‘Going Outside for Fresh Air, Sunshine and Walking’: A Qualitative Analysis of US Older Adults’ Therapeutic Landscapes during the COVID-19 Pandemic ^†

Abstract

Therapeutic engagement with nature can support health and wellbeing among older adults. This may be particularly important to cope with adversities of the COVID-19 pandemic when public health measures have been particularly stringent for individuals in this age group. Utilizing therapeutic landscapes as a conceptual framework, we conducted a secondary thematic analysis of qualitative data to explore older adults’ everyday experiences (n = 769) with outdoor spaces and nature during the early months of the COVID-19 pandemic in the US. The data analyzed is part of the COVID-19 Coping Study baseline survey collected online between April and May 2020. Preliminary findings indicate that participants purposefully engaged with nature and outdoor spaces in diverse ways. This engagement provided opportunities for exercising and maintaining a routine at a safe physical distance from others, which promoted their physical, mental, and social well-being.

1. Introduction

Exposure to nature and residential green and blue spaces has been associated with better physical and mental well-being in later life [1,2]. However, there is limited evidence of the role of such settings during the COVID-19 pandemic when public health efforts to contain the virus have included shelter-in-place orders and restrictions of movement. Although evidence is emerging about the relevance of contact with nature during COVID-19 [3,4,5,6], to our knowledge, no previous study has conducted an in-depth qualitative analysis to understand how older adults interpret and use nature during this time of collective trauma. The aim of this analysis is to explore the experiences and perceptions of older adults regarding the role of nature and the outdoors to support their health and well-being during the first months of the COVID-19 pandemic in the US. Our analysis utilizes the conceptual framework of therapeutic landscapes [7,8]. This research is part of a larger mixed-methods analysis of the role of parks, outdoors and natural environments among US older adults during the pandemic [9]. In this paper, the preliminary findings from the qualitative component of the project are presented as part of the proceedings for the 3rd International Electronic Conference on Environmental Research and Public Health (ECERPH-2021).

Theoretical Background

The concept of therapeutic landscapes was introduced by Wilbert Gesler in 1992 to explore why and how certain physical, social and symbolic environments “produce an ambiance that is conducive to healing” [7]. Early scholarship of therapeutic landscapes focused on sites with an established reputation of salutogenic effects, such as Bath in the UK, Lourdes in France, and Epidaurus in Greece [7,10,11]. Since then, the concept has been expanded to encompass health promotion and well-being maintenance across a large variety of settings ranging from the extraordinary to everyday places [8,12]. Studies have also considered experiences of diverse populations such as people living with mental health diseases, older individuals, children, migrants, people with disabilities, etc. [8,12]. Research of therapeutic landscapes specific to later life has focused on multiple places and activities. A few examples include green and blue spaces [2], third spaces such as coffee shops, libraries, Men’s Sheds, and day-care centers [13,14,15], walking groups [16], nature-based activities in the wilderness [17], and gardening in aged-care facilities [18]. These studies have contributed to a growing body of evidence that uncovers the therapeutic properties of place(s) as a relational achievement produced by unique assemblages of physical, affective, and social resources fitted within a broader cultural and historical context [19,20,21]. Accordingly, therapeutic landscapes are recognized as dynamic encounters that are constantly influenced by practices, mobilities and socialites of human and non-human actors [22]. The present analysis advances our knowledge of therapeutic landscapes by focusing on the perceptions of older people regarding the role of nature and outdoor spaces to support their health and well-being during a public health crisis that may present ambiguous opportunities for individuals to engage with place.

2. Methods

Data for analysis was collected as part of the COVID-19 Coping Study, a longitudinal mixed-methods study of US adults aged over 55 [23]. Participants were recruited between April and May 2020 using online multi-frame non-probability sampling (n = 6938). The survey included closed and open-ended questions about participants’ socio-demographic characteristics, ongoing experiences related to COVID-19, significant life events, health status, and well-being [23]. A list of keywords was used to screen open-ended questions and create a qualitative database for the present study, including all responses that relate to participants’ experiences, attitudes, and behaviors about engaging with outdoor spaces, parks, green/blue spaces, and nature during the pandemic (n = 769). Analysis was carried out with NVivo12 software following Braun and Clarke’s (2006) six steps for thematic analysis: (1) familiarization; (2) generation of initial codes; (3) search for themes; (4) review themes; (5) define and name themes; and (6) write up the analysis [24].

