PHYSICAL ACTIVITY OF OLDER PEOPLE, THERAPEUTIC LANDSCAPES AND
PUBLIC SPACES IN URBAN CHINA
By
Peiling Zhou

A DISSERTATION
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
Geography—Doctor of Philosophy
2018

ABSTRACT
PHYSICAL ACTIVITY OF OLDER PEOPLE, THERAPEUTIC LANDSCAPES AND
PUBLIC SPACES IN URBAN CHINA
By
Peiling Zhou
The purpose of my dissertation research is to examine the far-reaching influence of
physical activity practices among older Chinese people, in both their own community and in urban
public life. The overarching research question, therefore, is two-fold: (1) How do social spatial
environments influence older people’s self-care practices and thus influence their health and
wellbeing; and (2) How do the self-care practices of older people shape the social spatial spaces
of aging in neoliberal urban China, in return? To answer these questions, I utilized a mixedmethods approach in two study sites, Laolongyan neighborhoods in Huainan City, a mid-sized city
in China and Mudanyuan neighborhoods in Beijing, the capital and a large city in China.
This research consists of three objectives to address the goal of the dissertation. Each
objective is a separate study representing an article in the dissertation. The first article examines
the bi-directional relationships between physical activity and chronic disease in an older
population in China. Drawing on a six-year longitudinal health survey data of older people in four
neighborhoods in Huainan City and survival analysis and multilevel logistic regression, this study
revealed that health disparities among older people may widen as those sedentary experience
earlier onsets of chronic diseases and worse health trajectories, compared to more physically active
people. The second article examines the pathways by which physical activity behaviors are
impacted by the social and physical aspects of the built environment. Combining the Social
Ecological Model and the Stage of Behavior Change Model within a mixed-method approach, I

found (a) that the liveliness of an apartment building is important in attracting sedentary older
adults to initiate physical activity; (b) housing closeness to urban functional spaces is associated
with the initiation of physical activity through social networks of neighbors; and (c) social
networks of neighbors is the most important factor in regulating physical activity. The third article
investigates physical activity spaces simultaneously as therapeutic and public spaces. Engaging
with a combination of the concepts of therapeutic landscapes and public spaces, my case studies
in Huainan and Beijing demonstrate the possibility and synergies of combining the two
complementary approaches, -i.e., to help put health into public and build therapeutic landscapes
for all. This article also demonstrates the possible active role of older groups in the making of
therapeutic public urban spaces in China.
In summary, through this dissertation research, I demonstrated that the differential social
and physical environments led by the commercialized health care and health promotion services
markets can make a change in physical activities among older people, and therefore widen the
health disparity among older people with different behavior patterns. In return, the older group
occupies their physical activity practices and plays an active role in exploring and constructing
their therapeutic and public spaces. Tackling the problem of increasing health inequality within
the rapid demographic and social transitions in urban China requires considering the health and
wellbeing of all social groups and deconstructing the subjectivity of vulnerable groups, particularly
the older population. This dissertation enriches the discussions of the health belief model and built
environment effects on health, and expands the theoretical and field boundaries of therapeutic
landscapes and public spaces to define therapeutic public spaces.

Copyright by
PEILING ZHOU
2018

This dissertation is dedicate to millions of ordinary (older) people.

v

ACKNOWLEDGEMENTS

Doing a Ph.D. is a lonely journey, but I am fortunate enough to be able to spend my past
five years with many great people, to whom I owe many thanks. First and foremost, I would like
to thank my advisor Dr. Sue C. Grady, who has always been supportive along this journey. Sue is
the best Ph.D. advisor I could ever ask for. Without her support, I could not even imagine how to
finish this lonely journey. She has always encouraged and inspired me to pursue what I am
passionate about, no matter how rough my ideas are at the beginning. Over the years, she has spent
so much time listening to my thoughts and reading my work, and she has always given me feedback
with plenty of detailed comments. As a health geographer and advisor, she also cares about my
physical, mental, and emotional health; she encourages me to increase my physical activity and
make friends after work. I have learned a lot from Sue; I have learned how to be a good scholar,
advisor, teacher, and colleague.
I would also like to acknowledge my dissertation committee members: Dr. Kyle T. Evered,
Dr. Guo Chen, Dr. Anne K. Hughes, and Dr. Mark Rosenberg at Queens University for their
profound support for my research. I would like to thank Kyle and Guo for providing advice ever
since I arrived at MSU even when I had no clear idea about what my research topic would be. I
would like to thank Anne for providing suggestions for my paper and future research directions
and for encouraging me to explore the gerontology field. I would also like to give special thanks
to Mark for continuously caring about my project, for providing so many constructive comments,
and having me participate in several conference sessions since we first met at the 2014 Tampa
AAG.

vi

I acknowledge and am thankful for the support provided by my master thesis advisor, Dr.
Eric Laurier at the University of Edinburgh, and my bachelor thesis advisor, Dr. Yanwei Chai at
Peking University.
I am deeply grateful to the faculty, staff and graduate students in the Department of
Geography, Environment and Spatial Science at Michigan State University. Many thanks to the
department chair Dr. Alan F. Arbogast, graduate coordinator Dr. Ashton Shortridge, department
secretaries Ms. Judy Reginek, Ms. Claudia Brown, Ms. Sharon Ruggles and systems analyst Mr.
Wilson Ndovie for their support in my studying, research, funding applications, and job hunting.
I would like to thank Dr. Lifeng Luo, Dr. Randall J. Schaetzl, Dr. Julie Winkler, Dr. Catherine
Yansa, Dr. Jiaguo Qi, Dr. Jiquan Chen, Dr. Amber L. Pearson, Dr. Leo Zulu, Dr. Joe T. Darden,
Dr. Igor Vojnovic, Dr. Gary Schnakenberg, Dr. Linda Hunt, and Dr. Daniel Menchik for providing
supportive suggestions on my research project. I would like to thank all my lab mates, -i.e., Dr.
Peter Koh, Libbey Kutch, Fatima Barry, Lonnie Barnes, Qiong Zhang, and Mattie Bene for sharing
their insightful thoughts on health geography. I would also like to thank all the family members of
our Geography Graduate Group (TripleG), including Dr. Minting Ye, Dr. David Baylis, Dr. Jia
Feng, Dr. Zutao O’Yang, Dr. Steven Schultze, Dr. Joshua Vertalka, Dr. Susie Wu, Dr. Ying Tang,
Caitlin Clark, Christopher B. Connallon, Brad Peter, Victoria Breeze, Maura Casey, Jiang Chang,
Yi Fan, April Frake, Cadi Fung, Dee Jordan, Ameen Kadhim, Xiaomeng Li, Zihan Lin, Judith
Namanya, Amanda Rzotkiewicz, and my dear office mate Wei Liu for their company,
encouragement, and critique. Being part of this department has been an unforgettable and
wonderful experience.
I am grateful to all the friends I met in North America and in China. I would like to give
special thanks to my roommate Cheng Qian for her support and company at many enjoyable and
vii

terrible moments in these years. I am fortunate to meet Liao Zhang, Yue Dai, Yang, Jie Yu, Mengqi
Yang, Jessica Finlay and Stephanie Coen in my graduate study life. Many thanks also to my old
friends and colleagues Ya Han, Luxi Lin, Xiaolu Li, Yan Ma, Dr. Junxi Qian, Dr. Zuopeng Xiao,
Dr. Xiaoxia Xu, Dr. Tao Liu, Dr. Jiejin Wang, Dr. Tianbao Liu, Dr. Na Ta, Dr. Ying Zhao, Dr.
Yue Shen, Dr. Yan Zhang, to name but a few.
This dissertation is for my beloved family, my husband, my parents, and grandparents. I
am fortunate to have such a supportive family, which taught me to love, understand, empathize,
and reflect and have always respected my decision to be a scholar.
Finally, this dissertation is certainly for the millions of ordinary people in (and out of) my
field, who are suffering in everyday life, but always choose to be kind and optimistic and make
every effort to pursue a better life. We may not always recognize each other, but we can still make
a little difference in each limited field, encouraging and benefiting each other.

viii

TABLE OF CONTENTS

LIST OF TABLES......................................................................................................................... xi
LIST OF FIGURES...................................................................................................................... xii
CHAPTER 1……………………….…………………………………………………...….……... 1
INTRODUCTION…...................................................................................................................... 1
Aging Population and Physical Activity in Urban China……………………………………... 1
Goal and Objectives………………………………………………………………………….... 4
Study Areas…………………………………………………………………………..……... 5
Methodological Notes………………………………………………………………..……... 8
Summary of Dissertation Articles…………………………………………………………... 9
BIBLIOGRAPHY………………………………………………………………………………. 13
CHAPTER 2…………………………………………………………………………….………. 17
PHYSICAL ACTIVITY AND CHRONIC DISEASES AMONG OLDER PEOPLE IN A MIDSIZE CITY IN CHINA: A LONGITUDINAL INVESTIGATION OF BIPOLAR EFFECTS… 17
Introduction ...……………………………………………………………………………….. 17
Methods ………………...……………………………………………………………..…….. 20
Study Design ……………………………………………………………….…………….. 20
Data Sources and Population…………………………………….………………….….. 21
Measures………………………………………………………………………………….. 21
Data Analyses ..................................................................................................................... 24
Results...................................................................................................................................... 27
Prevalence of chronic diseases by socio-demographic characteristics ........................... 27
Physical activity and socio-demographic characteristics ................................................ 29
Chronic diseases that trigger physical activity changes ................................................ 31
Physical activity and the onset of chronic disease.............................................................35
Discussion.................................................................................................................................39
Conclusion………………………………………………………………………………...….43
BIBLIOGRAPHY………………………………………………………………………………..45
CHAPTER 3………………………………………………………………………..…………… 52
HOW THE BUILT ENVIRONMENT AFFECTS CHANGE IN OLDER PEOPLE’S PHYSICAL
ACTIVITY: A MIXED-METHODS APPROACH USING LONGITUDINAL HEALTH
SURVEY DATA IN URBAN CHINA......................................................................................... 52
Introduction………………………………………………………………………………….. 52
Data and Methods………………………………………………...………………………….. 54
Study Area and Population……………………………………………………………….. 54
Study Design………………………………………………………..…………………….. 55
Qualitative Phase……………………………………………………………...………….. 57
Sampling and Interviews…………………………………………………...………….. 57
Content Analyses ............................................................................................................59
ix

Quantitative Phase…………………………………………………………………….….. 61
Data Sources…………………………………………………………………….…….. 61
Physical Activity Measures............................................................................................. 61
Individual-Level Measures............................................................................................. 62
Built Environment Measures.......................................................................................... 64
Path Analyses.................................................................................................................. 65
Results...................................................................................................................................... 66
Descriptive Analyses…………………………………………………….……………….. 66
Content Analyses…………………………………………………………………...…….. 67
Path Analyses……………………………………………………………….. …………… 72
Discussion........................................................................………………………………….... 75
Conclusion………………………………………………………………………………….... 78
BIBLIOGRAPHY………………………………………………………………………………. 80
CHAPTER 4…………………………………………………………………………………..… 86
THERAPEUTIC PUBLIC SPACES FOR ALL: PERFORMANCE AND COLLABORATION
OF LEISURE PHYSICAL EXERCISERS IN URBAN CHINA...................................................86
Introduction………………………………………………………………………………….. 86
Making Therapeutic Spaces for Public/Putting Health into Public Spaces……………….…. 88
Physical Exercisers in a Transitional China…………………………………………...…… 93
Methodological Notes………………………………………………………………….....…. 96
Results.................................................................................................................................. 100
Stationary Leisure Exercisers and Hobbyists: Mid- and Older-aged Pathfinders….…… 100
Mobile Exercisers: Audiences and Consumers……………………………………..….. 106
Low-end Retailers: Supporters………………………………………………………….. 110
Discussion: Rethinking Public Spaces and Therapeutic Landscapes...................................... 113
Conclusion…………………………………………………………………………………. 117
BIBLIOGRAPHY……………………………………………...……………………………… 119
CHAPTER 5…………………………………………………………………………………… 126
CONCLUSIONS........................................................................................................................ 126
Main Conclusions………………………………………………………………….……….. 126
Contributions to the Literature…………………………………………………………..... 128
Practical Implications……………………………………………………………..……… 130
Future Research Directions…………………………………………………………….…. 133
BIBLIOGRAPHY…………………………………………………………………………..…. 136

x

LIST OF TABLES

Table 1: Description of variables and measurements of the 6-year longitudinal health survey data
in Huainan………………………………………………………………………………………. 24
Table 2: Description of baseline prevalence of chronic diseases in the three neighborhoods in
Huainan……………………………………………………………………………...………….. 28
Table 3: Multilevel logistic regression between socio-demographic features and physical activity
level among older people 2010 to 2015…………………………………………….……….… 30
Table 4: Logistic regression between the onset of chronic diseases and physical activity behaviors
2010 to 2015………………………………………………………………………………. 33
Table 5: Onset median age (MA) of chronic diseases and hazard ratio (HR) with different
levels/years of PA…………………………………………………………………………… 36
Table 6: The reference value of seven chronic diseases (International Classification of Diseases
Tenth Revision) (ICD-10)…………………………………………………………………….… 63
Table 7: Comparisons of interviewees and health survey population of research sites………... 67
Table 8: Content analysis coding results: Factors at individual and built-environment levels that
affect older people’s physical activity change……………………………………………...… 70

xi

LIST OF FIGURES

Figure 1: Location of Huainan City in Anhui Province, China………………………………..…. 6
Figure 2: Huainan City (left) and landscape (right) of the three study neighborhoods…..……… 7
Figure 3: Location of Mudanyuan and Olympic Center neighborhoods in Beijing……………. 8
Figure 4: Changing odds ratios (ORs) of PA by increasing age groups. a: PA vs. sedentary; b: PA
regular vs. irregular; and c: PA moderate vs. low………………………………………….. 31
Figure 5: The impacts of the diagnosis of different chronic diseases upon changes in physical
activity………………………………………………………………………………………...… 34
Figure 6: Survival estimates of different chronic diseases among people with different physical
activity levels. a: any chronic diseases; b: overweight and obesity; c: hypertension; d: diabetes; e:
hyperlipidemia; f: cardiovascular diseases; g: liver and biliary system diseases; h: kidney
diseases.………………..…………………………………………………………………….... 37
Figure 7: Survival estimates of onset of chronic diseases by age with different accumulative
physical activity years a: any chronic diseases; b: overweight and obesity; c: hypertension; d:
diabetes; e: hyperlipidemia; f: cardiovascular diseases; g: liver and biliary system diseases; h:
kidney diseases.……………………………..………………………………………………… 38
Figure 8: The process of mixed-methods integration……………………………………….… 56
Figure 9: Question flow of Structural Interviews on n=42 middle age to older adults……..… 58
Figure 10: Map of daily activity area for older residents in the three neighborhoods…………. 60
Figure 11: The Conceptual Model of individual, social and physical built environment correlates
of physical activity……………………………………………………………………………… 71
Figure 12: Results of multilevel path analyses testing individual and built environment effects on
older adults’ initiation, regulation, and maintenance of physical activity……………………. 73
Figure 13: Map of daily activity area and built environment characteristics and recommendation
for future intervention sites……………………………………………………………………… 75
Figure 14: a: Physical exercisers near a lake. b: A pavilion with Peking Opera Club. c: Tai-qi in a
frontage of park track. d: Square dancers in front of banks and restaurants………………… 103
Figure 15: a: Children freely play around the square dancer on the frontage. b: Old Karaoke singers
provide a lively and safe track for late commuters…………………………………………..… 105

xii

Figure 16: a: A group is jogging fast in the evening. b: an old walker, following a mother with two
children……………………………………………………………………………………...… 109
Figure 17: a. farmer’s market next to Yuan Dynasty City Wall Relics Park. b. Good and More
Grocery Store open next to Laolongyan Park. c. a sugar artist next to the walking track. d. a dad
just bought a kite for his son………………………………………………………………… 112

xiii

CHAPTER 1
INTRODUCTION
Aging Population and Physical Activity in Urban China
As a result of the decreasing fertility and the increasing life expectancy in the past half
century, the proportion of people aged 65 and over years is growing faster than any other age group
in almost every country (World Health Organization, 2015b). China is also experiencing a rapid
demographic transition. In 2015, there were 14.4 million older people in China (Ministry of Civil
Affairs of the People’s Republic of China, 2016), equating to 10.5% of the total population. By
mid-century, China’s older population will increase to 34.1% of the total population, making China
an important contributor to the global demographic transition (WHO, 2015b). With a rapidly
increasing older population, there is also the concern that the prevalence of chronic diseases will
also increase, as a result of aging, creating a greater social burden on the health care system, and
society as a whole. In 2013, 49.5% of older people in China were diagnosed with at least one
chronic disease, and the incidence is still increasing (WHO, 2006, 2015a). Since physical activity
(PA) has been shown to prevent chronic disease and delay chronic disease onset in the middleaged (54-64 years) and older people (aged 65 years and older) (US Department of Health and
Human Service, 2008; Warburton, Nicol, & Bredin, 2006), it is important, to examine and further
understand how to promote older people’s PA from the individual to community and society levels.
To understand older people’s PA in urban China, it is necessary to situate the PA behaviors
in the context of transitional urban China. First, PA behaviors can be viewed as a compromising
solution for older people whose health care needs are increasing, at the same time medicine and
health care services are becoming more commercialized and expensive for ordinary older Chinese
people. Since the Reform and Opening Up of China in the late 1970s, ‘marketized’ reform has led
1

to the ‘commercialization’ of health care services. Although a high percentage of older people’s
health care costs are covered by health insurance and compulsory savings, they still have to pay a
certain amount of those costs, out-of-pocket (Gu & Zhang, 2006). With only a limited pension,
ordinary older people in China may not be able to afford the health care services that they need,
and thus have to do their best to prevent disease, to delay or offset those costs. Since public leisure
PA activity spaces and PA facilities are largely accessible in terms of close distance and of no cost,
older Chinese people are choosing to practice PA outdoor to prevent geriatric syndromes and
chronic disease and minimize their health care costs.
Second, PA behaviors can also be treated as older people’s compromising solution to their
increasing daily needs in a rapidly urbanizing society. The informal daily care from family and
community is also declining due to rapid urbanization. Although the tradition of filial piety, or
xiao, emphasizes material provision and caregiving from younger generation to older, family
caregiving cannot be guaranteed in this new generation (Zhan & Montgomery, 2003). While a
large amount of labor outflow has decreased the availability of family caregivers in small cities,
the heavy working load and the rigorously enforced one-child policy also discouraged young
people from taking care of their older parents in large cities (Zhan, 2006). The commercialization
of housing and the decline of traditional neighborhoods and danwei compounds has additionally
disrupted social connections within communities, thus disrupting informal daily care from the
community–i.e., older people’s neighbors and community social support system. The consequence
of the increasing needs of daily services is an increasing culture of life-nurturing and increasing
desire for leisure physical activities among older Chinese, featured in their everyday urban life
(Farquhar & Zhang, 2012).

2

It is, therefore, important to examine the influence of the urban environment on PA of
older people, and understand the impacts of PA on the health and wellbeing of older people
at the individual, community and societal levels in in China. At the individual level, since older
people’s PA can be understood as a strategy to keep healthy at no-to-low cost in the
commercialized health-care and health-promotion market, it is essential to exam the influence of
physical activity on older people’s health status in order to promote a healthy aging society in
China.
At the built environment level, older Chinese are well known for their leisure physical
activity behaviors in urban public spaces (Tong, 2013), and this phenomenon in public spaces can
be attributed to the open access public spaces in China’s urban built environment. From this
perspective, examining the spatial accessibility of physical activity spaces can be helpful to
encourage sedentary older people to begin physical activity and promote a high-quality built
environment for PA practitioners.
In urban public spaces, the spectacle of leisure physical activity is both a health promotion
behavior and a performance of social identity (Qian, 2014). Investigating the potential capacity
of older people in the making of urban therapeutic and public spaces can contribute to
transforming the older population from the stigma of a social burden to active social participants,
thus contributing to the active aging process.
This study engages with three major bodies of literature. It first builds on the literature of
health geography, gerontology and geriatrics. Theoretically grounded in the health belief model
(Champion & Skinner, 2008), stages of behavior change model (Marshall & Biddle, 2001), social
ecological model, and longitudinal analysis, this study examines the bidirectional relationships
between older people’s chronic diseases and PA behaviors in a non-Western country. It further
3

examines the bipolar health behavior trajectory between sedentary and physically active people in
their later life. This study then builds on the literature of urban geography. Theoretically, it
contributes to further examine the interactive effects of the built environment, neighborhood social
networks and aging process upon the change of PA behaviors, which provide feasible suggestions
for community health-promotion interventions. As a health-oriented study, it certainly builds on
the literature of medical and health geography. While introducing the stages of behavior change
model and social theories upon public spaces into health geography, it contributes to further remind
health geographers about the potential active role of the older population within neoliberal cities.
It also theoretically further develops the concept of therapeutic landscapes by emphasizing the
collaboration between different social groups in order to make a therapeutic landscape for all.
Goal and Objectives
The goal of the dissertation research is to further understand the impacts of PA on the health
and wellbeing of older people at the individual, community and societal levels in in China. In
particular, this dissertation achieves this goal by answering three separate research questions:
1. How and to what extent does physical activity affect the onsets of chronic diseases among older
people and how and to what extent do the onsets of chronic disease affect physical activity
behaviors in return?
It is hypothesized that physical activity will delay the onset of chronic diseases among
older people, and the onsets of chronic diseases may promote or reduce people’s physical activity
behaviors.
2. How and to what extent does the social and physical built environment affect older people’s
behavior to change their physical activity practices?
4

It is hypothesized that high quality social and physical built environments can encourage
more older people to start and maintain regular physical activity.
3. How can physically active older people as a social group collaborate with other social groups in
public spaces in the making a therapeutic landscape of all?
It is hypothesized that older people can collaborate with other groups and play an active
role in the making of therapeutic landscapes and therapeutic public spaces.
Study Areas
This dissertation research conducts two case studies of older people in neighborhoods in
one mid-sized city and another large city in China. Three neighborhoods in Huainan, Anhui
Province (Figure 1) as the main case, and two neighborhoods in Beijing as the supplementary case.
Huainan, one of the 120 most rapidly growing industrial cities since 1949, is selected for two
reasons. First, while there is plenty of literature discussing older people’s health and healthpromotion behaviors in large cities (Cheng, Rosenberg, Wang, Yang, & Li, 2011; Hu, 2012), less
is known about older people’s health and health-promotion behaviors in medium and small-sized
cities. Huainan had a population of 3,456,000 in 2016, of which 12.9% were older adults (National
Bureau of Statistics, 2017). Huainan is a microcosm of the nation’s rapid aging-demographic
transition in most middle and small cities, characterized by a growing older population with limited
healthcare services, and rise in chronic disease morbidity and related mortality. Second, Huainan
is my hometown city so rapport had been built and research data sources were accessible. The
older people in these neighborhoods were also open to talking with me about their activity spaces,
their apartments and community social interactions.

