Health & Place 34 (2015) 97–106

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Health & Place journal homepage: www.elsevier.com/locate/healthplace

Therapeutic landscapes and wellbeing in later life: Impacts of blue and green spaces for older adults Jessica Finlay a,b,n, Thea Franke b,c, Heather McKay b,c, Joanie Sims-Gould b,c a

Department of Geography, Environment and Society, University of Minnesota, 414 Social Sciences, 267 19th Ave S, Minneapolis, 55455 MN, USA Centre for Hip Health and Mobility, 2635 Laurel Street, Vancouver, BC, Canada, V5Z 1M9 c Faculty of Medicine, University of British Columbia, 317-2194 Health Sciences Mall, Vancouver, BC, Canada, V6T 1Z3 b

art ic l e i nf o

a b s t r a c t

Article history: Received 18 December 2014 Received in revised form 27 March 2015 Accepted 2 May 2015

This paper extends the concept of therapeutic landscapes by investigating how green and blue spaces affect older adult health and wellbeing. We draw on interview data from participants aged 65–86 years old who described their everyday experiences with green and especially blue spaces across Metro Vancouver, Canada. Landscapes embedded with therapeutic qualities included parks, gardens, street greenery, lakes, and the ocean. Interactions with these spaces influenced participants' perceived physical, mental, and social health. Issues of safety, accessibility, and personal perception complicated this relationship. Overall, the findings indicate that nature plays a nuanced and influential role in the everyday lives of older adults. Better understanding how older adults experience health and landscape is critical towards developing everyday contact with nature that can improve quality of life for ageing populations. & 2015 Elsevier Ltd. All rights reserved.

Keywords: Therapeutic landscapes Health geography Older adults Canada

1. Introduction Within the therapeutic landscape research tradition, scholars have referred to how healing processes can be embedded in places, locales, settings, and milieus (Lea, 2008). Gesler (1993, p. 171) first identified therapeutic landscapes as places with “an enduring reputation for achieving physical, mental, and spiritual healing”. This encompasses physical, psychological, and social environments associated with treatment and the maintenance of health. Therapeutic landscapes include places such as spas, sacred sites, gardens, retreats, pilgrimage locations, homes, and health facilities (see Gesler (2009); Lea (2008); Conradson (2005); Williams (1998); Gesler (1992)). Scholars extended the concept to nontraditional healing landscapes, such as home settings (Williams, 2002), children's summer camps (Kearns and Collins, 2000), and collective gardening programs (Milligan et al., 2004). Thus, therapeutic landscapes encompass complex reciprocal relationships between a person and their broader socio-environmental setting (Conradson, 2005). There is a strong ideology in the urbanized Western world that people can “attain physical, mental, and spiritual healing by simply n Corresponding author at: Department of Geography, Environment and Society, University of Minnesota, 414 Social Sciences, 267 19th Ave S, Minneapolis, MN 55455, USA. E-mail addresses: fi[email protected] (J. Finlay), [email protected] (T. Franke), [email protected] (H. McKay), [email protected] (J. Sims-Gould).

http://dx.doi.org/10.1016/j.healthplace.2015.05.001 1353-8292/& 2015 Elsevier Ltd. All rights reserved.

spending time out-of-doors or seeking out remote or isolated places where they can ‘get away from it all’, surrounded by nature” (Gesler, 2003, p. 8). Nature often refers to untouched forests and lakes in the wilderness; it also refers to potted plants, trees along a street, a courtyard fountain, and other natural-appearing features. Thus, in this paper we refer to nature as a spectrum of habitats ranging from large wilderness areas to community gardens and cultivated plants in a domestic home (Maller et al., 2005). Recently nature was linked to health and wellbeing in the academic literature (e.g. Hartig et al., 2014; Mitchell, 2013; Dinnie et al., 2013; Hartig et al., 2011; Abraham et al., 2010; Bowler et al., 2010). Kaplan and Kaplan (1989) were pioneers in this field and asserted that individuals with access to nearby natural settings are healthier overall than other individuals. The long-term and secondary impacts of “nearby nature” also include higher satisfaction levels with one's home, job, and life in general (p.173). Exposure to nature (e.g. looking through a window, walking by a park) and actively participating outdoors (e.g. gardening, hiking) promotes both physical and mental health (Maller et al., 2005; Pretty, 2004). For example walking in a natural landscape, such as a forest, beach, and park, can promote psychological restoration and alleviate stress (Hartig et al., 2011; Abraham et al., 2010). Green space is a common umbrella term used to describe natural areas in wilderness and urban settings such as parks, gardens, and forests (e.g. van Dillen et al., 2012; Lee and Maheswaran, 2011, Maas et al., 2006). The quantity and quality of green space in one's neighborhood has been shown to have restorative impacts, and linked to greater perceived health

