HEALTH SERVICES RESEARCH CSIRO PUBLISHING
Australian Health Review, 2015, 39, 406–410 http://dx.doi.org/10.1071/AH14035
Outdoor areas of Australian residential aged care facilities do not facilitate appropriate sun exposure Seeta Durvasula1,6 MB BS, MPH, PhD, Lecturer Rebecca S. Mason2 MB BS, PhD, Professor and Head, Physiology Cindy Kok3 MD, PhD, Project Manager Monique Macara4 BSc (Hons), MPH, Research Assistant Trevor R. Parmenter1 BA, PhD, Professor Emeritus Ian D. Cameron5 MBBS, PhD (Med), FAFRM (RACP), Professor and Head, John Walsh Centre for Rehabilitation Research 1
Sydney Medical School Northern, University of Sydney, Kolling Building, Level 7, Royal North Shore Hospital, Reserve Road, St Leonards, NSW 2065, Australia. Email: [email protected] 2 Physiology and Bosch Institute for Medical Research, School of Medical Sciences, Building F13, University of Sydney, NSW 2006, Australia. Email: [email protected] 3 Garvan Institute of Medical Research, Bone Biology Department, Darlinghurst, NSW, 2010, Australia. Email: [email protected] 4 Institute of Bone and Joint Research, Department of Rheumatology, Royal North Shore Hospital, Reserve Road, St Leonards, NSW 2065, Australia. Email: [email protected] 5 The John Walsh Centre for Rehabilitation Research, Sydney Medical School Northern, University of Sydney Kolling Building, Level 7, Royal North Shore Hospital, Reserve Road, St Leonards, NSW 2065, Australia. Email: [email protected] 6 Corresponding author. Email: [email protected]
Abstract Objective. The aim of the present study was to assess whether the outdoor areas of residential aged care facilities used for a sunlight intervention trial had the design features that encouraged participants’ use of these spaces. Methods. The design principles recommended in the ‘Vitamin D and the Built Environment in Victoria’ guidelines were used to assess the outdoor spaces of residential aged care facilities that were used in a randomised controlled trial (RCT) of sunlight exposure. Attendance rates in the sunlight RCT were analysed in relation to global impression scores of the facilities using one-way analysis of variance. Results. Thirty-six outdoor areas of 31 facilities were assessed. The facilities met the guidelines for sun exposure, and were generally safe and accessible. However, many lacked privacy, security and aesthetic appeal. Most of the outdoor spaces were not used for regularly scheduled activities. Attendance rates were higher in those facilities with the highest global impression scores compared with those with the lowest scores (F(2,367) = 3.262, P = 0.039). Conclusions. The physical environment of the outdoor areas of residential aged care facilities was associated with their use for sunlight exposure. Suitably designed or modified spaces have the potential to encourage their greater use, and residential aged care facilities should also plan regular activities in those areas. These measures can facilitate safe sun exposure, as well as physical activity and social interaction in older people. What is known about the topic? Older people living in aged care facilities have inadequate outdoor sun exposure and vitamin D deficiency. The outdoor spaces of aged care facilities are not well used by residents. Design features that encourage greater use of outdoor spaces have been identified. What does this paper add? Participation rates in a trial of outdoor sun exposure in residents of aged care facilities were found to be higher in those facilities with better design features in their outdoor spaces. Most facilities do not schedule their regular activities outdoors. What are the implications for practitioners? Suitable design or modification of outdoor spaces of residential aged care facilities can encourage their greater use. Regular scheduling of leisure and social activities can further promote their utilisation. Journal compilation AHHA 2015
www.publish.csiro.au/journals/ahr
Sun exposure and aged care facilities
Australian Health Review
407
Additional keyword: accessibility. Received 16 February 2014, accepted 2 December 2014, published online 2 March 2015
Introduction Being outdoors has health, functional and psychosocial benefits for older people.1,2 Suitably designed built environments have the capacity to promote health and improve the quality of life of individuals.3 This includes older people who live in aged care facilities. Due to the aging of the population, increasing numbers of older people are living in aged care facilities. In 2011, over 165 000 people were in permanent residential aged care in Australia and approximately 4000 people received respite care in these facilities. From 1999 to 2011, the number of permanent residents of aged care facilities increased by 25% and the number of those receiving respite care increased by 60%.4 This population of older people in residential aged care has a high prevalence of falls and fractures, with vitamin D deficiency being an important risk factor.5 In Australia, the main source of vitamin D is synthesis through sunlight-derived ultraviolet radiation, and