5

Figure 1: Location of Huainan City in Anhui Province, China.
Three neighborhoods located in the downtown city were selected as the study area
according to our ‘cluster’ sampling criteria for this dissertation research (Figure 2): residential
areas with a large number of older people and prevalent collective older exercise groups in public
spaces. The three neighborhoods included one old inner-city neighborhood, one danwei compound,
and one private xiaoqu, which are three typical types of neighborhoods in Chinese cities (Liu &
Wu, 2006). Importantly, the health survey data, geographic data and self-care behaviors data were
available in these three neighborhoods, and there were some well-known outdoor activity spaces,
Laolongyan Park and City Stadium, to conduct participant observation.

6

Figure 2: Huainan City (left) and landscape (right) of the three study neighborhoods.
To make the Huainan case representative and comparable to large cities, two
neighborhoods in Beijing was selected as a supplementary case. As the capital of the nation,
Beijing had a resident population of over 21.7 million and around 7.6 million immigrants in 2015
(“Beijing Municipal Bureau of Statistics and NBS Survey Office in Beijing,” 2016). The healthpromoting industries and facilities developed earlier and are more mature than in many other cities.
The two study neighborhoods are Mudanyuan neighborhood and Olympic Center neighborhood.
Both neighborhoods are famous for their popular outdoor physical activity spaces, -i.e., Yuan
Dynasty City Wall Relics Park and National Stadium, respectively, which provide ideal fields for
participant observation. Unfortunately, the health survey data, geographic data and self-care
behaviors data in Beijing were not accessible so no statistical analyses could be conducted in
Beijing, like the case study in Huainan.

7

Figure 3: Location of Mudanyuan and Olympic Center neighborhoods in Beijing.
Methodological Notes
Based on the three research questions and hypotheses, a mixed-methods approach was
selected in data collection and the analytical process (Johnson & Onwuegbuzie, 2004). A
quantitative study was suitable for the first and second goals since the questions were based on
already constructed theories, -i.e., health belief model and survival analysis for the first goal, and
social ecological model and stage of behavior change model for the second goal. For the second
goal, however, the particular social and physical aspects of the built environment needed to be
identified before examining their influence on physical activity. Qualitative interviews were,
therefore, conducted to involve subjects’ perspective into the conceptual model. A qualitative
8

study was also conducted for the third goal so that the dynamic process of making the therapeutic
landscapes between different social groups were able to be investigated in a contingent localized
field.
Quantitative data included a six-year health survey dataset of 3,198 older people in three
neighborhoods in Huainan, and GIS data on land use and land cover for the three neighborhoods
were collected in summer 2015. Quantitative analyses were conducted during the summer, fall and
winter of 2016. Qualitative field work was conducted from the summer of 2014 to the summer of
2016 in Beijing and Huainan. Field work in Beijing was conducted in the summers of 2014 and
2015 when I worked as a research fellow in the China National Health Development Research
Center and lived in Mudanyuan neighborhood. Field work in Huainan was conducted in the spring
and summer of 2016 when I was back home. Qualitative data analyses were conducted from the
summer of 2016 until the spring of 2017. Both quantitative and qualitative parts of this research
were approved by the Michigan State University IRB (# x15-413e) determined Exempt (April 24,
2015).
Summary of Dissertation Articles
This dissertation discusses the interactions between older people’s health status and health
promotion behaviors and urban spaces as both facilities and fields of their physical activity. The
three articles address first, the bidirectional relationships between older people’s physical activity
and their chronic diseases, second, the influence pathway of the built environment upon their
change of physical activity, and third, the potential role of older physical exercisers in the making
of therapeutic public spaces collaborating with other social groups. Combining these three studies,
this dissertation aims to link the literature of health geography, gerontology and geriatrics, health
promotion behaviors, and urban geography together to ultimately provide new research and
9

applied directions and implementations that promote an active aging society in China and
worldwide, wherein a demographic transition and with limited family/residential care and health
care resources. Through this study, I also argue that in contrary to the dominant ageist discourse
of considering the older population as a vulnerable dependent group, older physical activity
practitioners in urban China serve as a positive group taking care of themselves and constructing
a sharing therapeutic landscape in harmony with other generations of different social groups.
The first article, Bidirectional Relationships between Physical Activity and Chronic
Diseases: A Longitudinal Investigation, examines the bidirectional relationships between physical
activity and chronic diseases in an older population in China. Drawing on survival analysis to study
the effects of physical activity on chronic disease onset and vice-versa, multilevel logistic
regressions on the influence of chronic disease onset on physical activity, this study demonstrate
a bipolar trajectory effect that older people who participate in physical activity are diagnosed with
chronic diseases years later than sedentary people; post-diagnosis, physically active older people
are more likely to increase their activity levels, while sedentary older people are less likely to begin
physical activity. Health disparities among older people may widen as sedentary older people
experience earlier onsets of chronic diseases and worse health trajectories, compared to physically
active people. Based on these findings, I conclude that China is undergoing a rapid demographic
transition and interventions to reduce the costs of aging should focus on the sedentary and less
healthy older populations.
The second article, Built Environment and the Change of Older People’s Physical Activity:
A Mixed-Methods Approach, examines the pathways by which physical activity behaviors are
impacted by the built environment. Utilizing a mixed methods approach, this article combines
interviews and content analysis to identify individual and built environmental factors that impacted
10

older people’s physical activity and a multilevel path analysis to demonstrate the pathways by
which these factors led to the initiation, regulation, and maintenance of physical activity. This
study found that the liveliness of an apartment building is important in attracting sedentary older
adults to initiate physical activity. Housing closeness to urban functional spaces was associated
with the initiation of physical activity through social networks of neighbors, while social networks
of neighbors was the most important factor in regulating physical activity. Housing closeness to
urban functional spaces was also important in maintaining physical activity, particularly for those
with chronic diseases. Finally, those neighborhoods with the most physically inactive older people
were identified for future intervention. Based on these findings, I conclude that to increase older
people’s overall physical activity, future interventions should focus on residential form and access
to functional spaces, prior to investing in large-scale urban design interventions.
The third article, Therapeutic Spaces for All—Putting Health into Public: Performance
and Collaboration of China’s Leisure Physical Exercisers in Public Open Spaces, is written in
front of the challenge of neoliberalism in the making of therapeutic landscapes and public spaces.
This article argues that these challenges might be rethought within the fields of health and urban
geography and that benefits can be gained through investigating how space can be simultaneously
researched as therapeutic and public space. By a review of current work in health and urban
geography that focus on urban public spaces for leisure activity, it first demonstrates the possibility
and synergies of combining the two complementary approaches. Drawing on the case study in
Huainan and Beijing, it shows how different social groups can collaborate in the contingent
localized production of a therapeutic and public place. This study links the experience and
encounter in outdoor leisure activity spaces with the demographic transition and the post-socialist
neoliberal transition in contemporary China in order to explore the possible active role of the older

11

generation in response to the neoliberal transition. Based on the case study, I argue that the
combination of the two approaches can expand the boundaries of both therapeutic landscapes and
public spaces, and can help to put health into public and build therapeutic landscapes for all.
This dissertation focusing on the physical activity of older people in China contributes to
a better understanding of medical and health geographies of the older population. It estimates the
influence of physical activity upon the onsets of chronic diseases in China, a non-western country,
and points out the bipolar health trajectory effect of physical activity on older people’s health and
life-quality in their later stage. This study also finds the differential impacts of the built
environment upon physical activity behaviors of middle-aged versus older-aged groups,
contributing to not only depicting a high-quality built environment for physically active older
groups but also finding built environment factors that can encourage sedentary groups to begin
physical activity practices. In addressing the social justice issue, this study builds on the work of
Rosenberg (2014) that challenges the widely assumed facts that therapeutic landscapes and public
spaces serve the middle-class by showing the possible collaborating relations of different social
groups as a strategy in response to the global challenge of neoliberalism (Harvey, 2013).

12

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13

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World Health Organization. (2015a). China country assessment report on ageing and health.
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Filial Piety and Structural Constraints. Gender & Society, 17(2), 209–229.
https://doi.org/10.1177/0891243202250734

16

CHAPTER 2
PHYSICAL ACTIVITY AND CHRONIC DISEASES AMONG OLDER PEOPLE IN A
MID-SIZE CITY IN CHINA: A LONGITUDINAL INVESTIGATION OF BIPOLAR
EFFECTS

Introduction
The care of older people (65 years and older) with chronic disease has improved because
of advanced medical technology and the promotion of healthy lifestyles. However, as mortality
decreases and older people live longer, the prevalence of chronic diseases may increase, adding to
the costs of a country’s health care system (World Health Organization, 2014; Zeng, Feng, Hesketh,
Christensen, & Vaupel, 2017). In China in 2015, there were 14.4 million older people (Ministry
of Civil Affairs of the People’s Republic of China, 2016) equating to 10.5% of the total population.
By mid-century, China’s older population is expected to increase to 34.1% of the total population,
making China an important contributor to the global demographic transition (WHO, 2015a). In
2013, 49.5% of older people in China were diagnosed with at least one chronic disease (WHO,
2006; WHO, 2015b). In 2015, the Chinese National Health and Family Planning Commission
developed the National Ageing and Health Strategy and Implementation Plan to improve the health
of China’s aging population through prevention programs that reduce the early onset of chronic
disease, and increase wellbeing. The primary strategy of the Plan is to promote healthy lifestyles,
through education on nutritious diets, smoking cessation, and participation in physical activity
(World Health Organization, 2015a).
There are many studies that have investigated the impacts of physical activity (PA) on older
people’s health in China (Li, Xu, Chi, & Guo, 2014; Liu & Lou, 2016; Monda, Adair, Zhai, &

17

Popkin, 2007; Yu et al., 2009). However, only a few of these studies (Li et al., 2014; Liu & Lou,
2016) have focused on older people in mid- and small-sized cities. In these cities, residential care
services are limited and there is a shortage of high-quality public health care services (Chen, 2011).
In addition, older people’s children may have moved out of the area, leaving their parents without
family care support (Zhan & Montgomery, 2003). These two factors may be important barriers to
promoting healthy lifestyle behaviors in older people in China. Studying the associations between
PA and the onset of chronic disease in older people residing in mid- and small-sized cities in China
can, therefore, help to target specific interventions to promote healthy aging, while also reducing
the social and economic costs associated with chronic disease burden in China.
Studies have shown that regular exercise prevents chronic disease in middle-aged (54-64
years) and older people (Hughes et al., 2011; US Department of Health and Human Service, 2008;
Warburton, Nicol, & Bredin, 2006). Regular PA has been shown to reduce the risk of
cardiovascular

diseases

(Macera,

Hootman,

&

Sniezek,

2003),

hypertension

and

hypercholesterolemia (Myers et al., 2002), and Type 2 diabetes (Myers et al., 2002; Warburton,
Gledhill, & Quinney, 2001) and serves as a therapy to prevent and postpone the onset of chronic
disease, such as cardiovascular diseases (Franklin, Swain, & Shephard, 2003), diabetes (Gregg,
Gerzoff, Caspersen, Williamson, & Narayan, 2003), and poor kidney function (Hawkins et al.,
2011). For older populations, PA can also reduce the risk of injuries from falls (Nelson et al., 2007)
and mobility disabilities (Pahor et al., 2014). Although the benefits of PA are widely cited (Genton
et al., 2011; Warburton et al., 2006), sedentary lifestyles are still common among older adults,
women and low-income groups worldwide (Hallal et al., 2012) and older adults without a high
school education in China (Muntner et al., 2005). Importantly, people may have alternative health
beliefs; some people may not believe that doing PA will benefit their health so they chose to live

18

a sedentary life in their younger years (Wang, Liu, Ren, Lv, & Li, 2015) attributing to a higher
risk of chronic disease; some other people may only practice low-frequent and low-intensity PA
for fun, therefore they are unable to achieve the full health benefits (Hallal et al., 2012; Muntner
et al., 2005); some people believe that staying sedentary can reverse the disease process, thus
reducing PA practice after a diagnosis of chronic disease, even though PA can attenuate or reverse
the disease process to a certain extent (Watz et al., 2008). How different health beliefs translate
into positive or negative PA behaviors may in part explain health gaps during later stages of life.
The bidirectional relationships between PA and chronic diseases should therefore, be considered
simultaneously to understand how PA practice affects the onsets and progression of chronic
diseases and how chronic diseases affect people’s PA behavior, resulting in a bipolar PA and
chronic disease effect.
The purpose of this study is to investigate the bidirectional relationships between PA and
different chronic disease onsets among older people in a mid-sized city in China. To study these
bidirectional relationships, this study is informed by the Health Belief Model (Champion &
Skinner, 2008). The Health Belief Model helps to distinguish attitudes and beliefs in regards to
chronic disease risk and PA behaviors -e.g., older people with a chronic disease diagnosis might
believe that PA will exacerbate their symptoms, worsening their disease and thereby, minimize
their PA practices vs. the beliefs that PA will help to prevent or delay the onset of disease or
following a diagnosis, improve their symptoms with increased PA practice. Through testing the
bidirectional relationships between PA and different chronic disease onsets, future health
trajectories for population groups may be inferred to inform future aging health policy and
planning initiatives in China.

19

Methods
Study Design
This observational study utilizes a retrospective longitudinal study design to examine the
bidirectional relationships between PA and the onset of seven different chronic diseases of 3,094
older residents in three neighborhoods. This study took place in three neighborhoods in Huainan
City, a mid-sized city in Anhui Province, China. Huainan had a population of 1.61 million in 2014,
with 16.2 % of the population over 65 years of age (National Bureau of Statistics, 2015). The
researchers received permission from one tier-2 public hospital in Huainan City to analyze six
longitudinal years (2010-2015) of clinic data, comprising older people’s routine annual health care
visits. This hospital was responsible for surveying the health of older people in their catchment
area, which included three contiguous neighborhoods. There were N=3,198 older people in these
three neighborhoods of which 97% (N=3,102) were included in this survey. These three
neighborhoods are typical of Huainan City and China (Kiu & Wu, 2006), with one old inner-city
neighborhood, one danwei compound, and one private xiaoqu. This study addressed the following
questions:
(1) What were the prevalence of chronic diseases among older people in the three
neighborhoods and how did PA vary across socio-demographic groups?
It was hypothesized that PA would vary by age, gender, education, income and the presence
or absence of a chronic disease.
(2) How did the onset of a chronic disease trigger change in older people’s PA practice
levels?
The hypothesis was two-fold based on the Health Belief Model –i.e., the onset of chronic
disease would increase the likelihood of sedentary and/or no change in PA, or increase PA practice.

20

(3) Whether and to what extent was PA associated with the later onset of chronic disease?
It was hypothesized that active older adults would have a later onset of chronic disease
compared to sedentary older adults.
Data sources and population
In Huainan City, and many other cities in China, free annual medical exams begin at 55
years of age (General Office of the State Council of the People’s Republic of China, 2015).
Therefore, the longitudinal health survey data included adults over 55 years (range, 55 to 99 years)
(n=3,102). Eight participants were excluded from the study because they only attended the clinic
once –i.e., participated in the survey once and then dropped out. Other participants who visited the
clinic 2 to 5 times –i.e., participated in the survey 2 to 5 times remained in the study, including
older people with missing clinic visits (n=490)--right-censored and older people newly recruited
(n=856)—left-censored. Since this study aims to study how the onsets of a chronic disease trigger
changes in PA behaviors and how PA associated with the later onset of chronic diseases, only
participants with two or more than 2 waves’ records were considered. The mean number of clinic
visits for those participants who did not complete all 6 years of visits was n=2.3. There were 1,756
participants who attended all six-years of clinic visits. The final dataset comprised 3,094 individual
clinic visits, resulting in 13,636 observations for this study.
Measures
Information from the health survey dataset and the coding schemes used in this study,
included:
Socio-demographic (see Table 1): five year age groups (55-59, 60-64, 65-69, 70-74, 75-79, 80-84,
85-89, 90-94 and 95-99 years), gender (0=male; 1=female), educational level (0=none-to-primary
school; 1=middle school; 2=high school; and 3=college), and self-rated income (0=none-or-low
21

income; 1=high income). There is no specific cut-point by which to define none-low income and
high income. On the original questionnaire, participants were asked to choose one out of the two
direct options (A. None-low income; B. High income).
Chronic Disease: To assess chronic diseases, the following data were integrated: physical data
from the physical exam (height, weight and blood pressure and electrocardiogram), and peripheral
venous blood samples for several chronic diseases. Seven chronic diseases were studied including,
overweight and obesity (OBT), hypertension (HTN), diabetes (DBT), hyperlipidemia (HTC),
cardiovascular diseases (CD), liver and biliary system disease (LBSD), and poor kidney function
(PK). Overweight and obesity were calculated using the body mass index (BMI) weight/height2
of the individual (BMI 25.0 to 29.9=overweight and BMI=30 or greater=obese); hypertension was
indicated by systolic blood pressure >140mmHg and diastolic blood pressure >90mmHg; diabetes
was indicated by fasting plasma glucose (FPG)>126mg/dl; hyperlipidemia was indicated by serum
total cholesterol (TC)>240mg/dl; cardiovascular diseases were indicated by abnormal
electrocardiograph results (Yes vs. No); liver and biliary system disease was indicated by serum
Alanine aminotransferase (ALT)>40U/L, total bilirubin (Tbil)>1.2mg/dl and direct bilirubin
(Dbil)>0.4mg/dl; and poor kidney function was indicated by serum creatine (Cr)>1.39mg/dl and
blood urea nitrogen (BUN)>23.3mg/dl. The normal range values provided by the hospital were
used to determine if a test was normal or abnormal. These normal range values were checked
against the same diseases provided in the Merck Manuals (Merck Manuals Professional Edition,
2013b, 2014a, 2014b, 2015, 2016a, 2016b) (See detailed classification standards at (Zhou, Grady,
& Chen, 2017). For reference, the normal range values for Cr (<1.39mg/dl) and BUN (<23.3mg/dl)
were slightly higher than the U.S. standards (1.2mg/dl and 20mg/dl, respectively) (Merck Manuals
Professional Edition, 2013a). It was also recognized that some abnormal electrocardiography

22

findings (such as Sinus arrhythmia or change on one wave) may not have indicated a
cardiovascular disease, thus only those abnormal electrocardiograph findings indicated by a
cardiologist on the health survey record were coded as Yes (abnormal). These disease indicators
were repeatedly measured at each of the six-year time points. When a new chronic disease
appeared for the first time in a given year, that year was referred to as the onset of the chronic
disease. Using the normal range values provided by the hospital, the prevalence rates of the seven
chronic diseases were calculated within the (n=3,094) population, stratified by the sociodemographic groups.
Physical Activity (see table 1): To assess PA, the following data were integrated: (a) the selfreported frequency of PA per week, and (b) the self-reported length of time (in minutes)
participating in PA. In the original questionnaire, PA frequency was measured as, 0=no activity;
1=irregular activity (randomly practicing PA); 2=regular activity less than three times a week
(stable practice of PA but infrequent); and 3=regular daily activity (stable practice of PA and
frequent); the length of activity in the survey was measured as, 0=no activity; 1=less than 20
minutes; 2=20 to 60 minutes; 3=60 minutes or greater. For this study, these two metrics were
combined to calculate the metabolic equivalent (MET) minute of PA per week, based on which
the annual repeated PA were categorized into four levels according to the International Physical
Activity Questionnaire (Craig et al., 2003). The PA practice levels included, 0=no PA; 1=irregular
PA (not included in IPAQ categories); 2=low PA (PA practice less than 599 MET-min/week); and
3=moderate PA (PA practice between 600-3000 MET-min/week) (IPAQ Research Committee,
2005). In this study, MET measures –i.e., PA levels mainly represented leisure PA, excluding
domestic PA (housework as PA) and occupational PA (wage-earning occupation work as PA)
(Monda et al., 2007). A PA level was assigned to each of the six-year time points, representing

23

the overall activity level in the year prior to the clinic visit.
Table 1: Description of variables and measurements of the 6-year longitudinal health survey data
in Huainan.
Variable Names

Code for this study

Measurement in the
dataset

Sociodemographic
Age groups

0=55-59, 1=60-64, 2=65-69, 3=70-74, 4=75-79,
5=80-84, 6=85-89, 7=90-94 8=95-99 years
0=male, 1=female
Gender
Educational level 0=none-to-primary school, 1=middle school,
2=high school, and 3=college
0=none-or-low income, 1=high income
Self-rated
income
Physical Activity
0=no PA; 1=irregular PA (not included in IPAQ
Levels
categories); 2=low PA (PA practice less than 599
MET-min/week); and 3=moderate PA (PA
practice between 600-3000 MET-min/week)1

Same
Same
Same
Same

By frequency
length2.

and

Notes. 1. The calculation of the metabolic equivalent (MET) minute of PA per week, based on
which the annual repeated PA were categorized into four levels according to the International
Physical Activity Questionnaire.
2. Frequency: 0=no activity, 1=irregular activity, 2=regular activity less than three times a week.
Length: 0=no activity; 1=less than 20 minutes; 2=20 to 60 minutes; 3=60 minutes or greater.
Data Analyses
The statistical analyses were separated into three tasks: First, prevalence rates of disease
and PA levels were estimated. Binominal logistic regression was used to estimate the relationships
between the prevalence rates of each of the seven disease groups and the four socio-demographic
categorical variables (age group, gender, education, and income). To study the PA levels and how
PA varied across socio-demographic groups, two-level multilevel binominal logistic models were
estimated with annual PA levels (Level-1) nested within each individual (Level-2) (Gelman, 2006)
to predict (a) if older people were sedentary vs. practiced PA (PA level-0 vs all others), (b) if older
people practiced irregular vs. regular PA (PA level-1 vs level-2 or 3, excluding level-0

