The Design of Health Promoting Outdoor Environments for People with Young-Onset Dementia—A Study from a Rehabilitation Garden
Abstract
:1. Introduction
1.1. Dementia
1.2. Young-Onset Dementia
1.3. Non-Pharmacological Intervention
1.4. Dementia-Friendly Environments
1.5. Evidence-Based Design
1.6. The Quality Evaluation Tool
1.6.1. Evidence-Based Environmental Qualities for the Outdoors
1.6.2. Model Highlighting Different Zones of Contact with the Outdoors
1.7. Aim
2. Materials and Methods
2.1. Study Design
2.2. Setting
2.3. Participants
2.3.1. Recruitment
2.3.2. Individuals with YOD from the Memory Clinic
2.3.3. Staff Included in the Garden Study
2.3.4. The Garden Program
2.4. Data Collection
2.4.1. Data from YOD Participants
2.4.2. Data from Participating Staff
2.4.3. Interviews
2.5. Data Analysis
2.5.1. Phase 1: Preparation Phase
2.5.2. Phase 2: Organization Phase
- All data were reviewed for content and coded according to pre-existing categories: the environmental qualities A1–B13 of the QET.
- Data that did not fit into the categorisation framework but corresponded to the purpose of the study were assigned new appropriate codes. (This allowed aspects that did not belong to existing categories to give rise to new categories.) After careful consideration, data assigned new codes were either:
- Included in existing categories where clear similarities could be found, thereby developing the existing categories (i.e., environmental qualities) and adapting them to the particular target group (individuals with YOD), or
- Added as a new category, or
- Added to the results as “additional findings”, for example, when related to the well-being and life situation of the YOD participants, creating a broader understanding of the target group. This was used, for example, in the overall description of the main categories: group A. Being comfortable in the outdoor environment or group B. Access to nature and surrounding life.
- Tables were developed to structurally organise data by main categories (i.e., group A and B), categories, and new categories. Data from YOD participants and staff were kept separate. Each category now contained descriptions from the collective perspective of all study participants, that is, both YOD participants and staff. However, to understand who said what, a clear distinction was made between the data from the different participant groups.
- The transcripts were read through again and the coding and categorisations were double checked, to make sure it was done correctly the first time and that nothing had been forgotten, misinterpreted or taken out of its context.
2.5.3. Phase 3: Reporting the Analysing Process and the Results
- Category description. A summary was created for each category. The YOD participants and staff perspectives were woven together to describe the quality as comprehensively as possible. To understand who said what, a clear distinction was made between data from YOD participants and data from staff.
- Order of categories. The order of environmental qualities under the main category group B. Access to nature and surrounding life was discussed and determined by relating the study results to the SOS. The categories represent qualities ranging from most stimulating (B1) to most restorative (B13) for the target group.
- Specific considerations for the physical environment related to each category were drawn from the category descriptions and placed in separate tables for clarity and easy access. The considerations aim to be useful in practical situations, for example when designing outdoor environments for the specific target group. The format is based on QET and how the environmental qualities are presented there. The QET descriptions were modified, information added or removed, based on data from the current study and the intervention context. A development of QET’s environmental qualities, with a focus on the specific target group, emerged as a result.
2.6. Ethical Considerations
3. Results
- First, an overall description of the two main categories: group A. Being Comfortable in the outdoor environment, and group B. Access to nature and surrounding life.
- This is followed by descriptions of all 20 categories, within main categories A and B (containing 7 and 13 qualities respectively).
- Finally, tables summarise specific considerations for the physical environment related to each environmental quality.
3.1. Being Comfortable in the Outdoor Environment (A)
3.1.1. Closeness and Easy Access (A1)
3.1.2. Entrance and Enclosure (A2)
3.1.3. Safety and Security (A3)
3.1.4. Familiarity (A4)
3.1.5. Orientation and Way Finding (A5)
3.1.6. Different Options in Different Kinds of Weather (A6)
3.1.7. Calmness (A7)
3.2. Access to Nature and Surrounding Life in the Outdoor Environment (B)
3.2.1. Contact with Surrounding Life (B1)
3.2.2. Social Opportunities (B2)
3.2.3. Joyful and Meaningful Activities (B3)
3.2.4. Sensory Experiences of Nature (B4)
3.2.5. Species Richness and Variety (B5)
3.2.6. Seasons Changing in Nature (B6)
3.2.7. Culture and Connection to Past Times (B7)
3.2.8. Openness (B8)
3.2.9. Symbolism and Reflection (B9)
3.2.10. Space (B10)
3.2.11. Serene and Peaceful (B11)
3.2.12. Wild Nature (B12)
3.2.13. Secluded and Protected (B13)
4. Discussion
4.1. Results
4.1.1. Dementia-Friendly Outdoor Environments
4.1.2. Contribution to Evidence-Based Design
4.1.3. Development of the QET & Environmental Qualities Important to People with YOD
Qualities in Group A
Qualities in Group B
4.1.4. Significance of “Four Zones of Contact with the Outdoors”
4.2. Methodological Considerations
4.2.1. Site
4.2.2. Recruitment
4.2.3. The Interview Situation
4.3. Future Research
5. Conclusions
- An environmental quality was added to the QET, Calmness (group A), which was perceived both fundamental and crucial to the well-being of individuals with YOD
- As the individuals with YOD were quick to taste what the garden had to offer including things that could be unripe or even inedible, it is important to avoid poisonous berries or plants in outdoor environments for the specific target group.
