Cross-National Comparison of Environmental Factors Important to Facility-Based Senior Living

Abstract

Objective:

Focusing on environmental factors important to facility-based senior living, this research intends to identify cross-national similarities and differences in perspective on elderly care between senior-living professionals in the United States and China.

Background:

American models of senior-living facility design have been introduced in China. In social and cultural context, environmental factors important to facility-based senior living are expected to be different by nation and need to be clarified.

Method:

Questionnaire data were collected from 188 staff members working in senior-living facilities in the United States and China. Seven factors summarized through literature review were investigated. The frequencies of each factor selected by the participants as one of the three most important factors were ranked. The influence of personal and social factors on environmental perception was analyzed using analysis of variance tests.

Results:

Common area and cross-facility home-like decoration were similarly valued by both groups as two of the three most important factors. Residential room was valued more in the United States whereas natural lighting was valued more in China. Chinese participants with more work experience valued building layout more. Amenities were valued less than expected in both countries.

Conclusion:

Environmental factors important to facility-based senior living are different between countries. American models of senior-living facility design should be adjusted for use in China. There is much to be gained from investigating the similarities and differences in perspective on elderly care.

Keywords

older adults senior living environment evidence-based design cross-national comparison

Introduction

Phenomenon of Aging

Worldwide, people aged 60 years or over was 743 million in 2009 and expected to be 2 billion in 2050 (National Institute on Aging & World Health Organization, 2011). Within the older population, the proportion of people aged 80+ (80 years or over) will reach 19% in 2050 (United Nations [UN], 2013). In the United States, the number of people aged 65 and older was 46 million in 2014 and expected to be 84 million in 2050 (Federal Interagency Forum on Aging-Related Statistics [FIFARS], 2016; Ortman et al., 2014). The population of Americans aged 80+ is projected to grow rapidly since the baby boomers are moving into this age-group. In China, the number of people aged 65 and older was 131 million in 2015 and expected to be 430 million in 2050 (World Bank, 2016). The 80+ is the faster growing group in the population of older Chinese.

China and the United States currently are the countries with the largest (23 million) and second largest (12 million) populations of people aged 80+ in the world (UN, 2013). In 2050, China will have 90 million people aged 80+ and still be the country with the largest population of people in this age bracket (National Bureau of Statistics of China [NBSC], 2015). Meanwhile, 32 million people aged 80+ will be living in the United States (UN, 2013).

Trends and Marketing Needs

As the absolute number of people in the oldest age-group increases, the demands on society for facility-based senior living grow. Older adults generally have declines in physical and cognitive functioning and eventually lose the ability to independently maintain their living at home. Their needs for some form of elderly care increase with age. It is estimated that over two thirds of Americans who reach age 65 will need long-term care services during their lifetime (Kemper et al., 2006). More than 7% of Americans aged 65 or older live in institutional settings, and the percentage of Americans aged 85 or older living in institutional settings reaches to 23 (FIFARS, 2016; Harris-Kojetin et al., 2016).

In China, a new growth market of senior-living services has been developed. The need for facility-based elderly care has been traditionally low in China due to cultural traditions of older parents living with adult children and intergenerational support of family care. However, these traditions are changing. More adult children seek jobs internationally and in big cities other than their hometowns, and thus their older relatives back home have less access to family co-residence. While this type of migration will likely continue to rise, the growing number of older Chinese geographically separated from their adult children requires facility-based senior living and care. Balancing cultural traditions against the modern reality, care for the elderly in China is still predominantly by the family, but more families cannot accommodate the needs of their older relatives and more elderly Chinese need facility-based care services. Responding to their needs, the number of beds in senior-living facilities will increase from 3.7 million to 6.5 million in the next 5 years in China (NBSC, 2015). Chinese government encourages overseas capital to invest in China’s elderly care.

