The saliency of geographical landmarks for community navigation: A photovoice study with persons living with dementia

Abstract

This study uses the photovoice method to explore how persons living with mild-to-moderate dementia perceive neighborhood landmarks and identify characteristics that render these landmarks salient for outdoor navigation. Previous research has highlighted the role of well-designed, stable geographical landmarks in improving the navigability of neighborhoods for persons living with dementia. However, the specific attributes that render landmarks salient have not yet been sufficiently explored, resulting in inadequate evidence-based environmental design guidelines for dementia-friendly communities. To address this gap, a photovoice study was conducted with five community-dwelling persons living with dementia and their care partners, as part of a dementia-friendly neighborhood walking program in the city of Seattle, USA. Photovoice facilitated the exploration of saliency of neighborhood landmarks from an emic perspective by (i) empowering persons living with dementia to identify and take photos of salient landmarks during the group walk and (ii) interpret and reflect on attributes that contributed to saliency using the photos as visual aids in a focus group discussion and survey questionnaire. Participants associated the saliency of landmarks with two groups of attributes: (i) visual distinctiveness, which encompassed physical aspects, such as size, shape, color, texture; and (ii) meaningfulness, which included subjective factors of personal and emotional significance that linked the landmarks to participants’ pasts, passions, hobbies, and emotions related to having dementia. Findings suggest that outdoor landmarks should be designed for maximum legibility and noticeability, as well as familiarity, recognizability, and memorability. The evidence from this research also points to the likely positive effect of salient neighborhood landmarks on the community navigation of persons living with dementia.

Keywords

dementia built environment neighborhood landmarks mobility wayfinding navigation photovoice dementia-friendly communities urban design

Introduction

Navigation, which comprises mobility or locomotion (i.e., the ability to move from place to place) and wayfinding (i.e., the ability to explore environments and remember routes to move from one place to another (Kitchin, 1994)) are known to impact the health and well-being of older adults (Hunter et al., 2016). Unimpaired outdoor mobility is especially important for older adults living with dementia to successfully perform their daily routines and remain healthy, active, and engaged in the neighborhood (Clare et al., 2014; Clarke et al., 2012; Rantakokko et al., 2016; Schneider, 2013). However, impaired physical and cognitive capacities tend to constrain their mobility and wayfinding (Clare et al., 2014; Passini et al., 2000). Difficulty in performing orientation (i.e., self-determination of one’s current location, as well as the direction in which one is moving to the next location) and wayfinding commences in the early stages of dementia and gradually worsens with the progression of the disease (Bosch & Gharaveis, 2017). Cognitive issues in dementia that affect orientation and wayfinding include reduced spatial abilities (e.g., inability to distinguish between left and right and different shapes and sizes) and reduced spatial memory (e.g., ability to recall the location of different destinations) (Blackman, Mitchell, et al., 2003; Brittain et al., 2010; Olsson et al., 2013; Sandberg et al., 2017).

According to the Ecological Model of Aging, older adults with reduced personal competence will likely experience higher levels of stress due to environmental press (i.e., “the demand character of the context in which the person behaves” (Lawton, 1986, p. 11)) than those who have higher competence, resulting in maladaptive behavior and a poor person–environment fit. Aspects of the neighborhood environment that may be easily negotiated by able-bodied persons to fulfill outdoor mobility and navigation become significant barriers in the attempts made by persons living with dementia to be out and about in their community and realize their social identity. Some of these barriers are as follows: (i) high volumes of competing sources of stimuli in high traffic areas (Blackman, Mitchell, et al., 2003; Brorsson et al., 2011; Lloyd & Stirling, 2015; Phinney, Kelson, Baumbusch, O’Connor, & Purves, 2016); (ii) complex street layouts (Mitchell et al., 2004); (iii) inadequate infrastructure (e.g., lack of outdoor lighting or accessible restrooms) (Blackman, Mitchell, et al., 2003; Blackman, Van Schaik, et al., 2007; Brittain et al., 2010); (iv) lack of distinctiveness in the neighborhood environment (e.g., identical streets with a lack of landmark features) (Blackman, Mitchell, et al., 2003; Mitchell et al., 2004). When one’s neighborhood is filled with such environmental barriers and lacks adequate supports and cues for navigation, the physical environment could become the primary reason for exacerbated mobility and navigation challenges faced by persons living with dementia (Blackman, Mitchell, et al., 2003; Brorsson et al., 2011; Mitchell et al., 2004; Sandberg et al., 2017). These challenges could ultimately result in community-dwelling older adults with dementia leading a sedentary lifestyle and avoiding going outside their homes, which in turn could lead to experiences of lowered autonomy, social isolation, and loneliness (Alzheimer’s Australia, 2014; Alzheimer’s Society, 2013; Teipel et al., 2016). Therefore, supporting outdoor navigation of community-dwelling older adults with dementia to help them maintain their out-of-home mobility and independence needs to be considered as an important public health priority (Global Coalition on Aging, 2017). This approach is synchronous with that of the social model of disability, which calls for a greater focus on the impact of environmental barriers on the outdoor mobility of people living with dementia, rather than deficits caused by cognitive impairment (Dorenlot, 2005; Downs, 2000; Wilkinson, 2002).

A supportive neighborhood physical environment designed to adequately respond to the needs, abilities, and issues of persons living with dementia could improve orientation and wayfinding and potentially reduce their anxiety about going outside (Davis & Weisbeck, 2016). Landmarks are known to serve as important points of spatial reference for persons living with dementia while performing orientation and wayfinding in the neighborhood environment (Blackman, Van Schaik, et al., 2007; Brittain et al., 2010; Brorsson et al., 2011; Mitchell et al., 2004; Olsson et al., 2013; Sandberg et al., 2017; Sheehan et al., 2006). Therefore, landmarks play a critical role in developing dementia-friendly urban design that enables individuals to better understand their neighborhood environment and experience fewer navigation challenges. Part of the task of designing dementia-friendly landmarks is determining the saliency of these environmental cues and the key characteristics that cause them to contrast with their surroundings and stand out to persons living with dementia.Caduff and Timpf (2008) describe saliency of landmarks as a property resulting from “the trilateral relationship between observer, referenced spatial feature, and physical environment" and an important concept that can help assess landmarks based on how “relatively distinct, prominent, or obvious [their] features [are] compared to other features” in the environment (p. 250). Saliency is suggested as emerging from this interaction of the properties of the landmark and its surrounding context with the characteristics of the observer, thereby implying that it is not an inherent property of landmarks (Caduff & Timpf, 2008). This paper will focus more closely on the characteristics of landmarks that contribute to saliency and less so on the contextual and personal characteristics.