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(Hansmann et al., 2007; Maas et al., 2006), and positively affect reported stress and quality of life (Thompson et al., 2012; Bowler et al., 2010; van den Berg et al., 2010; Maller et al., 2005). Proximity and design of locally available green space were associated with physical activity and obesity (e.g. Lachowycz and Jones, 2011; Coombes et al., 2010; Maas et al., 2008; Björk et al., 2008). Green spaces can also provide valuable meeting places for users to develop and maintain neighborhood social ties (Lee and Maheswaran, 2011). Blue space is another important concept that may promote health and wellbeing. For this paper, we define blue space as aquatic environments, both in natural and urban areas, with standing or running water. Blue space encompasses oceans, lakes, and rivers, as well as smaller water features such as fountains and streams (White et al., 2010). In the discipline of therapeutic landscapes, Foley (2011, p. 477) describes holy wells in Ireland as “a piece of micro-landscape of healing and wellness”. Many healing places were historically situated close to springs and other sources of water (Gesler, 2003), and people continue to travel to baths, spa towns, sea bathing locations, modern spas, and holy wells to “take the waters” seeking tranquility and healing (Foley, 2010; Smyth, 2005). In environmental psychology, aquatic elements are associated with positive mood effects, attractiveness, and perceived restorative abilities in both built and natural environments. Both the sounds of water (e.g. breaking waves), and immersing oneself into water (e.g. to bathe or swim) are often considered calming and restorative (White et al., 2010). Juxtaposed against an abundant literature on green spaces, we know relatively little about the relation between blue space, health and wellbeing. To date, this enquiry resides predominantly within the fields of environmental toxicology and microbiology (Volker and Kistemann, 2011). There is a small but growing literature on the therapeutic qualities of blue space, including Volker and Kistemann's (2013) study on health-related components of public promenades on the Rhine River in two German cities. Wheeler et al. (2012) and White et al. (2013) found a positive association between coastal proximity and self-reported health in the English census. Coleman and Kearns' (2014) innovative study used photo-elicitation interviews with older adults in Waiheke Island, New Zealand, to examine how blue space affects experiences of place, ageing and wellbeing. The analysis focuses on how island settings pose challenges for older residents (e.g. isolation, lack of services), but also help maintain wellbeing through strong affective ties to blue space. This area of literature broadens research on the salubrious effects of natural environments from its traditional focus on terrestrial green space (where blue space is more of an after-thought) to purposefully include and investigate blue space. Building on this literature, we need further studies evaluating how blue landscapes affect health and wellbeing. This includes purposeful consideration of different social groups, including older adults. We will soon have a global population comprised of a high proportion of older people. This changing demographic challenges us to consider the kinds of environments that promote healthy ageing. Nature is one key component of wellbeing, and green and blue spaces can provide older people with opportunities to enhance physical health, mental wellbeing, social connections and enhanced quality of life. However, we know relatively little about these associations. Few studies to date address experiences of older adults explicitly (notable exceptions include Coleman and Kearns, 2014; Aspinall et al., 2010; Sugiyama and Ward Thompson, 2007; and Milligan et al., 2004). Given the diversity of older adults' health, functional status, attitude, and lifestyle, green and blue spaces may affect them very differently. That is, how do socio-environmental and individual factors work together to nurture and support health and wellbeing

in older adults? Further, how do the personal perceptions and circumstances of older adults influence their nature-health relationship with landscapes? To begin to address these questions, we focus on how green and blue spaces can have restorative and health-promoting potential for older adults. Specifically, we assess whether and how these spaces can promote older adults’ physical activity, mental wellbeing, and social connectedness. The paper examines issues specific to older adults that affect their experiences with potentially therapeutic landscapes, including safety, accessibility, and perception. We are sensitive to a range of lived and mundane everyday experiences of informal therapeutic landscapes. This contributes to the production and cultivation of more diverse therapeutic geographies.

2. Methods Data acquisition: we conducted in-depth, qualitative interviews with community-dwelling older adults in Metro Vancouver, Canada over two time points (T1 ¼2012 and T2 ¼ 2013). Participants were drawn from a larger cross-sectional study (Walk the Talk; n¼ 161) that examined factors that promote or inhibit older adults' health and mobility. For Walk the Talk, we recruited participants from a provincial government agency that provides rental subsidies for low-income older adults. Participants spent more than 30% of their monthly gross household income towards the rental of their home, and were below the low-income threshold criterion of Shelter Aid for Elderly Renters (monthly income in Canadian dollars does not exceed $2550 for singles, $2750 for couples and $1776 for individuals living in shared accommodations) (BC Housing, 2010). Upon approval from the University of British Columbia Research Ethics Board and upon completion of the larger cross-sectional study, we distributed follow-up packages with information on the companion in-depth interviews. We mailed potential participants a letter of introduction and then followed-up with a phone call. 141 of the 161 participants consented to future follow-up. Twenty-seven participants who resided across a range of neighborhoods in Metro Vancouver (proximity to green space; accessibility; high, medium and low walkability; varying socioeconomic status) partook in the follow-up interviews at this time point (T1 ¼2012). The semi-structured, sit-down interviews lasted approximately 60–90 min. Participants were asked about their health, physical activity, mobility levels, travel behaviors, and the local built, social, and natural environments. After the sit-down interview, participants were asked to voluntarily engage in a walking interview (approximately 15 min). For this optional walk around their neighborhood, participants chose a familiar route and made all decisions regarding location, route, speed, and duration. The walking interviews contributed importantly to our findings: they were embedded within more refined theories of place and health, and grounded in the lived experiences of participants. Through questions and observations along the walking interview, we were able to examine participants' interpretation of and interaction with their local neighborhood context, such as visible embodied or emotional responses, while experiencing these contexts in situ (Kusenbach, 2003; Carpiano, 2009). Walking interviews represent a unique tool that we used to examine how physical, mental, social, and spiritual dimensions of space and place interacted with older adult health and mobility (Carpiano, 2009; Kusenbach, 2003; Ståhl et al., 2008). They added a layer of depth and context, in addition to the sitdown interviews, for analysis. Participants were over 65 years old, and reported leaving their home at least once a week. They were able to walk at least 10 m with or without a mobility aid, and had no significant memory problems. Participants were interviewed at the time and location

