Understandings and Perceived Benefits of Outdoor-Based Support for People Living with Dementia
Abstract
:1. Introduction
2. Materials and Methods
2.1. Focus Groups and 1-1 Interviews
2.2. Walking Focus Groups
2.3. Thematic Analysis
- Data condensing (reviewing participants’ views and experiences, coding sections of the narratives into initial themes, and eventually generating categories to group these themes into nodes);
- Data display (differences between the themes from people living with dementia, care partners, older people, and the three different types of organizations we include in our focus groups and 1-1 interviews);
- Drawing conclusions (using final nodes, conclusions can be drawn and verified with the narratives and relevant literature).
3. Findings
3.1. Participant Characteristics
3.2. Thematic Findings
3.3. Understandings of Outdoor-Based Care
3.3.1. Built Environment
… sidewalks and roads and curbs, and how those all work together for people who are not only getting older, but also have other issues, like maybe mobility or perception issues, perhaps difficulties with balance, with hearing, with vision or use a wheeled device, or a cane, or something like an assistive device for maneuvering those, because I think that they are not good right now.(OFG1-P2)
If you look into the research on city planning and walkability and the things that you need to do to make it enjoyable to be outside, some of those things actually improve people’s health. There’s plenty of data around that in the city planning field.(FG1-05-D)
But I think in this particular case is really thinking about the external environment and opportunities within parks and outdoor spaces that you could intentionally design and support and provide care to people living, I guess, with dementia is what we’re thinking of….(OFG1-P1)
3.3.2. Outdoor Activities
any kind of activity that is getting people outside, so could be outdoor walking outdoor on our patio as well as in our garden spaces(OIN-3)
…any social activity outside getting fresh air, whether it’s gardening, social behaviors court sports, football, walking, cycling, running any kind of outdoor activities…(OIN-6)
I like walking, so I walk on my own.(FG6-32-D)
I think a lovely place probably people know about is walking along the lake, especially in the summertime. I mean, (FG6 -36-D) love ships, and there’re a lot of ships coming in.(FG6-37-CP)
It’s not an institution. It’s something that is natural. It’s something that maybe people are more comfortable connecting with other people around.(OFG2-P2)
3.4. Perceived Benefits of Outdoor-Based Care
3.4.1. Mental Well-Being
I think for me, being outdoors is very peaceful and serene.(FG1-07-D)
You can use your head. Do you know what I’m saying? The cobwebs are gone and you can sort of get a fresh start, you know?(FG6-30-CP)
Just breathing in that air, you know, just sitting there, even closing your eyes and, and listening to and listening to the quietness of, of nature.(OIN-2)
But if we can get out, if I can take him for a walk somewhere, especially like parking a couple of blocks away when we have an appointment, and him walking, he does far better. His mood is just so much better after having walked. Whether it’s a difficult walk or raining, or anything. It just is way better, because if he’s stuck inside like today, I know that I’ll have a rough day because he will.(OFG1-P2)
You can get fresh air. You can get out of your house and see the nature. I enjoy that especially with my daughters.(FG4-18-D)
I have enjoyed today so much, but tomorrow I might not remember, I wish I could remember but I know I might not. But today has been beautiful.(Quote from WFG1-02-PLWD)
Longer life, healthier body, better mental health. Making life worth living. You can get rid of your telly for the summer.(FG1-04-OA)
The place I walk … there’s a beautiful field and lots of trees around it. I just stand there because I’m from—raised in [another province] and it reminds me of home. So, I say a little prayer and that this is [home province] to me. Then I turn around and go back.(FG5-27-D)
Gardens signify calm. Just by definition, they’re places of comfort, calm, and respite.(OFG3-P5)
Walking in gardens is good for everybody.(FG1-01-D)