Although there are previous studies that have broadly examined the importance of legibility of the neighborhood physical environment for the outdoor navigation of persons living with dementia and how different environmental cues (e.g., landmarks) contribute to legibility (Burton & Mitchell, 2006; Mitchell & Burton, 2010; Mitchell et al., 2004), there is a lack of research that focuses more specifically on the characteristics of these environmental cues that render them important for outdoor navigation. Delineating these characteristics is essential to systematically design and implement environmental cues as part of dementia-friendly communities (DFCs) initiatives and support the outdoor mobility and navigation of persons living with dementia. This is where the incorporation of conceptual frameworks of landmark saliency can be useful to characterize landmarks, so as to evaluate their effectiveness for the purposes of orientation and wayfinding. According to Caduff and Timpf (2008), characteristics of the landmark and its context that contribute to saliency include: (a) perceptual characteristics (i.e., geometric attributes of the cue, such as size, shape, and orientation); (b) cognitive characteristics (i.e., recognizability and familiarity of the cue); and (c) contextual characteristics (e.g., mode of locomotion, position, and field of view of the older adults in relation to the cue). Sorrows and Hirtle (1999) have also developed a conceptual framework that identifies three broad interrelated categories of salient landmark characteristics based on their association with: (i) visual features that render the landmark salient (e.g., spatial prominence, singularity, clarity of form, and contrast with surroundings); or (ii) typical or atypical meaning or content attached to the landmark, as well as personal, historical, and/or cultural importance and familiarity of the landmark; and (iii) the location of the landmark within the structure of the surrounding space (e.g., intersections, plazas, squares). Landmarks that demonstrate strong characteristics in each of these three categories are more likely to be chosen and prove effective in route navigation (Sorrows & Hirtle, 1999). These categories also help identify different landmarks for different navigation scenarios, e.g., landmarks that have strong visual and structural features would improve navigation in unfamiliar environments, while those with strong meaning and content would be most commonly used in navigating familiar environments (Sorrows & Hirtle, 1999).

Studies that have explored the role of neighborhood environmental design in the community navigation of persons living with dementia have briefly mentioned different characteristics of landmarks that are ideal for wayfinding support within each category discussed above: (i) visual characteristics, e.g., color of building façade (Brorsson et al., 2011); (ii) cognitive characteristics, e.g., well-defined function or purpose associated with the landmark (Blackman, Van Schaik, et al., 2007), stability or permanence (Mitchell et al., 2004); (iii) structural characteristics, , e.g., positioning landmarks at critical decision points, such as forks, intersections, crosswalks (Mitchell et al., 2004). However, there have been no studies that have systematically employed a framework to characterize the properties of outdoor landmarks for dementia-friendliness or evaluate their saliency for community navigation.

A number of DFC initiatives (City of Burnaby, 2016; City of New Westminster, 2016; City of Richmond, 2018; District of West Vancouver, 2017) are recognizing outdoor mobility and navigation support as a key priority area alongside areas such as (i) education, raising awareness, and advocacy in the community; (ii) providing appropriate and accessible community services for dyads (i.e., persons living with dementia and their caregivers); (iii) augmenting social participation and engagement of dyads through adequate and appropriate dementia-friendly programming; (iv) encouraging local businesses to become dementia-friendly; and (v) providing training and support in dementia-friendliness for staff and service providers. More specifically, these initiatives have earmarked the design and maintenance of dementia-friendly landmarks, with particular emphasis on designing new public art (PA) landmarks and conserving heritage structures (HSs) that already serve as important landmarks, alongside other proposed urban design-related actions (e.g., (i) improving the design of signage in public spaces; (ii) creating safe, comfortable, and accessible pedestrian and transit systems) to promote outdoor mobility and navigation (City of Burnaby, 2016; City of New Westminster, 2016; City of Richmond, 2018; District of West Vancouver, 2017). Therefore, it is necessary to have well-defined taxonomy and criteria to help identify and assess salient characteristics that render landmarks dementia-friendly for the purpose of community navigation in order to support these proposed actions of different DFC initiatives. This study is an effort in this direction and intended to explore the saliency of neighborhood landmarks from an emic perspective (i.e., through the insights of persons living with dementia) to understand how persons living with dementia perceive these landmarks, and thereby, identify the different characteristics that contribute to their saliency. This research also acknowledges the importance and value in engaging persons living with dementia as active participants in the research process, due to the under-researched nature of this subject. Involving people living with dementia as experts of lived experience increases the rigor of the research methods and validity of findings, thus making them translatable for real-world application in policy and practice (Mann & Hung, 2018).

Methods

Participants

The study was conducted with eight members of a neighborhood walking group for persons with early-stage memory loss in a large city in the Pacific-Northwest region of USA. The group consisted of both persons living with dementia and their care partners. Of these, five are persons living with mild to moderate dementia and three are partners. The average age of the persons living with dementia was approximately 60 years and there was a greater proportion of men than women (i.e., four males and one female). The three care partners in the group were all spouses and female. Two out of five persons living with dementia lived alone and therefore were not accompanied by a care partner. The members of the group were not residents of the neighborhood in which the study was conducted and were mostly unfamiliar with it, except for one participant who had some prior exposure to the neighborhood due to his professional background.