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of their choosing; they signed an informed consent form and were given a $20 grocery gift card in recognition of their time. After 12 months (T2 ¼2013), we contacted the older adults who expressed interest in an additional qualitative follow-up by phone, and 19 agreed to participate in a second round of sit-down and walking interviews. Of 8 participants who did not participate in the second round, 2 cited poor health, 3 could not be reached, and 3 were out of the country. Ages ranged from 65 to 86 years, and 8 different self-identified racial and ethnic groups were represented (Caucasian, Aboriginal, Chinese, South East Asian, Japanese, Filipino, Dutch, and German). Data analyses: interview data were organized using the qualitative software package NVivo 10. We reviewed transcripts using framework analysis, as it is more conducive to specific research questions, a pre-designed sample, and a priori issues. Our primary focus was to describe and interpret events in a particular setting (Ritchie and Spencer, 2002). Our analysis is heavily based on, and driven by, original accounts and observations from participants in our study. Framework analysis allows for within-case and between-case analysis and is comprehensive (Srivastava and Thompson, 2009). Data are sifted, charted and sorted based on key issues and themes in five steps: (1) Familiarize, (2) Identify a thematic framework, (3) Index, (4) Chart, and (5) Map and Interpret (Ritchie and Spencer, 2002; Srivastava and Thompson, 2009). We briefly discuss each step below. Interviews were professionally transcribed verbatim. First, two team members read through transcripts to get a sense of the interviews (Familiarize). Second, a preliminary thematic framework, consisting of themes and subthemes, was developed through a series of team meetings. These were based on key issues and common themes emerging from the transcripts related to built environment and participants' experiences of health, mobility, and social environments (Identify a thematic framework). Third, the lead author used Nvivo 10 software to code interviews based on the thematic framework, and generated discussion among team members as new sub-themes were identified. Full paragraphs were coded so that contextual meaning was not lost. As part of the interpretive process, we held a series of team meetings to discuss data related to common themes. We adopted the constant comparison method (Glaser and Strauss, 1967) to compare and contrast themes within and across groups so as to best represent similarities and differences in the data. A total 40 codes were identified and reduced to 4 themes. Themes included built environment, social environment, natural environment and individual/personal. There were a total of 6 codes related specifically to the natural environment. The natural environment codes were interconnected with codes from the built environment, social environment and individual/personal.We used a number of strategies to reinforce the rigor of our study. These included: cross-checking full transcripts against original audio files for quality and completeness; reflexive memo-ing throughout the data generation and analysis process; identification and thoughtful examination of “outliers” or “deviant cases” (i.e., those participants and themes that did not fit within the

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overarching coding structure and the overall “story” created by researchers and participants) (Seale and Silverman, 1997).

3. Findings Participants frequently discussed their appreciation of and healthful interactions with green and blue spaces in Metro Vancouver. Through framework analysis, we identified the key influence of blue and green spaces on the physical, mental, and social wellbeing of participants. For physical wellbeing, interviewees felt motivated to get out of the house to exercise and enjoy the fresh air. For mental wellbeing, experiences provoked feelings of renewal, rejuvenation, and restoration. Participants also expressed widespread appreciation for the tranquility of blue spaces in particular as places to relax, contemplate, and connect spiritually to loved ones. These spaces enhanced social wellbeing by providing opportunities for social interaction and engagement, especially in green spaces. This was particularly important as many participants lived alone and worried about isolation and loneliness. Finally, participants spoke about the maintenance and continuation of their healthful interactions with green and blue spaces in later life. We summarize these findings in Table 1. These findings are complicated by issues of safety, accessibility, and perception, which are discussed in-depth in a later section. 3.1. Everyday contact with green and blue spaces Participants spoke at length about the importance of mundane everyday contact with green and blue spaces. They varied in scale from small garden plots and potted patio plants to vast urban parks, forests, and the ocean. For example, Judith (74 years)1 was recovering from a fall at the time of the interview and discussed how she tried to walk each day on the Seawall (a seaside walking trail that stretches around Vancouver and West Vancouver). She expressed strong personal attachments and satisfaction from spending time by the water: Sometimes you see the seals down there and, you know, the herons and – it's beautiful… I never tire of it. It's just beautiful down there. Elizabeth (73 years) treasured the little gardening area outside her home. She felt a strong sentimental attachment stemming from planting the garden with her late husband, and discussed finding tranquility and spiritual peace while gardening. Participants pointed out micro-scale features of the local environment during walking interviews, such as smell of herbs in a garden or the sound of a trickling courtyard fountain. Trees, flowers, shade, and pristine natural features were considered positive neighborhood elements that promoted enjoyable physical activity outdoors. Many participants referred to an array of settings where they could engage in healthful activities like walking and gardening, observe pleasant scenes, and feel spiritual peace. Many

Table 1 Summary of the effects of green and blue spaces on the physical, mental, and social wellbeing of older adults. Physical wellbeing

Mental wellbeing

Social wellbeing

Motivated physical activity for both recreation and purposeful exercise. Sense of improved physical health. Popular combined green and blue destinations (e.g. forested park along a river, lake, or ocean). Sense of improved psychological health. Feelings of renewal, restoration, and rejuvenation. Blue spaces in particular are relaxing and stress reducing places to escape the strains of later life. Blue spaces contribute to sense of spiritual connectedness with loved ones. Essential for social interactions (e.g. planned with family and friends, unplanned with neighbors). Pleasant collective experience of nature (social inclusion; community). Multi-generational enjoyment, particularly in green spaces (e.g. public parks with paths, fields and playground structures).