Inner peace. This place [name of garden] gives you inner peace.Quote (WFG1-02-PLWD)
There is definitely the whole therapeutic exercises that comes with gardening, both mentally and physically. So that is something we have been involved in for a very long time which benefits seniors, the benefits, people of all walks of life.(OFG4-P1)
She always gives me stuff to do outside [Laughter] like cutting the grass.(FG4-22-D)
.. I think there’s definitely a like people have said just the reduction of stress, like just being able to do that kind of work [gardening], and really just like to stop your mind from worrying sometimes, and just calm your like blood pressure.(OIN-3)
I miss having a garden. I moved into a condo in [name of area]. We are on the ground floor, but we have no garden. It is all concrete and not, I can’t garden.Quote (WFG2-06-PLWD)
3.4.2. Social Well-Being Benefits
They put on a barbecue for all their volunteers and stuff, but I think that they could take advantage of a lot of these things like this as far as putting on a summer barbecue for all the Alzheimer’s people and their spouses or whatever, and get them all together and socialize and get some socializing, get them out getting something to eat, and makes kind of a party atmosphere right now.(FG6-34-OA)
…It offers more of a, it’s a social time when you can be outside of people. You have barbecues. You have picnics…(OIN-7B)
Yes. Him and his friend they’ve known each other since they were in elementary school. Then they—yes. So, they’ll going to start soon again with the biking. They bought themselves an electric bike. [Laughter] So, they don’t need—they’ll use the pedal between. Yes. I’m so proud that he’s still into biking. Yes.(FG5-24-CP)
I think the unobstructive way in which it offers social opportunity and the ability for people to kind of be together and… not to have that front and center in your face, I think, is really great.(OFG1-P3)
Yes, lawn bowling is fun. It’s actually fun, [Laughter] surprisingly fun.(FG3-14-D)
like the social dimension….can be passive, like you don’t necessarily have to be having a conversation with someone to have a social benefit from being outside in the world. But certainly, by being outside, you do open yourself up sometimes to you know—short conversations or interactions with other people.(OIN-5)
I’ve watched them play on the park, but I haven’t gone in and.. (FG6-35-D)… Yes. There were benches outside. It’s nice just to sit and watch.(FG6-33-CP)
passive participation of watching kids in the splash picnic feeding the birds. We also have strategies to use the outdoor influences to keep the focus is really important.(OFG2-P7)
….where there’s nature, a lot of animals. I’m thinking about like the swans and the ducks and geese at [walking area].(FG1-07-D)
Walking, looking for the birds.(FG4-21-CP)
Yes, and I walk the dog…(FG4-22-D)
And another thing, too, is that you get people from all walks of life from many different communities getting involved which can build community. They can tear down walls, build community, remove barriers. all those things.(OFG4-P1)
just having a place where they could come, and if they wanted to socialize or they wanted to meet neighbors, it’s an opportunity to do so.(OIN-10)
Some of the other things I think of is attending my grandkids’ events, so track and field, volleyball, soccer.(FG1-02-D)
…then connecting with others. I think people meet each other in these spaces, and they make friends. So like reducing socialized isolation, and you know, helping with like loneliness. Yeah, and just feeling like a sense of purpose.(OIN-3)
Yes, and the kids, they are sometimes ahead of me and I say, “Stop! I am not that fast [Laughter] so you can stop and stay with me.” So, chit-chat with them and it’s really enjoyable.(FG4-18-D)
They [people living with dementia] often fall into isolation and isolation is very detrimental to the escalation of the disease. So by having them in, you know, communicating and being involved with other people is going to be good for brain chemistry and good for them overall. So being a part of a group being with others is healthy and it, you know, takes away that isolation that they often find themselves feeling.(0FG4-P1)
3.4.3. Physical Well-Being Benefits