Context

This study was conducted as part of a dementia-friendly neighborhood group walking program for persons living with early-stage memory loss. In this program, walks are scheduled to take place twice every month. A typical walk is 2–3 miles long, lasts 1–1.5 hours, and is planned along a pre-determined route within a local neighborhood. At pre-determined points of interest along the walking route, the walk leader and program volunteers share information about the neighborhood, its history, and stories associated with it. This particular context was chosen for this study as it afforded the opportunity to explore the research questions in a unique group setting. Conducting the inquiry in a group setting was expected to (i) enable participants with dementia to not only provide their own unique insight but also build on fellow participants’ insights (Krueger & Casey, 2014); and (ii) offer them the opportunity to discuss their experience with others (i.e., both persons living with dementia and care partners) to find shared meanings and values (Wilkinson, 2002). Therefore, the insights derived from conducting the study in a group setting were expected to add a unique dimension to the body of evidence from previous exploratory studies on neighborhood landmarks and dementia in which data collection was done on an individual-by-individual basis (Blackman, Van Schaik, et al., 2007; Brorsson et al., 2011; Mitchell et al., 2004).

The present study was conducted during a walk in a neighborhood with a prominent and central Landmark District, a dense, mixed-use historic quarter with a variety of public spaces and local businesses, as well as a transit corridor, located along a state highway, six blocks away from the Landmark District. The route for the group walk looped around these and other parts of the neighborhood, including residential areas, and covered 19 points of interest that were selected by the walk leader for their historical and contemporary significance.

Procedure

Photovoice is a participatory visual research method which involves participants first taking pictures that represent issues that are important to them in their daily lives and then discussing the meanings in those pictures with the researcher through interviews or focus groups (Wang & Burris, 1997). It centers the perspective of marginalized and minority groups of people and gives them the opportunity to visually document issues within their community and catalyze positive change (Wang & Burris, 1997). Photovoice has three main goals: (i) to help people reflect on the strengths and issues in their community; (ii) to facilitate critical conversations among groups of people about community issues that are important to them using photographs as discussion aids; and (iii) to ensure that people’s reflections are brought to the attention of decision-makers (Wang & Burris, 1997). Photovoice is a tool to facilitate participatory processes of knowledge production, which involve participants (i) collecting visual data through photographs; (ii) selecting those photos that best capture the issues and strengths in their community; and (iii) identifying themes and patterns that emerge from the discussion facilitated by selected photos (this thirdpart of the photovoice method is not employed in this study) (Wang & Burris, 1997). While photovoice has been previously used to reveal neighborhood environmental facilitators and barriers to active living for community-dwelling older adults (Belon et al., 2014; Mahmood et al., 2012; Mason & Gonzales, 2018; Newman, 2010), this method has not yet been applied to explore the neighborhood environmental perceptions of older adults living with dementia. To address this gap, the study was designed based on the principles and techniques of photovoice.

The study began with participants receiving a brief introduction to the study and having an informal and unstructured conversation (10–15 min) about elements in the environment that they consider as landmarks and the role landmarks played in their lives. This dialogue took place before the group walk under the guidance of the program coordinator (third author) and was not conducted as a focus group or audio-recorded. Participants were encouraged to abide by their subjective definitions of geographical landmarks and follow their instincts in identifying landmarks during the group walk. The persons living with dementia were given Polaroid cameras and asked to photograph landmarks that were of interest or that stood out to them at any point during the walk. They were also encouraged to seek the support of their care partner or a volunteer in taking pictures or storing the Polaroid prints for the duration of the walk. During the walk, the first author ensured that all participants were able to operate their cameras and take photos without any difficulty and assisted them with the replacement of Polaroid film so that they were able to take photos throughout the walk. Care partners and volunteers carried audio recorders to capture their conversations with the persons living with dementia during the walk. However, due to technical difficulties, the audio data had to be omitted from the analysis.

Around 30–45 minutes after the walk ended, the group participated in an hour-long focus group facilitated by the program coordinator, who has worked closely with members of the group-walking program since it first started. Having a facilitator well-known to participants helped create a familiar, safe, and comfortable atmosphere for them to express their thoughts and engage in discussion. Persons living with dementia were asked to go through the photos they had taken during the walk and select approximately five that stood out to them at that moment and explain why they found them to be interesting and what caught their attention. Asking participants what made their chosen landmarks stand out to them was expected to shed light on the characteristics of these landmarks that rendered them salient. Care partners and volunteers were also asked to report their discussion with persons living with dementia at the time that photos were taken during the walk. The focus group conversations were audio-recorded and transcribed. During the focus group, the first author took additional notes to supplement the transcript data.

Three weeks after the group walk, an online survey was emailed to participants. In this survey, participants were shown five pairs of PA and HSs, the two dominant categories of landmarks photographed during the walk. The landmarks presented in the survey were the ones selected (for further discussion) by participants during the focus group out of all the photos taken during the group walk. For each of these pairs of photos, participants were asked to choose the landmark that stood out to them the most. Once they made their choice, an open-ended question was presented asking participants to explain why they chose one landmark over the other. Participants’ survey responses were meant to triangulate and supplement their focus group responses in regard to the identification of salient landmarks and the different characteristics that contributed to their saliency.

Data analysis

All photos of landmarks taken during the walk were digitized and categorized based on three criteria: (i) type (i.e., PA/HS/signage), (ii) source (i.e., pre-determined point of interest by walk leader/self-determined), and (iii) selected for further discussion during the focus group or not. This helped identify the most prevalent types of landmarks captured during the walk and also those that were oft-considered salient during the focus group. Thematic analysis (Braun & Clarke, 2006) was used to analyze the focus group transcript data and identify themes pertaining to salient characteristics of neighborhood landmarks with the help of the Atlas.ti qualitative analysis software. First, the transcript was read closely so as to become familiar with the data and develop a sense for emergent themes. Through multiple readings of the transcript, initial codes were generated. The transcript was then loaded on to the analysis software where detailed line-by-line coding was conducted, which were then organized within themes. These themes were further organized and refined by (i) collapsing themes that were similar; (ii) separating those that were distinct; and (iii) removing those that were irrelevant, thus resulting in the final set of themes. Survey responses were analyzed using descriptive statistics (i.e., frequency distributions) on the Minitab statistical software to assess participants’ relative preferences between HSs and PA. Data from the open-ended survey questions were linked to the codes and themes derived from the focus group transcript.