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participants associated green and blue landscapes with enjoyable activities that provided both active and passive opportunities to “get out” and “enjoy life”. Engagement with these spaces contributed to perceived physical health benefits from moderate to vigorous activities (e.g. walking, gardening, swimming), and psychological benefits from passive experiences (e.g. viewing pleasant scenes, listening to birds) (Milligan et al., 2004). These experiences were integral to many participants' efforts to build and maintain a fulfilling daily routine in retirement. Without formal employment, participants prioritized having daily activities and regular excursions outside the home. Elizabeth (73 years), for example, incorporated daily exercises, walks, and weekly volunteering in a public garden to escape boredom and loneliness. She explained: Without that structure, you 're just drifting, you 're floating and going dull. Green and blue spaces were integral to many participants' maintenance of habits and quality of life in retirement. Without the routine of employment, many participants sought activities to “fill the day” and reasons to leave the home. Green and blue spaces enabled participants to uphold structure (e.g. afternoon dog walks, weekly walks with friends, regular volunteering commitments), and stimulated frequent activity outside the home. This was important to quality of life by decreasing boredom, isolation and loneliness, as well as providing a sense of purpose physically, spiritually and/or socially. We will discuss specific contributions to physical, mental, and social wellbeing (important components of quality of life), in the following sections. 3.2. Physical wellbeing Green and blue spaces promoted participation in physical activity for most participants. Activities in green spaces primarily comprised of lower-impact walking and gardening, and also included hiking, bicycling and tennis for more mobile participants. Anna (73 years), for example, felt motivated to walk in the local parks in her area: [They 're] nice and quiet, and you can sort of hear the birds and you can see the flowers more. I find it a really invigorating experience if it's at least a 15, 20 min walk. Norma (76 years) felt enthusiastic about walking because of the natural beauty in her neighborhood: Well, I like to look around and see things. Right now all the beautiful flowers [are in] bloom – the trees are blooming and that. And I 'll stop here and there and listen to the birds. Many participants expressed a desire to actively walk in a pleasant outdoor landscape and immerse themselves in the sights, sounds, and smells. Blue spaces were generally positively regarded, as participants felt a positive association with fountains, ponds, beaches, rivers, lakes, and the ocean. For example, Judith (74 years) felt she walked more because she lived by the Seawall. Blue space provided opportunities for physical activity alternatives to walking and other weight-bearing activities. This enabled some participants to maintain their activity level into older age. Ava (74 years) commented on her desire to return to swimming, as she had done when she was younger, as her mobility limitations increased and stamina for walking decreased. She told us that her upper body strength was deteriorating and old injuries were increasingly 1 Figure in brackets following a participant's pseudonym represents his/her age at the time of research.

bothering her, but that she felt that by returning to swimming she would be able to maintain being physically active over time: I want to get back to swimming. I used to be a real swimmer, and I don't have the upper body strength to do that now. So that bothered me a lot. So that's what I'm concentrating on is trying to get my upper body back in shape so that I can swim. Multiple participants chose to take us to their favorite blue destinations during the walking interview, which varied in scale from a courtyard fountain and koi pond to a river boardwalk and ocean-side pathway. These places offered multisensory enjoyment, including the sounds of moving water, tranquil surroundings (described in the subsequent section), and opportunities in warmer weather to physically experience the water (e.g. dipping one's fingers or feet in the water). Abraham et al. (2010) observed that an esthetically appealing landscape is key to gaining outdoor physical activity through both recreation and exercise. Many appealing environments for participants incorporated green and blue space together, such as forested parks along lakes, rivers, and the ocean. James (68 years) vigorously walks with his walking poles in local parks, particularly on trails around a lake. He appreciates the local sights and scenes while walking. James noted that he had no chronic health conditions and walked for almost 60 min each day. This supports Takano et al. (2002) broader findings, where the availability of green space was associated with better physical health and increased survival rates in older adults. The health benefits of regular physical activity are well supported and include positive effects on cardio- and cerebro-vascular diseases, diabetes, particular cancers, osteoporosis, depression, and fall-related injuries (e.g. Foster et al., 2005; Kahn et al., 2002; Meisinger et al., 2007; Williams, 2001; Thomas et al., 2006; Gregg et al., 2000). Although one walk in a forest or along the beach does not significantly impact long-term health, regular walks cumulatively reduce the onset of problematic health conditions (Hartig et al., 2011). To illustrate, Gloria (68 years) recently purchased a pedometer after being advised by her doctor to partake in more daily physical activity. Gloria explored new walking routes to take advantage of local parks and neighborhoods: Well, the beach is nice, it's very nice… There's lots of walking. But you know, when we go around we're near the waterfront too, and we can see the beautiful gardens even when we're out, what people have planted. Gloria is a destination-based walker, which suggests she needs a reason or purpose to walk. Gloria walks fifteen to twenty minutes each day to local destinations such as the duck pond, which she described as a nearby desirable destination. When asked during our walking interview to use a typical route, Gloria took us to her favorite building with a “living wall” covered in lush green plants. Participants used both green and blue space destinations as reasons to “get out the door”. This was for both social reasons (described later), and a desire to “keep the joints moving” to combat mobility deterioration. Rose (73 years), for example, challenges her mobility limitations and fatigue to leave the house regularly. She explained: I think it's healthy if you go out, get some fresh air and, you know, move what you can, move the old joints whenever you can. I don't think it's good to be stuck in all of the time. Rose, like many others, walks along her local streets and in nearby parks. These spaces offer opportunities to achieve a more physically active lifestyle, which has the potential to mitigate negative biological changes associated with ageing. Specifically,

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physical activity may delay or prevent the onset of common chronic diseases and physical decline (Sugiyama and Ward Thompson, 2007; Blair and Morris, 2009; Grant, 2010). Regular physical activity improves older adults' functional capabilities by developing muscle strength, aerobic capacity, balance, and flexibility (Ip et al., 2013). Physical activity also generates positive effects on cognitive functioning and memory (Bherer et al., 2013). Robert (71 years) explained that he walks regularly to feel stronger and maintain his mental and physical health: They have really made a point the last few years that the brain really benefits from exercise. And so everybody at my age is, you know, terrified that their brain's going to go to mush so we're all into doing things that keep us active. Norma (76 years) described her personal motivation to partake in regular physical activity outside to achieve perceived health benefits and minimize perceived aging-related deterioration of bodily functions: I just know I have to go out and do walking because if I don't, I'm going to get old too fast. It just seems when you go out, your brain kind of clears up or something… The fresh air and watching the trees and looking at different things, it just gives you a different outlook.

