Health promoting qualities in outdoor environments at residential care facilities for older adults – a research approach

Type of the Paper: Peer-reviewed Conference Paper / Full Paper

Track title: Inclusive design & health promotion

Health promoting qualities in outdoor environments at
residential care facilities for older adults – a research approach

Madeleine Liljegren 1*, Anna Bengtsson 2, Göran Lindahl 3 and Helle Wijk 4*

1 University of Gothenburg and Chalmers University of Technology, Sweden; madeleine.liljegren@gu.se; 0000-0003-4656-9019

2 Swedish University of Agricultural Sciences, Sweden; anna.bengtsson@slu.se; 0000-0003-1312-9711

3 Chalmers University of Technology, Sweden; goran.lindahl@chalmers.se; 0000-0003-0007-7270

4 University of Gothenburg and Chalmers University of Technology, Sweden; helle.wijk@gu.se; 0000-0003- 2396-6505

Abstract: The present research project focuses on health and building design parameters for developing outdoor environments at residential care facilities (RCFs) for older adults. The objective of the project is to develop an evidence-based guideline and method for design, planning, and evaluation. The starting point for the project is that outdoor environments at RCFs are often difficult to reach from the indoor environment and are not adapted for outdoor rehabilitation and outdoor stays. Most often, rehabilitation activities for older adults at RCFs are performed indoors, as there is no formal right by law to include daily outdoor stays at RCFs. Pending the development of outdoor rehabilitation as well as changes in the regulations regarding access to daily outdoor stays, it is imperative to examine health-promoting qualities in the outdoor environment. It is also important to focus on the older adult’s possibilities for moving between indoor and outdoor environments to reduce the risk of feeling locked in. The present paper describes and discusses a mixed-methods approach that builds up the five sub-studies in the project.

Keywords: health-promoting; older adults; outdoor environment; residential care facilities; work- ing method for design, planning and evaluation

1. Introduction

United Nations sustainability Goal 11:7 emphasises the importance of enabling public access to “green and public spaces, in particular for [...] older adults and persons with disabilities." This means that all persons should have the possibility to live and participate in societies under equal conditions, both in indoor and outdoor environments, regardless of functional capacity. However, this is not the general situation today, for example, at residential care facilities (RCFs) for older adults in Sweden. An improvement in accessibility to the outdoor environment at RCFs is therefore a need to consider in planning, design, and evaluation. In Sweden, there are approx. 2 100 RCFs, and about 88 000 older adults are living in this type of housing. About half of the older adults at RCFs experience a decline in their functional capacity in terms of extensive mobility difficulties on their own (The Swedish National Board of Health and Welfare, 2019, in Swedish), for example, between indoor and outdoor environments.

Before focusing on the importance of being outdoors for older adults, three main concepts must be considered and understood. The first concept is health. To understand what health is in this context, we use the WHO definition: "Health is a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity" (World Health Organisation, 1948). The second concept is health promotion, which is defined as “the process of enabling people to increase control over and improve their health” (World Health Organisation, 1986). The third concept is outdoor environment, and, in this context, it relates both to the physical environment that is directly adjacent to the RCFs buildings and to the physical environment in the neighbourhood. All three concepts contribute perspectives that are fundamental to this research project. 

Why is it important to have access to an outdoor environment? Contact with nature supports healing and contributes to an improved experience of health (Bengtsson, 2015). Being outdoors in a health-promoting environment has the greatest health effect for fragile and vulnerable persons, but in general, it is important to have the possibility to choose where you want to be, for example, the possibility to be outdoors as an alternative to indoors (Bengtsson 2015). Another significant aspect is that outdoor environments at RCFs are often difficult to reach from the indoor environment, which can lead to a risk of older adults being and feeling confined, which can have negative influences on health (Dahlqvist et al., 2019). This necessitates a greater understanding of the outdoor environment and its potential for health and wellbeing at RCFs. Older adults at RCFs are often frail, which means they have a variation in needs, conditions, and functional ability (Nordin et al., 2017). Fall injuries are a common cause of injury to older adults, and the consequences are often serious and require rehabilitation (Gell & Patel, 2019). At present, rehabilitation for older adults at RCFs is mainly carried out indoors, where a development in the field advocates the introduction of outdoor rehabilitation. Research emphasizes the importance of outdoor environments for rehabilitation, and we need to offer varied environments that suit people's different needs (Palsdottir et al., 2018). The physical environment's design can be an enabling or hindering factor for both outdoor rehabilitation and outdoor stays (Calkins, 2018; Nordin et al., 2017). In Sweden, outdoor rehabilitation is already a treatment recommended for persons with stress-related mental illness (Vårdguiden, 2022 in Swedish), which makes it interesting to introduce also for frail older adults with physical disabilities.