Ethical considerations

The study design was approved by the Institutional Review Board of Cornell University. Through close collaboration with the community partner, measures were taken to ensure that participants were gradually introduced to the study goals, objectives, and expectations well-ahead of the time of the research (i.e., starting two months before the day of the walk) and were encouraged to ask questions or express concerns at any point leading up to the study. Participants were made aware that their participation was voluntary and that they could choose to walk with the group without participating in the photovoice study. Before commencing the group walk, the persons living with dementia gave their informed consent by signing consent forms with the assistance of their care partners or a volunteer, wherever necessary. Participants were also informed that they could withdraw from the walk or the focus group at any point during the study.

Results

Participants reported using geographical landmarks in their everyday life to navigate through their respective neighborhoods. The types of neighborhood landmarks that they commonly used included PA, sports facilities, shopping destinations, mountains, lakes, and the ocean. Landmarks were considered essential for reinforcing participants’ memory of both familiar and unfamiliar neighborhood environments, as well as aiding the recall of familiar route information. Changes due to neighborhood redevelopment (e.g., closure of local businesses and the disappearance of familiar destinations) were reported as barriers to participants’ ability to maintain familiarity with the outdoor environment. However, participants reported that PA commissioned as part of new development projects in their neighborhoods buffered the impact of the loss of familiarity and acted as landmarks that were used in community navigation.

During the group walk, the persons living with dementia took a total of 66 photos of 32 landmarks. Twelve of these landmarks were discussed in detail during the focus group. The most frequently photographed type of landmarks was PA (43.07%), followed by HSs (21.53%). In the online survey, PA landmarks were more frequently selected as noticeable (56%) than HSs (44%), thus suggesting a slightly higher saliency of PA landmarks. The following sections offer detailed explanations for why PA and HSs were considered salient by persons living with dementia. Based on participants’ responses, the salient landmark characteristics were grouped into two categories: i) visual distinctiveness; and ii) meaningfulness.

1. Visual distinctiveness

The first group of salient landmark characteristics falls under the category of “visual distinctiveness.” The characteristics that it comprises are a) unique form; b) bright color; c) distinct material quality; d) appropriate scale; and e) clear and distinct signage.

1a. Unique form

PA landmarks with a unique physical form were considered to be salient by persons living with dementia. In the survey, a public art landmark, PA1 (Figure 1) drew responses, such as “visually pleasing,” “weird and puzzling,” and “memorable,” due to its unusual shape and contrast with the surrounding landscape. One participant (P3) remarked in the survey that the interesting obelisk-like shape of this landmark drew his attention and made him “want to approach it.”

1b. Bright color

The use of bright colors (i.e., colors that are not too dark, have strong contrast, and do not merge with surroundings) in PA was considered to be an attractive physical feature that contributed to the saliency of landmarks. A public art landmark, PA2 (Figure 2), was specifically chosen in the survey as salient by one participant (P5) as he found it to be unique and colorful.

1c. Distinct material quality

Properties of materials used in PA landmarks were also found to contribute to their saliency. One participant (P5) reported being particularly drawn to translucent surface materials, which resulted in his attention being drawn to a public art landmark, PA3 (Figure 3). According to the participant, the presence of materials with eye-catching qualities in this landmark was likely to be remembered by him and aid in recall while performing navigation. During the focus group, he said, “I like the fact that the disc is glass and that’s something that’s attractive to me. I would remember and use [PA3] as a landmark in terms of navigating my way around.” The recognizability of the translucent surface material was further reinforced through recycling known, everyday materials that the participant reported being familiar with.

If I was driving around a city that I didn’t know, [PA3] would definitely make an impression in my mind and the next time I saw it, I would recognize it again. I like that it was made out of reflectors— the fact that it was a material that was for actually a different function— repurposed. (P5)

1d. Appropriate scale

Inadequate scale was associated with poor saliency. Despite being uniquely designed, a public art landmark (PA4) (Figure 4) was not perceived as noticeable by a participant due to its relatively small size that caused it to blend into the surrounding area. In the survey, he said, “[PA4] is unique and memorable but could easily get lost in the crowd” (P5).

HSs, on the other hand, were found to be salient because of their relative prominence in the neighborhood physical environment. With regard to a heritage structure, HS1 (Figure 5), shown in the survey, a participant said, “[HS1] is somewhat dramatic and large in size and clearly marked” (P5).

1e. Clear and distinct signage

Clear and legible signage on landmarks was found to augment saliency. Signage on the façade of a heritage structure, HS2 (Figure 6), was appreciated by a participant for its distinctive style, effective contrast, and unique typography. In the survey, he said, “The vertical words on [HS2] are clear yet unusual and strong in contrast” (P5).

2. Meaningfulness

The second set of salient landmark characteristics fall under the category of “meaningfulness.” The characteristics discussed here are a) connection to personal interest; b) emotional resonance; and c) well-defined purpose.

2a. Connection to personal interest

PA was found to be salient due to its connection to some personal interest of persons living with dementia. One participant found the public art landmark, PA4, to be meaningful as it reminded him of his passion for biking and he acknowledged that this landmark was both familiar and functional. In the survey, he said, “[PA4] is just a place to lock up your bike but I do a lot of biking and that’s just a nice, modern art-kind of presentation of a bicycle” (P3). Similarly, another participant’s (P4) love for live theatre informed her choice of the heritage structure, HS1, as a meaningful landmark.

2b. Emotional resonance

Landmark saliency was also expressed by means of emotional resonance, i.e., aspects of the landmark evoked deeply emotional responses from persons living with dementia. A public art landmark, PA5 (Figure 7), was found to be meaningful by a participant as it symbolized strength and perseverance, which were values that she sought in her experience of living with dementia. In the focus group, she said, “[PA5] is about strength [and] being strong in this Alzheimer’s journey that I am on” (P4).