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To me, it's a spiritual experience going down and watching the water. Looking at the trees. That's a – what I call – beautiful. Helen's observations reflect Gesler's (2003, p. 8) idea that many people can heal mentally and spiritually by “simply spending time out-of-doors or seeking out remote or isolated places where they can ‘get away from it all’, surrounded by undisturbed nature”. Helen's connection to her husband's bench also speaks to the work of Wylie (2009, p. 281), who notes that “memorial benches [have] the potential to offer scope for more general reflections upon relationships between self and landscape, subject and world.” Elizabeth (73 years), similar to Helen, values the peacefulness and spiritual connectedness of blue space. She and her late husband lived by a river where it was quiet and serene. The river created for them a sense of belonging and a strong attachment to their home. Elizabeth repeatedly spoke of the joy and satisfaction she experienced while working outside in her garden by the river, which she maintains in honor of her husband. These examples reflect how many older adults who endeavor to remain connected to deceased family members and friends. They also highlight the importance of blue and green spaces to facilitate the maintenance of health over time. Numerous participants expressed that they derived spiritual inspiration, peace and self-connection from waterscapes. It's just so beautiful right on the water. And the water just – if you're feeling at all upset over anything, just head down to the water. It just seems to calm your mind (Gloria, 68 years).

Norma often gardens in her backyard, and enjoys weeding, chopping and pruning her flowers and vegetables. She feels happiness and a strong sense of accomplishment for being active outdoors almost every day. This was similar to many participants in our study who noted maintained and improved physical health in later life through regular physical activity in green and blue spaces. Nature can also offer places to facilitate healing and recovery, a key component of the therapeutic landscape concept (Gesler, 1992). This is particularly important to older adults who face increased risk of disease, injury, and hospitalization. Barbara (75 years), for example, utilized local green spaces to help facilitate her recovery after a fall:

That people appreciate and admire sights and sounds of water, ranging from calm flows to energetic rushing waterscapes, is well documented (White et al., 2010). Calm water sounds in particular are associated with mental restoration and clarity. Helen (74 years) expressed her love of the water and her enjoyment from spending time along the waterfront:

When I was recovering from my hip [operation], one of the things I used to do is just go up the corner and sit on the bench and walk back.

Participants stressed the importance of spirituality derived from green spaces as well. James (68 years), for example, described his valued experiences in local parks where he engages all of his senses to rejuvenate:

Barbara began with short walks in her neighborhood to local parks to build back her physical strength. When we interviewed Barbara a second time twelve months later, she demonstrated remarkable strength and vigor. She had made an enthusiastic lifestyle change that embraced daily walking, stair climbing, and other exercises. Barbara felt better, had higher energy levels, had lost weight, and improved her stamina. Thus, natural landscapes provided Barbara and many other participants with physical and psychological health benefits over the life-course. Living close to green and blue spaces and enjoying nature each day was a key element of maintaining and/or improving participants’ health, sense of wellbeing, and quality of later life. 3.3. Mental wellbeing Green and blue spaces also represented important spiritual and restorative landscapes that promoted feelings of contemplation, spiritual peace and rejuvenation for participants. The spaces were used to escape the ‘clutter’ of everyday life (Lea, 2008). Participants took pleasure from the beauty of natural settings and peaceful environments. Helen (74 years) regularly went to a particular spot on the beach where there was a bench in memory of her deceased husband. Walking and sitting near that spot provided a sense of relatedness and reassuring spiritual connection:

I love the water… I have a phrase that I think is important, and I call it my ‘sit-and-stare time'.So it's just blanking your mind. I find I do that – I can do that by the water.

[The] trees are beautiful. Grass. Sky. Fresh air. A natural setting, nature with minimal intervention of human stuff [or] infrastructure… Also stillness, lack of noise. Hartig et al. (2011) noted that with concentrated urban populations, people often feel the need to escape overwhelming artificial and built environments. Nature often involves getting away from those concentrated spaces, and is thus an engaging and pleasant experience. Green and blue spaces can promote interest, pleasantness, and calmness. They offer sites of ‘restoration,’ a term that describes ways that people recover diminished resources used in the effort of meeting strenuous demands of everyday life (Bowler et al., 2010; Hartig et al., 2011). For many participants, green and blue spaces were places of retreat for rest, reflection, and self-care. Stillness was a valued quality for spirituality and retreat (Bissel and Fuller, 2010; Conradson, 2010, 2007), particularly to alleviate perceived stresses of the aging process (e.g. medical issues, fatigue from everyday tasks, financial hardship, family burdens). Feelings of stillness, restoration, and peace through contact with nature can be especially important for older adults straining to cope with everyday routines and commitments. To illustrate, Anna (73 years) has very limited mobility. Her severe arthritis and degenerative disk disease caused significant curvature of her