24

observations), or (c) if older people practiced low-level vs. moderate PA (PA level-2 vs level-3,
excluding level-0 or 1 observations). Since we aimed to compare sedentary (Level-0) with all other
physically active groups (Level-1, Level-2 and Level-3), and to compare irregular (Level-1) with
the regular PA groups (Level-2 and Level-3), three separate multilevel binominal models were
estimated instead of a multinomial logistic regression model. The PA level was modeled as a fixed
effect of age-group at Level-1 and of gender, education, and income at Level-2; since most
individuals were retired or almost retired, there was no intrapersonal variation of income level over
the six years. After deleting the participants with missing values, n=3,057 participants with
N=11,742 observations in total were used.
Second, to study the impacts of chronic disease onsets on PA, logistic models were used to
estimate the change in PA, before and after the onset of a chronic disease. Since one individual
could have only one onset of a certain disease and only the following year after the onset of disease
would be considered for each individual, the variation within each individual was zero; models
were thus reduced to a one-level logistic model. As the survey data did not include a family medical
history to identify risky populations, nor a medical history with the year of a disease diagnosis
prior to the beginning of the survey, only older people who had no chronic disease at baseline, and
the onset of a disease in the subsequent years (n=1,657) were studied. The following logistic
models were constructed: First, for those older people who had no PA (Level-0) at baseline and an
onset of disease in the subsequent year, the response in model 1 was whether PA was initiated vs.
sedentary in the year following the diagnosis. Second, for those older people who practiced PA
(Level-1,2,3) at baseline and experienced the onset of disease in the subsequent year, the response
in model 2 was whether the individual changed their PA vs. their PA remained the same, in the
year following the diagnosis. Third, for those older people who changed their PA level in the year

25

following their diagnosis in model 2, the response in model 3 was if they strengthened or lightened
the intensity of their PA level, in the year following their diagnosis. For example, if the blood
pressure of individual #17 exceeded the borderline value in Year 3, the onset of hypertension was
allocated to Year 3, and Year 2 (baseline) and Year 1 were considered negative. These three
models were estimated, controlling for age group, gender, education, and income levels.
Finally, two Cox proportional hazards models with time-varying covariates were used to
examine the impacts of PA on the onsets of chronic diseases. The same initial data used in the
second analysis was also used here—only older people who had no disease at baseline but reported
an onset of chronic disease in the subsequent year (n=1,657). In both Cox proportional hazards
models, the age of onset of a certain chronic disease was assigned to each individual as a survival
time, since the incidence rate of chronic disease was a function of the aging process, instead of the
onset time from baseline (Lamarca, Alonso, Gómez, & Muñoz, 1998). In model 1, the PA level
was considered as a key independent variable. Since too few individuals (n=50) conducted lowlevel PA, the low and moderate level activity observations went into one group -i.e. regular low to
moderate PA (RPA). Finally, the three groups in model 1 were RPA, no PA (NPA), and irregular
PA (IPA). In model 2, the individuals’ cumulative PA in years was calculated as the key
independent variable. Since too few individuals participated in PA for over five years, Years 4, 5,
and 6 were aggregated into one group. Finally, the five-year groups in model 2 were categorized
as 0, 1, 2, 3, 4 or over. Gender, education and income levels were used as control variables. When
a certain chronic disease was examined, all other diseases were also controlled to account for
potential variation in co-morbidities. Schoenfeld residual plots were used to test the proportional
hazards assumption. The statistical analyses were conducted in Stata Release 14 (StataCorp, 2015).

26

Results
Prevalence of chronic diseases by socio-demographic characteristics
In 2010, the highest chronic disease prevalence rates in the general population of older
people were hypertension (51.4 per 100 older people), followed by cardiovascular diseases (38.3),
overweight and obesity (31.2), diabetes (13.6), hyperlipidemia (8.9), liver and biliary system
disease (7.5) and poor kidney function (4.8) (see Table 2). From the middle through older to oldest
age groups, there was a statistically significant increase in prevalence of hypertension (48.2 middle
age to 55.3 older to 57.7 oldest-old), cardiovascular diseases (31.9 to 43.0 to 48.9), diabetes (11.8
to 15.3 to 15.9), and poor kidney function (2.9 to 5.3 to 9.5). The prevalence of overweight/obesity
and liver and biliary system disease significantly decreased after 75 years of age (31.2 to 31.9 to
26.6) and (8.2 to 7.5 to 5.7), respectively. Compared to males, females had a significantly higher
prevalence of hyperlipidemia (11.3% vs. 6.6) but lower prevalence of hypertension (45.1 vs. 57.6),
cardiovascular diseases (34.3 vs. 40.0), diabetes (11.5 vs. 15.4), liver and biliary system disease
(5.8 vs 9.0), and poor kidney function (3.3 vs 5.8). There was not a significant difference in the
prevalence of overweight and obesity by gender. After none-to-primary schooling, there was a
negative linear relationship between higher education and the most highly prevalent diseases:
hypertension (middle=53.4 to high=49.0 to college=47.1), cardiovascular diseases (36.8 to 35.9 to
33.4) and overweight and obesity (31.5 to 30.2 to 28.3). Compared to all other educational levels,
college educated older people had a significantly lower prevalence of diabetes (12.3). Education
levels did not have a significant effect on the prevalence rates of hyperlipidemia, liver and biliary
system disease, and poor kidney function. Finally, the prevalence of overweight and obesity was
slightly higher for older people who were poor compared to higher income (31.3 vs. 30.5). There
was not a significant difference in the prevalence of other chronic diseases for high income vs.

27

none-to-low income groups, controlling for the other socio-demographic characteristics. These
findings show substantial variability in chronic disease prevalence for older Chinese living in these
three neighborhoods, with increasing age, male and lower education significant risk factors.
Table 2: Description1 of baseline prevalence of chronic diseases in the three neighborhoods in
Huainan.
N2

55-64
65-74

2553
969
1018

>=75

566

Gender

Male
Female

1385
1168

Educatio
n

Primary 774

Total
Age

Middle
High
College
Income

High
Low/no

852

Prevalence of Chronic Diseases %
OBT3
HTN
DBT
HTC
31.2
51.4
13.6
8.9
31.9
48.2
11.8
9.1
32.2
55.3** 15.3** 8.4*
*
26.6**4 57.7** 15.9*** 8.8*
*
31.2
57.6
15.4
6.6
31.2
45.1** 11.6*** 11.3***
*
33.9
55.4
14.8
9.0

31.5**
*
206 30.2**
*
695 28.3**
*
414 30.5*
2125 31.3*

CD
38.3
31.9
43.0**
*
48.9**
*
40.0
34.3**
*
42.1

LBSD
7.5
8.2
7.5

PK
4.8
2.9
5.3***

5.7**

9.5***

7.0

5.8

9.0
5.8
5.8*** 3.3***

53.4*

13.0

8.6

36.8*

7.5

4.8

49.0**
*
47.1**
*
51.1
52.1

14.6

8.4

35.9**

8.0

4.5

12.3*

8.7

33.4*

8.2

3.5

14.6
13.2

8.3
8.8

38.9
37.2

7.7
7.5

4.6
4.8

Notes. 1. Logistic regressions were used for binominal analyses between the prevalence of
chronic diseases and the four socio-demographic categorical variables.
2. N=2553 residents over 55 years living in the three neighborhoods at least six months and
recruited in the baseline survey.
3. OBT: overweight and obesity; HTN: hypertension; DBT: diabetes; HTC: hyperlipidemia; CD:
cardiovascular diseases; LBTD: liver and biliary system diseases; PK: poor kidney function.
4.*p<0.05, **p<0.01, ***p<0.001.

28

Physical activity and socio-demographic characteristics
Table 3 shows the estimated PA levels by socio-demographic characteristics. Importantly,
as age increased, the odds that older people would practice PA was low –i.e., they were more likely
to be sedentary. However, for those who practiced PA, their practice was regular (vs. irregular)
and of moderate (vs. low) intensity, demonstrating a persistent and positive PA trajectory despite
increasing age. In addition, the odds of PA practice for females (OR=0.81, 95%CI:0.81-0.93,
p<0.01), middle (OR=0.77, 95%CI: 0.65-0.92, p<0.01) or college (OR=0.63, 95%CI: 0.58-0.87,
p<0.001) educated, or older people of none-to-low income (OR=0.71, 95%CI: 0.58-0.87, p<0.001)
were also low –i.e., they were more likely to be sedentary. However, for those who practiced PA,
their practices were more likely to be regular, for females (OR=1.26, 95%CI: 1.14-1.40, p<0.001),
college educated (OR=1.23, 95%CI: 1.04-1.44, p<0.01) and none-to-low income (OR=1.22,
95%CI: 1.04-1.41, p<0.05). There were no significant differences in PA intensity (moderate vs.
low), for those practiced PA, except for college educated (OR=0.34, 95%CI: 0.16-0.73, p<0.05).
These findings show that older people living in the three neighborhoods are primarily sedentary
and those who practice PA, practice regularly but of varying intensity mainly by age group.

29

Table 3: Multilevel logistic regression1 between socio-demographic features and physical
activity level among older people 2010 to 2015.
Physical Activity Level2
PA VS Sedentary
Regular VS Irregular
Moderate VS Low
Odds
95% CI
Odds
95% CI
Odds
95% CI
Ratio
Ratio
Ratio
<55
1
1
1
Age
55-59
0.32***4 0.25-0.42 3.53***
2.79-4.46 2.21
0.91-5.31
(years)
60-64
0.26*** 0.20-0.35 4.64***
3.65-5.90 3.04*
1.19-7.73
65-69
0.26*** 0.19-0.35 9.25***
7.15-11.95 6.20*** 2.29-16.76
70-74
0.37*** 0.27-0.52 9.34***
7.15-12.19 7.04*** 2.44-20.34
75-79
0.28*** 0.20-0.40 10.46*** 7.85-13.93 6.65*** 2.15-20.58
80-84
0.17*** 0.11-0.25 10.95*** 7.64-15.68 6.13*
1.50-25.00
>=85
0.13*** 0.08-0.23 10.16*** 6.13-16.86 18.39*
1.10305.98
1
1
1
Gender
Male
0.71-0.93 1.26***
1.14-1.40 1.31
0.80-2.15
Female 0.81**
1
1
1
Education Low
0.65-0.92 1.05
0.92-1.20 0.73
0.37-1.43
Middle 0.77**
0.91
0.67-1.21 0.97
0.79-1.19 0.50
0.18-1.33
High
1.04-1.44 0.34*
0.16-0.73
College 0.63*** 0.51-0.78 1.23**
1
1
1
Income
High
0.71*** 0.58-0.87 1.22*
1.04-1.41 0.87
0.44-1.72
Low
11742
8340
5200
N of Observations3
3057
2829
2234
n of Individuals
Notes. 1. In these two-level logistic regression models, the repeated PA level measure (level-1)
were nested within each individual (level-2).
2. Dependent variables are if the individual did PA (level-0 vs all others) in model 1, if the
individual had regular or irregular activity (level-1 vs level-2 and 3) in model 2, or if the
individual had low-level or moderate activity (level-2 vs level-3) in model 3.
3. n=3057 individuals with N=11,742 observations in total were used.
4. *p<0.05, **p<0.01,***p<0.001.
When the PA intercept coefficients (data not shown) were plotted by their response variable
(PA vs. sedentary, PA regular vs. irregular, and PA moderate vs. low) across all age groups, the
proportion of older people practicing PA decreased (Figure 4a) but the proportion of older people
practicing regular vs. irregular and moderate vs. low PA, increased with age (Figures 4b-c)
supporting the findings above. Among those 65-79 years of age, there was a small but increasing
trend in PA, but thereafter with increased age, PA decreased.

30

among All Participants with 95% CIs

b

Changing Probability of Regular PA among PA with 95% CIs

.6
.4
.2

.5

.6

.7

.8

Predicted Percentage of Regular PA

.8

.9

a Changing Probability of PA

<55

55-59

60-64

65-69

70-74

75-79

80-84

>=85

<55

55-59

60-64

65-69

70-74

75-79

80-84

>=85

Changing Probability of PA among Regular PA with 95% CIs

.8

Predicted Percentage of Daily PA

1

c

<55

55-59

60-64

65-69

70-74

75-79

80-84

>=85

Figure 4: Changing odds ratios (ORs) of PA by increasing age groups. a: PA vs. sedentary; b:
PA regular vs. irregular; and c: PA moderate vs. low.
Chronic diseases that trigger physical activity changes
Table 4 shows that for middle to older people who were sedentary at baseline, the onset of
any chronic disease did not prompt them to initiate PA (OR=0.75, 95% CI: 0.57-0.97, p<0.01). In
particular, the odds of initiating PA were lowest for older people diagnosed with cardiovascular
disease (OR=0.64, 95% CI: 0.41-0.95, p<0.05) or liver and biliary tract disease (OR=0.39, 95%
CI: 0.16-0.94, p<0.05) –i.e., were more likely to remain sedentary. However, for older people who
practiced PA, the onset of any chronic disease prompted a change in PA practice (OR=1.23, 95%
CI:1.09-1.38, p<0.05), in particular for hypertension (OR=2.44, 95% CI: 1.82-3.28, p<0.001),
overweight and obesity (OR=1.99, 95% CI: 1.37-2.89, p<0.01), or hyperlipidemia (OR=1.59, 95%
CI: 1.24-2.02, p<0.01); while the odds of changing PA practice was low for those diagnosed with
31

diabetes (OR=0.73, 95% CI: 0.57-0.96, p<0.05), poor kidney function (OR=0.59, 95% CI: 0.410.90, p<0.01), or cardiovascular diseases (OR=0.48, 95% CI: 0.39-0.58, p<0.001). Of those who
changed their PA practices after the onset of any chronic disease, the odds of strengthening PA
practice was high (OR=2.53, 95% CI: 2.08-3.08, p<0.001), particularly for diagnoses of
hypertension (OR=3.22, 95% CI: 2.08-4.99, p<0.001), overweight and obesity (OR=2.86, 95% CI:
1.57-5.21, p<0.001), hyperlipidemia (OR=1.79, 95% CI: 1.25-2.58, p<0.001), or diabetes
(OR=1.71, 95% CI: 1.04-2.84, p<0.05). These results were controlling for differences in age group,
gender, education and income levels. In summary, these findings show that following a disease
diagnosis, sedentary older people were less likely to change their PA practices, while older people
who practiced PA, also strengthened their PA practice. The PA trajectories following
cardiovascular disease diagnoses were variable, with sedentary and older people who practiced
PA, unlikely to change their PA practice; but those who changed their PA practice, were more
likely to strengthen their practice. Importantly, for the two other highly prevalent chronic
diseases—hypertension and overweight and obesity, older people were more likely to change and
strengthen their PA practices.

32

Table 4: Logistic regression1 between the onset of chronic diseases and physical activity
behaviors 2010 to 2015.
Physical Activity2
Initiate PA vs.
Change vs. Remain
Strengthen vs.
Sedentary
Lighten
Odds 95% CI
Odds
95% CI
Odds
95% CI
Ratio
Ratio
Ratio
0.75** 0.57-0.97
1.23*
1.09-1.38
2.53*** 2.08-3.08
Any onset
3

0.77
0.45-1.31
0.83
0.62-1.10
1.95**
1.17-3.24
Onset of the First
0.61-1.44
1.10
0.88-1.38
1.89**
1.29-2.77
Onset of the Second 0.94
0.60
0.35-1.00
1.23
0.98-1.55
2.13*
1.42-3.19
Onset of the Third
Types of Diseases
1.10
0.39-3.21
1.99** 1.37-2.89
2.86*** 1.57-5.21
Overweight
1.33
0.60-2.96
2.44*** 1.82-3.28
3.22*** 2.08-4.99
Hypertension
1.03
0.5202.04 0.73*
0.57-0.96
1.71*
1.04-2.84
Diabetes
1.11
0.59-2.08
1.59** 1.24-2.02
1.79*** 1.25-2.58
Hyperlipidemia
0.64* 0.41-0.95
0.48*** 0.39-0.58
0.89
0.63-1.25
Cardiovascular
Diseases
0.39* 0.16-0.94
0.95
0.67-1.30
1.15
0.68-1.92
Liver& Biliary
System Diseases
0.45
0.16-1.24
0.59** 0.41-0.90
0.75
0.38-1.46
Kidney Function
Disorder
Notes. 1. Three logistic regression models were used to examine the association between the
change in PA and the onsets of chronic diseases controlling for age, gender, education, and
income.
2.For the sedentary individuals at baseline, the response in model 1 was if he/she initiate PA in
the following year after the onset of their disease; for the individuals with PA behaviors, the
response in model 2 was if he/she changed or remained at their PA level in the following year;
for those who did change their PA level in model 2, the response in model 3 was if they
increased or decreased their PA level in the following year after the onset of a certain chronic
disease.
3.*p<0.05, **p<0.01, ***p<0.001.

33

Figure 5 shows the differential impacts of a new diagnosis of chronic disease on PA change.
The left figure represents the odds of initiating PA vs. remaining sedentary, for sedentary people
following a new diagnosis; and the right figure represents the odds of strengthening PA vs.
lightening PA among those who were previously active, following a new diagnosis.

Figure 5: The impacts of the diagnosis of different chronic diseases upon changes in physical
activity.
Notes. The left figure represents the odds ratio of initiating PA vs. remaining sedentary following
a diagnosis of chronic disease, for those older people who were sedentary at baseline; the right
figure represents the odds ratio of strengthening physical activity versus reducing physical
activity following a diagnosis of chronic disease, among those older people who were physically
active at baseline.

34

Physical activity and the onset of chronic disease
This last analysis (Table 5) shows that both regular and irregular PA were significantly
associated with later onsets of chronic disease overall (Hazard Ratio (HR)=0.31), as well as the
onsets of overweight and obesity (HR=0.43), hypertension (HR=0.26), hyperlipidemia (HR=0.21),
diabetes (HR=0.17), cardiovascular diseases (HR=0.17), poor kidney function (HR=0.17) and
liver and biliary system diseases (HR=0.13). According to the median age (MA) of any type of
onset between physically active (MA=63) and sedentary groups (MA=56), PA practice was
significantly associated with the later onsets of chronic diseases overall by 7 years; with the later
onsets of overweight and obesity and diabetes diagnoses by 8 years; with the later onsets of
hypertension and hyperlipidemia diagnoses by 7 years; with the later onsets of liver and biliary
system diseases and poor kidney function diagnoses by 5 years; and with the later onsets of
cardiovascular disease diagnoses by 4 years (see Figure 6). Furthermore, participating in PA over
3 year’s duration was significantly associated with a later onset of chronic diseases overall
(HR=0.21), and specifically for hyperlipidemia (HR=0.31), cardiovascular diseases (HR=0.16),
poor kidney function (HR=0.15), hypertension (HR=0.14), and diabetes (HR=0.11) (see Figure 7).
Interestingly, participating in PA for over 3 year’s duration was not significantly associated with
later onsets of overweight and obesity, nor liver and biliary system diseases.

35

Table 51: Onset median age (MA) of chronic diseases and hazard ratio (HR)
levels/years of PA.
Model 13:
Model 24:
PA level
Cumulative PA years
NP IPA RPA 0
1
2
3
4
A
MA 56 63
65
61 62
63
66
66
All Onset
5
*** ***
**
***
***
HR 1
0.31 0.4
1
0.8
0.63 0.46 0.21

with different
N of
obs.

N of
sub.