3. Results

Preliminary results suggest that during the implementation of public health restrictions, participants engaged with nature through diverse activities and with diverse motivations. Our initial thematic map and coding structure is detailed in

Table 1. Initial thematic map and coding structure from analysis *.

Older People’s Experiences, Attitudes, and Behaviors in/with Parks and Nature During COVID-19
Preliminary Themes	Codes
1. Types of engagement	1.1-Fitness activities outdoors (i.e., walking, running, cycling) 1.2-Outdoor maintenance projects (i.e., gardening, yardwork) 1.3-Passive activities outdoors   1.3.1.-Sitting, Reading   1.3.2.-Sensory/embodied (i.e., watching, hearing, feeling [sunshine])   1.3.3.-Symbolic contact (i.e., drawing, virtual walks, walking through)
2. Rationale for engagement	2.1-Maintaining fitness and physical challenge 2.2-Managing emotions   2.2.1.-Control of negative affect (i.e., stress, anxiety)   2.2.2.-Generate positive affect (i.e., productive, useful) 2.3-Development of new routines   2.3.1.-Filling time voids and keeping busy   2.3.2.-Noticing nature   2.3.3.-Adapting outside habits (i.e., new schedule, new route) 2.4-Social well-being   2.4.1.-Community building   2.4.2.-Staying connected   2.4.3.-Beyond human connections 2.5-Safety and perceived risk of infection   2.5.1.-Public health compliance (self, others)   2.5.2.-Avoidance (i.e., of others, of places)   2.5.3.-Planning and precautions
3. Barriers and enablers	3.1-Household characteristics 3.2-Neighborhood characteristics   3.2.1-Accessibility of desirable characteristics   3.2.2-Behaviors of others sharing the space 3.3-Weather
4. Perceived environmental changes	4.1-Air pollution 4.2-Wildlife 4.3-Traffic

* Through further iterations of analysis, the coding structure and themes may be redefined and/or rearranged.

. We identified four preliminary themes: (1) Types of engagement; (2) Rationale for engagement; (3) Barriers and enablers; and (4) Perceived environmental changes. A brief overview of each preliminary theme is described below, accompanied by illustrative quotes from participants. Quotations are accompanied by the participant pseudonym and their age at the time of data collection. A ppt file and introductory video from the ECERPH-2021 are available as Supplementary Materials.

3.1. Types of Engagement

Multi-scalar engagements with nature and outdoor environments were described by participants ranging from the home (e.g., through garden views from a household window, tending to potted flowers on a balcony) to neighborhood and broader community (e.g., long walks in a nearby park or taking photographs in a wildlife area). Responses indicate taking part in diverse types of outdoor activities, for example, Sean (67 y) referred he was “going outside for fresh air, sunshine and walking”. Others described how certain activities could provide a sense of outdoor engagement without necessarily stepping outside their homes by “opening the windows”, “letting fresh air in”, “feeling the sunshine through the window”, or “watching a pretty bird outside”. Nonetheless, participants also indicated an intrinsic “need to get outside” and purposefully sought to include the outdoors in their daily routines, even for just a short period of time. For instance, Ann (82 y) stated she was “making sure to get outside for at least a few minutes”, and Paula (56 y) mentioned she “scheduled going outside to just breathe air!”. Some participants also referred to longer times spent in outdoor activities and an increased interaction with natural environments. Peter (70 y), for example, described he had “spend more time working in the yard for physical stress relief and getting caught up on yard improvements”. Examples of other extended outdoor engagements were described by Mary (72 y), who increased the duration of her dog’s walks, and Noreen (73 y), who shared: “I’ve been working in my garden more than usual. It gets me outside and gives me a feeling of accomplishment”.

The diverse types of outdoor activities described in some cases represented continuity from previously established routines. However, participants also referred to new opportunities to engage with outdoor spaces, new ways to do so and/or the emergence of new feelings in relation to their activities. Ronan’s (67 y) narrative provides insights into how a previous routine was adapted to the pandemic context and the emergence of ambivalent emotions related to this activity:

“I love playing golf and am still getting out but much less frequently than before. I practice social distancing, touch nothing, etc. during golf but some regular golf friends are staying home, and I feel a little guilty to be heading to the golf course in a time of pandemic. But it is great for mental health and decent exercise (walking)”.