On a similar note, this participant had an emotional response to a different public art landmark, PA1, which represented similar values as above, as well as courage and determination to fight against all odds. In the focus group, she said, “to me, [PA1] is a middle finger to the world. [It is about] living life to the [fullest and enjoying] every second that I’ve got left” (P4). While the previous two landmarks appeared salient for their emotional resonance expressed through symbolism, the participant used the metaphor of time in her dementia journey to explain why a heritage structure, HS3 (Figure 8), was meaningful to her. The landmark was symbolic of her determination to stay rooted in the present, while being aware of the finitude of time, and preserving time while it lasted. “Time is passing by…and it’s passing so fast! I’m getting older and I’m also declining and [HS3] just reminds me that I need to cherish every single minute that I’ve got left” (P4).

2c. Well-defined purpose

Landmarks that did not have a definite purpose and could not be easily recognized or named as something with a known function were likely to not be viewed as salient. This was why the public art landmark PA3, lacking a well-defined function or purpose, was found to be less salient when compared to the visually distinctive heritage structure, HS2, in the online survey.

Discussion

This study aimed to understand how persons living with dementia perceive landmarks in the neighborhood environment and explore the pathways and characteristics that render landmarks salient. Landmark saliency is of much relevance in the discussion around supporting community navigation for persons living with dementia and knowing which properties and characteristics contribute to saliency could guide the design of new neighborhood landmarks, as well as the enhancement of existing neighborhood landmarks.

Findings indicated that PA in the study site was considered to be relatively more salient than the HSs. Some participants reported being drawn to PA due to their fondness for artwork, while others found them to be attractive due to their salient visual characteristics. Previous researchers have concluded that public artwork plays an important role in promoting meaningful engagement (Kelson et al., 2017) and identified both PA and HSs as salient landmarks for persons living with dementia (Mitchell et al., 2004). The results of this study add to the extant knowledge of the saliency of neighborhood landmarks by suggesting that persons living with dementia may be more likely to notice PA than HSs in an unfamiliar neighborhood setting, i.e., there may be an association between the familiarity of neighborhood setting and saliency by landmark type. Further research would be necessary to evaluate this hypothesis to examine if persons living with dementia are indeed likely to find HSs more salient in familiar settings and PA in unfamiliar settings. Evidence to support this hypothesis could inform the prioritization of action areas for planning and designing the neighborhood environment as part of DFC initiatives.

This study suggests that landmark saliency was achieved through characteristics related to visual distinctiveness and/or meaningfulness. These categories are consistent with the conceptual frameworks (Caduff & Timpf, 2008; Sorrows & Hirtle, 1999) of saliency of landmarks discussed earlier and demonstrate how these frameworks are applicable to guide research on the supportiveness of environmental cues for the outdoor navigation of people living with dementia. In terms of visual distinctiveness, both PA and HSs are likely to be salient when appropriately scaled, while those that were relatively small in size were not considered to be salient. Unique shape and the use of bright colors and familiar materials were also found to augment the visual distinctiveness of PA. This finding is supported by evidence from previous research that suggests the benefit of having brightly colored neighborhood landmarks to support persons living with dementia in community navigation (Mitchell et al., 2004). Findings also revealed that visual distinctiveness may be enhanced by incorporating clear and legible signage into the façade of HSs. This finding is consistent with previous evidence which suggests an improvement in identification and community navigation among persons living with dementia due to the the combination of well-designed signage with landmarks and destinations (Blackman, Van Schaik, et al., 2007).

In terms of meaningfulness, this study suggests that both PA and HSs carry meaning due to i) an association with a personal interest or hobby; ii) familiarity and importance of a related function or purpose; and/or iii) emotional resonance through symbolic or metaphoric association with one's dementia journey. This concept of landmark saliency expressed through meaningfulness is supported by evidence from previous research on the place-relations of persons living with dementia in familiar settings that reveals the relative importance of meaningfulness, familiarity, personal history, and “insideness” over visual saliency of the neighborhood physical environment (Kelson et al., 2017; Ward et al., 2018). The findings also suggest that landmark saliency in unfamiliar settings could manifest through the presence of meaningful associations for persons living with dementia, despite them having little or no prior experience of being in that environment. Study participants were able to identify and recognize a number of aspects in the neighborhood environment that were familiar to them. For example, a heritage structure, HS3, appeared familiar to participants as it was reminiscent of similar structures that they had encountered in other neighborhoods and was specifically recognized as a recurrent landmark in the cityscape. While some research has explored the role of unfamiliar outdoor settings in fostering place attachment among cognitively intact older adults (Phillips et al., 2012), future studies should explore how place-relations are established within unfamiliar settings among persons living with dementia and draw the conceptual links with visual saliency of the neighborhood landmarks and their impact on community navigation. It is important to note that the different pathways (i.e., personal interest, familiarity of purpose, and emotional resonance) of meaningfulness are interrelated (as are the individual categories of landmark saliency, i.e., visual distinctiveness and meaningfulness). An example of this relationship is seen in some PA and HSs that prompted deep insight and reflection on people’s dementia journey. It is quite likely that these landmarks served as vehicles for personal metaphors owing to the fact that some aspect of the landmark was easily recognizable and identifiable, which enabled the participant to find personal meaning. In order to encourage meaning-making, it is important for landmarks being newly introduced into the urban landscape to have aspects that are unambiguous and identifiable, even in the case of abstract PA (e.g., PA3, which was made with a material that was immediately recognized by the participant, thus augmenting its saliency).