3414

1657

2

64
66
61 61
64
63
66
540
257
*** ***
HR 1
0.43 0.28 1
0.68 0.83 1.06 0.96
MA 55 62
67
60 61
62
65
67
733
376
Hypertension
*** ***
*
**
***
***
HR 1
0.26 0.27 1
0.59 0.41 0.31 0.14
MA 55 66
63
63 60
64
65
68
1069 472
Diabetes
*** **
*
***
***
***
HR 1
0.17 0.6
1
0.61 0.46 0.27 0.11
66
62 64
63
66
66
1143 515
Hyperlipidemia MA 56 63
*** ***
**
*
***
HR 1
0.21 0.28 1
0.57 0.77 0.52 0.31
61
62 63
62
66
68
1965 849
Cardiovascular MA 56 71
HR
*** **
**
***
***
***
diseases
1
0.17 0.71 1
0.67 0.53 0.36 0.16
MA 57 66
62
62 63
63
66
66
675
292
Liver and
*** ***
biliary system
HR 1
0.13 0.44 1
0.97 1.59 1.49 0.95
diseases
MA 59 74
65
68 67
67
68
68
94
39
Kidney
***
*
**
function
HR 1
0.17 0.8
1
0.7
0.52 0.3
0.15
disorder
Notes. 1. Two Cox proportional hazards models with time-varying covariates were used to
examine the impact of PA on the onset of chronic diseases controlling for gender, education level,
income level and other types of chronic diseases.
2. For each disease, the two rows report the dependent variables-onset of different diseases by
onset median age (MA) and hazard ratio (HR).
3. In model 1, the PA level was the independent variable (NPA: sedentary; IPA: irregular physical
activity; RPA: Regular physical activity).
4. In model 2 the cumulated PA years was the independent variable.
5. *p<0.05, **p<0.01, ***p<0.001.
Obesity

MA

56

36

Kaplan-Meier survival estimates on overweight

0.00

0.00

0.25

0.25

0.50

0.50

0.75

1.00

1.00
0.75

Kaplan-Meier survival estimates on any chronic condition

50

60

70

80

90

50

60

Age
NPA
RPA

IPA

a

IPA

0.75

1.00

Kaplan-Meier survival estimates on diabetes

0.50

70
Age
NPA
RPA

80

50

90

IPA

c

60

70
Age
NPA
RPA

d

80

90

IPA

Kaplan-Meier survival estimates on cardiovascular condition

0.00

0.00

0.25

0.25

0.50

0.50

0.75

0.75

Kaplan-Meier survival estimates on hypercholesterolemia

50

60

70

80

50

90

60

Age
IPA

e

80

90

IPA

Kaplan-Meier survival estimates on kidney condition

0.75
0.50
0.25
0.00

0.00

0.25

0.50

0.75

Kaplan-Meier survival estimates on liver&biliary tract condition

70
Age
NPA
RPA

f
1.00

NPA
RPA

1.00

90

0.25

60

1.00

50

1.00

NPA
RPA

b

80

0.00

0.00

0.25

0.50

0.75

1.00

Kaplan-Meier survival estimates on hypertension

70
Age

50

60

70
Age
NPA
RPA

80
IPA

90

50

g

60

70
Age
NPA
RPA

h

80

90

IPA

Figure 6: Survival estimates of different chronic diseases among people with different physical
activity levels. a: any chronic diseases; b: overweight and obesity; c: hypertension; d: diabetes; e:
hyperlipidemia; f: cardiovascular diseases; g: liver and biliary system diseases; h: kidney
diseases.
37

Kaplan-Meier survival estimates on overweight

0.00

0.00

0.25

0.25

0.50

0.50

0.75

1.00

1.00
0.75

Kaplan-Meier survival estimates on any chronic condition

50

60

70

80

50

90

60

Age
0 years PA
2 years PA
4 years PA or over

b

90

1 years PA
3 years PA

0.25

0.50

0.75

1.00

Kaplan-Meier survival estimates on diabetes

70
Age

80

50

90

60

c

d

80

90

1 years PA
3 years PA

Kaplan-Meier survival estimates on cardiovascular condition

0.00

0.00

0.25

0.25

0.50

0.50

0.75

0.75

Kaplan-Meier survival estimates on hypercholesterolemia

70
Age
0 years PA
2 years PA
4 years PA

1 years PA
3 years PA

1.00

60

0 years PA
2 years PA
4 years PA

50

60

70

80

50

90

60

Age

e

f

80

90

1 years PA
3 years PA

Kaplan-Meier survival estimates on kidney condition

0.75
0.50
0.25
0.00

0.00

0.25

0.50

0.75

Kaplan-Meier survival estimates on liver&biliary tract condition

70
Age
0 years PA
2 years PA
4 years PA or over

1 years PA
3 years PA

1.00

0 years PA
2 years PA
4 years PA

1.00

80

0.00

0.00

0.25

0.50

0.75

1.00

Kaplan-Meier survival estimates on hypertension

50

1.00

0 years PA
2 years PA
4 years PA

1 years PA
3 years PA

a

70
Age

50

60

70
Age
0 years PA
2 years PA
4 years PA

80

90

50

60

1 years PA
3 years PA

g

70
Age
0 years PA
2 years PA
4 years PA or over

h

80

90

1 years PA
3 years PA

Figure 7: Survival estimates of onset of chronic diseases by age with different accumulative
physical activity years. a: any chronic diseases; b: overweight and obesity; c: hypertension; d:
diabetes; e: hyperlipidemia; f: cardiovascular diseases; g: liver and biliary system diseases; h:
kidney diseases.
38

Discussion
This study is the first longitudinal study to assess the bidirectional relationships between
PA and chronic diseases in an older population in a mid-sized city in China. There are three main
findings from this research. First are the socio-demographic differences in the prevalence of
chronic diseases and PA practices. Chronic diseases were higher among people > 65 years of age,
men (excluding the diagnosis of hyperlipidemia), and those with less education. Only older people
with none-to-low incomes had a higher prevalence of overweight and obesity compared to similar
older people with higher incomes, but there were no significant differences in other types of
chronic diseases between the two income groups. These findings suggest that early education as
a prerequisite for income later in life was a primary socioeconomic driver of chronic disease
burden in this older population.
There were also socio-demographic differences in PA practice, with sedentary behaviors
more common with increasing age, among women, higher educated and lower income groups.
However, of those women, higher educated and lower income groups who practiced PA, they were
more likely to practice regularly, although of varying intensity. These findings are similar to those
shown by studies at the national level in China (Muntner et al., 2005; Ng, Norton, & Popkin, 2009)
and in studies worldwide (Bauman et al., 2012; Hallal et al., 2012). Reasons why older women
are more sedentary than older men may be their home-life responsibilities, in particular, caring for
their spouse or grandchildren. Reasons why older women who practice PA, practice regularly may
have to do with their retirement age of 55 years (James, 2002), and more leisure time to conduct
regular, and even daily PA. The findings on the educational and income disparities, parallel and
further explain the patterns found in national studies of PA in other countries (Muntner et al., 2005).
For example, this study demonstrated that low-educated older people were more likely to practice

39

PA than middle and college-educated ones, but less likely to practice PA regularly. Plausible
reasons for this finding may be that older people with less education were more likely to work in
labor-intensive industries with more occupational PA so that they had good physical health for PA
but less belief in the need for regular PA. High-income people were more likely to participate in
PA but less likely to practice regular PA. Applicable to China, non-manual labors usually have
higher incomes than manual labors and the former retire 5 years later than the latter. Therefore,
some older people with higher incomes in this survey may not be retired, and thus having less
leisure time to conduct regular PA (James, 2002), but had higher motivation for PA to keep healthy,
while poor older people may have been sedentary if their basic needs were not met, and they didn’t
have the physical or mental energy to practice PA. While statistical analyses in this paper are not
sufficient to fully explain the educational and income disparities in PA, future studies could
perhaps utilize qualitative methods to further explore these relationships.
The second main finding from this study showed that a chronic disease diagnosis was one
of the most important triggers, bipolarizing PA practices between sedentary and physically active
groups. In this study, a chronic disease diagnosis was associated with 32% of sedentary people
remaining sedentary, indicating that sedentary older people perceived a new chronic disease
diagnosis as a barrier to PA -e.g., fear that PA could exacerbate their disease symptoms and/or
worsen their health. In contrast, older people who were physically active and subsequently
developed a chronic disease were more likely to increase their PA level after a chronic disease
diagnosis, indicating optimism that PA could reduce their symptoms of disease and/or improve
their health. Enthusiasm to regulate and increase PA practice was strongest after the first chronic
disease diagnosis. These findings demonstrate the complexity of attitudes and beliefs toward PA
behaviors and practices for older people newly or otherwise diagnosed with a chronic disease.

40

Understanding the personal perceptions of disease risk to one’s body following a chronic disease
diagnosis, and how these perceptions differ for sedentary and active older people, may be
fundamental to improving everyday PA practices in general, and following a disease diagnosis in
particular, for older people (Crombie et al., 2004; King et al., 1992). Ultimately, it will be
important to encourage sedentary older people to practice PA prior to a chronic disease diagnosis,
to improve their health trajectory if or when a chronic disease develops.
Whether older people initiated PA or increased their PA after the onset of a chronic disease,
depended on the type of diseases -i.e., in this study, people with onsets of cardiovascular and liver
and biliary system diseases were less likely to be active. The attitudes and beliefs toward disease
onset and progression and PA practice may be related to traditional health beliefs in China, that
“people with certain diseases should relax more to keep their health” (personal observation-March
2016). Thus, education should target patients with chronic diseases, particularly those with
cardiovascular and liver and biliary system diseases, so that they may still benefit from PA
practices, messaging “even if the disease(s) cannot be cured”. There are also older people
diagnosed with hypertension, overweight and obesity, diabetes or hyperlipidemia, who were more
likely to increase (strengthen) their PA following their diagnosis. There is an important need
therefore, to further educate older people about the benefits of strengthening PA after the onset of
a chronic disease, particularly cardiovascular diseases (Franklin et al., 2003; Warburton et al.,
2006). This education could come from family, friends, neighbors, social networks and through
community activities (Brewer et al., 2007; Rothman & Salovey, 1997)—similar types of
communication messaging used to encourage PA in the general, older population.
The third main finding of this study showed that older people who were physically active
had significantly later onsets of chronic diseases, compared to similar older people who were

41

sedentary. For the most prevalent chronic diseases, PA practice delayed overweight and obesity
and diabetes by 8 years; hypertension by 7 years; and cardiovascular diseases by 4 years. Future
PA promotion interventions should therefore, encourage sedentary older people in particular to
initiate PA to delay the onset of these most highly prevalent diseases. Accurate and customized
physical activity guidelines should be created and delivered to ordinary older Chinese people.
Although it is not too late to initiate and regulate PA after the onset of a chronic disease, it can be
more beneficial to encourage healthy people to maintain a regular PA lifestyle prior to the onset
of a chronic disease (Macera et al., 2003; Warburton et al., 2006).
In summary, these findings show the bidirectional relationships between chronic disease
onsets and PA, and the bipolar health trajectory effects of chronic disease onsets on PA. Under
this scenario, it is likely that future health trajectories between physically active and sedentary
older populations will widen as the population ages. When physically active older people were
diagnosed with a chronic disease, their health trajectories appeared to be strong, as PA helped to
maintain health while living with a chronic disease (Warburton et al., 2006). Comparatively,
sedentary older people who experienced an onset of chronic disease, compared to their more active
counterparts, were less likely to initiate PA. Although we do not know the underlying attitudes
and beliefs toward disease risk and PA benefits, or physical explanations, the sedentary may have
had a less healthy trajectory as their chronic disease progressed, and may therefore, need to be
managed more carefully through therapeutic regimes of care.
There are some limitations of this study. The data used in this study was from a health
survey in three neighborhoods in Huainan, a mid-sized city in China. Although comparisons have
been made between the results of this study and other sampling studies at national level in China
(Muntner et al., 2005) and at global level (Hallal et al., 2012), more case studies are needed in

42

different locations, different city sizes, as well as in rural areas to provide supportive evidence for
similar patterns and impacts of PA among older Chinese people. In terms of measurement, this
study applied a self-reported questionnaire to measure PA. However, through the use of this
measure, domestic, occupational, and other types of PA were missing from this study (Craig et al.,
2003; Monda et al., 2007). Furthermore, the abnormal electrocardiogram results reported by the
physician was the sole indicator of cardiovascular diseases, and a more robust measure could be
obtained with other diagnostic criteria such as blood work and other procedures –e.g., angiogram
results. Moreover, this was an observational study, so only associations between PA and sociodemographic groups and chronic disease and PA, could be found. Since this dataset excluded the
highest-risk patients –i.e., those diagnosed with diseases younger than 55 years, the results may be
an underestimation of the true prevalence of chronic disease risk and an overestimation of survival
time, which may vary by chronic diseases. However, it is still valid to compare the relative
differences in survival time within the selected disease groups, which can also demonstrate the
significant positive effect of PA. Finally, geriatric syndromes were not investigated in this study.
Older people’s perception of body may be experienced as more than the diagnosis of a certain
chronic disease reflected in this study. As WHO’s Global Strategies on Healthy Ageing suggests
(World Health Organization, 2016), impairments and geriatric syndromes such as decreases in gait
speed or muscle strength, which are often overlooked by health professionals, are easily perceived
by older people as a problem. Reminding older people to pay attention to such syndromes could
help those who are sedentary to initiate regular PA prior to the onset of chronic disease, after which
it may be physically more difficult to initiate PA.
Conclusion
In conclusion, this study highlights the prevalence of chronic disease types and PA

43

practices by socio-demographic groups, in three neighborhoods in Huainan, a mid-sized city in
China. The findings showed bidirectional relationships between chronic disease and PA, and
bipolar health trajectory effects—some chronic disease diagnoses triggered PA practices, and PA
practices delayed the onsets of most chronic diseases, in particular, the most highly prevalent
chronic diseases—hypertension, cardiovascular diseases, overweight and obesity, and diabetes.
While the National Ageing and Health Strategy and Implementation Plan aims to promote healthy
lifestyles among older populations, the health beliefs that “adequate PA is not necessary to keep
healthy” (Wang et al., 2015) and “PA may worsen the symptoms” (Watz et al., 2008) still
commonly exist. Therefore, additional emphasis could be placed on addressing the bipolar health
trajectories between physically active and sedentary older populations, identifying the differences
in older people’s perceptions of PA as a risk vs. benefit to chronic disease prevention and symptom
control. To improve the quality of life of older people, while reducing the economic costs of
chronic disease burden, public health recommendations to encourage PA among the sedentary,
and those with certain chronic disease diagnoses will be beneficial as China’s aging population
increases during its rapid demographic transition. Future studies should continue to delve into the
attitudes and beliefs of older people toward PA behaviors and practices. Customized physical
activity guidelines could also be developed to address these attitudes and beliefs, and could be
delivered to ordinary older Chinese people. These lessons from China may be applied to other
countries also experiencing an increasing aging population.

44

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https://doi.org/10.1016/j.socscimed.2017.09.032

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CHAPTER 3

HOW THE BUILT ENVIRONMENT AFFECTS CHANGE IN OLDER PEOPLE’S
PHYSICAL ACTIVITY: A MIXED-METHODS APPROACH USING LONGITUDINAL
HEALTH SURVEY DATA IN URBAN CHINA

Introduction

The global population of older adults is estimated to increase from 900 million in 2015 to
2.1 billion in 2050, with 30 percent of this increase attributed to the growing older population in
China (World Health Organization, 2016). Hallal et al. (2012) reported that globally, older people
are the least active population group. In China, only 45% of older adults meet the WHO
recommendation for 150 weekly minutes of moderate-to-vigorous physical activity (PA) to
achieve health benefits (Hallal et al., 2012). This percentage is even lower (9.8%) in urban China
(Muntner et al., 2005; World Health Organization, 2010), which may in part explain the rising
prevalence of chronic diseases in this population (J.-G. Wang, 2015; World Health Organization,
2006; Xu et al., 2013; Yang et al., 2012). Physical inactivity can be an important cause of chronic
disease morbidity among older adults (Bauman et al., 2012), which also adversely affects life
quality, community-based aging and ultimately increases social and economic burdens. Physical
inactivity among older people in China and the rising health concerns in this population have
prompted researchers and public health officials to identify key factors and generate new policies
and interventions to promote PA among older adults, particularly in urban areas.

At the individual level, increasing age and chronic diseases can be key barriers to initiate
and maintain PA (Brawley, Rejeski, & King, 2003). As age increases, people become less
52

physically active contributing to the onset of chronic disease. At the community level, the physical
infrastructure and how older people perceive the built environment can also impact PA (Berke,
Koepsell, Moudon, Hoskins, & Larson, 2007; Cunningham & Michael, 2004; Ding & Gebel, 2012;
Kerr, Rosenberg, & Frank, 2012; Sundquist et al., 2011). Within a Social Ecological Framework
(Centers for Disease Control and Prevention, 2017), both social and physical aspects of the built
environment are considered to be important correlates of PA among older populations
(Cunningham & Michael, 2004; King et al., 2011). In terms of the physical aspects of the built
environment, features such as land use mix (Li, Fisher, Brownson, & Bosworth, 2005), walkability
(Marquet & Miralles-Guasch, 2015) and density of services (Subramanian, Kubzansky, Berkman,
Fay, & Kawachi, 2006) are known to promote PA, but it can take decades to redesign and
reconstruct urban infrastructure. As older people walk in and out of their apartments every day,
their social interactions with neighbors, as well as the physical aspects of their local community
have the potential to influence their PA. Older people in urban China generally have control over
their choice of housing (Zimring, Joseph, Nicoll, & Tsepas, 2005) with most older people living
in apartment buildings, increasing their potential for social interaction with their neighbors, that
can influence their PA.

While there is the potential of altering PA through housing, community and urban
infrastructure, it remains, however, unknown whether an improved built environment will
encourage sedentary older people to initiate PA or simply provide more convenience to those who
are already physically active (Rosenberg, 2016; Schwarzer, 2008). In addition to initiating PA,
there may be other challenges to promoting PA to meet the WHO guidelines for maintaining such
behaviors (Van Cauwenberg et al., 2011). These challenges, also referred to as PA barriers are
more likely to restrict older compared to younger people’s daily activities. Triggers to initiate,
53

regulate and maintain healthy behaviors, including PA, have been studied using Stages of Behavior
Change Models, such as the Transtheoretical Model (Marshall & Biddle, 2001) and the Precaution
Adoption Process Model (Schwarzer, 2008). However, relatively few studies have examined how
built environment interventions impact PA change (McNeill, Wyrwich, Brownson, Clark, &
Kreuter, 2006; Schwarzer, 2008). Moreover, less is known about the effectiveness of social
interaction and physical built environmental interventions on PA in older populations (Brawley et
al., 2003), particularly among the growing and understudied older population, experiencing a rise
in chronic disease prevalence in China (Ying, Ning, & Xin, 2015). The purpose of this study,
therefore, is to improve our understanding of how individual and social and physical aspects of the
built environment can motivate older people to initiate, regulate, and maintain their PA.

Data and Methods

Study Area and Population

This study was conducted in a mid-sized city, Huainan in Anhui Province in central eastern
China. Huainan had a population of 3,456,000 in 2016, of which 12.9% were older
adults(65+ years)(National Bureau of Statistics, 2017). Huainan is one of the 120 most rapidly
growing industrial cities in China-a microcosm of the nation’s rapid demographic transition,
characterized by a growing older population, limited healthcare services, and a rise in chronic
disease morbidity and related mortality (F. Wang, 2008). Like other industrial mid-sized cities in
China, Huainan is different from large global cities as it remains walker-friendly with access to
functional spaces from most residential locations. In this research, three contiguous neighborhoods
in Huainan were selected to study because of research access to outpatient longitudinal health

54

survey records.

The older people in these neighborhoods were also open to talking with

researchers about their activity spaces and community social interactions.

Study Design

This study combined the Social Ecological Model and the Stages of Behavior Change
Model to investigate intervention pathways by which characteristics of the individual and their
social and physical built environments contributed to the initiation, regulation, and maintenance
of PA.

From a social ecological perspective, the social and physical aspects of the built

environment are examined in order to recommend interventions in community engagement and
neighborhood design. From a stages of behavior change perspective, three stages of PA -i.e., the
initiation, regulation, and maintenance of PA are studied in order to identify features of the social
and built environments that promote PA at each of these change levels.

This study applied a mixed-methods approach in data collection and the analytical process.
In the qualitative phase, older adults were interviewed about their PA and content analysis was
used to evaluate their responses. Subsequently, their activity spaces were mapped to show the
approximate residential locations in relation to outdoor functional PA spaces and PA practice
locations in the built environment. Information gained in regards to the motivators and barriers
for PA were used to build a conceptual model by which to test factors associated with the initiation,
regulation, and maintenance of PA from a population perspective. In the quantitative phase, six
years of longitudinal health survey records comprising 97% of older residents were obtained from
the hospital serving the three neighborhoods. Multilevel path analyses were conducted to estimate
the associations between individual and social and physical built environment characteristics and
changes in PA, including the mediating effects of chronic diseases and physically active neighbors.
55

In addition, random slope path analysis was used to examine the moderating effects of age in these
relationships (Rouquette et al., 2015). The process of mixed-methods integration is shown in
Figure 8 and described more fully below. Finally, the residential locations of sedentary older adults
were identified and mapped to show where to begin community interventions. To protect the
confidentiality of all the participants, all identifiable information was removed from the final
datasets. The qualitative and quantitative data collection procedures were approved by the
Michigan State University Internal Review Board (IRB#x15-413e).

Figure 8: The process of mixed-methods integration.

56

Qualitative Phase

Sampling and Interviews

The aims of the qualitative interviews were to identify individual and social and built
environment factors within older people’s activity spaces, that helped to motivate or were barriers
for the initiation, regulation, and maintenance of PA, ultimately integrating information from both
scholars’ and subjects’ perspectives. Forty-two interviews were conducted from February to
August 2016 in the three neighborhoods. Quota sampling was used to ensure a representative
sample of men(n=22) and women (n=20), middle (55-64 years, n=21) and older (65+ years, n=21)
aged adults and relatively healthy and less-healthy participants, because the construction of
knowledge and everyday activity varies within these population groups (Bernard, 2011). The lesshealthy group was defined as middle-aged or older adults reported to have more than three types
of geriatric syndrome(n=40) or chronic disease(n=27) that affects the frequency and intensity of
their daily activities. In the qualitative study, geriatric syndromes included delirium, incontinence,
frailty, dizziness, sleep problems, falls, and osteoporosis (Inouye, Studenski, Tinetti, & Kuchel,
2007). Chronic diseases included obesity, hypertension, diabetes, hyperlipidemia, cardiovascular
conditions, stroke, cancer, liver and biliary system conditions, and poor kidney functions (Marrero,
Bloom, & Adashi, 2012). At least 5 people were interviewed from within each gender by age and
health group. The interviews were mainly conducted in public parks near the three neighborhoods;
however, because it was difficult to find less-healthy older adults who participated in PA, these
interviews were conducted in local clinics.

All interviews were conducted in the local language, Mandarin. Figure 9 shows the flow
of questions for the structured interviews. After introducing the research aims and obtaining oral
57

consent, each interviewee was asked about their socio-demographic, physical and behavioral
histories, including age, education level, income level, if they had any geriatric syndromes or
chronic diseases, and the type, frequency, and length of time spent on their PA. Those interviewees
who conducted PA were asked to give the reasons or motivators for initiating, regulating and/or
maintaining their PA. Those who were sedentary, or used to be active but gave up PA, were asked
to talk about their motivators and/or barriers to initiating and/or regulating their PA, or reasons
that made them give up PA after they had started. After answering these questions, each
interviewee was asked to point out their daily activity space on a printed map from Google Earth
for use in the construction of their activity space and for use in the content analysis (Figure 9).

Figure 9: Question flow of Structural Interviews on n=42 middle age to older adults.
58

Content Analyses

The qualitative analysis was led by the researchers who conducted the interviews. Studies
regarding factors that could affect PA were reviewed to guide the content analysis’ coding process
(Ding & Gebel, 2012; Li et al., 2005; Ying et al., 2015). The interview records were first
transcribed into text in Mandarin and then coded into two categories (Table 8). The first category
of codes included individual and built environment factors that may have affected a change in PA
with additional descriptors as subcategories. The second category of codes included the role of
these factors as the motivator or barrier for initiating, regulating or maintaining PA. These
subcategories of codes were generated from the frequently mentioned themes/phrases within the
interviews (Elo & Kyngäs, 2008). The frequencies and percentages of each code category out of
all of the interviews were generated. Finally, the main individual and social and physical built
environment characteristics reported by the interviewees were used to generate a conceptual model
outlining potential individual and social and physical environmental pathways of PA influence in
the population-based quantitative analysis using the health survey data.