inadequate sun exposure is an important contributing factor to vitamin D deficiency in many older people. The importance of safe sun exposure, particularly in older people and others at high risk of vitamin D deficiency, has been recognised.6 Thus, for older people in residential aged care, promoting safe sun exposure is one way of reducing the risk of vitamin D deficiency, and the design of the facilities’ outdoor spaces has an important role in this regard. However, outdoor areas of aged care facilities have been reported to be underutilised. Cutler and Kane7 assessed the indoor and outdoor amenities of 40 nursing homes and interviewed residents, families and staff about the residents’ use of outdoor spaces. They found that one-third of physically able residents go out less than once a month. There was also very low involvement by residents in planned outdoor activities, with 48.1% not participating in any outdoor activities. The environment and accessibility of the outdoor spaces were felt to be factors in their inadequate use. Few design guidelines for residential aged care facilities specifically address the need to provide appropriate sun exposure. ‘Vitamin D and the Built Environment in Victoria. A Guideline for Planners, Engineers, Architects and Policy Makers in Local and State Government’8 was developed for the Victorian state government in Australia. It recommends design features that enable direct sunlight exposure in built environments and these include: adjustable shade devices or deciduous trees; accessibility for those with mobility impairments; safety, privacy and security; a pleasant and appealing environment; and the development of activities to encourage the use of areas with direct sun exposure. Similar recommendations have been made for dementia care facilities in Victoria.9 A cluster randomised controlled trial (RCT) of sun exposure in older people in residential aged care facilities in northern Sydney, Australia, aimed to assess whether short periods of daily sun exposure over 1 year would increase vitamin D levels and reduce falls in this population.10 The study showed
no significant decrease in falls or increase in vitamin D levels in the intervention group. However, in the 17% of participants who attended more than half the available sessions, there was a significant reduction in falls and increase in vitamin D levels. This poor adherence to the sunlight intervention was likely to have been an important factor in its lack of success. A follow-up study investigating the reasons for the poor adherence found that, in addition to poor health, decreased mobility and outdoor temperature discomfort, the outdoor environment used for sun exposure was a factor in determining attendance.11 The purpose of the present study was to assess whether the outdoor areas of the residential aged care facilities used in the previous sunlight RCT had features that encouraged participants to go outdoors. Methods In the sunlight cluster RCT,10 602 participants were recruited from 51 residential aged care facilities in northern Sydney and the Central Coast of New South Wales (NSW). Of these, 397 participants in 33 facilities were randomised to receive sunlight exposure, and the rest were in the control group. Participants in the intervention group had outdoor sun exposure of their face, hands and arms for 30–40 min, 5 days a week, for 12 months. During midsummer, these sessions were run between 8.30 and 9.30 am and during mid-winter they were run between 9.30 and 11 am, so as to avoid the peak UV periods. Sunlight officers assisted participants to go outdoors and supervised the sunlight sessions. The outdoor spaces used for sun exposure were chosen on the basis that they received unshaded morning sun and there was space for the participants to sit outside. The design principles stated in ‘Vitamin D and the Built Environment in Victoria. A Guideline for Planners, Engineers, Architects and Policy Makers in Local and State Government’8 were used as a basis for developing criteria to assess the outdoor areas that were involved in the RCT. Although there are other guidelines for optimal design of outdoor spaces in residential aged care facilities, they do not specifically address the issue of suitable sun exposure for vitamin D production. The six criteria were graded on a five-point Likert scale (1 = strongly disagree; 5 = strongly agree). The criteria and explanatory notes are given in Table 1. Apart from the specific criteria, an overall indicator to assess whether the outdoor spaces of the facilities were likely to encourage their use was developed. This 10-point global impression scale took into account all available information from the individual criteria to give a single score (1 = not likely to encourage use of outdoor space; 10 = most likely). General observations about the outdoor spaces were also made at each site. Eleven outdoor spaces of 10 residential aged care facilities were initially rated by two observers (SD and a colleague) to test the practicality of administering and scoring the scale.
