0.95, the root mean squared error of approximation (RMSEA) ≤ 0.05, and the standardized root mean squared residual (SRMR) ≤ 0.08. We also calculated the chi-square statistics of the models. All analyses were performed using Stata version 15 (StataCorp LLC, College Station, TX, USA) and R version 3.6.3 (R Development Core Team).

Results

Descriptive Statistics

Table 1 shows the characteristics of the study sample. Females predominated (76%). Most participants were aged 65 to 79 years (48%), married (50%), and living with their spouse only (44%). Most participants completed primary or secondary education (33% and 32%, respectively) and did not use any walking aids (70%). On average, participants rated their subjective financial sufficiency as 3.0 (SD, 0.7), that is, as adequate. Participants in general somewhat agreed that the built environment in the district in which they resided was age-friendly. The M (SD) of the outdoor spaces and buildings domains were 72.2 (13.1) and 65.6 (14.7) out of 100, respectively.

Table 1.

Characteristics of the Study Sample (N = 2,247).

Characteristics	M (SD) or n (%)
Female	1,715 (76%)
Age
50–64 years	353 (16%)
65–79 years	1,085 (48%)
80 years or older	809 (36%)
Marital status
Married	1,115 (50%)
Widowed	907 (40%)
Never married/divorced/separated	225 (10%)
Education attainment
No formal education/kindergarten	584 (26%)
Primary	748 (33%)
Secondary	711 (32%)
Postsecondary	204 (9%)
Living arrangements
Alone	684 (30%)
With spouse only	997 (44%)
With others	566 (25%)
Monthly personal income (HK$)
0–5,999	1,619 (72%)
6,000 or above	628 (28%)
Subjective financial sufficiency (range, 1–5)^a	3.0 (0.7)
Using a walking aid	733 (30%)

Note. SD = standard deviation.

5-point scale, ranging from 1 = very insufficient to 5 = abundant.

The age-friendliness of outdoor spaces and buildings was moderately correlated (r = .48, p < .001). Participants with a stronger sense of community rated the two domains as more age-friendly (r = .27, p < .001 and r = .33, p < .001, respectively). Outdoor space was mildly correlated with MCS (r = .11, p < .001) but not with PCS (r = .01, p = .5). Buildings was weakly correlated with both PCS (r = .07, p = .002) and MCS (r = .05, p = .012). Chronological age was negatively correlated with PCS (r = −.23, p < .001) but not with MCS (r = .04, p = .08). Participants tended to perceive outdoor space and buildings as more age-friendly (r = .21, p < .001; r = .13, p < .001, respectively) (Table 2).

Table 2.

Pearson Correlations Between Age-Friendliness of Outdoor Spaces and Buildings, Sense of Community, and Health-Related Quality of Life.

Variables	Age group^a	PCS	MCS	SOC	Outdoor spaces
PCS	−.23***
MCS	.04	−.051*
SOC	.17***	.12***	.14***
Outdoor spaces	.21***	.01	.11***	.27***
Buildings	.13***	.07**	.05*	.33***	.48***

Note. PCS = physical component summary; MCS = mental component summary; SOC = sense of community.

Eight 5-year age groups (50–54, 55–59, . . ., 85+).

p < .05. **p < .01. ***p < .001.

A path model of PCS and MCS

We constructed an unmediated path model of age-friendliness of the built environment and health-related quality of life. With respect to the direct relationship between the independent variable and outcome, outdoor spaces had no direct relationship with PCS (H1), but had a significant influence on MCS (H2; unstandardized coefficient = .060; 95% CI = [0.034, 0.086]; p < .001). Buildings had a significant relationship with PCS only (H1; unstandardized coefficient = .035, 95% CI = [0.014, 0.055]; p = .001). The corresponding standardized coefficients were .11 (95% CI = [0.06, 0.16]) and .07 (95% CI = [0.03, 0.11]), respectively.

We added sense of community to the path model to test its mediation effect (Figure 1(a) and (b)). While outdoor space and buildings were moderately correlated with each other, both factors were positively associated with sense of community (path a). Sense of community in turn was significantly associated with both PCS and MCS (path b). After adjustment of the covariates, the direct relationship between outdoor spaces and MCS (path c’) remained significant (unstandardized coefficient = .043; 95% BCa CI = [0.022, 0.065]). The relationship between buildings and PCS became nonsignificant (unstandardized coefficient = .016; 95% BCa CI = [−0.002, 0.33]). In other words, outdoor spaces and buildings contributed to physical and mental health through sense of community (Table 3).

Figure 1.

(a) Standardized estimates of the path model. (b) Standardized estimates of the path model with adjustment.

Table 3.