The additional output from the qualitative analysis was a map of older people’s daily
activity spaces—the aggregate of their spaces is referred to as the daily activity area within the
three neighborhoods, for use in the quantitative analysis(Figure 10). The daily activity area in the
three neighborhoods was defined as the area extent within which walking was accessible for all of
the interviewees. After acquiring this area, the land use and land cover used for daily activity were
digitized in ArcGIS v.10.4 (ESRI, 2016). The digitalized features included the apartment footprints
for the three neighborhoods, networks of pedestrian paths, and functional spaces including,
functional services, such as fast-food stores, farmer’s markets, supermarkets, pharmacies, schools,

59

hospitals, PA facilities and natural and human-made water bodies. Google Earth was used to
define the boundaries of the street network, functional spaces, and daily activity area. To improve
the accuracy of the locations of functional spaces, a survey on Street View in Google Earth and a
land-use survey performed by the investigator in the field in the spring of 2016, were also
conducted.

Figure 10: Map of daily activity area for older residents in the three neighborhoods.

60

Quantitative Phase
Data Sources
The aim of the quantitative phase was to examine the proposed pathways of influence
between older individual-level characteristics, social and physical built environment factors and
change in PA from a population perspective. A six-year longitudinal health survey dataset(20102015) of older adults was obtained from the local hospital serving the three neighborhoods.
Included in the dataset were data on individual’s socio-demographic characteristics (gender, age,
education and income levels), home address, clinical data from the physical exam (height, weight
and blood pressure), diagnostic results for several chronic diseases and importantly, the PA level.
Since the annual medical exams for urban residents over 55 years is covered by basic health
insurance (General Office of the State Council of the People’s Republic of China, 2015), 97% of
middle(n=1,177) to older(n=1,925) aged residents (total =3,102)(herein referred to as ‘older’) in
the three neighborhoods participated in the survey. Over the six-year survey, some older residents
did not complete the six-year survey(n=490) and others(n=856) were newly recruited during the
six year time period, reducing the number of survey respondents to n=3,094, and observations
N=13,636. Each individual’s characteristics were coded per below and spatially assigned to an
apartment according to their home addresses. The geographic data generated from the qualitative
phase were measured within the daily activity area.

Physical Activity Measures
In the longitudinal health survey, PA was measured by the frequency of PA per week, the
length of time participating in each activity, and the intensity of each activity during the year.
Based on this combined information, PA for each observation were coded into three levels,
61

0=sedentary; 1=irregular or regular PA but did not meet the WHO recommendation; and
2=Regular PA that met the WHO recommendation (World Health Organization, 2010). The
13,636 observations over the six years were then separated into three groups for assessment in
individual models. The first group (N=5,931 observations) included observations who initiated PA
vs. remained sedentary, -i.e., those reporting sedentary at baseline (level-0) and later changing
their PA from level-0 to level-1 or level-2 (positive response for initiating PA). The second group
(N=4,256 observations) included those who regulated PA vs. remained level-1 PA, -i.e., those
beginning at level-1 PA (baseline) and later changing their PA from level-1 to level-2(positive
response for regulating PA). The third group (N=4,251 observations) were those who gave up PA
vs. maintain PA, -i.e. older people beginning at level-2 PA (baseline) and later changing their PA
from level-2 to level-1 or level-0(negative response for maintaining PA). Some observations were
repetitively calculated in more than one group. For example, older people could initiate PA (level0 to level-1) in a certain year and then regulate PA (level-1 to level-2) in the next year; in such
situations the observation level-1 was a positive response in the initiation of the PA model and
baseline in the regulation PA model.

Individual-Level Measures
There were two types of individual-level measures: socio-demographic and health features.
The socio-demographic characteristics were coded: gender(1=female; 0=male); age groups(0=5564; 1=65-74; 2=75 or over), education level(0=primary school or below; 1=middle school; 2=high
school; 3=college) and income(1=high income; 0=no or low income). Health features included 7
chronic diseases indicated by the physical exam and laboratory records according to the normal
range values provided by the hospital (Zhou et. al., in preparation), including overweight and

62

obesity, hypertension, diabetes, hyperlipidemia, cardiovascular conditions, liver and biliary system
conditions, and poor kidney functions. The normal range values (Table 6) were checked against
the same diseases provided in Merck Manuals (Merck Manuals Professional Edition, 2013b, 2014a,
2014b, 2015, 2016a, 2016b). Those observations within the normal range value for a chronic
disease were coded as 0 (negative); and those surpassing the normal range values, suggestive of a
certain disease were coded as 1 (positive). For a given year, the onset of a chronic disease was
coded as 0 if it was ‘negative’ and was coded as 1 if it was ‘positive’, for the first time.
Table 6: The reference value of seven chronic diseases (International Classification of Diseases
Tenth Revision) (ICD-10)1.
OBT2
HTN2
DBT2
HTC2
CC2
LBTC2
KF2
E66
I10
E08-11
E78.5
N/A
N/A
N/A
ICD-10
Codes
ALT>40U/L Cr>1.39
Reference BMI>2 SBP>14 FPG>126 TC>240 Abnormal
5
0mmHg mg/dl
mg/dl
ECG
Tbil>1.2mg/ mg/dl
of the
DBP>90
excluded
dl
BUN>2
survey
mmHg
arrhythmias Dbil>0.4mg/ 3.3mg/d
.
dl
l
ALT>40U/L Cr>1.3
Reference BMI>2 SBP>14 FPG>=12 TC>240 N/A
5
0mmHg 6mg/dl
mg/dl
Tbil>1.2mg/ mg/dl
value
DBP>90
dl
BUN>2
from
mmHg
0mg/dl
Merck
Manuals
51.4
13.6
8.9
38.3
7.5
4.8
Prevalenc 31.2
e (%)
41.9 in 14.1-15.5 11.1N/A
N/A
N/A
Prevalenc 43-57
in 2010
17.5 in
e over 60 in 2015 2002
2008
in China
(%)
Notes. 1World Health Organization, 2017.
2
OBT: overweight and obesity; HTN: hypertension; DBT: diabetes; HTC: hyperlipidemia; CC:
cardiovascular conditions; LBTC: liver and biliary, KF: kidney failure.

63

Built Environment Measures
The built environment comprised the activity area, including 166 apartment buildings and
an array of functional spaces as described above in the three neighborhoods. The social aspect of
the built environment was measured using the percentage of physically active residents in an
apartment building, as an indirect indicator of the social networks within the apartment site. The
physical aspects of the built environment included two measures: the liveliness of an apartment
site and the closeness of an apartment site to functional spaces. In this study, the liveliness of the
apartment was defined as the metric choice (prediction of population movement) between selected
origins (residence) and destinations (functional spaces) (Turner, 2007). The metric choice, or
betweenness centrality, was calculated by counting the number of times each apartment or
functional space fell on the shortest paths between all pairs of origins and destinations within the
street network in the daily activity area (Turner, 2007). Frequently used nodes were assigned a
high value and less frequently used nodes were assigned a lower value. Assuming that apartments
with greater pedestrian movement flow were ‘livelier’ than those with less pedestrian movement
flow, the metric choice was used to indicate the liveliness of the apartment site. The second
measure, closeness centrality between selected origins and destinations was used to reflect the
closeness of apartment sites to functional spaces. The closeness centrality was calculated by the
reciprocal of the total distance of shortest paths between all pairs of origins and destinations within
the street network of the daily activity area (Turner, 2007). Apartments close to functional spaces
were assigned high values and apartments farther away were assigned a low value. These two
indices were calculated in NetworkX version 1.11 package (Hagberg, Swart, & Chult, 2008) in
Python 3.6 (http://www.python.org).

64

Path Analyses
Each of the three PA measures was used as a dependent variable in separate path analyses.
The independent variables as described above were conceptualized from the content analysis.
Two-level path analyses were estimated, where the within-level represented the observations and
the between-level represented their corresponding apartment sites, -i.e., observations nested within
apartment sites. In all three models, the individual-level variables included age group and the
onset of chronic disease, controlling for gender, education, and income; and the built-environmentlevel included the percentage of physically active neighbors in an apartment site, the liveliness of
the apartment site, and the closeness of the apartment site to functional spaces. The onset of
chronic disease was modeled as a mediator since older-aged adults experience more chronic
disease than middle-aged adults. The percentage of active neighbors was also modeled as a
mediator, since high quality built environments can attract more physically active residents.

Finally, the moderating effects of age on built environment characteristics and maintenance
of PA relationship was modeled, since each of the built environment characteristics could operate
differently, -i.e., as a motivator or barrier to maintaining PA in middle vs. older-aged residents.
First, cross-level interaction terms, age group*built environment characteristics were estimated to
predict a negative response to PA maintenance (the random slope coefficients were studied).
Second, the middle and older age groups were stratified to estimate in separate models the effects
of the built environment characteristics on PA maintenance.

Since the observed variables were not normally distributed, weighted least-squares
parameter estimates (WLSMV) were used in the three models. Goodness-of-fit indices tested,
included the Bentler Comparative Fit Index (CFI>0.95), Tucker-Lewis Index (TLI>0.95), and
65

Root Mean Square Error Of Approximation (RMSEA<0.06) for the binary outcomes (Hu &
Bentler, 1999). Standardized path coefficients were presented to facilitate observable comparisons
between the coefficients. The multilevel path analyses were applied in Mplus Version 7.1 (Muthen
& Muthen, 2012).

Results

Descriptive Analyses

The interviewees and health survey population data were diverse by gender, age,
educational, income, health conditions and PA levels (Table 7). In general, the proportion of
subgroups between those interviewed and surveyed were relatively similar with some differences
in gender, income level and presence of chronic disease. These findings show that the older
population in the three neighborhoods was slightly poorer (no/low income: 83% vs. 68%) and less
healthy (chronic disease: 88% vs. 64%) than the sample of those interviewed; which was expected
because those less healthy were more difficult to find outside of clinics. In summary, the
qualitative information gained from the interviews and content analysis was substantive in terms
of informing the population-based PA models.

66

Table 7: Comparisons of interviewees and health survey population of research sites.
Interviewees1
Population2
(n=42)
(n=3102)
Male
22 (52%)
1683 (54%)
Gender
Female
20 (48%)
1419 (46%)
55-64 years
21 (50%)
1177 (38%)
Age
65-88 years
21 (50%)
1925 (62%)
Illiterates/Primary School
15 (36%)
940 (30%)
Educational Level
Middle School
18 (43%)
1035 (33%)
High School or above
9 (21%)
1094 (35%)
No/Low income
29 (69%)
2582 (83%)
Income Level
High income
13 (31%)
503 (16%)
Yes
40 (95%)
N/A
Geriatric
3
No
2 (5%)
N/A
Syndromes
4
Yes
27 (64%)
2730 (88%)
Chronic Diseases
No
15 (36%)
46 (12%)
No
11 (26%)
895 (29%)
Physical Active
Yes–Irregular
13 (31%)
826 (27%)
Yes–Regular
18 (43%)
1381 (44%)
Notes. 1Interviews conducted in summer 2016; 2Survey population at baseline.
3
Geriatric syndromes include delirium, incontinence, frailty, dizziness, sleep problems, falls, and
osteoporosis.
4
Chronic diseases include obesity, hypertension, diabetes, hyperlipidemia, cardiovascular
conditions, stroke, cancer, liver and biliary system conditions, and poor kidney function.
Characteristics

Content Analyses

The results were summarized by the three individual-level factors, including age or aging
process, onset of chronic disease, and family responsibilities; and four social and physical builtenvironment-level factors, including social networks of neighbors, liveliness of apartment sites,
closeness to functional spaces, and air quality according to their roles(motivators or barriers) in
initiating, regulating and maintaining PA(Table 7). Although air quality was not a major focus of
this study, it was important to learn if air pollution was a barrier to PA prior to the study of social
and physical built environmental factors. After counting and categorizing the frequency of each

67

factor, aging process as a potential moderator to regulate and maintain PA were investigated, since
a high percentage(55%) of sedentary interviewees considered age as a barrier to initiating PA.
Importantly, the polarizing effect of age on the decision to initiate, regulate or maintain PA was
also related to the onset of chronic disease. For example, there was a large percentage of sedentary
interviewees, whose onsets of chronic disease became a barrier to initiating PA. Finally, three
interviewees reported that they could not conduct regular PA because they had family
responsibilities, such as taking care of their grandchildren or doing housework for their offspring.

At the built environment level, over one-half of interviewees mentioned that social
networks among their neighbors were a motivator to initiate, regulate, and maintain PA. They
reported that physically active neighbors attracted them to start PA and they monitored each other
to regularly conduct PA throughout the year. The following two quotations show how the social
aspect of the built environment affected the interviewees’ initiation and maintenance of PA.

“I did not exercise right after retirement. Lei’s mom (a neighbor) invited me to play with
them. She even gave me a sports suit.... It is hard to maintain for one person. But we are a
group.” (Nin, female, age 68, physically active, healthy).

“No reasons to give up. It’s good to exercise with my old neighbors every morning.”
(Hua, male, age 80, physically active, stroke victim).

A group of interviewees also mentioned that the liveliness of their apartment site was a
motivator to start PA. For example:

68

“I lived next to the main street. Many people walk through there. I can see them from my
balcony. It’s…lively. I like lively places.” (Yong, male, age 67, physically active,
Alzheimer & lung cancer).

“It’s (outside) very lively at this time of a day. Once the voice begins, I leave home.”
(Ying, female, age 62, physically active, diabetes).

Some interviewees felt that the location of their apartment affected their PA. Living close
to a functional space was a motivator to initiate PA, while living far away from a functional
space was a barrier to maintain PA. This finding was mostly generated from those interviewees
over 70 years. For example:

“My home is close to everywhere. Outdoor is the farmer’s market. Very convenient. I
often exercise along with buying food for my rabbit and my family.” (Fang, female, age
64, physically active, healthy).

“Look, I live here (an inconvenient place). Now (I’m) getting older and cannot walk far.
(I) exercise sometimes. Less than before.” (De, male, age 70, physically inactive,
osteoporosis and fragile).

However, living close to a functional space was also considered to be a barrier to PA for
a few interviewees:

“For myself, I think living close is good. It’s convenient so I go out every day. But I think
it may be a double-sword for some people. Living too close makes him (her husband)
lazy.” (Jie, female, age 63, physically active, hypertension).
69

“No exercise. Why exercise? I don’t. There is a playground out of my apartment. Noisy,
dirty, crying kids…I have plenty of housework at home.” (Fen, male, age 62, physically
inactive, heart disease).

Although it was suspected that poor air quality would impact older people’s PA, only two
interviewees mentioned that air pollution “May have kept them at home for a few days during
the winter season.”

Table 8: Content analysis coding results: Factors at individual and built-environment levels that
affect older people’s physical activity change.
Factors

Initiate PA

Regulate PA

Maintain PA

Motivators Barriers Motivators Barriers Motivators Barriers
(n=42)
(n=11)
(n=18)
(n=13)
(n=18)
(n=24)
Individual level
Aging process
Onset of chronic
disease
Family
responsibilities
Built environment level
Social networks of
neighbors
Liveliness of
apartment sites
Closeness to
functional spaces
Air quality

1 (2%)
33 (79%)

6 (55%)
7 (64%)

4 (22%)
11 (61%)

N/A
N/A

5 (28%)
2 (11%)

6 (25%)
N/A

2 (5%)

1 (9%)

N/A

3 (23%)

N/A

2 (8%)

22 (52%)

N/A

13 (72%)

N/A

11 (61%)

N/A

11 (26%)

N/A

N/A

N/A

2 (11%)

N/A

4 (10%)

N/A

N/A

N/A

16 (67%)

N/A

N/A

N/A

N/A

2 (15%)

N/A

N/A

Figure 11 generates a conceptual model from the results of content analysis. At the
individual level, increasing age was shown to be a barrier for sedentary older people to initiate PA,
but a motivator for physically active older people to regulate and maintain PA. However, as age
increased, older people in general appeared to be less likely to maintain PA because of their
increasing geriatric syndromes. Thus, the onset of chronic diseases appeared to be a mediator in
70

the age and PA change relationship. At the built environment level, the liveliness of an apartment
site appeared to attract older people to initiate PA., while the apartment’s closeness to functional
spaces helped to maintain PA. The liveliness of an apartment site and its closeness to functional
spaces may also have contributed to an increase in the number of physically active neighbors. Thus,
the physically active neighbors may have operated as a mediator in the physical built environment
and change in PA relationship.

Finally, the different opinions of middle and older-aged

interviewees toward PA indicated that age might operate as a moderator in the closeness of an
apartment to functional spaces and PA maintenance relationship.

Figure 11: The Conceptual Model of individual, social and physical built environment correlates
of physical activity.

71

Path Analyses

The results of multilevel path analyses are shown in Figure 12. For the three models -i.e.,
the initiation, regulation, and maintenance of PA, the CFI (1.00>0.95), TLI (1.00>0.95) and
RMSEA (0.000<0.06) demonstrate the fitness of the models. At the individual-level, age was
negatively associated with PA initiation (b=-.133, SE=.034, p<.001), -i.e., as age increased, people
were less likely to start PA. However, age was positively associated with PA regulation (b=.192,
SE=.028, p<.001) and PA maintenance (b=.094, SE=.020, p<.001) although the effect of age on
PA maintenance was relatively small. Thus, as age increased PA became more regular and more
likely to be maintained. However, age also affected the change in PA indirectly through the
mediator–onsets of chronic diseases, as age was positively associated with the onset of chronic
diseases (b=.116, SE=.031, p<.001). The onset of chronic diseases were negatively associated with
PA initiation (b=-.116, SE=.055, p<.05), positively associated with PA regulation, with a high path
coefficient (b=.326, SE=.065, p<.001) and negatively associated with the maintenance (b=-.186,
SE=.048, p<.001) of PA.

At the built environment level, the liveliness of apartment sites (b=.308, SE=.163, p<.05)
and the percentage of physically active neighbors (b=.651, SE=.097, p<.001) were positively
associated with PA initiation. Apartment closeness to functional spaces appeared to in part,
explain the strong effect that the percentage of physically active neighbors has on those
relationships (b=.144, SE=.014, p<.001). The percentage of physically active neighbors was also
positively related to PA regulation (b=.582, SE=.139, p<.001).

The random slope for age was significant(b=-.933, SE=.072, p<.001)(not shown),
indicating that the association between the percentage of physically active neighbors, the closeness
72

to functional spaces and the maintenance of PA varied across ages. Separate models between
middle and older age groups showed that the percentage of physically active neighbors was
positively associated with the maintenance of PA, both among the middle-age group(b=.910,
SE=.202, p<.001) and the older-age group(b=.785, SE=.081, p<.001). While the closeness to
functional spaces was negatively associated with the maintenance of PA for the middle-age
group(b=-.116, SE=.039, p<.001), it was positively related to the maintenance of PA among the
older-aged group(b=.517, SE=.108, p<.001).

Figure 12: Results of multilevel path analyses testing individual and built environment effects on
older adults’ initiation, regulation, and maintenance of physical activity.
Note.*p<0.05;**p<0.01;***p<0.001.
73

According to the results of the path analyses, three types of intervention sites were defined
by integrating and overlapping the information regarding the percentage of physically active
residents, apartment closeness to functional spaces, and the prevalence of chronic diseases in the
three neighborhoods (Figure 13). First, the color range representing percentage of physically
active residents in apartment sites is divided using a standard deviation classification scheme. The
average(olive yellow) represents apartments within one standard deviation of the mean. The
active(light green) and less active(light yellow) represent apartments above and below the average
between one and two standard deviations, respectively. The highly active(dark green) and highly
inactive(orange) represent apartments greatly above and below the average beyond two standard
deviations, respectively. Second, the color range representing apartment closeness to functional
spaces using walking tracks, is divided into five classes using a natural break classification scheme.
The darkest track represents those walking paths that are farthest from functional spaces, and the
lightest track represents closest to functional spaces. Third, the lattice represents the health of
residents in their apartment sites. Unhealthy apartments were defined as those with a prevalence
of chronic diseases below the mean. Type 1 intervention sites(red boundary) were defined as those
apartments with unhealthy and least physically active residents, located on a track far from
functional spaces. In these apartments, physical inactivity is already associated with chronic
diseases and interventions are urgently needed. Type 2 intervention sites(orange boundary) were
defined as those with healthy but least physically active residents, located on a track close to
functional spaces. In these apartment sites, PA can be promoted to prevent and delay the onset of
chronic diseases among older people. Finally, Type 3 intervention sites(blue boundary) were
defined as those with unhealthy, but highly physically active residents. In these apartments,

74

physical inactivity may not be the main cause of chronic disease and thus, further studies are
needed to learn more about the health of these residents.

Figure 13: Map of daily activity area and built environment characteristics and recommendation
for future intervention sites.
Notes. Type 1 intervention sites (red boundary) were defined as those apartment sites with
unhealthy, least physically active residents located on a tract farthest from functional spaces.
Type 2 intervention sites (orange boundary) were defined as those apartment sites with relatively
healthy but least physically active residents located on a track closest to functional spaces. Type
3 intervention sites (dark blue boundary) were defined as those apartments with relatively
unhealthy but highly physically active residents.
Discussion

Paralleling other studies in Western countries (Annear, Cushman, & Gidlow, 2009; GilesCorti & Donovan, 2002; King et al., 2011), this study demonstrates the important impacts of social

75

networks among neighbors, -i.e., physically active neighbors can initiate, regulate and maintain
PA, for both middle and older-aged adults in China). This finding suggests that physically active
individuals in neighborhoods can empower other residents to participate in PA through their social
networks in apartment buildings and surrounding neighborhoods. Physically active residents,
particularly those who have retired, are willing and have great potential to cultivate a physically
active atmosphere among their neighbors. Empowering this group can be an effective and
economical strategy to promote PA among older residents in neighborhoods.