A quote from one participant (P4) in relation to a PA landmark, i.e., “[It is about] living life to the [fullest and enjoying] every second that I’ve got left,” perfectly encapsulates the value of outdoor walking and community participation for people living with dementia. Previous research with a neighborhood walking group has shown how people living with dementia perform social citizenship (i.e., “a relationship, practice or status in which the person with dementia is entitled to experience freedom from discrimination, and to have opportunities to grow and participate in life to the fullest extent possible” (Bartlett & O’Connor, 2010, p. 37)) through group walks in the neighborhood by disrupting normative assumptions and beliefs that surround dementia and those who live with it (Phinney, Kelson, Baumbusch, O’Connor, & Purves, 2016). Beyond the immediate relevance of the salient landmarks for facilitating outdoor mobility and navigation, the insights that came from participants in relation to some neighborhood landmarks reflected dimensions of their social citizenship, such as (i) personal interests, passions, and hobbies (e.g., cycling, recycling); ii) social positions based on past professions (e.g., participants’ reflection of landmarks through the lens of past professions, including graphic design, law, and real estate); and iii) outlook towards life with dementia (e.g., determination to overcome social prejudices and persevere to maintain quality of life). It is clear, therefore, that outdoor mobility for people living with dementia is a matter of rights, social justice, and citizenship and the neighborhood environment has a critical role to play in facilitating independence beyond the home environment(Argyle et al., 2017; Keady et al., 2012).

This study draws from the social model of disability, which frames disability as a result of physical and social environmental barriers, by focusing on the delineation of salient landmark characteristics that may lead to evidence-based urban design recommendations to augment the cognitive accessibility of the neighborhood environment. Previous research suggests that although there is a lack of knowledge and awareness of dementia-friendly design among municipal urban planners, there is an interest among them to learn, adopt, and implement guiding principles for dementia-friendly design (Przydatek, 2014). This research suggests that an integral part of sensitizing the world of physical planning and urban design to a dementia-friendly approach is to learn from people living with dementia themselves; how they experience the neighborhood, and more specifically, how they practice outdoor mobility and navigation with the help of environmental cues like landmarks, and what kinds of environmental supports they would need to best equip them in this endeavor. The study offers interesting and unique insights from the emic perspective and draws linkages between these perspectives and salient characteristics that could potentially inform the development of urban design guidelines. However, it should be noted that given the exploratory nature of this research, the study findings may not be directly translatable into urban design guidelines. Future research on this topic needs to lay greater emphasis on testing and evaluating (Blackman, Van Schaik, et al., 2007) the salient characteristics discussed in this study, so that they may be applied as design principles by urban planners and architects to create dementia-friendly neighborhood environments.

This study successfully demonstrated the power of photovoice in engaging with persons living with dementia to elicit textured insights on the neighborhood physical environment. Having a Polaroid camera allowed participants to see the picture of the landmark in print as they were witnessing it in real-time, which may have helped reinforce their memory of seeing the landmark during the group walk and aided in recall during the focus group that followed. Having photos to elicit responses during the focus group was not only helpful to promote recall but also helped persons living with dementia derive new information from the pictures and provide more insightful responses. Thus, this method enabled participants to not only identify landmarks that appeared salient to them as they walked through the neighborhood, but also reflect on the characteristics that contributed to their saliency.

While most studies exploring the place-relations of persons living with dementia in outdoor settings use the walk-along interview technique with one individual at a time (Mitchell et al., 2004; Ward et al., 2018), this study was unique in its application of photovoice to engage a group of persons living with dementia and care partners walking together in an urban neighborhood. Previous research on group walking among persons living with dementia has explored how walking with a group fosters a supportive social environment and facilitates social citizenship in the neighborhood environment (Kelson et al., 2017; Phinney, Kelson, Baumbusch, O’Connor, & Purves, 2016). The present study also sheds light on the role of neighborhood group walks in enabling persons living with dementia to maintain out-of-home mobility in the neighborhood environment. Ensuring that the physical environment is dementia-friendly by facilitating i) positive stimulation (through visual interest, variety, and complexity); and ii) orientation, safety, and comfort (through the presence of familiar and recognizable features) would likely enhance the neighborhood group-walking experience for persons living with dementia. Research has shown the importance of group walks in the context of dementia-friendly recreational programming and the social benefits it has in terms of i) enabling community participation and engagement among people living with dementia (Lin et al., 2014); and ii) reframing them as active social citizens with the potential to contribute meaningfully to their community while challenging stigmatizing representations, attitudes, and beliefs surrounding dementia in society (Phinney, Kelson, Baumbusch, O’Connor, & Purves, 2016). While previous research focuses on the social aspects of the neighborhood environment in the context of dementia and group walking, there is a lack of emphasis on the physical environmental aspects that contribute towards the person–environmental (P–E) relations among people living with dementia participating in outdoor group walks. It has been suggested that environmental gerontological research should aim to bridge the gap between the physical and social environmental aspects of P–E transactions by focusing on both the physical and social dimensions of the environment (Wahl & Lang, 2003). Therefore, future research should explore the socio-physical environmental aspects of neighborhood group walking for persons living with dementia in tandem and inspire more organizations to offer such dementia-friendly recreation programs that allow persons living with dementia and their care partners to participate and engage with different neighborhood environments in their city.

Limitations

Since the study was conducted as part of a guided walk with pre-determined pause-points with landmarks selected by the walk leader, there may have been a natural bias introduced in participants’ identification and selection of salient landmarks during the group walk. In order to address this limitation, participants were encouraged (both during the introductory dialogue prior to the walk, as well as at points between pre-determined points along the walking route) to take pictures of landmarks that they found to be interesting besides the pre-determined points of interest. Correspondingly, there were several instances where participants photographed landmarks seen along the way that were not pre-determined points of interest on the guided walk. Study participants were able to freely self-select such landmarks and even identify ones that were slightly off the planned route. As a result, a variety of landmarks, including both self-determined and pre-determined points of interest, were produced. Although the proportion of photographs taken during the group walk of pre-determined landmarks (61.53%) exceeded that of self-determined landmarks (38.47%), this was compensated for by introducing a second process of selection during the focus group where participants chose an even mix of pre-determined as well as self-determined landmarks that appeared most salient to them at the time of the focus group. However, despite the efforts to introduce self-determination into the selection of salient landmarks, the authors acknowledge that the pre-determination of points of interest specifically for their historical and contemporary importance may have introduced bias in the findings and prompted the emergence of HSs and PA as the most prominent types of landmarks identified by participants. Therefore, future studies should explore landmark saliency outside the context of a guided walk, so as to better facilitate self-determination of salient landmarks and examine the validity of the patterns of saliency found in the present study.