Investors from the United States have started investing in China’s elderly care. American models of facility-based senior living have been introduced in China, including the ways of designing and planning senior-living facilities. Compared with traditional Chinese models of senior living, the American models include more private or single-resident rooms and are more likely to use active design strategies. Some facilities targeting the medium and high end of the Chinese market directly borrowed design items from U.S. precedents, such as Western-style interior decorations. In China, these items are perceived by many people as the icons of a modern lifestyle and high quality of life. Benefited from China’s economic growth and the well-off pension systems for government employees, many families are willing to pay a premium for their elderly relatives to live comfortably in high-quality senior-living facilities. The monthly fees range from 6,000–20,000 yuan (US$1,000–3,000) and vary according to the level of care. While those Western-style items seem appropriate for developing senior-living facilities in the United States where they were developed, the present study considers their suitability for use in China. Strategies related to the design of senior-living environments should be considered within the context of local cultures and the resident population (König et al., 2019). This international comparative study investigated senior-living professionals’ perspective on elderly care, with an emphasis on the built environment in senior-living facilities.

Aim

Focusing on environmental factors important to facility-based senior living in the United States and China, this research aims to identify cross-national similarities and differences in perspective on elderly care. The extent to which these environmental factors are valued is expected to be different by culture and country. Older adults are environmentally docile, and the influence of environments on them increases with age. In order to develop appropriate environments for senior living, clarifying the similarities and differences is a crucial issue.

Literature Review

Environments in Senior-Living Facilities

Senior-living facilities provide elderly care (e.g., assistance with daily-living activities) in institutionalized residential settings. The lines between levels of elderly care (e.g., independent living and assisted living) are becoming blurred due to the fast-paced improvements in technology for senior living and the needs for a flexible level of care. Relocation between levels of elderly care, even within the same facility, has been found to negatively influence elderly’s mental and physical health (Roth et al., 2016). It is generally preferred that a senior-living facility can provide multiple levels of care to a resident without relocating the resident. In response, many senior-living facilities provide multiple levels of care on one site. Services provided in these facilities range from shopping transportation to activities of daily living (e.g., eating and bathing) and memory care. Environments in these facilities play a critical role in elderly care and need to be investigated.

Physical environments in a senior-living facility influence residents’ quality of life (Joseph et al., 2015). Associated with age-related functional decline, older adults are more environmentally docile and less environmentally proactive than young adults (Lawton, 1989). Environmental hazards to them are frequently found in building entrances, kitchens, and bathrooms. Common environmental features (e.g., typical steps) may inhibit older adults’ interaction with their environments and sequentially reduce their mobility and ability to pursue preferred lifestyles (Haselwandter et al., 2015). Universal design features (e.g., ramps instead of steps) compensate for age-related capability decline and thus contribute to continual engagement in life (Carr et al., 2013). To promote safety and enhance independence, the application of universal design features in senior-living facilities is generally required in many countries including the United States and China. Beyond universal design, there are environmental design factors important to facility-based senior living. Based on a literature review and following the steps of typical environmental design starting from site planning to building design and interior design, this research focused on the factors and grouped them into seven categories: outdoor environment, building layout, residential room, common area, amenity, cross-facility home-like decoration, and natural lighting.

Important Environmental Factors

Outdoor environment for access to nature and active living

Access to green areas near the residence helps elderly residents to maintain health and promotes independence and longevity (Freeman et al., 2019; Takano et al., 2002; Z. Wang & Shepley, 2018). Engaging in outdoor activities increases the opportunities for older adults to access nature and meet people, leading to reduced risk of depression (Alidoust et al., 2018; Bassi et al., 2018; Z. Wang & Lee, 2010). In a senior-living facility, gardens adjacent to the entrance area and indoor–outdoor transitional areas encourage the residents to go outside and engage in active living (Rodiek, 2013; Z. Wang et al., 2012). There are promising impacts on levels of agitation in the residents with dementia who spend time in a garden (Whear et al., 2014). Walking loops are widely provided for memory care residents to ensure safety. Older adults expressed a preference for trees, shrubs, grass, and frequent shaded sitting places in outdoor environments (Rosenberg et al., 2013). In China, many community-dwelling older adults engage in outdoor activities such as square dancing. For walking, they prefer pathways with soft or even pavement but no connection to activity areas (Zhai & Baran, 2017). More research is needed to investigate residents’ use of outdoor environments in senior-living facilities in China.