Today, the importance of the physical environment for health and well-being is high on the agenda nationally and internationally (Centre for Healthcare Architecture, 2021, in Swedish); this also applies to the environment at RCFs (Bengtsson, 2015; Joseph et al., 2016; Nordin et al., 2017). Persons whose various disabilities and diagnoses result in specific needs in the health care environment are becoming increasingly important and prominent, in relation to health and behaviour, when designing health care environments (Patrick, 1997). Research focusing on environments and their impact on health is developing and growing, and there are increased demands on evidence-based design for healthcare facilities (Bengtsson 2015; Iwarsson 2012; Nordin 2015). With an ageing population, the need for RCFs increases. It is therefore important to provide environments that meet the needs and functional abilities of older adults. Based on this background, quality assurance and development of the outdoor environment at RCFs are aspects that need to be studied.

The overall aim of the ongoing research project presented in this paper is to describe and discuss the four-year project focusing on health-promoting qualities in outdoor environments at RCFs for older adults. The intention is to develop an evidence-based guideline as well as a method to support design, planning, and evaluation. The overall methodology for the research project is mixed methods. The project duration is 2021–2025, and at the time of writing, data collection for sub-studies I and II is ongoing.

The paper starts by presenting the theories and models on which the project is based. After that, some knowledge gaps are defined. Then follows a discussion concerning the overall design of the research project and the potential of the included sub-studies to address the identified gaps.

2. Theories and Models

The project takes its starting point in Lawton's theory on the ecological model of ageing (1983) and the principal model of four zones of contact with the outdoors (Bengtsson 2015). Lawton’s theory originates from gerontological science and includes the importance of balancing the demands of the care environment in relation to people's functional competence. It describes a person's behaviour and how it can be understood as a product of competence (intellectual, emotional, and practical ability) and the environment's demands (physical environment and psychosocial climate). The theory implies that people with high competence will behave more often in a way that is adequate for the situation compared to those with lower competence. The theory also highlights that both high and low demands from the environment can have a negative impact on an individual. The principal model of four zones of contact with the outdoors was developed within the environmental psychology discipline by Bengtsson (2015). The model identifies four essential zones to study the potential of the outdoors for users with a holistic approach to the physical environment (Bengtsson, 2015). Zone 1 consists of the contact with the outdoor environment from inside the building (through windows); zone 2 consists of the transition between indoors and outdoors (entrances, balconies, or conservatories); zone 3 consists of the outdoor environment (garden) that belongs to the building; and zone 4 consists of the surrounding outdoor environment in the community (Bengtsson, 2015) (Figure 1). (Zone 0 represents the indoor environment without contact with the outside world.) A body position concept has been integrated with the principal model of four zones of contact with the outdoors (Bengtsson et al. 2018, in Swedish). Four different body positions are identified: 1.) lying position; 2.) sitting position; 3.) standing position; and 4.) in motion (in a wheelchair or walking with or without support from another person or aid) (Figure 1).

Figure 1: Four zones of contact with outdoor environment in relation to body position. Illustration: Anna Bengtsson and Madeleine Liljegren.

2.1. Knowledge gaps
The overall knowledge gaps identified concern health-promoting qualities in the outdoor environment in relation to older adults living at RCFs. More specifically, the gaps concern:

• Knowledge concerning older adults’ access to outdoor environments at RCFs (sub-study I).

• Knowledge of the needs and wishes of the older adults and care workers in contact with the outdoor environment at RCFs (sub-study II).

• A guideline that clarifies health-promoting qualities in the outdoor environment that should be prioritised when planning, designing, and evaluating the outdoor environment at RCFs (sub-study III).

• A working method that includes health-promoting outdoor qualities in the design, planning, and evaluation of new production or rebuilding of RCFs (sub-study IV).

• A strategical model at the national level to ensure the possibility of outdoor stays and outdoor rehabilitation for older adults at RCFs in Sweden (sub-study V).

Each identified knowledge gap leads to a research question for each sub-study in the research project, which will be described and discussed in the following section.

3. Discussion of study design
We will here describe and discuss the study design developed in relation to the overall aim of the study, namely, to increase knowledge of health-promoting qualities in outdoor environments at RCFs for older adults, and we will describe and discuss one sub-study for each specific research question.