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spine. She requires a mobility aid at all times, including while inside her apartment. One of Anna's key strategies for staying positive is getting outside each day: I don't want to be cooped up all day… I like fresh air and observing other people's beautiful yards… [I like] the fresh air and having a change of scenery. And some nice people stop, and they tell you interesting things about themselves. On days when Anna is not feeling well enough to walk, she will go to the park across the street to sit on a bench, or look at the flowers and bushes outside her window. Actively and passively viewing nature is important to people and represents an effective method to relieve stress and improve wellbeing (e.g. Maller et al., 2005; Kaplan, 1992). Nearby green and blue spaces can confer mental health benefits, even with short exposures (Pretty, 2004). Passive exposure to nature may be especially important to those with severe mobility limitations (e.g. the bedridden) as it represents one of few options to interact with nature. David (80 years), for example, has limited mobility and spends long periods of his day sitting on his outdoor patio looking at the trees, birds, and other animals. He stated: I think that it would drive me up the wall if I couldn't go out and sit in the park or something (David, 80 years). David finds tranquility as a self-proclaimed “nature-lover”, and feels calm and peaceful when outdoors. Green space enables older adults to obtain some distance from daily stresses. Trees and animals attract his attention without being physically exhausting, and align with his intention to seek calm solitude and mental restoration (Abraham et al., 2010). Green and blue spaces thus importantly nurtured feelings of tranquility, restoration, and rejuvenation, as well as spiritual connectedness. 3.4. Social wellbeing A major use of green and blue spaces described by participants was to stimulate contact with friends, family, and neighbors. Both green and blue spaces served as places for social interaction amongst participants. Where younger generations may use these spaces more to escape and rejuvenate from their busy work life, our participants used these landscapes to be active physically, spiritually and socially. Many interviewees met friends regularly to socialize while walking together. Jean (71 years) walks around the Seawall with her companions. Betty's (70 years) friends will often call her in the evening to go walking the next day in a nearby park. Betty noted that walks up to 1.5 h long go by quickly while chatting with friends in the “fresh and beautiful” park. Several participants belonged to formalized social groups, such as hiking and walking clubs or gardening groups. To illustrate, Elizabeth (73 years) volunteers weekly at a botanical garden, which she has volunteered at for over 20 years. She walks around with fellow volunteers to collect seeds for the garden, and maintains the grounds: The social [atmosphere] – it's just amazing, the people come from so many different walks of life and they make friends. Local green space in particular enhanced social integration and contributed to social interaction, community building, and empowerment. Jack (87 years), for example, appreciates spontaneous interpersonal connections in the green space near his home: Sometimes you pet a little dog or something like that. It's kind of neat to be able to see other people that live in your city, too, so that you’re not just isolated. Anna (73 years) enjoys the park in close proximity to her home

as it provides the opportunity to watch and interact with others: Q: Do you like living across from the park? A: I love that. Q: What about it? A: Well, because you see the children and the people walking around… Sometimes I take my coffee along and sit there and read. And the people who walk their dogs will sometimes stop and talk and say, “Where do you live?” It's kind of a social thing, too. During our walking interview, Anna was delighted to watch children playing and families enjoying the park and community gardens on a sunny and warm afternoon. An older gentleman in a wheelchair slowed while approaching us during the walk, smiled, and spontaneously said “What a beautiful day!” Anna happily agreed, and smiled as she moved past him pushing her walker. Green and blue spaces were intimately linked to participants' social wellbeing, and helped to relieve perceived aloneness in everyday life. Many participants live alone and implied fears of isolation. These spaces provide opportunities for spontaneous and planned multigenerational social activities. Parks were perceived as pleasant spots to relax on a bench, watch people, have picnics, and enjoy chatting with friends and family. Some participants described pleasant outings to parks and beaches with grandchildren. James (68 years), for example, enjoys watching ducks with his granddaughter in a local park. He laughed as he described the length of their walks as his granddaughter takes very small steps and does not walk in a straight line. This aligns with the findings from Maller et al. (2008) who note that simple observation is itself an activity and one that appears to offer restorative impacts. Judith (74 years) also appreciated multigenerational community sites as she loves to see children and families. She purposefully travels through the community center on her daily walk to the Seawall in order to “check out the action” and “chit-chat” with her neighbors. Overall, participants expressed a strong sense of appreciation for multigenerational places. They enjoyed bustling public spaces of their neighborhoods, including active streetscapes and parks. The children, families, workers, and other people using these spaces were a major draw for our participants. They provided opportunities for participants, many living alone, to seek out social connections and build their sense of community. This aligns with literature linking nature to the formation of social networks and feelings of connectedness in later life (Milligan et al., 2004; Sugiyama and Ward Thompson, 2007), as well as an important multigenerational element. Two participants that did not have strong family or friend networks found companionship with animals. Mary (75 years) shelters cats and enjoys feeding birds and crows in her yard (to her neighbors’ chagrin and her delight). During the walking interview, she was clearly familiar with local dogs in neighbors' backyards. She talked to them as we walked by, and moved closer to pet them. David (79 years) told us during his interview that his only close friends were the squirrels he feeds in his backyard. He does not have close family or friend networks, and seeks companionship by spending time giving peanuts to squirrels in his backyard. Our participants sought companionship and social interaction through a variety of channels available to them, in which green and blue spaces were key locations for social connectedness. Higher levels of social interaction amongst older adults were associated with improved health and functional status (Ståhl et al., 2001). For example, frequent social participation (daily to weekly) was associated with decreased risk of dementia (Seeman et al., 2001). Social engagement provided older adults with a meaningful social role, which conferred a sense of value, purpose, identity, and attachment to one's community (Gardner, 2014). Ageing is often