- The more stimulating qualities emerged as the most desired and appreciated ones by the individuals with YOD, turning the Triangle of supportive environments model upside down in relation to the Sensory Opportunity Spectrum (group B), indicating that the target group can be described as sensitive to understimulation.
- A certain need for more restorative qualities was experienced towards the end of the intervention, and a sensitivity to certain stimulation was also noted in the study.
- There seem to be no need or desire for seclusion (i.e., solitude) for the participants with YOD. Instead, they wanted to experience peace and tranquility together with the group. This contrasts with previous versions of the QET and other target groups in the garden.
- The study confirms the importance of including both individuals with YOD and experienced staff in research studies of this nature, for a broader perspective and increased opportunity for a comprehensive understanding.
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Characteristics | Individuals with YOD |
---|---|
Age (years) | |
| 61.5 51–67 |
Gender, n (%) | |
| 4 (67%) 2 (33%) |
Type of dementia, n (%) | |
| 5 (83%) 1 (17%) |
Severity of dementia, n (%) | |
| 3 (50%) 1 (17%) 2 (33%) |
Use of walking aids, n (%) | |
| 1 (17%) |
A. Being COMFORTABLE in the Outdoor Environment Seven Environmental Qualities, Which Constitute Considerations of the Physical Environment, for Designers to Pursue in Therapeutic Gardens. These Qualities Have Characteristics That Support People with YOD’s Ability to Dare to Go Outside, and Feel Comfortable Enough to Use the Environment. They Are Important to Consider Throughout the Green Area so That Everyone Can Use the Space on Equal Terms. |
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A1. Closeness and Easy access There is a nearby green outdoor environment (e.g., garden) for the target group. It is clearly visible through windows and easily accessible from the building where the target group is staying. It is easy to get in and out independently, even with aids such as a walker, taking into account doors, locks, thresholds etc. |
A2. Entrance and Enclosure The enclosure of the outdoor environment (hedges, fences, etc.) corresponds to the level of security and safety that the target group needs without being perceived as restrictive or confining. There is a clearly visible and welcoming entrance, e.g., a gate that must be opened and passed through, making it easier for target groups with orientation difficulties to understand where they are. |
A3. Safety and Security (a) Safety: the risks of psychological discomfort in the outdoor environment are very small. The outdoor environment is appealing, without intrusive impressions such as loud noises or a lot of movement that can be interpreted negatively by the target group. Consider risks of outsiders intruding and risks of being viewed against one’s will by outsiders. |
(b) Security: the risks of physical discomfort in the outdoor environment are very small, such as the risk of tripping, slipping or falling into water. There are no poisonous plants and berries. Ground coverings are available in terms of width, edges, slopes, surfaces and materials. Colouring and contrasts are of such a nature that the target group does not misinterpret e.g., dark fields to be holes in the ground. Steps and thresholds are of normal height. |
A4. Familiarity The green area feels like a natural part of the setting. It is easy to see and get to know the outdoor environment. Its character, content and usage possibilities are familiar and easy to understand. Elements that are new, modern and abstract are avoided, as they can be perceived as intimidating and difficult for the target group to grasp. |
A5. Orientation and Wayfinding Design and layout of paths, places and landmarks are clear and help people understand and orient themselves in the outdoor environment. It is important that hedges (that are not too high and obscure the view), paths and walkways lead back to the starting point and not to dead ends. There is a good overview that makes it easy to read and understand the environment. The outdoor is varied and there is a range of features, such as objects, plants and ground surfaces. The variation in the environment provides important clues that can facilitate orientation. |
A6. Different options in different kinds of weather Footpaths and seating areas are positioned so that there is possibility of sun, shade and shelter from wind and rain. Flexible chairs that can be moved around are available. In case of rain or cold weather, transition zones such as a greenhouse offers weather protection, as well as vegetation, heat, light and good contact with the outdoor environment. |
A7. Calmness The environment is calm, peaceful and undemanding. It is neither overcrowded nor has unexpected or disturbing features, such as heavy traffic or loud voices. It is clear who uses and has access to the environment. |
B. Access to Nature and Surrounding Life Thirteen Environmental Qualities, Which Constitute Considerations of the Physical Environment, for Designers to Pursue in Order to Increase the Possibility of Both Stimulation and Restoration for People with YOD in Therapeutic Gardens. These Qualities Follow a Gradient in the Sensory Opportunity Spectrum (SOS) of Supportive and Health-Promoting Environments—from Most Stimulating (B1) to Most Restorative (B13). |
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B1. Contact with surrounding life The environment provides rich opportunities to focus on the small and close perspective of the natural environment, such as plants and animals. The focus is on the current location. There are opportunities to visit the environments and/or society outside, to take part in the life and experience the activities that take place there. |