3.1. The overall study design
The overall methodology for the research project is mixed methods, which means that different methods (quantitative and qualitative) are combined (Sandelowski 2014). The project comprises five sub-studies, and due to the complexity of the overall research question, different methods are used to achieve the purpose. The first sub-study is quantitative, and the other ones are qualitative. All five sub-studies relate to and build on each other. In the first sub-study, a national survey concerning access to outdoor environments at RCFs is conducted. The second sub-study builds upon interviews with older adults and care workers at RCFs, focusing on their needs and wishes in contact with the outdoor environment. The results from sub-study I and II, together with a literature review and design tools for RCFs, will in sub-study III support the development of an evidence-based guideline for the design, planning, and evaluation of RCFs. In sub-study IV, the guideline will be further developed and integrated with standard working methods for the design, planning, and evaluation of RCFs. Finally, in sub-study V, a strategical model at the national level will be developed to ensure the possibility of outdoor stays and outdoor rehabilitation for older adults at RCFs in Sweden.

To increase the knowledge of health-promoting qualities in outdoor environments at RCFs for older adults, it is important to gather data from different perspectives and target groups. Planned target groups are: older adults, staff, and business managers at RCFs, as well as professional groups and experts who are involved in various ways in the design and planning. The research project consists of five sub-studies, one for each research question.

Sub-study I: What access do older adults at RCFs in Sweden have to outdoor environ- ments?
Today, we do not know how many RCFs in Sweden have their own outdoor environment, even less about the other zones, according to the model developed by Bengtsson (2015). The sub-study aims to investigate access to outdoor environments at a national level. Theoretically, this sub-study relates to the model of the four zones of contact with the outdoors (Bengtsson, 2015). The idea is to analyse site layouts of the outdoor environ-ments and drawings of each floor in the building to gain knowledge of access to the outdoors, balconies, and roof terraces at each special residence in Sweden (about 2100 RCFs). The result will be presented in diagrams and illustrations. On an overall level, the target group is older adults who live at RCFs. Indirectly, each municipality’s building permit unit is the target group for data collection. Data is collected through the following procedure: 1.) The National Board of Health and Welfare provides a list of all RCFs in Sweden, categorised by municipality and 2.) All municipalities’ building permit units (n = 290) are contacted via e-mail and asked to provide drawings of each resident’s outdoor environment and floor plans. The data is analysed based on the four zones of contact with the outdoors (Bengtsson, 2015). In addition, the various municipalities are categorised based on Sweden’s municipalities and regions’ municipal group divisions. All RCFs for older adults in Sweden, regardless of the type of operation (municipality, private, or foundation), are included.

Sub-study II: What are the needs and wishes of older adults and care workers concerning the outdoor environment at RCFs?
Theoretically, this sub-study relates to Lawton’s theory on the ecological model of ageing (1983), while we will investigate needs and wishes and connect them to facilitating and hindering factors in the environment. The sub-study also relates to previous research about older adults and physical indoor and outdoor environments at RCFs (Nordin et al., 2017). The aim is to map the needs and wishes of older adults and care workers in contact with the outdoor environment at RCFs. The method is a qualitative, semi-structured interview study (Polit & Beck, 2021) carried out in the form of walking interviews (King & Woodroffe, 2017). Themes that are central to the interviews are facilitating and hindering factors in the environment in the four zones. Participants in sub-study II are older adults and care workers at RCFs. Data is collected through a strategic selection of three RCFs within one Swedish region. Interviews are conducted with older adults (4 per RCF) and care workers (5 per RCF). Data is analysed based on qualitative content analysis (Lindgren et al. 2020).

Sub-study III: Which qualities in the outdoor environments for older adults at RCFs are health promoting and should be prioritized?
Theoretically, this sub-study also relates to the model of the four zones of contact with the outdoors (Bengtsson, 2015), previous research about RCFs (Nordin et al., 2017; 2015), and availability in outdoor environments (Iwarsson et al., 2012). The aim is to develop a guideline regarding qualities in outdoor environments at RCFs. The method is guideline development, ensured via the Delphi method (Keeney, Hasson, & McKenna 2011). Participants in sub-study III are experts in the field—researchers as well as practitioners. By combining evidence from previous research (systematic literature review and validated and reliable instruments) and the current project’s sub-studies I–II, data is obtained (see, e.g., Armijo-Olovo et al. 2010; Moher et al. 2009; NCCMT NCCfMaT 2011). Data is analysed based on qualitative content analysis (Lindgren et al. 2020).