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associated with a gradual loss of social roles and connectedness. Thus, local green and blue spaces may represent important sites that provide older people meaningful opportunities to connect with family, friends, and neighbors. Social wellbeing, essential to an enhanced quality of life, may be promoted through the provision of local nearby green and blue spaces. 3.5. Perception, safety, and accessibility Participants notably experienced nature in very different ways, and perceived green and blue spaces contrarily at times. For example, public parks could be perceived as either pleasant and inviting, or threatening and dangerous. Norma (76 years) does not walk or read in particular parks anymore because she is afraid of homeless people that she thinks moved to the area. She does not feel safe and worries about being attacked. James (68 years) by comparison lives in the same region, but does not feel threatened by these same parks or people. He regularly enjoys walking on the trails and spends time in them. The presence of other people in green and blue spaces could be perceived both positively and negatively. Many participants enjoyed busy places and avoided walking in sparsely populated areas. Several participants (particularly older females) mentioned feeling vulnerable to crime when walking alone. They avoided particular areas regarded as less safe, and did not walk at night. As Conradson (2005, p. 338) suggests, “individuals clearly experience even scenic environments in different ways, in terms ranging from enjoyment through to ambivalence and even anxiety”. Spaces experienced in different ways reflect the dialectical relationship between a person and their broader socio-environmental setting. This aligns with work on contested therapeutic landscapes, where individuals had diverse views of and compatibilities with landscapes (Williams, 2007). Older adults have distinct and diverse therapeutic relationships with green and blue spaces. These relationships are mediated by perceptions, circumstances and embodied identities. Participants' unique embodied biographies (including their gender, race/ethnicity and cultural background, mobility level, and self-confidence) affected their relationship with potentially therapeutic landscapes. Participants that were very familiar with spaces generally felt safer and more secure venturing there. Jack (86 years), for example, found his neighborhood to be safe because he has developed a high level of comfort and familiarity with it over the past 25 years. Rea (69 years), by contrast, recently moved to her neighborhood and did not feel comfortable walking in the local parks or sidewalks. She limits her walks to the parking lot of her apartment complex and adjacent church, or drives to a local park in her old neighborhood if she wants to go for a longer walk. Level of comfort and established routines were important variables affecting participants' perceptions and use of green and blue spaces. Accessibility is also based upon individual perceptions and ability levels that may influence how older people utilize outdoor spaces. Green and blue spaces might pose a challenge for older adults if activities in these spaces require a high level of strength, agility, and stamina (Sugiyama and Ward Thompson, 2007). To illustrate, Gloria (68 years) greatly appreciated moving to her neighborhood where benches are interspersed to provide rest spots, and tree-lined streets shield pedestrians from both sun and rain. Gloria commented that these local features enhance her ability and motivation to walk outside regularly for both recreation and to conduct daily tasks (e.g. grocery shopping, renting library books, meeting friends). To return to the example of Jack (87 years), in comparison he expressed a desire to live farther away from his congested and polluted street, and closer to green and blue spaces such as Stanley Park: I love the mountains and I love the water, and I can't see any here… If I lived down [by Stanley Park], I'd walk on the Seawall every

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day, no doubt about it. But I just don't have the energy to ride my bicycle down that far. And I just don't want to take the car down there because then it's counterproductive driving the car down and walking and driving the car back, so I just don’t do it. Jack's comments illustrate how ease, convenient access and local facilities are important to promote older adults’ use of outdoor spaces. Traffic – both vehicular and pedestrian – were often discussed as barriers. Many participants mentioned feeling unsafe in heavy traffic environments (e.g. cars running lights and disregarding stop signs; bikers dangerously riding on sidewalks). They reflected on embodied struggles due to chronic illness, disability, and overall progressing older age during interviews, and discussed efforts to find enabling places in everyday life (Chouinard and Wilton, 2010). Enabling features included trees for shade, and regularly located benches, bathrooms, and water fountains. Smoothly paved and wide walkways were particularly essential for those who had limited mobility or used walking aids. These participants also particularly noticed the timing of crosswalks. Many struggled to cross during short-timed lights and sought alternative and less stressful routes. Anna (72 years), for example, struggles to cross in time with her walker: Q: Do you feel comfortable crossing the street when you're going to the store? A:Sometimes I don't because there's not enough time, even though I'm a pretty quick walker, there's not enough time because always then the red light goes on and that really ticks me off… Once I thought, “Oh boy, if that car doesn't stop, what's going to happen to me?” You know? Q: So you find it's quite difficult to walk from one side to the other? A: Well, especially if you've got something in your walker. Gloria (68 years) has a higher level of mobility than Anna, but also explained how she crosses streets very carefully and does not “take chances” on her walks. She lives in a higher income neighborhood than Anna and is appreciative that her municipality recently installed longer-timed crosswalks for slower walkers, wheelchair, and scooter users. There are extra signals to cross the street in a shopping area, making it more pedestrian-oriented. These new traffic stops significantly impacted Gloria's daily patterns and walking activity. Municipal maintenance of green and blue spaces was viewed as important for esthetic reasons as well as to reduce potential fall hazards. Participants with lower levels of mobility particularly feared these barriers (e.g. garbage, lack of cleanliness), while more able-bodied participants mentioned these apprehensions for the future as they aged and expected their mobility to decrease. Some participants chose not to walk outside because of these physical barriers. Robert (71 years), for example, walks for exercise on the treadmill instead of nearby parks. He claimed that he could walk faster and safer on the treadmill, whereas outside he had to dodge barriers such as people, dogs, and bikes. Other participants feared falling, particularly on slippery and uneven surfaces. Participants perceived weather as a major factor affecting outdoor activity and experiences of green and blue spaces. Ava (74 years), for example, had fallen during the past winter: I am afraid of falling, yeah, because I have such a lot of osteoporosis. I don't want to fall… I pick a good day, a non-icy day to buy more groceries than usual to make sure that I've got enough. Participants had more outdoor activities in the summer and warmer temperatures. Many participants stayed indoors during the winter, citing rain, darkness, and cold as the primary barriers. They also relied more on children, friends, and community services (e.g. accessible bus services) to navigate outdoors during bad weather. Motivated participants strategically modified their practices to