Test of Mediation With Bootstrapping Standard Errors.

Association	Indirect effect (path a*b)	Direct effect (path c’)	Total effect	Proportion of total effect mediated
Association	Coeff.^a [95% BCa CI]	Coeff.^a [95% BCa CI]	Coeff.^a [95% BCa CI]	%
Outdoor spaces-PCS	0.007 [0.004, 0.012]	0.002 [−0.016, 0.021]	0.010 [−0.009, 0.029]	Not reported^b
Buildings-PCS	0.013 [0.009, 0.019]	0.016 [−0.002, 0.33]	0.029 [0.011, 0.045]	44.8%
Outdoor spaces-MCS	0.007 [0.004, 0.011]	0.043 [0.022, 0.065]	0.050 [0.028, 0.072]	14.0%
Buildings-MCS	0.012 [0.007, 0.018]	−0.018 [−0.038, 0.000]	−0.006 [−0.025, 0.012]	Not reported^b

Note. Results adjusted for age, gender, marital status, living arrangements, financial sufficiency, monthly household income, and use of walking aids. CI = confidence interval; PCS = physical component summary; MCS = mental component summary.

Unstandardized coefficients. ^bProportion was not reported because the total effect was nonsignificant.

The magnitude of the indirect effect reflected the extent to which sense of community mediated the relationship. Sense of community mediated 44.8% of the total effect between buildings and PCS, and 14.0% between outdoor spaces and MCS. The indirect effects (path a*b) of outdoor spaces on PCS (H3) and buildings on MCS (H4) were statistically significant, demonstrating that sense of community was a significant mediator even though the total effects were nonsignificant. To conclude, sense of community accounted for part of the relationship between perceived built environment and health.

Discussion

The conceptual framework of the age-friendly community movement is driven by the explicit assumption that age-friendly features promote active aging. Although no causality could be drawn from the results of this research, it is one of the few studies to affirm the role of sense of community in the relationship between perceived built environment and physical and mental health of middle-aged and older adults. The study produced several key findings. The unmediated path model shows that age-friendly buildings were related to better PCS (H1) while age-friendly outdoor spaces were related to better MCS (H2). The mediation analysis found a direct association between age-friendly outdoor spaces and better mental health only. Age-friendly outdoor spaces and buildings both indirectly contributed to better physical and mental health through improved sense of community (H3 and H4). Instead of examining physical environment in general, our study specifically focused on the appraisal of outdoor spaces and buildings. Our study is also unique for its simultaneous examination of physical and mental health, thereby generating more specific findings to inform the mechanisms linking the built environment and health.

Our findings identified a direct positive effect of outdoor spaces on the mental health of middle-aged and older persons, but not their physical health. Previous studies investigating the association between outdoor environment and health have mainly focused on exposure to green space, and have consistently demonstrated the beneficial impact on mental health associated with the availability of green space (Houlden et al., 2018; Wu et al., 2015), as have studies on self-rated health (de Vries et al., 2003; Maas et al., 2006). The association between environment and mental health might be explained by stress recovery theory highlighting the restorative effects of the natural environment (Ulrich et al., 1991). People exposed to the natural environment report less stress and tend to show more positive affect and sustained attention (Ulrich et al., 1991). The composite score for outdoor spaces used in this study further indicates the direct positive effect of overall age-friendliness of the outdoor urban environment on mental health.

Sense of community was a partial mediator of the association between age-friendliness of the built environment and health, accounting for 14.0% to 44.8% of the total effect. These results further enhance Wahl’s developmental model of aging (Wahl et al., 2012) that age-friendliness of the built environment might foster a stronger sense of community. While the processes underpinning these associations have not yet been explored, these results are consistent with the Canadian Community Health Survey (CCHS) that also demonstrates a robust association between sense of community-belonging and physical and mental health (Kitchen et al., 2012). It was postulated that an age-friendly environment (accessible, safe, and comfortable-to-use outdoor spaces and buildings) might provide favorable conditions for people to interact and bond with others in their community. An increased sense of community would then increase opportunities for people to participate in health-promoting activities. The CCHS found that sense of community-belonging was consistently associated with exercise, weight loss, and improved diet (Hystad & Carpiano, 2012). An alternate explanation was that people with a stronger sense of community might have a stronger support network which led them to manage physical and mental health risk factors earlier.