408
Australian Health Review
S. Durvasula et al.
Table 1. Criteria for assessment of outdoor areas Criterion
Features
Outdoor area is easily accessible to residents
Proximity to rooms Accessible for people with mobility difficulties (e.g. has level surfaces, ramps, lifts, no obstacles) Doors to outside area are easy to open and close (e.g. automatic or sliding doors) Is secure, has no obstacles, uneven or slippery surfaces Handrails present Staff are close by or can be contacted if required Has pleasant environment (e.g. garden, trees) Is not noisy Has comfortable and adequate seating and tables Is visible from inside Is well maintained Secure, private or screened areas available There is minimal line of sight from overlooking buildings, roads or other public areas At least some scheduled activities in the hostel are held outdoors, such as: physical activities (e.g. exercise classes, walks) leisure activities (e.g. craft, quizzes) residents’ meetings and/or social activities refreshments (e.g. morning teas, BBQs) Aspect (i.e. northerly) Appropriate adjustable shading, deciduous trees
Outdoor area is safe
Outdoor area is appealing
Outdoor area offers privacy and security
Outdoor area is used for regular activities
*
*
*
*
The area has the appropriate sun exposure
Following this, the criteria were clarified. Subsequently, the facilities were rated by a single observer (SD). Frequencies of scores for each criterion and descriptive statistics were calculated. The rate of attendance of sessions in the sunlight RCT by participants was calculated as the number of sessions attended over 12 months as a proportion of sessions held at the respective facilities. Global impression scores were divided into three groups: low (4 or less), medium (5–6) and high (7–10). Oneway analysis of variance (ANOVA) was used to test whether the rate of attendance differed significantly according to the global impression score groups. For four facilities that had more than one outdoor area, the mean global impression score for the different areas was used because it was not possible to determine which participants sat in which of the outdoor spaces. The sunlight RCT had the approval of the Human Research Ethics Committee of the Northern Sydney Central Coast Area Health Service. Results Of the 33 intervention residential aged care facilities in the sunlight RCT, one had closed since the intervention had finished. In another facility, it was not possible to arrange a site visit. Of the remaining 31 residential aged care facilities, three had two outdoor spaces each that were used for the sunlight sessions, and one had three outdoor spaces. In the rest, one outdoor area was used. Therefore, 36 outdoor spaces of 31 facilities were assessed. Table 2 lists the minimum, maximum and mode (most frequently occurring) Likert scores for each of the criteria. The outdoor spaces were generally accessible, safe and were suitable for sun exposure (mode = 4). However, some lacked appeal,
Table 2. Minimum, maximum and modal Likert scores of outdoor areas by assessment criteria Range of scores: 1 (strongly disagree)–5 (strongly agree) Criterion Outdoor area is easily accessible Outdoor area is safe Outdoor area is appealing Outdoor area has privacy and security Outdoor area is used for scheduled activities Outdoor area has suitable sun exposure
Mode Minimum Maximum 4 4 3 3 1 4
1 2 1 1 1 3
5 5 5 4 5 5
privacy and security (mode = 3), and very few of the areas were used for regular activities (mode = 1). The global impression scores ranged from 1 to 8, with mode of 6. In the four facilities with two or more outdoor areas, the scores across the different areas of each facility were mostly similar: Facility 1, scores 2 and 4; Facility 2, scores 5 and 6; Facility 3, scores 2 and 5; Facility 4, scores 4, 5 and 7. The Likert scores of the six main criteria were collapsed into three categories, namely Strongly Agree–Agree (scores 4–5), Neutral (score 3) and Disagree–Strongly Disagree (scores 1–2), and Fig. 1 shows the percentage scores achieved by the outdoor areas for each category. As can be seen in Fig. 1, the strongest positive scores (4–5) were those for suitable sun exposure, where there were no negative findings. Safety, accessibility and appeal were the next highest scores, although the proportion of Strongly Agree–Agree scores for these criteria were
Australian Health Review, 2015, 39, 406–410 http://dx.doi.org/10.1071/AH14035
Outdoor areas of Australian residential aged care facilities do not facilitate appropriate sun exposure Seeta Durvasula1,6 MB BS, MPH, PhD, Lecturer Rebecca S. Mason2 MB BS, PhD, Professor and Head, Physiology Cindy Kok3 MD, PhD, Project Manager Monique Macara4 BSc (Hons), MPH, Research Assistant Trevor R. Parmenter1 BA, PhD, Professor Emeritus Ian D. Cameron5 MBBS, PhD (Med), FAFRM (RACP), Professor and Head, John Walsh Centre for Rehabilitation Research 1