3.2. Rationale for Engagement

Older adults appreciated that outdoor spaces provided opportunities for exercising, social interaction, and maintaining a routine at a safe physical distance from others, which boosted their social, mental, and physical wellbeing. For instance, Robert (62 y) stated: “I’m putting in more time on my bicycle than I have in the past so I’m feeling fitter (also discovered some new places to ride to avoid people and traffic)”. Meanwhile, Susan (60 y) and Lauren (68 y) respectively referred “I just try to get outside to help with things” and “working in the garden has been an important part of each day being productive”. Outdoor environments were also considered as an opportunity to interact with others at a safe physical distance. For example, participants shared they were meeting family or friends for 6ft apart walks or looked forwards to an outdoor chat with neighbors and strangers if they could remain physically distanced.

Moreover, participant’s narratives indicate that access to nature provided respite from feelings of entrapment at home and refuge from a variety of stressors related to COVID-19 (i.e., an overwhelming amount of information, diminished boundaries between work and relaxation places, poor domestic conditions, etc.). Clara’s (71 y) response, “I have really curtailed going anywhere where I need a mask, instead opting for outdoor activities where I don’t need one”, further indicates that certain participants were attracted to the outdoors as a safe place to escape from public health restrictions. Additionally, for participants such as Lisa (61 y), the outdoors provided opportunities to exercise a sense of agency under uncertain times: “I have taken control of the things I can control (…) I stay inside, and I walk outside for short periods at times when few people are around.”

Although most participants’ responses contemplated nature in a positive light, some also indicated the potential for negative affects. The contrast is clear between accounts from Linda (63 y), who wrote she was “Spending as much time out in the woods bird watching and hiking. Seeing life go on as normal in the environment is reassuring”, and Mark (67 y), for whom the nature resurgence in spring was an unwelcomed contrast with the losses and disruptions experienced during the pandemic:

“There is a steady undercurrent of feeling helpless to do much to make the situation better—beyond making the recommended changes in activities that bring one in close contact with others/practicing social distancing. The unseen nature of the danger—particularly as spring is here and days are warm, trees are budding out, flowers blooming -yet life as we knew it is so dramatically changed in almost every aspect. That is profoundly depressing, and the unknown of how long before any sense of normal life will return.”

3.3. Barriers and Enablers

The area and local community where participants were living significantly influenced the opportunities for therapeutic encounters to emerge. Many participants going through the pandemic in natural and built environments that fitted their needs and capabilities remarked how fortunate they felt. For instance, Kathleen (76 y) expressed: “I am so grateful to be living in such a beautiful area with family and friends close by.” Being familiar with the resources available in the local area was also a facilitator. Carole’s (64 y) experience highlights how a new environment may add to other COVID-19 stressors:

“Since I am “stuck” in California having driven here to visit my son and his family, everything is unfamiliar. If I were home, I would know which store is best for groceries, where the best hospital/doctors are located. We are in the mountains and driving is different for us. So, I would say, part of coping is trying to learn about the area and what we need to protect ourselves.”

The behaviour and compliance with public health restrictions of other individuals sharing a place were also identified by participants as potential barriers or enablers. Rita (74 y), for example, mentioned: “Going outside is difficult because most younger people are not wearing masks”, while in her account, Dona (63 y) described she had benefited from an enabling environment: “I see that most people in my community are being safe and respectful, and I am thankful to live in a rural area where we can get outside and enjoy nature”.

Participants also referred to how the ephemeral characteristics of landscapes could facilitate or hinder therapeutic encounters. These included seasons, with spring being related to “good weather” (e.g., sunshine, warmth, blooming) and increased opportunities for engaging in gardening, growing vegetables, watching wildlife, etc., whereas winter was related to “bad weather” (e.g., snow, rain, wind, cold) and created challenging conditions to enjoy outside environments. Margaret (76 y) provided an example of the former:

“It has been a life changer—some good, some bad (…) The “bad” is learning how to structure life with the “stay in place” orders. We are lucky that it is spring and now gardening is an option for free time.”

3.4. Perceived Environmental Changes

Participants’ responses in relation to therapeutic encounters during the pandemic also reflected on the environmental changes that had been facilitated by everyday life being interrupted. Some of the environmental changes mentioned included a reduction in traffic, air, and noise pollution, as well as a return of wildlife and increased birdsong. For instance, Esther (71 y) shared:

“Let’s talk about the good things going on… air is cleaner, town is nice and quiet like it was 20 or so years ago. You see a lot more people out walking with family and dogs.”