Another important finding from this study is the differential effects of the physical built
environment on initiating and maintaining older adults’ PA. The liveliness of the apartment site
can promote sedentary older people to initiate PA, while the closeness of an apartment to functional
spaces can affect older people’s decisions on whether to maintain or give up on PA. Efforts could
be made to improve the liveliness of apartment sites to help sedentary older people initiate PA.
Given the important findings of the moderating effects of age, more attention should be given to
older populations, particularly those with geriatric syndromes and chronic diseases who live far
from functional spaces, as they are more likely to give up PA because of their inaccessible
apartment locations. A fundamental and flexible solution is to intervene before the onset of chronic
diseases. Guiding and assisting older people to select their retiring apartments close to functional
spaces, may increase the likelihood of their PA and delay the onset of the aging process. In
addition, while investment in large-scale urban design and infrastructure can take time, increasing
the accessibility of functional spaces would also be beneficial to the older population.

There are some limitations to this study. First, there were some differences in individual
characteristics between the interviewees and longitudinal survey data, thus it is possible that

76

selective-interview bias entered into the quantitative analysis. However, the PA between the two
groups were similar, and given the difficulty of data collection in China, the sample of older people
obtained for the interviews was a highly successful attempt to acquire new information for this
study. Second, since the longitudinal health survey data were collected from a local hospital, some
important factors related to PA revealed in the interviews could not be examined in the quantitative
model. For example, data on the attendance and location of PA were lacking. Third, the effect of
other local factors that might affect PA, such as urban sprawl and the temporal variation in urban
pollution could not be investigated. Fourth, to simplify the quantitative models, the built
environment was defined as the apartment site, yet physical activity may also be affected by social
and physical aspects of a nearby apartment or a neighborhood. Finally, this study is among the
first to investigate the impacts of individual and social and physical built environment factors on
older adults' PA change in a mid-sized city in China; comparisons with other case studies in other
cities and in other countries would be very beneficial.

However, strengths of this study were to combine the Social Ecological Model and the
Stages of Change Model to point out residential forms, where changes could be made in
community engagement, neighborhood design and the location choice of older people’s
apartments (Giles-Corti & Donovan, 2002; James F. Sallis et al., 2006). In addition, separating PA
into three stages(initiation, regulation, and maintenance) helped to identify interventions to
promote PA at different stages of PA (Marshall & Biddle, 2001). Another strength of the study
was the mixed-methods approach. On the one hand, qualitative interviews and content analysis
allowed for the identification of a daily activity area, within which factors pertaining to individuals
and the built environment (motivators and barriers) were identified from both scholars’ and
subjects’ perspectives. These informed findings were then used to test causal relationships, instead
77

of vague associations. Importantly, also were the multilevel path analyses that incorporated
findings from the content analysis to demonstrate significant direct and indirect causal
relationships, -i.e., how individual and social and physical built environment characteristics acted
independently and interactively to affect PA change) (James F. Sallis et al., 2006) and consider the
cross-level interactions without overstating the statistical significance of the built environment
level predictors (Rouquette et al., 2015). This approach led to informed evidence-based
interventions to promote PA and healthy aging. Previous studies on PA and the built environment
in China (Ying et al., 2015) and Western countries (Bancroft et al., 2015; Ding & Gebel, 2012;
Frank, Schmid, Sallis, Chapman, & Saelens, 2005) describe what a health-promoting built
environment should look like to promote PA. This study advances that line of research by
proposing interventions that can not only encourage sedentary older people to begin PA
(Rosenberg, 2016), but can also help older people to regulate and maintain their PA. Based on
these findings, intervention sites were defined and the most vulnerable populations were identified
through the mapping. The next step in this study would be applying the interventions on the
targeted populations.

Conclusion

This study builds on the built environment and health behavior literature by combining the
Social Ecological Model and Stages of Behavior Change Model and examining the causal
relationships between the built environment and PA among middle-aged and older adults, through
a mixed-methods approach. The findings from this study provide informed interventions at both
individual and built environment levels, which will promote healthy PA among older adults in
urban China. Three types of intervention sites were defined, specifically to increase older people’s

78

overall PA. Future interventions should focus on empowering physically active residents to
promote sedentary neighbors to remain active on a regular basis; residential form and access to
functional spaces could be changed through individual decision-making, prior to investing in largescale urban design interventions.

79

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80

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CHAPTER 4
THERAPEUTIC PUBLIC SPACES FOR ALL: PERFORMANCE AND
COLLABORATION OF LEISURE PHYSICAL EXERCISERS IN URBAN CHINA
Introduction
Both health geographers and urban geographers emphasize the increased need for social
justice in their work (Harvey, 1992; Rosenberg, 2014). Health geographers contribute to this aim
by promoting the health of marginalized and vulnerable populations in society -e.g., older people,
minority populations, and social deprivation (Guagliardo, 2004; Wolch, Byrne, & Newell, 2014).
Since the healing places, -i.e., therapeutic landscapes, are largely privatized and have differential
proximities for different social groups, the discussion of therapeutic landscapes in the literature is
largely limited to those of mid-to-upper classes and misses marginalized and vulnerable
populations (Rosenberg, 2016). A theoretical framework that expands the meaning and value of
therapeutic landscapes, as healing and health promoting places for all people, -i.e., rich and poor,
young and old, local and immigrant populations, requires further development in the field
(Rosenberg, 2016) and is an aim of this paper.
In contrast, urban geographers contribute to the social justice literature, by focusing on how
urban spaces can serve all people, especially in reference to parks, squares, and boulevards (Harvey,
2013; Young, 2011). This literature also describes and interprets the conflicts and segregation
between social groups within public spaces (Harvey, 1992), -e.g., fears of attending parks in poorer
areas, and the poor not feeling welcome in parks in upper-income neighborhoods. These studies
highlight the growing disparities in access to urban public spaces, such as through the
gentrification of neighborhoods and the privatization of parks and other public spaces (Mitchell,
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1995) but missing from the literature is how this untoward trend will impact the health of the
marginalized and vulnerable populations. There is a need therefore, to find common ground
between the work of health geographers and urban geographers, to find therapeutic meaning in
urban public spaces, while addressing the conceptual and practical barriers of inclusion for all
people in these ‘healing’ places.
This study aims to contribute to the gap in literature between health geography and urban
geography by combining the concepts of therapeutic landscapes and public spaces. In particular,
therapeutic landscapes will be viewed as a collaborative construction between different
demographic (young and old) and social (rich and poor, local and immigrant) groups, with
therapeutic benefit resulting from the construction of new social identities by bringing together
disparate groups, through the creation of harmonious atmospheres, within these public spaces.
Emerging from this discussion is a new concept that we refer to as “therapeutic public spaces.”
China has a large and growing older population, who are dependent upon outdoor exercising to
meet their daily physical and social needs. Therefore, a case study of older people practicing
activity in outdoor urban spaces in one large city (Beijing) and one mid-sized city (Huainan) in
China is presented to highlight the need and value of therapeutic public spaces.
This study has two objectives. First, this study will attempt to show the synergies between
the therapeutic landscape and public space approaches to understand the possible collaboration
between different social groups in the making of therapeutic—public spaces. This study will
followtherapeutic landscapes studies and emphasize the interactions between different groups, and
then build upon the public spaces literature by adding the pursuit of health as a way of engaging
public life. This paper juxtaposes the healing functions and identity construction functions as
people’s dual aims of physical activity practice in therapeutic public spaces, and shows how they
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construct their identity by a spectacle of health promotion practices (physical activity) and how
they pursue their health by constructing their identities. By doing so, this paper argues that different
groups of populations participating in activities together in public spaces, will enhance each other’s
practice and create a “therapeutic landscape for all”.
Second, this paper links the Chinese long-lasting traditions of filial piety, life-nurturing
movements (including physical activity in public spaces) with the newly emerging rapid
demographic and neoliberal transition in recent years. I argue that physically active older people
play a fundamental role in creating a “therapeutic landscape for all” and successfully “escape
without leaving” the commercialization of everyday life in neoliberal China. Although relying on
limited pensions after retirement, older people contribute to society by constructing their active
identity and working with other exercisers in the making of public spaces. In the following sections,
I will first introduce the combined therapeutic public approaches and then introduce the Chinese
long-lasting and newly emerging contexts, before introducing the case study.
Making Therapeutic Spaces for Public/Putting Health into Public Spaces
In this section, I will first introduce the origins and development of the therapeutic
landscapes and public spaces approaches followed by their contributions to social justice, and then
introduce the three foundations of the combined approaches. Therapeutic landscapes were
developed as an approach to examine “how places can be harnessed with healing functions to
promote the health and wellbeing of people within these places” ( Gesler, 1992; Smyth, 2005).
Originally proposed as an approach to study the relationships between the natural environment and
human health with “a lasting reputation of healing” ( Gesler, 1993; Gesler, 1992), the concept also
discuss various forms of human-made landscapes, including institutional spaces, such as hospitals

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(Curtis, Gesler, Fabian, Francis, & Priebe, 2007), asylums (Philo, 1997), residential care facilities
(Cheng, Rosenberg, Wang, Yang, & Li, 2011), and everyday spaces, such as public parks (Milligan,
Gatrell, & Bingley, 2004), neighborhoods (Wakefield & McMullan, 2005), and home (Williams,
2002). When talking about human-made everyday spaces, therapeutic landscapes often include
green and blue spaces and assume that the inherent meanings of such blue or green elements, such
as trees, gardens, lakes and fountains, are therapeutic for both physical (Bancroft et al., 2015) and
mental (Völker & Kistemann, 2011) health, -e.g., the physical and mental benefits from exercising
and participating in recreational activities.
Therapeutic landscape studies have emphasized the importance of social justice in two
ways. First, studies ask to what extent market-oriented green/blue spaces reduce accessibility for
all, leading to disparate uses of these spaces by different social groups (Kearns & Collins, 2000;
Wolch et al., 2014). Since social inequality can occur in space in the healing function itself, and in
the ways in which therapeutic spaces are provided (Smyth, 2005), therapeutic landscapes studies
have started to focus on the interpersonal communications and encounters within the spaces
(Conradson, 2005; Foley & Kistemann, 2015). These studies, however, by in large take place in
neoliberal Western societies and serve a relatively homogeneous group. For example, studies have
shown how patients of similar socio-economic status attend hospitals of similar quality (Kearns,
Barnett, & Newman, 2003); exercisers of similar incomes purchase gym memberships of similar
status (Foley, 2015); and older retirees with time find leisure in gardens (Milligan et al., 2004).
Aside from a few studies that describe the insecurity of people as they encounter different social
groups (Philo, 2014; Poland, 1998), there is a need for further studies that describe the positive
collaboration between people perceived as different. Moreover, vulnerable groups, such as older
people, or socio-economically vulnerable, such as by race, ethnicity or low income and refugees,
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are often either absent or stereotyped in a relatively negative role within the same spaces ( Laws,
1993; Sampson & Gifford, 2010). The remaining questions here are whether and how to build a
therapeutic landscape with different majority and vulnerable groups of people who are pursuing
their health and wellbeing without conflicts, even collaborating their practices with each other.
Researchers on public spaces, instead care about social justice by reflecting on how places
can adapt to construct the social identities of social groups. Originally emerging from a place where
“bourgeois publish their public opinions among aristocrat” (Habermas, 1991), the concept
gradually widens itself by shedding more lights on people with lower social status, including the
working-class (Fraser, 1990) , homeless (Mitchell & Staeheli, 2006), refugees (Malone, 2002) and
LGBTs (Hubbard, 2001). The definition of ‘public’ has also been extended from Habermasian
political claims to a Goffmanesque stage where people of different social backgrounds construct
their own identities by performing in front of others in cafes, along sidewalks, and in parks and
shops (Goffman, 1959, 1963, Laurier & Philo, 2006b, 2006a; Qian, 2014). Such public spaces
with encounters from different social groups are declining since the public spaces are being
privatized and commercialized through gentrification and banishing people with lower social
status out of previously public spaces (Harvey, 2013; Mitchell, 1995). A small but visible group
of research focuses on the strategies and tactics of people at lower strata in public spaces,
suggesting the possible contributions they make in the maintenance of public spaces (Amster, 2008;
Duneier & Carter, 1999). Missing from this literature is that people not only attend public spaces
to construct their social identities, but they are also motivated by more practical reasons such as
businessmen visiting a cafe to meet clients; white-collar workers waiting at bus stops for
commuting; retirees visiting parks for exercises; and venders selling used-books on sidewalks to
make a living. Simply by pursuing these fundamental needs, people can engage in politics and
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construct identities (Farquhar & Zhang, 2012; Rose, 2007), and only when people of different
social groups achieve their ultimate needs in front of others can public spaces be maintained.
Concern for the decline of public spaces is, therefore, that people will not have access to their
livelihoods to achieve their fundamental needs in such spaces (Mitchell, 1995). In other words,
people’s ultimate needs in public spaces, such as promoting health or making a living, should not
be neglected in the maintenance of public spaces. Pursuing physical, mental and emotional health
and wellbeing as dimensions of health and employment as a basic livelihood should not be
underestimated in public spaces studies.
Work exploring the origins and development of therapeutic landscapes and public spaces
above suggest that a marriage of these two approaches is not only possible, but also a beneficial
solution to the dual problem of social justice. A combined approach, therapeutic public spaces, is
built upon the following three common foundations of the two approaches. First, it is possible to
combine because of their similar focus on open spaces in urban areas. While therapeutic landscape
studies in urban areas have paid more attention to blue/green spaces (Rosenberg, 2016), the
concept of public spaces can expand the foci of therapeutic landscapes to include more ordinary
spaces, such as sidewalks, bus stops –i.e., places where “the healing process can work itself out”
(Wilbert M. Gesler, 1992, p. 743). On the other hand, with the focus on health and healing in public
spaces, urban geographers may begin to explore spaces traditionally thought to be ‘therapeutic’
such as heritage sites, national parks, and public gyms.
Second, both approaches focus on the roles of different groups of people within the spaces.
Therapeutic landscapes studies argue that while the role/identity of different groups can influence
the local atmosphere (Duneier & Carter, 1999) and then influence people’s pursuit of mental and
emotional health (Glenda Laws, 1993), people of all age groups and social backgrounds should
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be able to acquire the sense of healing on a physical, mental and emotional level (Poland, 1998;
Sampson & Gifford, 2010). Public spaces studies have primarily emphasized that people of
different social strata should be able to construct their own social identities in the same arena
(Harvey, 2013). By combining the two approaches, the subjectivity of people in therapeutic public
spaces should be defined by both their socio-economic and their fundamental needs in the place
of healing -i.e., the pursuit of health for their body and mind.
Third, both approaches have paid attention to the symbolic interactions between people of
different ages and social groups, and their surrounding environments. Therapeutic landscapes has
its long lasting interests on the symbolic meanings of the local physical environments -i.e., where
people work, live, play and heal, such as water, plants, room design of hospitals, that experienced
and encountered by different groups of people within the spaces (Foley, 2015; Völker &
Kistemann, 2013; Zhou & Grady, 2016). Such symbolic interactions have the potential to promote
the collaboration of different groups in the same spaces, if the ultimate needs of health are
commonly desired and/or achieved, although conflicts may also occur if some symbols obstruct
the achievement of health (Zhou & Grady, 2016). However, few studies discuss the possible
collaboration between different social groups in the making of therapeutic landscapes.
Comparatively, studies on public spaces often apply multiple social theories to study the symbolic
meanings of appearance, gestures, and conversations during the interactions (Goffman, 1963;
Laurier & Philo, 2006a; Qian, 2014). Therapeutic landscape studies can inspire public spaces with
its emphasis on physical and psychosocial health as one of the most important needs in public
spaces (Low, Taplin, & Scheld, 2009), thus addressing the decline of public spaces in neoliberal
society. Simultaneously, public spaces studies can inspire therapeutic landscapes with its deep
ground of social theories, not limited to inter-subjectivity and non-representational theories (Foley,
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2015; Foley & Kistemann, 2015), but also the performativity and ethnomethodology approaches
(Garfinkel, 1963, 2002, Goffman, 1963, 2009), thus opening a discussion of collaboration of
different groups in the making of therapeutic landscapes. Applying such a combined approach,
this paper is a blueprint of therapeutic public spaces constructed by the collaboration of different
social groups in every possible spaces of Chinese cities, reflecting and hopefully expanding the
boundaries of therapeutic landscapes and public spaces in previous studies.
Physical Exercisers in a Transitional China
The overwhelming majority of conceptual and empirical studies of therapeutic landscapes,
and public spaces take place in Western contexts. In contemporary China, older people’s leisure
physical activities in public spaces can be understood from recent to historical contexts-the recent
rapid demographic transition, neoliberal transition after the Reform and Opening Up, collectivist
ideology in the socialist period, and the long-lasting filial piety tradition in history.
Since the 21st century, the older population has grown rapidly in China as well as many
other countries of the world. China had over 14 million older people over the age of 65 years, and
by the end of 2015 older people will comprise approximately 10.5% of the total population (World
Health Organization, 2015). In line with the rapid aging transition are increasing health and social
burdens, including increasing chronic disease and geriatric syndrome prevalence, and
hospitalization and institutionalization costs. In response to this, the World Health Organization
(WHO) (World Health Organization, 2002) and Chinese government developed multiple programs
to encourage older people to engage in physical activity, which in turn will maintain and promote
their health and wellbeing of life and reduce societal costs. Since the late 1990s, a life-nurturing

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movement, including leisure physical activities and hobbies, has been observed among Chinese
middle-aged and older populations in urban public spaces (Farquhar & Zhang, 2012).
Outdoor physical activity is an inexpensive type of health-promotion practice in the
commercialized health promotion market of China’s neoliberal society after the Reform and
Opening Up (Farquhar & Zhang, 2012). To transfer the burden of rapid aging costs from the state
to individuals and society, the market developed a health-related industry from the diverse needs
of older people for health-related consumption products, under the guidance of the government
(Zhang & Ong, 2008). In no more than ten years, health-related industry has surpassed many other
economic sectors and has become the fifth largest economic sector in China’s economy (Sun,
2015). The mushrooming of care facilities and institutions for the older population, including
physical activity courses, rehabilitation trainings, as well as residential care institutes for older
people with disabilities or dementia, are high-priced and inaccessible for ordinary older retirees
with limited pensions. The expensive health care facilities provide services for high-income
customers and do not offer financial assistance to those with only a retirement pension, in particular
in poor provinces and small cities, thus creating large health disparities between those who receive
care and those who do not (Lin, 2009, p. 200). In addition, the large labor outflow in these declining
cities has caused a great scarcity on older family-caregivers. Therefore, the popularity of leisure
physical activity in public spaces is not only an extension of a life-nurturing tradition, but also a
fundamental mission of the large number of ordinary older people (in their own words) – because
“we are not rich to use high-priced care facilities, we have to promote (at least maintain) our health
and pursue some kind of wellbeing in an inexpensive way” (Zhou personal communication,
February 2016). Although leisure physical activity in public spaces is not totally free, a monthly

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payment of 5-20 RMB crowdfunding for facilities and clothes is affordable for those on a limited
pension (Qian, 2014).
Apart from the neoliberalism after the reform, the collectivist ideology generated before
the reform in the socialist period also shape older people’s physical activity practices. The older
generations grew up in socialist period and spent most of their young age in the early stage of
Reform and Opening Up period, and finally got old in the neoliberal era. In the socialist period,
organizing and practicing collective physical exercise was a top-down biopolitics from the state to
the local level with the aim of maintaining the collective ideology and health of socialist labor
(Farquhar & Zhang, 2012; Qian, 2014). While experiencing the social transition over their
lifecourse, many older people still hold a collectivist sense and emphasize the honor of ‘collective’
life (Yu & Rosenberg, 2017). Interestingly, many older Chinese exercisers like to follow the stateorganized leisure activities in socialist China (Huang, 2006) and still conduct their physical
activities together in public spaces in almost every large, mid and small sized cities (Chen, 2003).
Moving across to this new era, this generation consider old-style collective outdoor physical
activity as an important way of constructing social identities (Qian, 2014). Inherited from the
socialist period, such an inexpensive way of practicing leisure physical activity and crowdfunding
strategies is not an innovation but an idiomatic strategy appropriated from the socialist period in
response to the phenomenon of health inequality in the neo era.
In addition to the new time contexts described above, older people’s physical activity is
also deeply rooted in the tradition of filial piety or xiao, a long-lasting Confucian idea. This idea
emphasizes offspring’s material provision and physical caregiving to their older, weak, and
dependent family members; the energy and creativity of older people in China is largely neglected
(Sharps, Price‐Sharps, & Hanson, 1998; Zhan & Montgomery, 2003). The dependent role of older
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people has been additionally extended to the community and the entire society, suggesting
respecting and taking care of all older people as if they were family. Nowadays, aging related
projects in China are called feeding older (yanglao) projects, demonstrating the old stereotype of
China’s older population in the new era. While continuously constructing the vulnerable
appearance of older people in Chinese society, the traditions of filial piety paradoxically deliver a
gerontocratic idea to the older group, -i.e., older means respectful and knowledgeable and should
be able to govern the younger generation, the whole family, and even the society. In this light, the
idea of filial piety in contemporary urban China empowers older groups to influence their life
world. They are willing to construct their social identities and participate in public life through
performance in public spaces, although their real influence can be different from their expectation.
The backgrounds of then and now led me to consider the leisure physical activity in public
spaces as both a health-promoting practice of a growing aging population in response to
commercialized health care services, and a performance about collective identity construction with
ambitions to influence other groups in public spaces.
Methodological Notes
The analysis in this paper is based on my fieldwork in public parks in both Beijing (summer
2014-2015) and Huainan city (spring and summer 2016). A large and a mid-sized city were studied
because different patterns of physical activities were expected between large and mid-sized cities.
Large cities attract more immigrants, and the health-promoting industries and facilities developed
earlier and are more mature than in small cities. Comparatively, the demographic transition is
more rapid in mid-sized cities but care-giving from family members is more scarce because of the