Our study augments the findings of previous research that age-friendliness is a useful dimension for assessing the quality of the built environment. Most previous studies have assessed public open space using objective measures (e.g., size, distance, and number). Although the scale used in this study could not reflect all dimensions of the quality of the built environment, it extended beyond the availability and accessibility of public open space and green space. Standardized criteria for assessing the quality or age-friendliness of public open space, including but not limited to green space, are lacking, despite their relevance to urban planning and design in high-density cities like Hong Kong. A study in Perth, Australia, found that lower psychosocial distress was associated with the quality but not the quantity of public open space as measured by 10 items covering atmosphere, comfort, safety, attractiveness and maintenance, seating, and so on (Francis et al., 2012). Qualitative and subjective appraisal of public open space has drawn increasing attention (Gascon et al., 2016), but the lack of standardized assessment tools has limited cross-study comparisons and our understanding of causal relationships. Our study demonstrates that the qualitative dimension of the environment could be an independent predictor of health outcome. Future studies should consider adopting more participatory methodological approaches that draw directly on older people’s personal experiences to understand the impact of features of the built environment on their quality of life (Chui et al., 2020).

We recommend the use of age-friendliness as one of the quality indicators of the built environment for the following reasons: features of an age-friendly city imply structure and services that support people of all ages; features such as accessibility, safety, and inclusiveness can be applicable to both physical and social environments. We examined the age-friendliness of outdoor spaces and buildings in alignment with the age-friendly city guide outlined by the World Health Organization. The guide outlines physical accessibility, service proximity, security, affordability, and inclusiveness as key indicators of age-friendly cities (Plouffe & Kalache, 2010). A previous study reported that an age-friendly physical environment was positively associated with a single-item measure of self-perceived health (Menec & Nowicki, 2014).

However, scarcity of land in a high-density city may undermine the development of a socially supportive environment. Urbanicity and living in high-rise apartments are associated with a lower level of sense of community (Kitchen et al., 2012). The situation is even less favorable to older people in Hong Kong, because only approximately half of public open space in the city is designated to serve the neighborhood population and is therefore relatively more accessible to older people. Older people lack access to public open space that supports their physical and social activities (Yung et al., 2016). In a qualitative study conducted by Chui et al. (2019), older participants expressed disappointment that for-profit real-estate development was generally afforded greater priority over public needs in Hong Kong. This helped explain the negative impact of a non-age-friendly environment on sense of community and activity patterns, with consequent health implications. The built environment and service arrangements that cater to the needs of older people may enhance their feelings of being part of the community.

Our study has several limitations. The cross-sectional design preempted identification of any causal relationships; it is possible that a greater sense of community enhances the perception of age-friendliness in the built environment or, conversely, that positive perceptions of age-friendliness in the built environment may enhance sense of community. We did not include objective measures of the built environment that might simultaneously contribute to sense of community and health outcomes. The scale focused on age-friendliness and therefore did not reflect the overall quality of the built environment. Thus, interpretation of our results should be made with caution. While the study represents a case study of a developed high-density city, it may be less relevant to other developed cities that have different modes of transport and/or better provision of open space.

Conclusion

Our overall findings have implications for future research and are relevant to future policy to develop an inclusive and supportive city in Hong Kong and other Asian high-density cities. The study illustrates the importance of evaluating both physical and qualitative attributes of age-friendliness of the built environment that might be associated with health-related quality of life, a relationship that might be partly explained by a third variable (i.e., level of sense of community). Future research should use more complex modeling to test the directionality of this relationship, along with longitudinal data to ascertain more conclusively the causal pathway linking perceptions of the built environment, sense of community, and the health of older people. Governments and policy makers may use the guidelines developed by the World Health Organization (2007) as a framework for future urban planning, especially in making the urban landscape more hospitable for the health and well-being of older people.

Supplemental Material

sj-pdf-1-jag-10.1177_0733464821991298 – Supplemental material for The Contribution of Sense of Community to the Association Between Age-Friendly Built Environment and Health in a High-Density City: A Cross-Sectional Study of Middle-Aged and Older Adults in Hong Kong

Supplemental material, sj-pdf-1-jag-10.1177_0733464821991298 for The Contribution of Sense of Community to the Association Between Age-Friendly Built Environment and Health in a High-Density City: A Cross-Sectional Study of Middle-Aged and Older Adults in Hong Kong by Jennifer Y. M. Tang, Cheryl H. K. Chui, Vivian W. Q. Lou, Rebecca L. H. Chiu, Robin Kwok, Michael Tse, Angela Y. M. Leung, Pui-Hing Chau and Terry Y. S. Lum in Journal of Applied Gerontology

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Hong Kong Jockey Club Charities Trust.

Ethical Approval

Review body: Human Research Ethics Committee of the University of Hong Kong. Study reference number: EA1510033.

ORCID iDs

Jennifer Y. M. Tang

Cheryl H. K. Chui

Supplemental Material

Supplemental material for this article is available online.

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