Sydney Medical School Northern, University of Sydney, Kolling Building, Level 7, Royal North Shore Hospital, Reserve Road, St Leonards, NSW 2065, Australia. Email: [email protected] 2 Physiology and Bosch Institute for Medical Research, School of Medical Sciences, Building F13, University of Sydney, NSW 2006, Australia. Email: [email protected] 3 Garvan Institute of Medical Research, Bone Biology Department, Darlinghurst, NSW, 2010, Australia. Email: [email protected] 4 Institute of Bone and Joint Research, Department of Rheumatology, Royal North Shore Hospital, Reserve Road, St Leonards, NSW 2065, Australia. Email: [email protected] 5 The John Walsh Centre for Rehabilitation Research, Sydney Medical School Northern, University of Sydney Kolling Building, Level 7, Royal North Shore Hospital, Reserve Road, St Leonards, NSW 2065, Australia. Email: [email protected] 6 Corresponding author. Email: [email protected]
Abstract Objective. The aim of the present study was to assess whether the outdoor areas of residential aged care facilities used for a sunlight intervention trial had the design features that encouraged participants’ use of these spaces. Methods. The design principles recommended in the ‘Vitamin D and the Built Environment in Victoria’ guidelines were used to assess the outdoor spaces of residential aged care facilities that were used in a randomised controlled trial (RCT) of sunlight exposure. Attendance rates in the sunlight RCT were analysed in relation to global impression scores of the facilities using one-way analysis of variance. Results. Thirty-six outdoor areas of 31 facilities were assessed. The facilities met the guidelines for sun exposure, and were generally safe and accessible. However, many lacked privacy, security and aesthetic appeal. Most of the outdoor spaces were not used for regularly scheduled activities. Attendance rates were higher in those facilities with the highest global impression scores compared with those with the lowest scores (F(2,367) = 3.262, P = 0.039). Conclusions. The physical environment of the outdoor areas of residential aged care facilities was associated with their use for sunlight exposure. Suitably designed or modified spaces have the potential to encourage their greater use, and residential aged care facilities should also plan regular activities in those areas. These measures can facilitate safe sun exposure, as well as physical activity and social interaction in older people. What is known about the topic? Older people living in aged care facilities have inadequate outdoor sun exposure and vitamin D deficiency. The outdoor spaces of aged care facilities are not well used by residents. Design features that encourage greater use of outdoor spaces have been identified. What does this paper add? Participation rates in a trial of outdoor sun exposure in residents of aged care facilities were found to be higher in those facilities with better design features in their outdoor spaces. Most facilities do not schedule their regular activities outdoors. What are the implications for practitioners? Suitable design or modification of outdoor spaces of residential aged care facilities can encourage their greater use. Regular scheduling of leisure and social activities can further promote their utilisation. Journal compilation AHHA 2015
www.publish.csiro.au/journals/ahr
Sun exposure and aged care facilities
Australian Health Review
407
Additional keyword: accessibility. Received 16 February 2014, accepted 2 December 2014, published online 2 March 2015
Introduction Being outdoors has health, functional and psychosocial benefits for older people.1,2 Suitably designed built environments have the capacity to promote health and improve the quality of life of individuals.3 This includes older people who live in aged care facilities. Due to the aging of the population, increasing numbers of older people are living in aged care facilities. In 2011, over 165 000 people were in permanent residential aged care in Australia and approximately 4000 people received respite care in these facilities. From 1999 to 2011, the number of permanent residents of aged care facilities increased by 25% and the number of those receiving respite care increased by 60%.4 This population of older people in residential aged care has a high prevalence of falls and fractures, with vitamin D deficiency being an important risk factor.5 In Australia, the main source of vitamin D is synthesis through sunlight-derived ultraviolet radiation, and inadequate sun exposure is an important contributing factor to vitamin D deficiency in many older people. The importance of safe sun exposure, particularly in older people and others at high risk of vitamin D deficiency, has been recognised.6 