physical certainly like whether you’re walking or riding a bike, you know, even if you just like walk to the park, and then the down on a bench for a while, just like being outside free, fresh air.(OIN-5)
I just want to be out and running around, but sometimes, I run too far. [Laughter].(FG6-35-D)
I also think the physical benefits of even being outdoors, like, you’re going to have to get up and walk or move in some way.(OFG1-P3)
I was just gonna say you could do so many things you could do, even like a photography class, You could do dance or motion.(OFG1-P1)
…outdoor boule courts, tennis courts, pickle ball… informal spaces that we provide to people in our community, but we also have some structured activities that we do host in a variety of outdoor locations.(OIN-8)
It’s always great to be outside. I think it’s super important for everybody to get the fresh air, and the vitamin D is super important… nothing’s like the sun.(OIN-6)
Exercise. Makes you hungry makes you sleep (FG3-11-OA) … Yes, makes sleeping and stuff, it helps, yes.(FG3-13-CP)
it’s just natural light, and you’re increasing your oxygen that helps release those happy hormones…”(OIN-7C)
3.5. Perceived Challenges to Participating in Outdoor Based Activities
3.5.1. Natural Elements
Last summer, the bocce group that I was participating with stopped because it was too hot. To get outside at 11:00 in the morning when it’s going to be 30 degrees or more, she makes me suggest that some of the infrastructure necessary for her to join the outdoors is going to be like a cooling center, [Laughter] fountains you can splash yourself in. Some recognition of the climate change is probably important.(FG1-05-D)
… if we see that its too hot… we do have policies … that we don’t go out, outdoor programing if its below a certain temperature with the wind chill and higher [than]… 28 degrees with humidex.(OIN-1)
Yes, [Laughter] and it’s not safe. The thing is, do I go out and risk falling and maybe end up in the hospital or have something wrong with me, or do I stay in? Like when we get the snowstorms, we just put the fireplace on and we’ll be here, watch TV. We’re not going anywhere. Do you know what I mean?(FG6-30-CP)
Unfortunately, all the outdoor stuff is hinging upon the weather.(FG4-19-CP)
I’m gonna point out our extreme weather… extreme weather is hazardous to their health right?(OIN-7C)
I had to think of breathing, and all of the things that come and get harder as a person is older.(OFG2-P1)
there’s no trees…so you end up cooking… people talking, getting sunstroke, getting heat stroke and … sunburned.(OIN-1)
You don’t really want to go there in 30-degree weather. It’s in full sun. The natural areas are great, but generally we’re at the top of a hill right now… To get into those natural areas, it’s down a hill and then back up a hill, and it can be slick.(OFG3-P5)
It’s huge. It’s not a path, it’s huge, like you can drive down it, well the staff drives down it but yes, it can be icy. We’re not going to take a chance and we can’t fall, we don’t want to fall.(FG2-08-D)
Weather. What’s the weather got to have a backup. Is it too hot, too humid. Is there water in nearby, or there washrooms nearby? I mean all the venue and logistical stuff.(OFG2-P4)
So, you know we’re always like keeping an eye on the weather for the week, and like checking in with people beforehand. If it’s not looking good, we might reschedule. So there’s has to be some flexibility in the schedule to be able to cancel or move a time if necessary.(OIN-5)
3.5.2. Transportation/Distance
I think sometimes the challenges is just their ability of transportation, of getting there. You know. That is always going to be a barrier for seniors in general, especially seniors struggling with some level of dementia. So be able to get there, be able to get home safely.(OFG4-P1)
I don’t drive anymore because I’m not safe. I am not safe driving. I had an accident once and I figured out why. I’m just not safe driving now. I can’t concentrate long enough. I’ve got my mind in, “Oh, I’m going to make that piece—I’m going to sew that when I go home. I’ve got a great idea for my next art piece.” Yes, I cannot drive now, but I’m a great bus expert, if I just remember where the hell I’m going.(FG1-04-OA)