This study explored how different landmarks were salient and may be useful as navigation cues for persons living with dementia. The photovoice method may have prompted participants to take photos of landmarks that were visually distinctive and meaningful but not necessarily ones that they might actually use while performing community navigation. The conclusions drawn in this study are limited to landmark saliency and not extended to their effectiveness for navigation cueing due to the lack of representativeness of everyday experience of navigating through the community in the study design. Further research would be necessary to specifically explore how landmarks with salient characteristics affect community navigation for persons living with dementia.

Finally, due to time and budgetary constraints, persons living with dementia in this study were not engaged as co-researchers and advisors in the research process. For instance, the present study did not employ participatory data analysis (i.e., involving participants in defining key themes and patterns), as recommended by Wang and Burris (1997) for applying photovoice to participatory needs assessment, due to logistical issues. The study also did not incorporate member checks to ascertain the validity of the findings. Therefore, findings may be biased to the researcher’s perspective and potentially inconsistent with the wayparticipants might interpret the data that was generated. Future research on this topic employing photovoice should, therefore, budget enough time and resources for the involvement of participants in analysis to ensure that the findings accurately communicate the themes and patterns that stand out to participants, thereby offering an authentic representation of their views on the topic. Furthermore, future studies should adopt the participatory action research (PAR) methodology, so as to involve persons with lived experience in research planning, design, analysis, and knowledge translation, to ensure maximum validity and impact of research findings while enabling persons living with dementia to be leaders and agents of social change (Mann & Hung, 2018).

Conclusion

This exploratory study with persons living with dementia suggests that public art and heritage structures exhibit landmark saliency through visual distinctiveness, in terms of form, scale, color, and material, as well as meaningfulness, in terms of personal significance, familiarity, and purpose. Identifying these characteristics helps operationalize landmark saliency as perceived by persons living with dementia. The salient characteristics identified in this study provide a useful starting point for a further in-depth exploration of how different salient characteristics of landmarks influence the community navigation of persons living with dementia. The evidence from future evaluation studies could be useful in generating design principles and guidelines (e.g., through evidence-based design implementation guides that feature dementia-friendly guidelines for achieving saliency in the design of public art landmarks, street signs, and transit signs) for creating a supportive neighborhood physical environment as part of dementia-friendly communities initiatives that have identified navigation support as a priority action area. Thus, this research contributes to the growing scholarship around generating evidence to design for cognitive accessibility and legibility in the neighborhood physical environment.

Footnotes

Acknowledgements

This study benefited greatly from the advice and guidance of Dr Corinna E. Löckenhoff, Associate Professor, Cornell University, and Dr Naomi A. Sachs, Assistant Professor, University of Maryland.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by grants provided by the Department of Design + Environmental Analysis, Cornell University, and Cornell University Graduate School.

ORCID iD

Kishore Seetharaman

Kishore Seetharaman is a PhD student in Gerontology at Simon Fraser University, Canada. He earned a Bachelor of Architecture degree from Anna University, India and a Master of Science in Human-Environment Relations from Cornell University, USA. His research focuses on issues of environment and aging and his current doctoral work specifically examines how the neighborhood physical environment influences the navigation patterns of persons living with dementia.

Mardelle M Shepley is a professor and chair of the Department of Design and Environmental Analysis and associate director of the Institute for Healthy Futures at Cornell University, USA. She serves on the graduate faculty in the Department of Architecture. A fellow in the American Institute of Architects, she has LEED AP and EDAC credentials. Shepley has authored/co-authored six books. Among the most recent are Health Facility Evaluation for Design Practitioners (2010), Design for Pediatric and Neonatal Critical Care (2014) and Design for Mental and Behavioral Health (2017). Shepley has worked full and part-time in professional practice for 25 years.

Cayce Cheairs has a BA in Psychology from Seattle University, USA and is currently pursuing a Master of Social Work at the University of Washington, USA. She has worked with older adults and persons living with memory loss since 2010. In her role at Seattle Parks and Recreation, Cayce works with community members and partner organizations to offer meaningful recreation opportunities for persons living with memory loss and their care partners.

References

Alzheimer’s Australia. (2014). Living with dementia in the community: Challenges & opportunities: A report of national survey findings.

Alzheimer’s Society. (2013). Dementia 2013: The hidden voice of loneliness. https://www.alzheimers.org.uk/sites/default/files/migrate/downloads/dementia_2013_the_hidden_voice_of_loneliness.pdf

Argyle

Dening

Bartlett

(2017). Space, the final frontier: Outdoor access for people living with dementia. Aging & Mental Health, 21(10), 1005–1006.

Bartlett

O’Connor

(Eds.). (2010). The meaning and value of social citizenship. In Broadening the dementia debate: Towards social citizenship (pp. 29–48). Policy Press.

Belon

A. P.

Nieuwendyk

L. M.

Vallianatos

Nykiforuk

C. I.

(2014). How community environment shapes physical activity: Perceptions revealed through the PhotoVoice method. Social Science & Medicine, 116, 10–21.

Blackman

Mitchell

Burton

Jenks

Parsons

Raman

Williams

(2003). The accessibility of public spaces for people with dementia: A new priority for the ‘open city’. Disability & Society, 18(3), 357–371.

Blackman

Van Schaik

Martyr

(2007). Outdoor environments for people with dementia: An exploratory study using virtual reality. Ageing & Society, 27(6), 811–825.

Bosch

S. J.

Gharaveis

(2017). Flying solo: A review of the literature on wayfinding for older adults experiencing visual or cognitive decline. Applied Ergonomics, 58, 327–333. https://doi.org/10.1016/j.apergo.2016.07.010

Braun

Clarke

(2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101.