The perception of these environmental changes may have played a role in individuals’ opportunities to negotiate therapeutic encounters by facilitating to “notice little wonders in nature more”. Eleonora (67 y) reflected on the possibilities renewed contact with nature and awareness of its benefits could have for dealing with current and future challenges:

“I am fine but am concerned about the long term for my adult children and my grandchildren, even though they are all fine for now. It will be interesting to see what we go back to when restrictions are lifted. I have enjoyed our clean air and the “slowing down” of everything, honestly. I hope we all come out of this for the better in the long run--caring more for each other, caring more for the poor and disadvantaged, not feeling so “entitled”, taking care of the environment and each other. If we don’t, it will be a lost opportunity.”

4. Discussion

The preliminary findings indicate that for older adults, diverse settings in the natural and built environment may act as well-being enablers and play an influential role in coping with the negative effects of the COVID-19 restrictions. Consistent with previous scholarship in therapeutic landscapes, evidence from our study suggests no place is intrinsically therapeutic [25], and older people’s experiences of place are continuously evolving according to their own preferences, needs, and capabilities [16,26,27]. Moreover, our results align with previous literature suggesting that therapeutic encounters can emerge in diverse landscapes representing a “palettic” assemblage that extends well beyond green and blue space constraints [28]. Participants’ wide variety of therapeutic encounters occurred in residential spaces, private and community gardens, nature reserves, roads, sidewalks, and many other environments that were under the influence of other individuals, plants, animals, and objects with whom spaces were shared and co-created. Participants’ responses also confirm that a wide range of activities in outdoor environments, such as walking, gardening, and sensory engagement, can support older people’s well-being [2,12,29]. These findings contribute to a body of work suggesting that individuals are as likely to discover therapeutic landscapes as they are to actively create and nurture them [19,21].

The preliminary results also suggest that access to spaces with desirable characteristics is unequally distributed, which is not surprising given the wide disparities among older people in the US [30] and the emerging evidence of disproportionate COVID-19 impact [31]. Previous research indicates that characteristics of local nature and outdoor environments (i.e., proximity, attractiveness, size, and number) may influence older adults’ health behaviors [32,33,34]. Although our findings suggest such patterns may have been reinforced by the pandemic, it would be useful for further research to systematically test these associations and explore underlying mechanisms which may differ from non-pandemic contexts.

Opportunities for public health interventions are highlighted in the myriad of ways in how people have adapted outdoor encounters and found new ways of connecting with nature to maintain their health and well-being during the pandemic. Our evidence suggests interventions to support older people during public health crises do not need to be constrained to large-scale investments, but support can also be provided with small-scale interventions such as pocket parks, desirable views from windows, and pleasurable soundscapes. Furthermore, our results also contribute to the abundance of evidence suggesting older populations as pro-active respondents during public health crises [35,36,37]. In line with emerging evidence that older people are most perceptive to environmental improvements during the pandemic [38], this finding suggests there is potential to involve older individuals in the development of inter-generational interventions that seek to provide solutions to challenges we are facing now or in the future, such as other infectious outbreaks, environmental degradation, and climate change. As the consequences from COVID-19 continue to evolve around the globe, we consider it is timely to grasp emerging lessons and act accordingly; as Mary Robinson stated, “a crisis should never be wasted” [39].

Strengths and Limitations

The recruitment strategy of the COVID-19 Coping Study allowed to form a large sample with a wide age range, diverse aging experiences and geographies. However, in the overall sample, men, racial/ethnic minority groups, Spanish speakers, and those with lower levels of education were underrepresented relative to the general population of older adults in the US [23]. We acknowledge that the characteristics of this sample likely influenced the opportunities for therapeutic encounters to occur. An additional limitation of the study is that the online survey format restricted opportunities of participation to individuals with access to digital technologies and does not allow to prompt participants for an in-depth/case orientated analysis. Nonetheless, our findings indicate interesting venues for further quantitative and qualitative research concerned with therapeutic landscapes and/or environmental gerontology. An additional study strength is the timeliness of data collection, which occurred during the first wave of the pandemic in the US. It would be relevant for further studies to analyze if therapeutic benefits remain or waver as the circumstances surrounding the pandemic evolve.

5. Conclusions

Our evidence suggests diverse landscapes and activities can provide support for older people’s health and well-being in a context of shared social upheaval. Findings also suggest how older adults sought to adapt connections to outdoor and nature landscapes to promote their social, mental, and physical well-being. We consider that a deeper understanding of the interactions with therapeutic landscapes provides opportunities to develop and adapt community and environmental interventions that promote the health and wellbeing of older people during pandemics and their aftermath. However, we caution against the use and development of blanket approaches and suggest that the diverse needs and capabilities of the older population should be considered.