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navigate these barriers. Participants would avoid potentially dangerous situations by modifying their routes and being aware of their surroundings. Some would walk one way and bus or taxi back home if experiencing fatigue or struggling with heavy groceries. Others would carefully choose specific days for activities outside the home. Rea (69 years), for example, walks inside her apartment and does chair exercises during bad weather. Others stayed home during ‘bad days’ (e.g. due to pain, fatigue, and illness) and only ventured outside when they felt well enough. Anna (72 years), for example, explained: Sometimes, I know I have to do something and I just say, ‘Oh, I can hardly move my legs. I'm not going to do it right now.’ Well, yesterday I wanted to take a walk so badly and it was nice out, [but] I knew I couldn't handle it. Barbara (75 years) is taking active measures to stay active outside and minimize her fears of falling: I don't run anymore because I did run for the bus and fell. And I think you have to pay attention probably all over Vancouver, but in [local neighborhood], there's lots of uneven sidewalks. Barbara is attentive to her environment, and is taking seniorspecific exercise classes to improve her balance and muscle strength, particularly her ankles. Affordability was one component impacting the degree of fit (Pechansky and Thomas, 1981) for older adult access to healthpromoting landscapes. Our study participants were all low-income, reflective of many older adults living at or below the poverty line. Elderly poverty is both a social and a fiscal problem that will be exacerbated as higher percentages of populations in developed countries move into the over-65 demographic (The Conference Board of Canada, 2013). Our participants were concerned about rent and other costs of living, and did not have funds for ample extracurricular expenses. Participants appreciated having access to pleasant parks and other public spaces and streetscapes as they provided affordable and enjoyable recreation opportunities. Proximity of resources was a major factor as many participants were not physically capable and/or financially able to drive. Many participants used public transit to access everyday services (e.g. grocery stores, medical facilities, community organizations, parks). Convenience of access by walking and bus were major factors participants associated with participation in green and blue spaces, as well as quality of life. We noted great diversity in the landscape preferences, needs, and uses across our sample of older adults. Preferences were associated with individual perceptions and embodied ability levels. Conradson (2005, p. 346) argued that a therapeutic landscape should be considered a “potentially therapeutic landscape” as many sites can be perceived as either healthy or unhealthy depending on a visitor's ‘lens’. Diverse experiences and perceptions of participants in our study support this contention. Thus, a better understanding of the complex person-place relationships for older adults is required to elucidate how nature affects the health and wellbeing of our ageing populations.

4. Conclusions Older adults experienced important everyday interactions with green and blue spaces across Metro Vancouver, Canada. This paper contributes to the production and cultivation of diverse therapeutic geographies by paying attention to experience of older adults. We investigated therapeutic relationships for a range of older adults with a variety of age, gender, racial/ethnic background, health status, and mobility levels. Though scholarship to

date predominantly focuses on salutary effects of green space, blue space also encompasses important therapeutic qualities, particularly for older adults. The findings demonstrate how both green and blue spaces can have a significant impact on physical, mental, and social health in later life. Participants felt motivated to get out of the house to exercise and enjoy the fresh air and surroundings. These spaces promoted mental wellbeing, in which experiences of nature provoked feelings of renewal, restoration, and spiritual connectedness. They also provided a space for multi-generational social interaction and engagement, including planned activities with friends and families, and impromptu social engagements with neighbors. It is important to note that nature was perceived very differently by participants: the same place could evoke diverse reactions ranging from enjoyment to indifference to concern. Individual perceptions and sense of safety influenced participants’ therapeutic relationship with landscapes. Furthermore, accessibility was an issue for spaces that required a high level of strength, agility, and stamina. Walkability was of particular importance to access. Many participants experienced green and blue spaces by walking, and access may have been limited in less walkable environments relative to participants’ level of mobility. This paper contributes to a sparse literature on therapeutic landscapes for ageing populations, and studies of how nature promotes physical, mental, and spiritual health and wellbeing. Our study sample provides a unique contribution to this literature by drawing on a growing and understudied demographic: low-income older adults. The cost of access to many services, programs, and facilities can pose a substantial barrier for this population. Due to limited resources the older adults in our study rely more on walking for utilitarian and recreational purposes. Further, participants sought out affordable exercise and leisure activities in green and blue spaces (e.g. walking on trails, visiting with friends in a park, enjoying local gardens while walking to the grocery store). We attend to their unique experiences with blue and green spaces, and the importance of these landscapes in maintaining health and wellbeing. We highlight that older people can perceive nature (both green and blue spaces) as a valuable resource. A better understanding of older adults’ experiences within a given landscape lends support to the development of natural spaces that may improve quality of life for ageing populations. Public health and urban development strategies have yet to conceive of ways that optimize nature as a health resource for older adults and to realize the full benefits of contact with nature contact as an upstream health promotion intervention (Maller et al., 2005). Day-to-day urban life can be distant from natural settings, and this study demonstrates that interventions do not need to be large-scale urban overhaul: installing smaller features, such as a small garden plot or courtyard fountain, can also positively influence older adults’ quality of life. Mixed green and blue spaces can have many therapeutic qualities, while green and blue spaces separately also have distinct influences on older adults. Notably, blue spaces can be particularly important for spiritual restoration and mental health, while green spaces are essential for community interactions and social wellbeing. Our paper uniquely teases out older adults' therapeutic relationships with landscapes, and focuses specifically on both green and blue spaces. Our findings suggest that blue space should feature more prominently in health policy and urban planning discourses regarding older adults. We acknowledge that our study has some limitations. Our study engaged older adults who received rental subsidy and lived in Metro Vancouver, Canada. Vancouver is known for its coastal mountains, beaches, and eco-friendly green spaces. The city's climate is mild year-round without prolonged sustained snow cover or ice. A third category of therapeutic relationships to research is white space (i.e. snow and ice), which can affect older adult

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mobility (Hanson et al., 2013) and health. Our findings are not generalizable to older adults of higher socioeconomic status or who live in dissimilar geographic locations or climates. However, this might also be perceived as a strength, as both the population and the location contribute to a scarce body of literature that explores the therapeutic properties of blue and green spaces for older adults. The findings can inform public health policy, particularly as it relates to environmental design. In closing, urban planning with a health focus might explicitly address availability of and access to green and blue spaces in residential living environments. Our study and others' suggest that convenient and frequent active and passive engagement with nature impacts the physical, mental, and social wellbeing of older people. Armed with a better understanding of factors in the local environment that nurture and support healthy ageing, local governments are positioned to make infrastructure changes that promote older adult mobility and health. Public policy that prioritizes creating and maintaining blue and green spaces would also serve to facilitate everyday access to these nurturing spaces. Finally, should decision makers choose to preserve and construct green and blue spaces that contribute to the health of older adults, they also support the health of people across all ages.

Acknowledgment This work was supported by a team grant from the Canadian Institutes of Health Research (AAM-108607).

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