Thus, for older people in residential aged care, promoting safe sun exposure is one way of reducing the risk of vitamin D deficiency, and the design of the facilities’ outdoor spaces has an important role in this regard. However, outdoor areas of aged care facilities have been reported to be underutilised. Cutler and Kane7 assessed the indoor and outdoor amenities of 40 nursing homes and interviewed residents, families and staff about the residents’ use of outdoor spaces. They found that one-third of physically able residents go out less than once a month. There was also very low involvement by residents in planned outdoor activities, with 48.1% not participating in any outdoor activities. The environment and accessibility of the outdoor spaces were felt to be factors in their inadequate use. Few design guidelines for residential aged care facilities specifically address the need to provide appropriate sun exposure. ‘Vitamin D and the Built Environment in Victoria. A Guideline for Planners, Engineers, Architects and Policy Makers in Local and State Government’8 was developed for the Victorian state government in Australia. It recommends design features that enable direct sunlight exposure in built environments and these include: adjustable shade devices or deciduous trees; accessibility for those with mobility impairments; safety, privacy and security; a pleasant and appealing environment; and the development of activities to encourage the use of areas with direct sun exposure. Similar recommendations have been made for dementia care facilities in Victoria.9 A cluster randomised controlled trial (RCT) of sun exposure in older people in residential aged care facilities in northern Sydney, Australia, aimed to assess whether short periods of daily sun exposure over 1 year would increase vitamin D levels and reduce falls in this population.10 The study showed
no significant decrease in falls or increase in vitamin D levels in the intervention group. However, in the 17% of participants who attended more than half the available sessions, there was a significant reduction in falls and increase in vitamin D levels. This poor adherence to the sunlight intervention was likely to have been an important factor in its lack of success. A follow-up study investigating the reasons for the poor adherence found that, in addition to poor health, decreased mobility and outdoor temperature discomfort, the outdoor environment used for sun exposure was a factor in determining attendance.11 The purpose of the present study was to assess whether the outdoor areas of the residential aged care facilities used in the previous sunlight RCT had features that encouraged participants to go outdoors. Methods In the sunlight cluster RCT,10 602 participants were recruited from 51 residential aged care facilities in northern Sydney and the Central Coast of New South Wales (NSW). Of these, 397 participants in 33 facilities were randomised to receive sunlight exposure, and the rest were in the control group. Participants in the intervention group had outdoor sun exposure of their face, hands and arms for 30–40 min, 5 days a week, for 12 months. During midsummer, these sessions were run between 8.30 and 9.30 am and during mid-winter they were run between 9.30 and 11 am, so as to avoid the peak UV periods. Sunlight officers assisted participants to go outdoors and supervised the sunlight sessions. The outdoor spaces used for sun exposure were chosen on the basis that they received unshaded morning sun and there was space for the participants to sit outside. The design principles stated in ‘Vitamin D and the Built Environment in Victoria. A Guideline for Planners, Engineers, Architects and Policy Makers in Local and State Government’8 were used as a basis for developing criteria to assess the outdoor areas that were involved in the RCT. Although there are other guidelines for optimal design of outdoor spaces in residential aged care facilities, they do not specifically address the issue of suitable sun exposure for vitamin D production. The six criteria were graded on a five-point Likert scale (1 = strongly disagree; 5 = strongly agree). The criteria and explanatory notes are given in Table 1. Apart from the specific criteria, an overall indicator to assess whether the outdoor spaces of the facilities were likely to encourage their use was developed. This 10-point global impression scale took into account all available information from the individual criteria to give a single score (1 = not likely to encourage use of outdoor space; 10 = most likely). General observations about the outdoor spaces were also made at each site. Eleven outdoor spaces of 10 residential aged care facilities were initially rated by two observers (SD and a colleague) to test the practicality of administering and scoring the scale.