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large amount of emigration to large cities and relatively small amount of immigration from local
rural areas (Gu & Zhang, 2006).
Two public parks were chosen in Beijing (Yuan Dynasty City Wall Relics Park and
National Stadium) and Huainan (Laolongyan Park and City Stadium). According to the pilot study,
these parks are green spaces with reputations for healing across their respective cities thus
attracting ample exercisers and hobbyists of diverse backgrounds, children, young and older
people, rich and poor, local residence and immigrants. Most of the activity groups were welcome
to participate, and the interactions between individuals and groups were, therefore, easy to observe.
Although diverse groups were welcome to practice physical activity in the same parks, people of
similar backgrounds tended to conduct similar activities in a certain time period. For example,
square dancers and hobbyists were mostly middle-and older-aged and often exercised in the early
morning and late afternoon; joggers were mostly young people and often jogged in the evening;
and tourists were also welcome during the weekends. Since the primary author was a young woman
with no children, she was welcome to visit the sites as joggers or visitors are welcome to do so.
The study sites also included sidewalks and the front square of groceries near these parks, since
leisure physical activities were not always nested within green spaces; instead they commonly
occurred on sidewalks and in front of some groceries.
The fieldwork, including participant observation and in-depth interviews, were conducted
in the morning, afternoon and evening when leisure physical activities and recreations occurred. I
started with regular jogging in the study sites to avoid the sense of hostility from my observing
groups (Philo, 2014), although there was one jogger who was a bit too active than others who
usually jogged only in the evening. Participant observations focused on the performance and
interactions between three groups: (a) 20 stationary exercise groups or individuals including square
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dancing dama, tai-qi groups, Latin dance groups and choruses, individual exercisers and hobbyists,
(b) 21 mobile exercisers including joggers and bicyclists, and (c) 10 retailers including venders,
craftsmen and shop assistants in the groceries nearby. Since people perform through various
modes, not limited to language but also through appearance, gaze, gestures, body actions (Goffman,
1959; Laurier & Philo, 2006a) and their arrangement of spaces (Zhou & Grady, 2016), these
multiple modes of performance were observed and documented. The observation results were
recorded in field notes and photographed with consent.
The in-depth interviews consisted of 43 open-ended interviews and several informal
interviews among the observed groups of people, including stationary leisure exercisers and
hobbyists (n=23), mobile exercisers (n=11), and venders and retailers (n=9), which were suggested
to be saturated in qualitative studies (Guest, Bunce & Johnson, 2006). Stationary exercisers were
randomly selected from the observed groups and individuals before the start of their activities to
avoid disturbing their daily activities. Interviews with this group were conducted to learn why they
practiced a certain type of activity, why they selected the current activity spaces, how they
constructed their identity with appearance and arrangement of surrounding spaces, and how they
reflected on their interactions (conversation, collaboration, or conflicts) with other encounters. To
promptly capture mobile exercisers such as joggers and pedestrians, walk-along interviews
(Carpiano, 2009; Kusenbach, 2003) were conducted with this group with consent. Interviews with
them were similar to those with stationary exercisers but almost none of these mobile exercisers
made any changes to the surrounding environments. Venders and shopping assistants were
recruited after purchasing their products and with consent. Interviews with this group focused on
why they selected the space to do their business and how they reflected on the interactions with
the physical exercisers there.
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Although the interview questions were structure-designed, the interview process was
actually semi-structured and open-ended since the interview itself became an opportunity for the
participants to perform and construct their identities (Ezzy, 2010). It would have been ideal to
recruit more respondents for in-depth interviews but time constraints and difficulty approaching
retailers limited the sampling size and the length and depth of some interviews. Besides the 43
respondents, many of the interviews could only be treated as informal interviews as the
respondents refused to be recorded or could not complete their entire interviews. These informal
interviews, which were not recorded or interrupted, were used to compare with the recorded
interviews to ensure saturation of the sampling (Yeung, 1997) –i.e., no new information was
obtained from additional interviewees.
In addition, observation notes, interview records, and photos were integrated into a
thematic analysis, searching for common and divergent performances and reflections on other
encounters and the activity spaces. Individual level data were compared within and between groups
(Glaser & Strauss, 2009) and triangulated between different research sites in the two cities (Yeung,
1997). Based on these analyses, I analyzed the role of each group of participants in the making of
therapeutic public spaces for themselves and for other encounters. In the next section, I present my
findings in three parts, detailing the performance of three groups of physical exercisers, -i.e.,
stationary physical exercisers and hobbyists, mobile joggers and pedestrians, and the supportive
retailers. For each group, I interpret the symbolic meanings of the appearance and the environment
they built-up, experienced and encountered, following a reflection on the role each group played
in the making of therapeutic public spaces and the relationships between such a physical activity
practice and the Chinese context. Since there were no obvious distinctions between the two cities
(except there were more immigrant participants in Beijing), I do not present a comparison between
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cities. The research was approved by the Michigan State University IRB (# x15-413e) determined
Exempt (April 24, 2015).
Results
Stationary Leisure Exercisers and Hobbyists: Mid- and Older-aged Pathfinders
Leisure exercisers and hobbyists selected many places as their ‘stations’ where they
practiced activities at a fixed time every day. Most of the participants were middle to older aged
adults and were retired or almost retired from their work. With ample and restless leisure time,
they occupied the spaces regularly and frequently. Inviting several old colleagues and going out to
practice leisure physical activities, every day had become their obligatory course of later life. There
were four typical types of exercise and recreation stations. The first type was public space with
forests (Jingshan Park, Beijing) or surface water (Laolongyan Park, Huainan) as reputable healing
elements for outdoor leisure (Figure 14a). Second, Chinese pavilions were an important choice as
places of leisure physical activities and recreation.
Such pavilions are designed following the old types of architecture in traditional fairs and
Chinese royal gardens (Hsu, Chiang, Tsai, & Wang, 2002). A pavilion is normally open structure
with a rectangle steeple supported by pillars. Pavilions in ancient times were commonly used as
theaters for royal and local opera performances. In contemporary public parks, such pavilions are
designed to provide pedestrians a seating place for sightseeing and rest. For the leisure exercisers
and hobbyists, however, a pavilion is considered as a perfect stage for their performance. In Yuan
Dynasty City Wall Relics Park, Beijing and Laolongyan Park, Huainan, almost all of the pavilions
have been occupied by ballroom dancers, qi-kong players, Peking Opera clubs, and choruses
(Figure 14b).
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“We are singing opera on this stage (the pavilion).” (Yun, female, retired, a member of
chorus, Yuan Dynasty City Wall Relics Park, Beijing)
“The music works well here (in the pavilion).” (He, male, a Jinghu player in a Peking
Opera club, Laolongyan Park, Huainan)
In addition to pavilions, squares, frontages and glades near pedestrian tracks within the
parks were also popular spaces for leisure physical activity and recreation. While large troops of
square dancers and choruses assembled in larger squares in front of the National Stadium and City
Stadium, diabolo players and Karaoke singers showed up in smaller glades and frontages in Yuan
Dynasty City Wall Relics Park and Laolongyan Park (Figure 14c). Importantly, different from
western concepts of urban green/blue spaces, Chinese leisure physical exercisers and hobbyists
also expanded their activity venues out of the parks, forests, and surface water to ordinary urban
public spaces-frontages of gated communities, restaurants, groceries, and schools next to
sidewalks. For these exercisers, public blue/green spaces and pavilions were too far from their
homes, or maybe these spaces were limited because they were occupied by other groups at a certain
time of a day, so instead they occupied the next best places, which were the most convenient.
Lacking the typical healing elements of vegetation and water, frontages next to sidewalks were
less beautiful and perhaps less therapeutic, since there was much more air and noise pollution.
Exercisers valued these spaces however, for their convenience, open-access, and free light in the
evening. In Beijing and Huainan, square dancers were observed in front of gated communities,
banks and restaurants (Figure 14d).
Day after day, these spaces gradually became the territories of exercisers and hobbyists for
a certain time of day. Compared with them, walkers utilized the tracks and spaces in the parks, but

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their mobility made it hard for them to ultimately occupy a specific space. By saying territories
here, I mean that middle to older aged people actually acquired a spatial and temporal jurisdiction
over spaces. Every morning and evening, such a space was reserved by a certain group. People
always came to the space on time to practice their activity and recreation in a fixed time period.
They usually brought their crowdfunded facilities such as microphones, outdoor speakers and
instruments, and then took them home after the activity. Their activities were never interrupted
by weather, -i.e., outdoor winds drizzly, chilly or smog, except when there were rainstorms.
Beyond the performance of physical exercise and hobbies, the people also administered the space
by taking the responsibility to keep the space nice and sanitary, displace the illegal parking, and
watch the security of surroundings. For a certain time of a day, these spaces were commonly
considered by passersby as these exercisers and hobbyists’ territory.
Notwithstanding a territory, it is an open sharing territory with a low threshold of entry
where almost anyone is welcome to join the exercisers’ group with permission, and most
importantly, all of the performance of exercisers and hobbyists needed audiences. The four types
of spaces were selected because of their convenience for audience watching and listening to the
performances (Figure 14a-d). The pavilions provided perfect audience seats around the center of
the stage. Pedestrians often stopped by squares and frontages to rest and watch the physical
activities and recreation. The applause and enjoying faces encouraged exercisers and hobbyists to
perform well through all kinds of practice. Some groups started to wear uniforms and invite
professional artists to teach and improve their performance. Within the groups, peers criticized and
helped each other to make progress and the best performer was elected to lead, guide, and monitor
the performance of every member. Different activity and hobby groups also competed and
compared their performances with each other by peer-reviewing uniforms, body movements, and
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their maintenance of surroundings. A number of competitions were held in front of the National
Stadium for square dance groups across the country (Fullerton, 2016).
a

b

c

d

Figure 14: a: Physical exercisers near a lake. b: A pavilion with Peking Opera Club. c: Tai-qi in
a front of a park track. d: Square dancers in front of banks and restaurants.
Through all kinds of performance to the public, these middle to older aged exercisers and
hobbyists produced open sharing spaces for public leisure, and a collective identity as an active
group. Although coming from different socio-economic strata, they had all labeled themselves and
had been labeled in their groups. Such a consistent identity was defined by their simple aims of
performance to promote health and to perform as active lively collectives in their later life,
strengthened by their consistent uniforms and sports suits obscuring their individual differences.

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In such an exercise and recreation space, age identity tended to be more important than socioeconomic identity.
“(We are) All daya (grandpas) and dama (grannies) come to exercise together. It is not
only about individuals, we are a collective and should have collective sense of honor.”
(Xiang, male, retired worker, a tai-qi player, the City Stadium, Huainan)
“Some day we will all belong to the crematorium. (No matter if you) rich or poor, (you
will become) a pile of soil.” (Yi, male, retired banker, a tai-qi player, Yuan Dynasty City
Wall Relics Park, Beijing)
The consistent identity was also confirmed by other participants of the spaces. In addition
to collective active and lively groups which self-identified themselves as such, in contrast other
participants treated the exercisers as an old weak group. By saying ‘weak’ they meant the middle
to older age adults were getting biologically weak so that they did not have that much energy and
motivation to harm themselves. Compared with the identity of insecure strangers for some
encounters in Western public spaces (Philo, 2014), such an assemblage of simple, active and weak
elements of the body coincidently guaranteed the security and friendliness of these localized spaces
in contemporary urban China. Moreover, the performers and audience were relatively fixed-most
of them attended at a fixed time of day and tended to be acquaintances day after day-which served
as eyes on the street to watch for possible risks and dangers from strangers (Jacobs, 2016).
In public parks and pavilions, parents walking with their children were not hesitant to allow
their children to play around the dancing groups so that they could have more private relaxed time
for themselves (Figure 15a). Children were welcome to play near the groups or join the dancing

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groups with older exercisers. Older hobbyists on the frontages of sidewalks in the evening also
provided a lively and secure track for late commuters (Figure 15b).
“They are daye and dama coming for physical exercise. And many people come and go
and watch (each other).” (Jun, mother of a 4-year-old girl, doctor, Yuan Dynasty City
Wall Relics Park, Beijing)
“They just come for exercise, and they are a group of people.” (Yuqin, female, young
commuter, the National Stadium, Beijing)

a

b

Figure 15: a: Children freely play around the square dancer on the frontage. b: Old Karaoke
singers provide a lively and safe track for late commuters.
According to the observations and interviews, I concluded that the stationary exercisers
and hobbyists created the foundation for therapeutic public spaces in both research sites. They first
occupied an undefined open space, harnessing it with a therapeutic function by adapting it into a
nice clean space for collective physical activities. Some healing elements such as water, vegetation,
and Chinese gardens were grabbed to create a therapeutic environment, spaces without such
elements were also occupied for their ultimate aims of promoting health. Such therapeutic spaces
were created not only for their pursuit of health but by adding the healing function to the space,
these exercisers and hobbyists constructed an identity of an active older collective obscuring socio105

economic strata and backgrounds, which attracted many other exercisers together as the eyes of
street maintaining security for children, pedestrians and commuters. Such a secure atmosphere
then attracted more social groups to accomplish their physical, mental and emotional demands,
develop their identities, and orient the space towards a more therapeutic and public dimension. A
description of these other social groups follows.
Mobile Exercisers: Audiences and Consumers
The mobile exercisers were a heterogeneous group of various ages and socio-economic
backgrounds. In this study, I selected the three most common groups to estimate their mutual
intersections and roles with other participants in the production of therapeutic public spaces. The
first group were joggers, individuals and groups. Many individual joggers ran during a fixed time
of day following a fixed track in the park. They often wore professional sports suits and running
shoes with sports bracelet to monitor various biological functions, such as heart rate. They often
wore earphones and seldom talked with each other due the strenuous nature of the activity. Joggers
also organized jogging clubs and exercised together. Similar to square dance dama, jogging clubs
also had uniforms (Figure 16a); different from them though, were jogging clubs where relatively
dynamic groups with new and old joggers rotated in and out depending upon their stamina. If the
stationary middle to older aged exercisers encouraged other older people to be active, the median
age of joggers was relatively young, as they performed and created an identity of younger intensive
athletes that tended to be more attractive and exciting for younger people.
The second group is the oldest-old walkers. This group could only spend a limited time
during the day to have a short walk in the park or along the near street because they may have
heavy family responsibilities such as taking care of children or have physical syndromes that do

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now allow them to group exercise. These oldest-old walkers, walk short distances and slowly,
never trying to compete with anyone else for speed (Figure 16b). They come to the park on the
way to the farmer’s market, and have to leave before their grandson’s (or granddaughter’s) school
ends. Generally, they are the most loyal audience watching their younger peers (middle to older
aged) perform. Even though the middle-aged exercisers and hobbyists try their best to perform
well, most of them are obviously amateurs and just practice for health. Such performances
therefore cannot attract a young audience. Young audiences may stop by to enjoy the performance
but only to be nice, but the oldest-old audiences appear to admire their peers. They admire these
exercisers and hobbyists for their courage, body strength and leisure time to practice the activities
and recreations that younger people enjoy and benefit from. A couple of quotes from the oldestold walkers illustrates how they differ from younger audiences.
“I’m old and don’t have energy to dance. I danced better than them when I was young. I
used to be a dance shower in the annual convention of my company.” (Cuifen, female,
69, coronary heart disease, Laolongyan Park, Huainan)
“I don’t have time. I have to take care of the kid. His parents don’t have time. Buy food,
cook the meal, and take the kid from and to school. Look at my stomach, I’m getting fat
since taking care of it.” (Rong, female, 67, Yuan Dynasty City Wall Relics Park, Beijing)
The third group is parents walking with their children (Figure 16b). The aim of this group
is no longer for intensive physical training. Instead, they hope to attach their children to nature and
diverse hobbies in such a lively space and thus build intimate relationships between parents,
children, and their lifeworld. In other words, the parents consider the public parks and sidewalk
frontages as ideal spaces to pursue the wellbeing of family life. They teach their children

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knowledge and skills that relate to nature such as plant knowledge in the spring when the flowers
bloom; they let their children play with pets on the grass; they take their children to fly kites in the
wind; they take their children to watch performances of various hobbies such as diabolo,
calligraphy, Tai-qi and Peking Opera and hope their children can be inspired and cultivate their
own hobbies; and some parents simply walk with their children to enjoy the leisure chatting time.
For such a group, natural elements, such as plants, grass, water and pets serve as important
therapeutic symbols to produce their family’s sense of wellbeing.
“Take the kid to feel the nature so that he can feel relaxed from the city of reinforced
concrete.” (Jia, female, mother of a grade 1 pupil, Yuan Dynasty City Wall Relics Park,
Beijing)
“I take her to learn the name of these flowers. This is the first time I teach her about that.
I’m too busy.” (Xiaoshu, female, mother of a 4-year-old girl, dentist, Yuan Dynasty City
Wall Relics Park, Beijing)
For the children, this is valuable leisure time with their parents and also provides space to
escape from their school’s homework, the everyday norms in the classroom and home and to be
themselves, which is a mental and emotional healing process for them.
“Boys of his age are full of energy. They want to run and jump and sweat. School teacher
always forbid them to avoid any damage. But he really needs it. If I forbid him, he will get
fatter.” (Qiong, male, father of a grade 3 pupil, the National Stadium, Beijing)
The parents group was the easiest to build rapport and conduct interviews. They were also
the easiest group to start conversations with each other. As mentioned before, many parents liked
to sit near the stationary exercisers and hobbyists and let their children play, while conversations
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naturally occured. After confirming their identities as parents for each other, the conversations
often started with the grade, personality, hobby, and education of their children. The core function
of the talks was to better educate their children. After several encounters, different parents and
children became acquaintances. Families of similar socio-economic backgrounds tended to build
rapport because of their similar attitudes and opinions on education. Parents and children are the
main consumers in these spaces. Children wanted food and water after sports and were curious
about new things. This market has been captured by the low-end retailers and craftsmen vendors.

a

Figure 16: a: A group is jogging fast in the evening. b: an old walker, following a mother with
two children.
In summary, the mobile exercisers expanded the range of participant groups from the
youngest-young to the oldest-old, and also helped to produce a more diverse, vigorous, and mobile
healing process for physical, mental, and emotional health, -i.e., for the tired bodies and minds of
the city. They are the beneficiaries of the secure and lively spaces created by stationary exercisers
and the blue/green elements provided by urban planners and highlighted by health geographers.
They also contributed to becoming the supporters and audiences of their middle to older aged peers
and produced a diverse and energetic atmosphere to the healing spaces in return. Although long
lasting in-depth relations were not expected to be created between people of different socio109

economic strata, rapport was naturally built among different parents with similar backgrounds and
small talk naturally occurred between different social groups. Also importantly, the large number
of parents and children attracted low-end retailers and craftsmen vendors, which created another
type of collaboration between different social encounters in the same public space.
Low-end Retailers: Supporters
As another group of participants, the low-end retailers and vendors did not come to these
spaces to pursue their health and wellbeing, rather they came to make a living. The role of this
group is important and essential for the production of therapeutic public spaces. In this paper, I
categorize low-end retailers into stationary retailers and mobile vendors according to their different
roles in the production of spaces. The stationary retailers provided low-end commercial activities,
including small restaurants, low-end groceries and farmer’s markets near the activity space (Figure
17a), many of which were developed ahead of the production of public parks or activity frontages.
While many middle to older aged retirees had more leisure time than younger people, they could
not walk as long as young people and they also had to achieve multiple purposes in a limited spatial
area (Su, Schmöcker, & Bell, 2009). Some of the retailers may go out early in the morning, practice
physical activity in the park, have breakfast in the small restaurants near the park, and then go
shopping in the groceries or farmer’s markets nearby. As a result, parks and frontages near these
stationary retailers were more likely to be selected as activity spaces for some retirees to exercise
and subsequently shop and accomplish some other tasks in one trip. In return, some low-end
groceries chose to locate next to the leisure activity spaces (Figure 17b).
The patterns of multi-purpose travel of retirees influenced the agglomeration of low-end
retailers near leisure activity and hobby spaces, but the collaboration was even more than that. As

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the main customers of these low-end retailers, middle- to older-aged exercisers were largely
supported by these retailers. Many low-end retailers allowed dama to dance at the frontages of the
groceries or restaurants who provided lights and free access to toilets because these people were
their main customers underpinning their business. The lobby in the grocery store even became a
rest space for these older people (Figure 17b).
“There are always many people here (in the lobby). Today is hot and stuffy, so even more
(people). We have air conditioner here. What can we do?” (Shop assistant, female, Good
and More Grocery Store, Huainan)
“Most of them (customers) are daye and dama coming exercise…every day.” (Restaurant
keeper, male, Yuan Dynasty City Wall Relics Park, Beijing)
A second group of retailers, the mobile vendors, represented those venders selling snacks,
used books and videos, toys, and craftsmen who only attended the activity spaces during a
particular time of the day when the spaces were lively and with adequate potential consumers
(Figure 17c). For example, used book vendors may only attend during the weekends to attract
young customers; craftsmen and snack vendor may attend later in the afternoon when children are
out of school; and commodity vendors attend in the evening when most middle to older exercisers
visit their usual public spaces. Many of these mobile vendors were immigrants or unemployed who
would participate in retaill temporarily to make a living. They may have other jobs during the other
time periods or follow their potential customers from one activity space to another throughout the
day.
“I am here every morning, then go to Laolongyan in the afternoon. It is lively there in the
afternoon.” (Craftmen, sugar artists, male, the City Stadium, Huainan)
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Although leisure exercisers and hobbyists could only create temporary localized small
markets in their activity spaces, such a series of small markets fed a growing low-end commerce.
From 2014 to 2016, more types of retailers occupied the study sites—from simple craftsmen and
second hand businessmen to sports facilities, supplementary food, herbal medicine, tourism and
residential care advertisers (Figure 17d). The mobile retailers enriched the functions and diversity
of the activity spaces. To target those with pensions, most of the products were low-end and
affordable. Vendors and their customers attended the space every day and often carried out
business, while gradually growing to know each other.