Sub-study IV: How can health-promoting qualities in the outdoor environment be inte- grated into the standard working method for the design, planning, and evaluation of new production or rebuilding of RCFs (sub-study IV)?
Theoretically, this sub-study relates to the same model and research as in sub-study III, and it also relates to research about design dialogues (Fröst, 2020). The aim is to further develop the guideline (from sub-study III) so that it can be integrated into standard working methods for the design, planning, and evaluation of outdoor environments at RCFs. The approach is method development through design dialogue (Fröst, 2020). Participants in sub-study IV are representatives from the health care sector and the building sector working on the new construction or refurbishment of RCFs. The design dialogue focuses on where and how environmental qualities from the guideline should be integrated into the standard working methods for the design, planning, and evaluation of outdoor environments at RCFs. Different alternatives regarding when the environmental qualities are to be addressed need to be studied to find out how they can be articulated in design and construction. The responsibility for where in the standard process and by whom the environmental qualities need to be brought in also needs to be studied. Qualitative content analysis (Lindgren et al. 2020) is used to analyse the data.

Sub-study V: How can the possibility of outdoor stays and outdoor rehabilitation at RCFs for older adults be ensured at a national level?
Overall, this sub-study is an example of translational research at stage four, i.e., conveying (or moving) results to the community (Translational Science Spectrum, 2017). In sub-study V, results from sub-studies I to IV are translated into a strategical model aiming at ensuring the possibility of outdoor stays and outdoor rehabilitation at RCFs for older adults at a national level. The method includes dialogues about rules and guidelines as well as method development for environmental analysis in collaboration with relevant authorities. Target groups are representatives from two Swedish authorities (the National Board of Housing, Building, and Planning and the National Board of Health and Welfare), the Swedish association for municipalities and regions, decision-makers from municipal health-care organisations, and representatives from the Swedish University of Agricultural Sciences’ environmental analysis programme for the built environment.

3.2. Ethical considerations
As older adults living at RCFs are in a position of dependence due to fragility and multi-morbidity, ethical considerations are highly relevant to the project (The Swedish Authority for Privacy Protection, 2022; Swedish Ethical Review Authority, 2022, in Swedish; The World Medical Association, 2008). All participants, both older adults and staff, receive oral and written information about the study. They also receive information about why they are invited to participate, and they need to give their written consent to the participation. Participants also receive information about who they can contact or if they want to cancel their participation. Participation can have both positive and negative consequences for older adults and staff. A positive consequence for the older adults is that they experience outdoor stays during the walking interviews, while a negative consequence might be an increased risk of fall accidents. Positive consequences for the care workers are possibilities for outdoor stays and increased knowledge of the importance of the outdoor environment for older adults. A negative consequence may be a lack of time.

Personal data will be treated confidentially in accordance with the Helsinki Declaration on Ethics (The World Medical Association, 2008). Data from the sub-studies will be presented at the group level and in relation to the four zones. Quotes will be anonymous. The project has received an approved ethics application from the Swedish Ethics Review Authority (diary number: 2020-06643).

4. Conclusions
RCFs for older adults with disabilities are important facilities in every well-functioning and sustainable society, a fact also in line with Lawtons ecological model (1983). To increase existence of health-promoting outdoor environments at RCFs, this research project aims to fill knowledge gaps in the interdisciplinary field of health care environments, which include the research disciplines of caring sciences, architecture, and landscape architecture. Five sub-studies are described and discussed to increase knowledge about health-promoting qualities in outdoor environments and ways of addressing this at RCFs for older adults. To conclude, this research project intends to increase knowledge concerning:

1. Access to outdoor environments for older adults at RCFs.

2. Older adults and care workers need and wishes concerning the outdoor environments at RCFs.

3. A guideline for health-promoting qualities in outdoor environments at RCFs.

4. A working method that includes health-promoting outdoor qualities in the design, planning, and evaluation of new production or rebuilding of RCFs.

5. Strategic models to ensure the possibility of outdoor stays and rehabilitation in health-promoting outdoor environments.

Data Availability Statement

The original contributions presented in the study are included in the article. Further requests can be directed to the corresponding author.

Contributor statement

The corresponding author conceived the idea for the manuscript. All authors contributed to the writing and development of the manuscript’s ideas and read and approved the final manuscript.

Acknowledgments (optional)

The research reported here was supported by Hjalmar Svensson foundation, HJSV2020044, Formas, project number 2020-01959, the Kamprad family foundation for entrepreneurship, research and charity, project number 20210117, Swedish University of Agricultural Science, Environmental monitoring and assessment programs/ Built environment, Forte, 2021-00212.

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