Building layout for function and wayfinding

Layout of a building for senior living should be functional for staff’s daily work and residents’ daily living. Location of the main entrance has been found to influence residents’ daily activities (Gu, 2012). Due to memory decline, older adults may experience difficulties in wayfinding, leading to increased stress, safety, and security issues. To aid their in-place recognition, function zones in the building should be separated and applied with distinct design factors (e.g., wall colors). Clear circulation is needed to promote wayfinding. American researchers suggest short corridors with uninterrupted visual cues (Isaksson et al., 2009; Passini et al., 2000). Chinese researchers note that appropriate spatial continuity and rhythm can enhance older adults’ spatial sensitivity and contribute to their wayfinding (H. Y. Wang et al., 2012). Regarding care units for cognitively impaired residents, small-scale living environments (5–15 residents) are suggested to facilitate social engagement and behavioral control (Marquardt et al., 2014).

Residential room for occupancy and care

Residential rooms in a senior-living facility are typically provided as private or shared occupancies. The ratios of private to shared rooms vary by facility and care level. Influenced by the American models, senior-living facilities recently built in China provide more private rooms than those built decades before. Private rooms have been recommended in inpatient settings for low nosocomial infection rates and high-quality sleep (Chaudhury et al., 2005; Hamilton, 1999; Ulrich et al., 2008). However, shared occupancies are preferred by oncology patients to avoid isolation (Anderson, 2009; Z. Wang & Pukszta, 2018). In comparison with inpatient rooms, senior-living residential rooms are different in the ways that residents receive care. Elderly care is typically provided for a longer period of time than inpatient care. Transfer between levels of care is frequently associated with relocation to a new residential setting. To promote a sense of belonging, room factors responding to residents’ individual needs such as a display cabinet for family photos are suggested (Garcia et al., 2012).

Common areas in the interior for social interaction

Interior common areas in a senior-living facility play a critical role in residents’ social life. Older adults spend an average of 19.5 hr per day inside their residence (Brasche & Bischof, 2005; Garcia et al., 2012). By engaging in social interaction, they can learn, share, and access needed information and thus reduce the risk of depression (Canham et al., 2018; Kaplan & Kaplan, 2003). Common areas provide spaces and opportunities for them to engage in social life, leading to confirmed social identities and links to the surroundings (Richard et al., 2009; Yao & Huang, 2017). The incorporation of multiple types of common environments (e.g., open and semi-open areas) in a senior-living setting facilitates residents’ active behavior (Barnes, 2006). The inclusion of common areas in residents’ daily path of travel and the proximity of common areas to residential rooms promote their social interactions (Campbell, 2015; Pinet, 1999). Common areas for entertaining family members and friends are also recommended to promote family–resident interaction (Percival, 2002).

Amenities for convenience, physical activity, and entertainment

Amenities for daily-living convenience (e.g., convenience stores) are typically provided in senior-living facilities. Spaces for physical activity (e.g., exercise rooms) have also been widely implemented. Elderly people who have access to recreational facilities are more likely to have adequate physical activity for health purposes (Booth et al., 2000). Media rooms, in-house libraries, art studios, and learning centers are widely introduced for residents’ entertainment, learning, and hobbies. Moreover, religious or spiritual meditative spaces are valued and provided in many senior-living facilities. Associated with different cultures and lifestyles, popular amenities may vary by facility and country and need more research.

Cross-facility home-like decoration for sense of belonging

Home-like decoration has been generally applied in senior-living facilities. Moving from home to a senior-living facility negatively influenced older adults’ sense of control (Perry et al., 2014). Before the move, an older adult may live in his or her own house; after that, he or she may share a bedroom with others and needs to rebuild social spheres of life. The reconstruction of life takes time and energy. Home-like decoration helps to reduce homesickness and promote residents’ sense of belonging in the facilities (Cooper Marcus, 1995; Scheidt & Norris, 1999). Home-like settings promote resident-directed conversations and social interactions among residents with dementia (Campo & Chaudhury, 2012; Roberts, 2011). From residential rooms to corridors, home-like decoration should be applied across the facility and designed to recall residents’ good memories of home and success.