a

b

d

c

Figure 17: a. farmer’s market next to Yuan Dynasty City Wall Relics Park. b. Good and More
Grocery Store open next to Laolongyan Park. c. a sugar artist next to the walking track. d. a dad
just bought a kite for his son.
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Stationary low-end retailers attracted older exercisers occupying spaces nearby. The
growing physical exercise and recreation groups provided a series of temporal localized markets
for low-end retailers. The agglomerative low-end retailers around the activity spaces provided
exercisers with convenience, services, and interests in leisure so that the therapeutic functions of
such spaces were enriched. Although the current relationships between exercisers and retailers
were collaborative and the wave of gentrification had not yet caused hostility between exercisers
and retailers, the experiences could be different in different situations within the same space. While
exercisers, no matter whether they were rich or poor, came to perform and to pursue health and
wellbeing, craftsmen and book sellers had to follow their customers day by day without time to
enjoy the healing elements of the spaces. Although considering the spaces as lively and therapeutic,
vendors identified themselves as businessmen to make a living instead of the users of therapeutic
spaces. While getting familiar with some vendors, I observed that the intersection between
exercisers and vendors was no more than business. Little is known about the exercise practices of
these vendors.
Discussion: Rethinking Public Spaces and Therapeutic Landscapes
This study aimed to integrate concepts of public spaces and therapeutic landscapes to
explore a potential therapeutic public space serving people of different age groups, socioeconomic
status, local or immigrant. Combining the concept of public spaces and therapeutic landscapes,
this study achieved the first goal by showing the collaboration between different ages and social
groups in the production of healing functions in urban public spaces. Based on my findings in two
Chinese cities, both the concept of public spaces and therapeutic landscapes are expanded. First,
this study revisits the role of blue/green elements in the production of healing functions. Different
from the arguments from Western cases that the blue/green elements essentially promote physical
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activity (Völker & Kistemann, 2011), this study argues that the symbols of Chinese garden
(pavilion as a theater) as well as the supportive low-end retailers can also provide an ideal
atmosphere to promote health where a large number of exercisers compete to occupy space. Even
without all these therapeutic elements, physical exercisers will still find other convenient spaces
to practice their activities and experience the healing function within those spaces, because the
physical activity itself is ultimately a self-intended behavior to promote health, construct identity,
purse a better quality of life, and reduce the individual and family burdens of care, while the
blue/green elements are just a potential resource to realize these goals. This conclusion may
explain why only a small number of studies have shown a positive association between parks and
physical activity (Bancroft et al., 2015) – these elements are like the icing on the cake, but not
always essential.
Second, the findings from this study are akin to Western cases of therapeutic landscapes in
that people achieve their sense of healing not only through experiencing the therapeutic process,
but also through encountering healing elements. Such healing elements can be surface water
delivering relaxed feelings to visitors (Foley & Kistemann, 2015), or the energetic exercise and
enjoyable activities of other older peers encouraging the oldest-old pedestrians (in this study).
Although the oldest-old cannot experience the body movements and sweat, the performance still
encourages them to keep going out and walk every day for the same purpose, bringing them a
sense of satisfaction and accomplishment. However, encountering green/blue elements and the
energetic exercise may not be able to heal the mobile vendors. The oldest-old experience and
encounter for the same purpose – to perform themselves and keep healthy; but the vendors come
to make a living and see others pursue higher needs they may not be able to pursue. In other words,

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even if these vendors encounter some healing elements, these elements may not provide them a
sense of healing.
Therefore, the third expansion of the study on therapeutic landscapes is to draw attention
to both the groups who achieve a sense of healing and those who cannot achieve that in the same
space. It raises a further question whether the divergent feelings of different groups lead to a sense
of insecurity and hostility (Philo, 2014). While the majority and minority physical exercisers
acquire a sense of security and healing, do the immigrants, unemployed, and low income persons
acquire insecurity and hostility instead? The therapeutic spaces in this study have undoubtedly
done a great job admitting people of different social strata to the same space, collaborating with
each other to achieve their own needs, and it is also undoubtedly that all the participants contribute
to the production of therapeutic public spaces. The pursuit of health and wellbeing here becomes
affordable and no longer a privilege of middle and upper classes. However, it appears to the lowend retailers, in particular those immigrant and unemployed vendors; that they help to create a
therapeutic space for others, but the carnival excludes themselves. Moreover, it is also necessary
to consider how to at least support current vendors in the space and avoid what Harvey (2013)
refers to as “the wave of gentrification further dissimilating the current beneficiaries”.
This study also expands the current discussion on public space by adding the pursuit of
health and wellbeing as an essential aims of public life. In this study, people from different socioeconomic strata and of different ages and health statuses share the same space for their health and
wellbeing. They perform through a spectacle of physical activity and support others as audiences.
Because of the simple purpose is to promote health, labels of different socio-economic strata
become vague and misted by age and health status. Compared with the insecure and hostile
atmosphere between different social groups in Western urban spaces (Philo, 2014), the assemblage
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of energetic but weak older groups, kind parents and vigorous young groups in this study create a
sense of security and liveliness for each other, no matter where they come from, what they do, and
whether they are poor or rich. In this light, older people with different levels of pensions can wear
the same uniform and dance in the same troop; children of different backgrounds can play football
together; professional and amateur singers can perform different tones in the same chorus; healthy
and unhealthy people can practice their own exercises in the same park. The affordable services
provided by low-end retailers also helped to blur the socio-economic differences. Poor or rich, the
products they buy will not distinguish them from others.
This study achieves the second goal by revisiting older people’s role in urban public life
within the demographic and neoliberal transition contexts. Paralleling Laws’ studies ( Laws, 1995;
Laws, 1993), this study reveals the positive role of older people in the production of urban public
spaces. In addressing the conflicts between their needs of health promotion and health care services
and the increasing commercialization of these services, these older people occupy the urban public
spaces as their everyday battlefields, escaping without leaving neoliberal society. Their healthpromotion practices not only benefit themselves but also all the exercisers and hobbyists by
merging the social deviation between different socio-economic groups. In such a therapeutic public
space, a new social norm has been built based on whether a person makes an effort to keep healthy
and perform rather than whether or not they can afford expensive items.
However, it is still too optimistic to conclude that a therapeutic public space for all has
been created or to generate this type of therapeutic public space to everywhere. While the presence
of immigrants and unemployed enrich the interests of the space, they are only accepted as service
providers instead of the service customers of the space. It remains a puzzle how this space
influences these people’s identity construction and health status. In addition, low-end vendors is a
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developing group and thus it is hard to predict whether and when the wave of gentrification will
engulf the current achievements of current exercisers and retailers. Moreover, the belief of
collectivism among the older generation plays a key role in the production of these therapeutic
public spaces. Older people enjoy their collective performance and harness their collective energy
to occupy spaces and construct their identities in front of others as a remarkable group. The sense
of filial piety may also play a role shaping other people’s attitudes of these older exercisers and
hobbyists increasing value to their identity. Whether this specialty of Chinese older people is
essential to maintain the liveliness of this type of space, also needs further exploration.
Conclusion
This paper has demonstrated the possibility and benefits of combining public spaces to
study and therapeutic landscapes to promote therapeutic public spaces for all. It expands the
boundaries of therapeutic landscapes in everyday urban spaces by rethinking the role of blue/green
elements in promoting the sense of healing and reconsidering the healing process as a production
through the experience and encounter of people. It also expands the boundaries of public space by
adding age and health into the consideration of public life. The combination of the two concepts
anticipates the possible challenges of neoliberalism posed by current health and urban geographies
and proposes a possible solution to this problem.
Since people’s occupancy and production of therapeutic public spaces are mainly
motivated by their needs for health promotion and the healing function may come from blue/green
elements and other factors, urban designers should revisit their city plans, following the
preferences of outdoor exercisers and adapting their activity spaces towards a more ‘health
promotion and healing’ direction. To protect current collaborative therapeutic spaces, future

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studies should continue to pay attention to groups who are excluded from the healing process of
the public space, and provide them with opportunities to also participate in the healing process. If
possible, urban administrators should also monitor and guide the development of low-end service
industry and avoid the wave of gentrification engulfing them. The health of this population within
urban areas will require further investigation.
In this study, Chinese older exercisers have successfully constructed an identity of a
remarkable social group fundamentally underpinning current therapeutic public space. Before
generalizing their role into other places with various occasions and cultures, it is worthwhile to
evoke, empower, and emplace the energy of the older population in contemporary China.
Encouraging such a growing population to contribute to society can not only relieve the social
burdens of care-giving, but may also find strategies and tactics in response to the neoliberal society
with increasing social inequality.

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CHAPTER 5
CONCLUSIONS
Main Conclusions
The first article, Physical Activity (PA) and Chronic Diseases among Older People in a
Mid-size City in China: A Longitudinal Investigation of Bidirectional Relationships, can be
considered a gerontological study which examines the bidirectional relationships between PA and
chronic disease onset among older people with socio-demographic disparities. Engaging with a
health belief model, such discussions contribute to a better understanding of the PA as a health
promotion practice and its practical impacts on older people’s health. There are two main
conclusions from this study. It first parallels the findings from previous studies that physical
inactivity is highest among older, male, low educated and high income people (Hallal et al., 2012;
Muntner et al., 2005), and further reveals the education and income disparities of PA, -i.e., people
with little education are more likely to participate in PA than middle and college educated people
but less likely to practice regular PA; while low-income people were less likely to participate in
PA but more likely to practice regular PA.
As one of the first longitudinal studies to assess the bidirectional relationships between PA
and chronic diseases in China, this study demonstrates the bipolar health trajectories between
physically active and inactive older populations. Physically active people are reported to be
diagnosed with chronic diseases years later than their physically inactive counterparts. Even after
being diagnosed with a chronic disease, their PA behaviors can help to maintain their health
(Warburton, Nicol, & Bredin, 2006). Comparatively, sedentary people are reported to experience
an earlier onset of chronic disease, and are less likely to initiate a PA after the diagnosis. Their

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later life, therefore, will have to rely on therapeutic regimes of care with additional costs to families
and the nation.
The second article, How the Built Environment Affects Change in Older People’s Physical
Activity: A Mixed-Methods Approach Using Longitudinal Health Survey Data in Urban China, is
a geographic study which examines the pathways by which older people’s PA are influenced by
the built environment intersected with social networks. Engaging with the social ecological
framework and stage of behavior change model (Schwarzer, 2008), I analyze how the physical
built environment intersects with social networks of neighbors and affect older people’s PA
behavior change. Importantly, this study finds the various effects of the built environment between
sedentary and physically active groups: a lively apartment environment can encourage sedentary
to start PA while living close to functional spaces can influence physically active people to
maintain their PA, and highlights the special needs of older population compared with other age
groups; and living close to functional spaces is more important for older people to maintain PA
than other age groups.
The first and second articles are closely related to one another. The conclusion of the first
article is the biological foundation of the second article (when PA is proved to be helpful for health
among the studied population, the benefit of encouraging PA through built environment
interventions can be guaranteed). Family and community engagement, and large-scale urban
design, therefore, find their ways to promote health in a rapidly aging society. In this way, the
second article supports the relevance of the first article, -i.e., making the biological findings useful
in health promotion practice.
While the first and second articles consider older population as a beneficiary of PA and
health-promoted built environment, the third article, Therapeutic Spaces for All—Putting Health
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into Public: Performance and Collaboration of China’s Leisure Physical Exercisers in Urban
Public Spaces, examines the benefits that the older population can make to the surrounding built
environment through their PA practice. Using case studies in two Chinese cities, it narrates how
older PA practitioners find, occupy, and produce and share PA in urban areas, how PA practitioners
of other age groups join and enrich the PA spaces, and how different social groups support each
other in their PA practices and ultimately make therapeutic public spaces together. Such
discussions parallel with Law’s (1993) emphasis on the positive role of the older population in the
making of both public spaces and therapeutic landscapes, instead of solely considering older
people as the passive beneficiary. Embracing the concept of therapeutic landscapes in health
geography (Gesler, 1992) and the concept of public spaces in urban geography (Harvey, 2013) I
also conclude that older people can collaborate with other social groups in urban public spaces and
help to put health into public and build therapeutic public spaces for all.
Contributions to the Literature
This dissertation contributes to the literature in four main fields. In the field of health
behaviors, it enriches the discussions of the health belief model (Champion & Skinner, 2008). The
first article finds the bipolar health trajectories between physically active and inactive groups,
reflecting the opposite results of two distinct health beliefs. On the one hand, older people who
believe the benefits of PA will experience a high quality of life and achieve benefits from their PA
practice. On the other hand, older people who do not believe the benefits of PA will experience
early onsets of chronic diseases and a relatively low quality of life. The findings of the distinct
health trajectories between physically active and inactive groups will help further understanding
of people’s attitudes and beliefs of health and their influence on health behaviors.

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Second, this study develops the literature on the built environment and neighborhood
effects in the second article. Adding the stage of behavior change model to the social ecological
model provides a combined framework to understand how particular factors of the built
environment and social networks of neighbors can shape and change PA behaviors at different
stages. This new framework contributes to addressing the theoretical challenge of the current
literature on built environment and neighborhood effects, -i.e. it can not only depict a high-quality
built environment for the physically active group but also delineate a built environment that can
encourage more (sedentary) people to become physically active (Rosenberg, 2016). As a result,
studies within this combined framework may provide more feasible interventions on community
engagements and urban design to ultimately benefit older people’s health.
Third, this study develops the concept of therapeutic landscapes in health geography. While
blue and green spaces play an important role in making a sense of healing in western countries
(Völker & Kistemann, 2011), the third article demonstrates that a therapeutic landscape can also
be created in other convenient spaces without blue/green elements as long as the spaces are widely
accessible and the healing function is facilitated. This study also emphasizes the multiple ways of
making sense of healing, through both experiencing and encountering process (Foley, 2015) by
both beneficiaries and non-beneficiaries. Importantly, this study points out the supportive groups,
particularly those immigrants and unemployed vendors, whose attitudes and situations await
further study in order to achieve an ultimate goal of health geographers-making therapeutic
landscapes for all (Rosenberg, 2014).
The third article also enriches the discussion on public space in urban geography. In my
two research fields, because of the simple purpose to promote health and wellbeing, people’s
biological backgrounds, such as their age and their bodies, mist their socio-economic labels. The
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weak identities of the main participants-the aging exercisers, the joggers, parents, and the children,
have nothing to do with the sense of insecurity and hostility which are ruining public spaces in
western countries (Philo, 2014). By showing the comradeship between people of different social
strata in the making of therapeutic landscapes, this study provides an alternative solution to the
decline of public spaces in western countries, -i.e., considering the pursuit of health and wellbeing
as an aim of public life may save the fragile public spaces in neoliberal societies.
Methodologically, this study uses a mixed-methods approach to qualitatively define the
possible role of the older population in therapeutic landscapes and the role of the built environment
on older people’s PA behaviors, and to quantitatively examine the bidirectional association
between PA and chronic diseases as well as the pathway in which the built environment intersects
with the social networks of neighbors to influence older people’s PA behaviors. This study
demonstrates the strength of the mixed-methods approach in health behavior studies (Wisdom,
Cavaleri, Onwuegbuzie, & Green, 2012). For qualitative components -e.g., the role of the built
environment, mixed methods studies reflect the objectivity of the study by declaring the data
collection procedures and triangulating the qualitative findings. For quantitative components,
mixed methods studies reveal the practical causal relationships behind the significant associations
between the built environment factors and changes of PA behaviors by involving participants’
voices in conceptual models. While only a few health behavior articles use mixed methods
(Wisdom et al., 2012), this approach may be a future sword thrusting into the essence of human
health behaviors.
Practical Implications
This dissertation provides implications for health promotion intervention among older
populations in two ways. First, the article on the bidirectional relationship between PA and chronic
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diseases provides implications on what information should be delivered to the older population to
promote their health. Given the findings that physically active and inactive older people may
experience distinct health trajectories, which deeply influence their quality of later life, more
accurate health knowledge should be delivered to older people in order to promote their PA
behaviors in an early stage. Since it is easier to change people’s PA behaviors before the diagnosis
of chronic diseases, health promotion interventions may be more effective among middle-aged
than older-aged adults. To maintain the progression of chronic diseases and reduce the medical
costs, however, interventions should also be conducted among older people with a diagnosis of
chronic diseases, messaging “you can still benefit from a certain amount of PA even if the diseases
cannot be cured”.
Second, this dissertation provides implication on the built-environment pathway of health
promotion. The article on the built environment and PA behavior change parallels other studies in
Western countries, suggesting that physically active neighbors can play an important role
empowering residents to participate in regular PA. Since older people retire early in China, they
are available and willing to conduct health promotion interventions among their neighbors.
Empowering this physically active group can be an effective and economical strategy to promote
PA among older populations in China. The article additionally shows the differential effects of the
built environment in shaping and maintaining older people’s PA, implicating PA promotion
interventions at different levels. A feasible and flexible solution at the individual level is to guide
older people to select apartments with high spatial accessibility to services. In the long run,
designing more lively and spatial accessible apartments can promote PA behaviors for a larger
number of older people.

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In response to the draft global strategy and plan of action on ageing and health proposed
by the World Health Organization (2016), this dissertation examines the achievements of the plan
from a local level. By evaluating the health conditions of an older population after health education
and survey were given, the first study demonstrates the effectiveness of health education and
survey that the plan suggests, but also identifies the remaining problems of health disparities
between sedentary and physically active populations. By evaluating the impacts of built
environments and neighborhood effects in shaping older people’s physical activity, the second
study delineates the outline of health-promoting cities and human settlements for older people that
the plan aims to build, but also identifies the potential issues which may affect older people’s
health. Future policy interventions should pay more attention to the effect of built environment
factors on older people’s health, which may be different from that on other populations; future
policy should also make efforts to eliminate the health disparities by drawing more attention on
sedentary people and those with chronic diseases at an early stage.
This dissertation provides a new direction to promote “inclusive, safe, resilient and
sustainable” cities as the plan suggests (WHO, 2016) and also addresses the possible problem
caused by a rapidly aging population. While older people in some areas of China (Bai, Lai, & Guo,
2016) and Western countries (Laws, 1993) are largely stigmatized as a social burden, this study
challenges this ageist opinion on older people and argues that older people can make a contribution
to the society. The article on the built environment and PA behaviors suggests that older physically
active residents can serve to cultivate a physically active atmosphere in order to promote health
and wellbeing in their neighborhoods. The article on the older PA practitioners points out the active
role of older population in urban public life. These older PA practitioners are the pioneers to
explore, invade, and cultivate a sharing therapeutic space through their performance and spectacle

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of PA behaviors and collaboration with other physically active groups. Empowering a large
number of older people and making full use of their capacities in health promotion practices may
become an effective and economical strategy in addressing the challenges from a rapidly aging
population. Moreover, since many older people are voluntarily providing health promotion
interventions by example, empowering this population may help to address the increasingly
distinct health trajectories caused by exacerbating socioeconomic inequalities of the neoliberal
China.
Future Research Directions
This dissertation addresses one of the most prevalent social issues-the (rapid) demographic
transition in both China and worldwide. The increasing older population provides many
opportunities but may also cause problems for governments, industries, and everyone within the
transitional society. Moving forward from this dissertation research, four directions are purposed
for my future research. First, to provide accurate and evidence-based health promotion
interventions for the older population, more empirical case studies can be conducted to find the
environmental factors at various levels, which may significantly affect older people’s health
promotion and health care practices. For example, in the case of Huainan, the liveliness of
apartment serves as a significant motivator that attracts older people to initiate PA. Detailed and
quantified index of the liveliness should be built in future empirical studies to support olderfriendly community design at built-environment level. Methodologically, more effective
prediction models, such as agent-based models and participatory methods can be used to examine
the practical effectiveness of certain interventions at a population-based level.
Second, some innovative technologies, such as smartphone apps and intelligent devices,
are widely used in middle- and older-aged populations for health promotion in my study area.
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While visible obstacles exist in innovative health promotion and health care (Herzlinger, 2006), it
is undoubtedly necessary to study the development and influence of such new technologies among
people’s health for two reasons. On the one hand, better or worse, some smartphone apps, such as
Fitness, or Pokemon Go on IOS and some smart sports equipment have dramatically shaped the
types and patterns of physical activities among both young and old population. Evaluating the
efficiency and effectiveness of such products can contribute to regulating and improving the
current innovative health promotion industry, and hopefully, finding a technological solution to
the increasing socioeconomic disparity in contemporary China. On the other hand, the prevalence
of these technologies also produces rich biological and behavior data for research. Obtaining and
making full use of these data can help scholars further understand health behaviors and provide
effective and feasible health promotion interventions.
Third, this dissertation is a start to reflect and redefine the identity of the older population.
While older people are socially constructed as a dependent vulnerable group awaiting caregiving
in Western society (Laws, 1993), such a stereotype of older people is also deeply rooted in the
tradition of filial piety in China (Zhan & Montgomery, 2003). However, I point out in the third
article that filial piety tradition also delivers a gerontocratic identity of the older generation,
empowering Chinese older population to become an energetic group in public realms. While this
study has demonstrated the active effect of older PA practitioners in urban public life, more studies
may be proposed to further understand the potential active role of older people in other public
realms, including the circumstances highly exposed to older people, -e.g., healthcare spaces,
tourism industries, and food and medicine industries.
While exploring the optimistic potential of the aging population, I am also concerned with
the pessimistic face of this group, which is commonly revealed in my field work. Identifying
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themselves as a vulnerable but energetic group who are willing to participate in almost every realm
of public life, older people’s achievements may not be able to meet the expectations of young
people. For younger generations, they are too busy to give daily care and not rich enough to provide
adequate financial support to the older generation. The young generation also widely accepts the
individualist value in the new era and on some level, expects to live their own life without
interruptions from the older generation. On the contrary, older people, ironically, expect daily care,
company, and sincere respect from the younger generation and are more than willing to participate
(sometimes interrupt) younger people’s life. The distinct willing and expectation between older
and younger generations may cause various contradictions in between. Conflicts are more likely
to occur as responding behaviors after an old person acquires incurable diseases or geriatric
syndromes, reminding themselves that they are less capable while also experiencing fear that they
will be abandoned. While conflicts between generations become a problem (Dennis, Basañez, &
Farahmand, 2010), intergenerational segregation can be another problem (Hagestad & Uhlenberg,
2005). Addressing the existing and potential intergenerational conflicts and segregation –e.g.,
through reducing the stress in the family with aging parents and encouraging the older people to
an active lifestyle, will become an essential project for geographers of aging in the rapid aging
society.

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