…in the rural areas transportation is always the issue… we don’t have any buses, so you’re either coming by car or taxi or DARTS. So that is a struggle for a lot of people to get to our courts if they don’t have their own transportation.(OIN-6)
Well, I could tell you when I found out that when I was told by my doctor that I can’t drive anymore, that was the most devastating thing to facing what’s happening to me right now. There are alternatives but not every place. [County] have a little thing called [County] Transit, and that—and they also have a special transit for people that have wheelchairs and things like that. They have one for that too. It’s very inexpensive. So that’s what I use now when I go to the pool because the pool isn’t here in [village]. That transit, you have to book it. You can’t just call them up that day and say, “Could you come pick me up at 8:00?” That kind of thing. You book it ahead. My daughter books them all for me. [Laughter] So that works. Other than that, I don’t know what I would do. Like I said, I was so devastated that I couldn’t drive anymore because… that was my whole independence.(FG1-03-D)
3.5.3. Financial Cost
I don’t think it’s common knowledge, though. No, I certainly don’t know what the process is. (FG6-33-CP). No, I haven’t heard about it either (FG6-37-CP) [Context, about learning about free bus transportation to enable people living with dementia to get to outdoor locations] I’ve never heard of that. So where would you go?(FG6-36-D)
…these kinds of programs are its its a challenge to continuously fund them… have to be able to continue to like resource the space… with tools and plants, making sure if things get broken like the little greenhouse or the shed … someone can fix those things… all of those pieces around maintenance and can continuance of programs.(OIN-3)
The programs that I run, as I mentioned earlier, are revenue-generating. So, any of these guided programs, there are fees associated with them.(OFG3-P5)
It’s just..…parking. So, I guess it depends on how they’re getting here, but yes, our trail system is free.(OFG3-P1)
I think there’s so much out there, but the availability and the knowledge and then there’s always if it’s an event like that, something that’s financial, the cost involved.(FG1-07-D)
We are very lucky that we’re able to operate with no charge programs both for the social Rec programs for the education programs and that’s you know that that helps allow people of all backgrounds to be involved.(OFG2-P7)
That’s what the government’s done, and I find it disgusting, really. The government, every time you would turn the TV on, the government will be telling you, especially for seniors, to get out and walk in the nature and everything else, and then every place that you want to go walking, they charge you for it …. they started charging all the way down the strip to park there.(FG6-34-OA)
the adaptive bike is free to participate. We don’t want there to be any financial barriers to access.(OIN-5)
3.5.4. Physical Access Barriers
we’ve tried to have like wheelchair accessibility for pickleball courts… the openings of your gates where people can sit if you have accessible picnic tables… needs to be considered and worked, we’re not good at it and we’re getting there, we are getting there, but we’re still not good at it for, just to be honest with you.(OIN-6)
Our location is on a street with no sidewalk, so even walks are not a possibility, and are our parking lot not very level. So it’s not safe.(OIN-7C)
The other thing is, they’re [outdoor performances] usually in the early evening, and by the time they’re over… …it’s dark and I find getting [location]- because it’s not well lit, I really find it difficult. Because even just going down to [location] there’s a way you can get out, cut across the roof and go down and beat everybody, and I can’t even do that because the lighting is so poor.(FG1-04-OA)
(WFG2-17-CP) and (WFG2-16-D) commented that the paths [in a garden] with cobblestones were not “the best”—the probing cane is meant to be swept side-to-side in front of the person using; the cane gets caught in the cracks between the stones; there are similar issues when there are cracks in the cement or grates or other aspects of the pathways that are not smooth. Fieldnote WFG2.