Natural lighting for health

Appropriate natural light exposure contributes to high-quality sleep in older adults and helps to maintain health (Dzierzewski et al., 2014; White et al., 2013). Natural light has been used in light therapy to treat a variety of problems related to aging (Hoof et al., 2015). It evokes the feeling of “biophilia” and is more comfortable than electronic lighting (Harb et al., 2015). The design of a 24-hr light and dark environment for long-term care mitigates residents’ symptoms of circadian disruption (White et al., 2013). Pleasant sunlight perceived by older adults promotes their engagement in active living (Z. Wang, 2014). Less exposure to natural light has been found to be related with more sedentary behaviors in older adults (Diaz et al., 2016). Natural light has been viewed as positive “Qi” or energy in China and is highly valued in Feng Shui theory.

In the development of a senior-living facility, aforementioned environmental factors should be implemented to promote care. There should be cross-national similarities and differences in terms of environmental needs and perception on care. The extent to which these factors are valued in the United States or China is expected to be different from each other and needs to be clarified.

Method

Theoretical Framework

This research involved multiple disciplines including architecture, planning, elderly care, and gerontology. According to the ecological model, needs for appropriate environments can be viewed as interactions between the users and their environments along physical, social, and personal dimensions (Lawton & Nahemow, 1973). This is true of senior-living facilities. The interactions between elderly residents, staff, and the social and physical environments in the facility determine residents’ optimal levels of functioning and the quality of care. To compensate for residents’ decline of personal competence (e.g., sensory loss and reduced mobility), the environments should be built to be senior-friendly through design and planning and within the context of its social and cultural characteristics.

Focusing on the seven environmental factors summarized through the literature review and based on the ecological model, this research developed the social ecological model of elderly care in senior-living facilities (as shown in Figure 1) and used it to investigate cross-national similarities and differences in perspective on elderly care.

Figure 1.

Social ecological model of elderly care in senior-living facilities.

Data Collection

Questionnaires and measures

A questionnaire was developed in English as the baseline questionnaire. It was developed by incorporating previously validated survey questions focusing on senior living. Specific items regarding the environmental factors were created and added. Based on the social ecological model of elderly care in senior-living facilities, this questionnaire collected three groups of data: personal, social, and environmental. The first part gathered data on personal and social variables. Four personal variables (age, gender, race, and education) were included. The two social variables were one’s facility role (caregiver, coordinator, manager, or other types of staff members) and years of experience working in senior-living services. The second part was focused on environmental perceptions. Participants were asked to identify their three most important perceptions from the list of seven factors.

The baseline questionnaire in English was refined after two pilot surveys conducted in two senior-living facilities in Sacramento, CA. Eleven staff members joined the pilot surveys and provided feedback on the questionnaire design and wording. Their comments aided in the refinement of the questionnaire. For instance, the factor common area was defined as common areas in the interior to reduce confusion. The refined questionnaire was reviewed a second time by pilot participants. A Chinese version of this questionnaire was then developed and refined after a pilot survey conducted in Beijing to confirm the wording in Chinese. In both American and Chinese surveys, participants’ age, gender, race, and education in the pilot studies and final surveys were similar. Multiple-choice questions were tested in the pilot surveys and confirmed to work well for research purposes.

Research sites and populations

This research was approved by a university-based institutional review board in the United States. Focusing on environmental design and senior-living staff members, there were no human research subjects included in research. To investigate the state of facility-based senior living, data were collected from facilities that provided multiple levels of elderly care including independent living, assisted living, and nursing care.

Associated with facility policies, research data from senior-living residents in the United States were unavailable to this cross-national study. Survey data from senior-living residents in China were collected. Due to limited data availability, the cross-national comparison of residents’ environmental perceptions couldn’t be completed in this phase of research. The team successfully surveyed staff working in senior-living facilities in both countries. On a daily basis, they provide care and services to senior-living residents and know the environments in the facilities well. To promote elderly care, it is worth investigating senior-living staff’s perceptions on senior-living environments. Two sets of data were collected through a 5-week online survey in the United States and 10 on-site surveys in China. A total of 188 senior-living staff members participated.