B2. Social opportunities There are opportunities in the outdoor environment for activities and places where you can meet, talk or just watch other people. In these places there are, for example, plants, water features, distinctive environments or elements to gather around, look at and talk about. There are seating options that make it easy and pleasant to meet and socialise outdoors. There are places where the whole group can gather and sit together, but also places for just a few to meet. Paths allow for walks where two or more people can walk together. |
B3. Joyful and Meaningful activities There are places in the outdoor environment for sedentary activities (such as relaxing or resting, reading, drinking coffee, reflecting, watching and listening to nature and other people), social activities, physical activities, therapeutic activities and gardening activities. These places are large enough for a group of people to be active at the same time. There are walking paths, preferably with a clear goal, which can be used for exercise as well as for leisurely walks. The activities offered correspond to the wishes, needs and abilities of the target group. |
B4. Sensory experiences of nature There are opportunities to get close, experience and be fascinated by nature with all one’s senses, by seeing, feeling, hearing, smelling, tasting and enjoying what nature has to offer. Trees, plants, flowers, fruits, berries, herbs, animals and insects are some examples. Experiencing natural elements such as sun, sky, wind and water is possible. There are areas that offer alternatives in stimulus intensity, regarding e.g., colours, sounds and scents, to avoid both over- and under-stimulation for the target group. |
B5. Species richness and Variety There are areas with species richness in terms of plants and/or animals that give varying expressions of life. There are opportunities to be fascinated by details in nature and to see, learn and experience new things. Species richness and variety in the outdoor environment provide a wide range of activities, an increased opportunity for sensory experiences and memory stimulation, and contribute with important clues about the season for the target group. |
B6. Seasons changing in nature There is an opportunity to follow the year’s changes in nature, partly with your senses but also through experiences and activities in the outdoor environment. During autumn, examples of this can be raking leaves, harvesting, cooking and tasting what is available (e.g., pumpkins or autumn apples), sitting around an open fire, or tying bunches of flowers and autumn leaves. This gives clues to people who have difficulty orienting themselves in time and space. |
B7. Culture and Connection to past times There are places in the outdoor environment that provide an opportunity to be fascinated by human history and culture. There are objects that stimulate the memory, such as cultivation lots, a barbecue area, old tools, machinery and building details. Berries, flowers and crops can also contribute with associations to previous experiences (“my grandmother used to grow these”). |
B8. Openness There are inviting open green areas with views of nature and plants. The view is also accessible from inside (e.g., via window) and has the potential to entice people to want to go outside. There are open areas overlooking central parts of the outdoor environment that facilitate accessibility and orientation for the target group. |
B9. Symbolism and Reflection There are elements in the outdoor environment that can give rise to symbolism and metaphors between one’s own life situation and nature. Reflections evoked by a sunflower that perseveres and remains brave even though it is no longer yellow and beautiful is an example. |
B10. Space There are areas that give the feeling of entering an undisturbed world or coherent whole. A private garden, an apple orchard or a peaceful greenhouse are some examples. These areas allow the individual or group to be by themselves and to feel that the place is only theirs. |
B11. Serene and Peaceful There are peaceful and well-maintained places in the outdoor environment with soothing elements of water and/or greenery that offer relaxation. Seeing water with associated plants and animal life, such as sitting by a pond and watching fish swimming is an example. The sound of rippling water is especially soothing. It is possible to experience tranquility and be close to other people at the same time. |
B12. Wild Nature There are opportunities to experience nature on its own undemanding terms. There are areas where plants appear to have come by themselves and where they have been allowed to develop freely, e.g., a meadow with tall grass or large apple trees. There is untouched wildlife as part of the natural environment, such as birds and insects. |
B13. Secluded and Protected There are surrounded and protected green places where you can do what you want undisturbed, be alone, have private conversations, rest or just watch other people from a distance. Visual contact with central parts of the environment, as well as seeing and/or hearing other people even from more secluded places is always possible. There is comfortable furniture that allows for rest. |
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Oher, N.; Tingberg, J.; Bengtsson, A. The Design of Health Promoting Outdoor Environments for People with Young-Onset Dementia—A Study from a Rehabilitation Garden. Int. J. Environ. Res. Public Health 2024, 21, 1047. https://doi.org/10.3390/ijerph21081047
Oher N, Tingberg J, Bengtsson A. The Design of Health Promoting Outdoor Environments for People with Young-Onset Dementia—A Study from a Rehabilitation Garden. International Journal of Environmental Research and Public Health. 2024; 21(8):1047. https://doi.org/10.3390/ijerph21081047
Chicago/Turabian StyleOher, Nina, Jonna Tingberg, and Anna Bengtsson. 2024. "The Design of Health Promoting Outdoor Environments for People with Young-Onset Dementia—A Study from a Rehabilitation Garden" International Journal of Environmental Research and Public Health 21, no. 8: 1047. https://doi.org/10.3390/ijerph21081047