I will tell you I was at—just as on and off topic, I was at a seniors center a couple days ago. I can’t remember, but it was one day this week anyhow. They had the door for the women’s bathroom and all around that door and the door was pink, and then the men’s bathroom, all around the men’s bathroom was blue. I thought it was phenomenal.(FG1-02-D)
I do know that our washrooms aren’t accessible yet. I shouldn’t say most people. I don’t know, the majority of people with dementia, whether they require a larger space, maybe not. There is that and. The building is actually confusing.(OFG3-P3)
Signage, too. Yes, we’ve been on a couple of trails and it’s like, “I thought you said this was a short trail.” “Well, I don’t know. I’ve never been on it before. I’m not sure.” The sign doesn’t really tell us how much farther we’ve got.[Laughter] (FG3-13-CP)
I had both knees replaced in the last couple of years, so I tend to be a little bit more careful in terms of myself, so I don’t go out as often as perhaps I should with her, but now she doesn’t go out unless it’s supervised.(FG6-31-CP)
I know when I started not being able to walk, I like to still get my fresh fruits and vegetables on my own because I can walk down one aisle and that’s about it ….(FG1-07-D)
(FG6-35-D) and I belonged to a golf club. Typically, we play with our old friends. We play together occasionally, but with the dementia, it’s got to the point where she can’t play with friends… She doesn’t know what to do…. You have to put the tee on. You have to put the ball on the tee. You have to aim it at the right direction in terms of prompting, and even then… Some of the ladies at the golf club have been really good with her and sort of helped her, but last year, we whittled down to one because it was just too stressful.(FG6-31-CP)
….the Alzheimer’s just kicked in and that was a mess. Then I said, “Okay. Enough, I can’t do this…..” It was kind of scary.(FG6-32-D)
… friends start to contract, right? It’s a two-way thing. They may not like to deal with somebody with dementia, because sometimes, they’ll just go, “I don’t want to see that.”(FG6-06-CP)
4. Discussion
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Category | Focus Groups with Organizations (OFG) (n = 17) | Organization Interviews (OIN) (n = 12) | Focus Groups with Older Adults (OA), People living with Dementia (PLWD), and Care Partners (CP) (n = 37) | Walking Focus Groups with Older Adults (OA), People Living with Dementia (PLWD), and Care Partners (CP) (n = 17) |
---|---|---|---|---|
Gender | ||||
Female | 12 | 10 | 25 | 13 |
Male | 5 | 2 | 11 | 4 |
No response | N/A | N/A | 1 | 0 |
Age | ||||
21–30 | 0 | 2 | 0 | 0 |
31–40 | 3 | 0 | 0 | 0 |
41–50 | 6 | 5 | 0 | 0 |
51–60 | 4 | 3 | 2 | 3 |
61–70 | 4 | 0 | 12 | 9 |
71+ | 0 | 0 | 22 | 5 |
No response | 0 | 2 | 1 | 0 |
Highest Level of Education | ||||
Community College or Technical School | 4 | 4 | N/A | N/A |
Bachelor’s Degree | 8 | 5 | N/A | N/A |
Graduate Degree | 5 | 1 | N/A | N/A |
No response | 0 | 2 | N/A | N/A |
Years of Service in Role/Organization | ||||
Less than 1 year | 1 | 2 | N/A | N/A |
1–3 yrs. | 4 | 3 | N/A | N/A |
3–5 yrs. | 1 | 0 | N/A | N/A |
5–10 yrs. | 4 | 1 | N/A | N/A |
10+ yrs. | 7 | 4 | N/A | N/A |
No response | 0 | 2 | N/A | N/A |
Dementia | ||||
Yes | N/A | N/A | 15 | 6 |
Years Since Diagnosis (Dementia) | ||||
Less than 1 year | N/A | N/A | 2 | 0 |
1–2 yrs. | N/A | N/A | 2 | 2 |
2–3 yrs. | N/A | N/A | 4 | 2 |
3+ yrs. | N/A | N/A | 7 | 0 |
No response | N/A | N/A | 0 | 1 |
Care Partner | ||||
Yes | N/A | N/A | 9 | 5 |
Older Adult Only | ||||
Yes | N/A | N/A | 13 | 6 |
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Innes, A.; Dal Bello-Haas, V.; Burke, E.; Lu, D.; McLeod, M.; Dupuis, C. Understandings and Perceived Benefits of Outdoor-Based Support for People Living with Dementia. Int. J. Environ. Res. Public Health 2024, 21, 1072. https://doi.org/10.3390/ijerph21081072
Innes A, Dal Bello-Haas V, Burke E, Lu D, McLeod M, Dupuis C. Understandings and Perceived Benefits of Outdoor-Based Support for People Living with Dementia. International Journal of Environmental Research and Public Health. 2024; 21(8):1072. https://doi.org/10.3390/ijerph21081072
Chicago/Turabian StyleInnes, Anthea, Vanina Dal Bello-Haas, Equity Burke, Dylan Lu, Mason McLeod, and Constance Dupuis. 2024. "Understandings and Perceived Benefits of Outdoor-Based Support for People Living with Dementia" International Journal of Environmental Research and Public Health 21, no. 8: 1072. https://doi.org/10.3390/ijerph21081072