In the United States, the team contacted one of the nation’s largest senior-living organizations to ensure a relatively large sample size while controlling for possible confounding variables. At the time of the survey, this organization had 46 facilities in multiple states, providing multiple levels of care and applied common management policies. Survey invitation letters were developed and distributed to these facilities. Limited by budget for research travel, this survey was conducted online. Of the 46 facilities, 25 participated from California, Virginia, and Kansas; others had scheduled other online events during the time of the proposed survey. The online survey was open for 5 continuous weeks in the spring of 2016. Survey emails were sent to staff working in these facilities twice during the survey weeks. There were 87 participants. At the time of survey, their facilities had run for an average of 11 years and the capacities ranged from 65 to 188 beds. In each of these facilities, there were a total of 8 to 12 staff members, and the number of survey participants ranged from 2 to 4 by facility.

In China, the development of large senior-living organizations is in its infancy. In the context of urbanization, many senior-living facilities are located in the suburban areas of big cities such as Beijing and Shanghai. Through phone calls and email, the team contacted 12 senior-living facilities in Beijing and Shanghai to introduce this research and send survey invitations. Four facilities in Beijing and six in Shanghai accepted the invitations to participate. The rest had already booked other activities during the time of the proposed surveys. All participant facilities provided multiple levels of care at the time of survey. On-site surveys were conducted in the facilities by the principal investigator and three assistants (graduate students in environmental design) in the autumn of 2016. Printed questionnaires were distributed to participants at the beginning of survey activities and collected at the end. There were 101 participants. At the time of survey, their facilities had run for an average of 4 years and the capacities ranged from 90 to 150 beds. Each of these facilities had 10 to 18 staff members, and the number of participants ranged from 6 to 12 by facility.

Data Analysis

Analysis of the survey data was focused on factor ranking to identify the cross-national similarities and differences. Data were separated by facility and country. Participants ranked the three most important factors. To investigate the influence of personal or social variables on environmental perception, variance tests were conducted by using the Statistical Package for the Social Sciences (Version 22.0; p ≤ .05, two-tailed).

Results

The three most important factors in the United States were residential room, common area, and home-like decoration, respectively (as shown in Figure 2). In China, the three most important factors were common area, building layout, and home-like decoration (as shown in Figure 3).

Figure 2.

Factors important to facility-based senior living in the United States. Numbers show how frequently a factor was selected by the participants as one of the three most important factors in senior living.

Figure 3.

Factors important to facility-based senior living in China. Numbers show how frequently a factor was selected by the participants as one of the three most important factors in senior living.

Similarities

In both countries, the factors common area and home-like decoration were highly valued. The factor common area was identified as either the most or second most important factor (identified by 49 of 87 participants in the United States and 67 of 101 in China). Home-like decoration was identified as the second or third most important factor (identified by 42 of 87 participants in the United States and 52 of 101 in China). Compared with other factors, amenity was valued less in both countries.

Differences

Regarding the factor residential room, it was perceived by American participants to be the most important in senior living while participants in China valued it the least. Chinese participants valued the factors building layout and natural lighting higher than American participants.

There were no significant differences between Chinese and American participants’ personal or social factors (as shown in Table 1). In both countries, the majority of survey participants were female (60+ %) and the average age was in the 30s. Their race was the largest ethnic group nationwide: Han (China) or non-Hispanic White (United States). Most of them worked in caregiving, coordinating, or managing senior living. Their months of experience working for senior-living services averaged to 49 (China) or 51 (United States). Participants’ average level of education was higher in the United States (college level).

Table 1.

Survey Participants in China and the United States.

Variable	American (N = 87)	Chinese (N = 101)	Measure
Age	36	32	Average in year
Gender	64	71	% of females
Race	48 (a)	92 (b)	% of non-Hispanic White (a), Han (b)
Education	3.1	2.8	Average level
Staff role	81	85	% of caregivers, program coordinators, and managers
Work experience	51	49	Average in month

Note. Han is the largest race population in China. Education levels were measured at four levels: middle school, high school, college, and graduate school.