408
Australian Health Review
S. Durvasula et al.
Table 1. Criteria for assessment of outdoor areas Criterion
Features
Outdoor area is easily accessible to residents
Proximity to rooms Accessible for people with mobility difficulties (e.g. has level surfaces, ramps, lifts, no obstacles) Doors to outside area are easy to open and close (e.g. automatic or sliding doors) Is secure, has no obstacles, uneven or slippery surfaces Handrails present Staff are close by or can be contacted if required Has pleasant environment (e.g. garden, trees) Is not noisy Has comfortable and adequate seating and tables Is visible from inside Is well maintained Secure, private or screened areas available There is minimal line of sight from overlooking buildings, roads or other public areas At least some scheduled activities in the hostel are held outdoors, such as: physical activities (e.g. exercise classes, walks) leisure activities (e.g. craft, quizzes) residents’ meetings and/or social activities refreshments (e.g. morning teas, BBQs) Aspect (i.e. northerly) Appropriate adjustable shading, deciduous trees
Outdoor area is safe
Outdoor area is appealing
Outdoor area offers privacy and security
Outdoor area is used for regular activities
*
*
*
*
The area has the appropriate sun exposure
Following this, the criteria were clarified. Subsequently, the facilities were rated by a single observer (SD). Frequencies of scores for each criterion and descriptive statistics were calculated. The rate of attendance of sessions in the sunlight RCT by participants was calculated as the number of sessions attended over 12 months as a proportion of sessions held at the respective facilities. Global impression scores were divided into three groups: low (4 or less), medium (5–6) and high (7–10). Oneway analysis of variance (ANOVA) was used to test whether the rate of attendance differed significantly according to the global impression score groups. For four facilities that had more than one outdoor area, the mean global impression score for the different areas was used because it was not possible to determine which participants sat in which of the outdoor spaces. The sunlight RCT had the approval of the Human Research Ethics Committee of the Northern Sydney Central Coast Area Health Service. Results Of the 33 intervention residential aged care facilities in the sunlight RCT, one had closed since the intervention had finished. In another facility, it was not possible to arrange a site visit. Of the remaining 31 residential aged care facilities, three had two outdoor spaces each that were used for the sunlight sessions, and one had three outdoor spaces. In the rest, one outdoor area was used. Therefore, 36 outdoor spaces of 31 facilities were assessed. Table 2 lists the minimum, maximum and mode (most frequently occurring) Likert scores for each of the criteria. The outdoor spaces were generally accessible, safe and were suitable for sun exposure (mode = 4). However, some lacked appeal,
Table 2. Minimum, maximum and modal Likert scores of outdoor areas by assessment criteria Range of scores: 1 (strongly disagree)–5 (strongly agree) Criterion Outdoor area is easily accessible Outdoor area is safe Outdoor area is appealing Outdoor area has privacy and security Outdoor area is used for scheduled activities Outdoor area has suitable sun exposure
Mode Minimum Maximum 4 4 3 3 1 4
1 2 1 1 1 3
5 5 5 4 5 5
privacy and security (mode = 3), and very few of the areas were used for regular activities (mode = 1). The global impression scores ranged from 1 to 8, with mode of 6. In the four facilities with two or more outdoor areas, the scores across the different areas of each facility were mostly similar: Facility 1, scores 2 and 4; Facility 2, scores 5 and 6; Facility 3, scores 2 and 5; Facility 4, scores 4, 5 and 7. The Likert scores of the six main criteria were collapsed into three categories, namely Strongly Agree–Agree (scores 4–5), Neutral (score 3) and Disagree–Strongly Disagree (scores 1–2), and Fig. 1 shows the percentage scores achieved by the outdoor areas for each category. As can be seen in Fig. 1, the strongest positive scores (4–5) were those for suitable sun exposure, where there were no negative findings. Safety, accessibility and appeal were the next highest scores, although the proportion of Strongly Agree–Agree scores for these criteria were