Regarding the influence of personal and social variables on environmental perception, no significance was found in the U.S. data. In China, participants with more experience working for senior-living services were more likely to value the factor building layout (p < .05). The association between age and the likelihood of selecting building layout as one of the three most important factors approached statistical significance (p = .06).

In summary, the factors common area and home-like decoration were cross-nationally valued by both American and Chinese participants as the most important factors in senior living. The factor residential room was valued more in the United States whereas natural lighting was valued more in China. Chinese participants with more work experience were more likely to value the factor building layout. Compared with other factors, amenity was valued less in both countries.

Discussion

In line with the literature in environmental gerontology, this study shed light on senior-living professionals’ perspective on facility-based senior-living environments. The U.S. and Chinese professionals reported similarities and differences across various dimensions related to site planning, building design, and interior design. Based on the social ecological model of elderly care, these environmental factors interact with personal and social factors and can contribute to facility-based senior living in both countries.

Common Areas in the Interior and Outdoors

The importance of indoor common areas to facility-based senior living was highlighted by the senior-living professionals in both countries. This is consistent with findings of previous studies (Richard et al., 2009; Yao & Huang, 2017). Social life is cross-nationally important to senior living and common areas in senior-living facilities should be well developed to promote it. Older adults frequently report feelings of loneliness and the need for social interaction. One of the popular reasons for older adults to move to a senior-living facility was the opportunity to meet and talk with others in the facility. Outdoor environments in a senior-living facility should include outdoor common areas for residents to engage in social interaction. Senior-living staff in both countries valued its importance at a medium level. Associated with age-related functional decline, older adults’ participation in outdoor activities is strongly influenced by weather and temperature changes. Compared with outdoor activities, activities in the interior are generally easier for them to engage in. Interior common areas should receive more attention in the development of a senior-living facility.

Social life is cross-nationally important to senior living and common areas in senior-living facilities should be well developed to promote it .

Residential Room and Cross-Facility Home-Like Decoration

Residential room was perceived as the most important factor in facility-based senior living in the United States. This is consistent with findings of previous studies (Chaudhury et al., 2005; Hamilton, 1999; Ulrich et al., 2008). However, research participants in China valued the factor residential room the least. This phenomenon may be associated with differences in lifestyle between older Chinese and Americans. In this research, 82% of the senior-living residential rooms in participant facilities in the United States were designed to be private whereas 78% of the rooms in Chinese facilities were shared by two or three roommates. Compared with those living alone, residents who had roommates may have more opportunities to interact with others and thus engage in more social interactions. In the context of China’s development, many of today’s older Chinese experienced shared occupancies in their 20s or 30s during the Cultural Revolution. Shared-room residents may enjoy talking with their roommates. Staff suggested that benefits of shared occupancies included the reciprocal daily support and safety observation from roommates. On the other hand, private-room residents generally enjoy private occupancy and have more opportunities to choose personal lifestyles, which are highly valued in Western cultures. More research is needed to clarify senior-living residents’ perspective on room type.

Cross-facility home-like decoration was highly valued by the participants in both countries. This is consistent with findings of previous studies (Cooper Marcus, 1995; Scheidt & Norris, 1999). Associated with different meanings of “home,” specific home-like decorations may vary by culture and location. However, the need for a sense of belonging to one’s residence is cross-nationally similar. In the development of home-like decorations, residents’ personal stories and life experiences should be thoughtfully considered in order to promote their sense of belonging to their facility.

Building Layout and Natural Lighting

The factor building layout was valued more by Chinese participants who had more experience working in elderly care. Facility-based senior living involves a variety of elderly-care services that need to be well organized in facility buildings. Staff with more work experience saw the importance of building layout to service operation and valued it more. Due to high population densities, senior-living buildings in China (three to seven stories) are generally taller than those in the United States (one or two stories). Senior-living staff in China may involve more vertical transportation, which may influence their perception of building layout. Nursing service for memory care is in its infancy in China, and more research is needed to investigate the appropriate building layout and unit size.

The importance of natural lighting in senior living was valued more by Chinese participants. Natural lighting is widely preferred in Eastern cultures as a positive environmental factor and plays a critical role in interior luminance. In the United States, active design strategies including artificial lighting are frequently applied to ensure indoor comfort. Together with the promotion of passive design strategies for sustainability, health and energy-saving benefits of natural lighting will receive more attention in the development of senior-living facilities.

Together with the promotion of passive design strategies for sustainability, health and energy-saving benefits of natural lighting will receive more attention in the development of senior-living facilities .

Amenities

Compared with other factors, amenities were similarly valued less by both participant groups. In current senior-living markets, many facilities intend to invest in new amenities to capture the attention of potential customers. However, this research found that senior-living staff valued it less than expected. Some amenities for senior living, such as an in-house cinema or swimming pools, are expensive. To better use the resources for elderly care, more research on senior-living amenities is needed. Since baby boomers in the United States and older Chinese who have no access to family co-residence are making decisions to move to senior-living facilities, future research should access what their preferred amenities are.

Limitations

Although carefully defined by conducting the literature review and pilot studies, the wording of precategorized environmental factors may be differently understood by the participants and influence their identification on factor importance. Commonly found in environmental behavior studies, the self-selection bias also exists in this research. Survey items created for this study can be further developed to guide future research.

Conclusion

This study indicated that social and cultural influences were key aspects of needs assessment for facility-based senior-living design. It was exploratory with the intent to demonstrate that there was much to be gained from investigating the cross-national similarities and differences in elderly care. It is clear that American models of senior-living facility design should be adjusted for use in China. Historical differences in the built environment in the United States versus China may lead to different expectations of need fulfillment for senior living. As opposed to their peers, the American professionals were more likely to value the importance of residents’ rooms whereas the Chinese professionals had higher expectation of natural lighting to fulfill residents’ psychological needs (e.g., Feng Shui theory). However, countries did not differ regarding global needs such as safety, social interaction, and home since universal design, common area, and cross-facility home-like decoration were cross-nationally valued as the most important factors in senior living.

The trends of ballooning elderly populations and demands on society for facility-based elderly care are not confined to the United States and China. Many other countries, particularly in Asia, have similar trends, and some may also be heavily influenced by foreign prototypes of senior-living design. Now is the time to determine which factors are most important in each culture so that facilities can make appropriate decisions with regard to the diverse needs of senior living. Future studies on senior-living environments should investigate older adults’ perspectives and suggestions. Larger and more ethnically diverse samples should be incorporated for a larger worldview.

Implications for Practice

Multiple types of interior common areas should be organized in harmony with the outdoor environments for senior living. Areas close to a facility’s entrance and resident rooms should be designed as common areas to promote social interaction. In a multiple-story building for senior living, a vertical circulation linking common areas across stories may be considered.

Cross-facility home-like decoration is necessary for high-quality senior living. Along with physical, social, and psychological dimensions, home-like decorations should be developed with respect to the residents’ social and cultural backgrounds.

Regarding senior-living room types, residents’ need for privacy and their willing to avoid isolation should be balanced. Given the differences between facilities in terms of residents’ health, education, and economic situation, the ratio between private and shared occupancies should be addressed in the context of individual projects.

Given the high importance of natural lighting to senior living, the orientation of windows in the environments where older adults spend long periods of time, such as their residential rooms and common areas, should be toward the sun. To develop the opportunities to open appropriate windows, these environments should be located in the areas with high accessibility of building envelopes. In order to invite pleasant natural light to the interior, the location of a building on its site is critical. To maximize pleasant indoor sunshine in the morning and minimize glare in the afternoon, north–south facing of the long sides of the building is recommended in the northern hemisphere.

Accessible outdoor environments in a senior-living facility need to be developed to promote residents’ physical and social activities. Outdoor handrails, walking trails, and screened outdoor setting areas should be considered. Along with the consideration of natural lighting, south-facing outdoors should be created in harmony with the shadow caused by the surroundings.

To develop appropriate amenities for a senior-living facility, suggestions from the residents and local senior-living professionals need to be carefully considered during the process of design.

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 National Social Science Foundation of China (13BG062).

ORCID iD

Zhe Wang, PhD

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