10.

Brittain

Corner

Robinson

Bond

(2010). Ageing in place and technologies of place: The lived experience of people with dementia in changing social, physical and technological environments. Sociology of Health & Illness, 32(2), 272–287.

11.

Brorsson

Öhman

Lundberg

Nygard

(2011). Accessibility in public space as perceived by people with Alzheimer’s disease. Dementia, 10(4), 587–602.

12.

Burton

Mitchell

(2006). Inclusive urban design: Streets for life. Routledge.

13.

Caduff

Timpf

(2008). On the assessment of landmark salience for human navigation. Cognitive Processing, 9(4), 249–267.

14.

City of Burnaby. (2016). Burnaby Dementia-Friendly Community Action Plan 2016. https://www.burnaby.ca/Assets/Burnaby+Dementia-Friendly+Community+Action+Plan.pdf

15.

City of New Westminster. (2016). Dementia-Friendly Community Action Plan 2016. https://www.newwestcity.ca/database/files/library/City_of_New_West_Dementia_Friendly_Community_Action_Plan_Report_2016_8_2.pdf

16.

City of Richmond. (2018). Dementia-Friendly Project 2018. https://www.richmond.ca/parksrec/seniors/programsevents/dementiafriendly.htm

17.

Clare

Nelis

S. M.

Quinn

Martyr

Henderson

Hindle

J. V.

, Jones, I.R., Jones, R.W., Knapp, M., Kopelman

M. D.

(2014). Improving the experience of dementia and enhancing active life-living well with dementia: Study protocol for the IDEAL study. Health and Quality of Life Outcomes, 12(1), 164.

18.

Clarke

P. J.

Ailshire

J. A.

House

J. S.

Morenoff

J. D.

King

Melendez

Langa

K. M.

(2012). Cognitive function in the community setting: The neighbourhood as a source of ‘cognitive reserve’? Journal of Epidemiology and Community Health, 66(8), 730–736.

19.

Davis

Weisbeck

(2016). Creating a supportive environment using cues for wayfinding in dementia. Journal of Gerontological Nursing, 42(3), 36–44.

20.

District of West Vancouver. (2017). Dementia-friendly North Shore Action Plan 2017. https://westvancouver.ca/sites/default/files/dwv/council-agendas/2017/dec/04/17dec04-8.pdf

21.

Dorenlot

(2005). Applying the social model of disability to dementia: Present-day challenges. SAGE Publications.

22.

Downs

(2000). Dementia in a socio-cultural context: An idea whose time has come. Ageing & Society, 20(3), 369–375.

23.

Global Coalition on Aging. (2017). Dementia innovation readiness index. https://globalcoalitiononaging.com/wp-content/uploads/2018/05/gcoa-adi-dementia-index.pdf

24.

Hunter

R. H.

Anderson

L. A.

Belza

B. L.

(2016). Introduction to community wayfinding. In Community wayfinding: Pathways to understanding (pp. 3–16). Springer.

25.

Keady

Campbell

Barnes

Ward

Swarbrick

, Burrow, S., Elvish

(2012). Neighbourhoods and dementia in the health and social care context: A realist review of the literature and implications for UK policy development. Reviews in Clinical Gerontology, 22(2), 150–163.

26.

Kelson

Phinney

Lowry

(2017). Social citizenship, public art and dementia: Walking the urban waterfront with Paul’s Club. Cogent Arts & Humanities, 4(1), 1354527.

27.

Kitchin

R. M.

(1994). Cognitive maps: What are they and why study them? Journal of Environmental Psychology, 14(1), 1–19. https://doi.org/10.1016/S0272-4944(05)80194-X

28.

Krueger

R. A.

Casey

M. A.

(2014). Focus groups: A practical guide for applied research. SAGE Publications.

29.

Lawton

M. P.

(1986). Environment and aging (Vol. 1). Center for the Study of Aging, Incorporated.

30.

Lin

S.-Y.

Becker

Belza

(2014). From dementia fearful to dementia friendly: Be a champion in your community. Journal of Gerontological Nursing, 40(12), 3–5. https://doi.org/10.3928/00989134-20141114-01

31.

Lloyd

B. T.

Stirling

(2015). The will to mobility: Life-space satisfaction and distress in people with dementia who live alone. Ageing and Society, 35(9), 1801–1820.

32.

Mahmood

Chaudhury

Michael

Y. L.

Campo

Hay

Sarte

(2012). A photovoice documentation of the role of neighborhood physical and social environments in older adults’ physical activity in two metropolitan areas in North America. Social Science & Medicine, 74(8), 1180–1192.

33.

Mann, J., & Hung, L. (2019). Co-research with people living with dementia for change. Action Research, 17(4), 573-590.

34.

Mason

Gonzales

(2018). CBPR with older adults: Exploring age-friendliness of several Greater Boston communities. Innovation in Aging, 2(Suppl 1), 919. https://doi.org/10.1093/geroni/igy031.3420

35.

Mitchell

Burton

(2010). Designing dementia-friendly neighbourhoods: Helping people with dementia to get out and about. Journal of Integrated Care, 18(6), 11–18.

36.

Mitchell

Burton

Raman

(2004). Dementia-friendly cities: Designing intelligible neighbourhoods for life. Journal of Urban Design, 9(1), 89–101.

37.

Newman

S. D.

(2010). Evidence-based advocacy: Using photovoice to identify barriers and facilitators to community participation after spinal cord injury. Rehabilitation Nursing, 35(2), 47–59.

38.

Olsson

Lampic

Skovdahl

Engström

(2013). Persons with early-stage dementia reflect on being outdoors: A repeated interview study. Aging & Mental Health, 17(7), 793–800.

39.

Passini

Pigot

Rainville

Tétreault

M.-H.

(2000). Wayfinding in a nursing home for advanced dementia of the Alzheimer’s type. Environment and Behavior, 32(5), 684–710.

40.

Phillips

Walford

Hockey

(2012). How do unfamiliar environments convey meaning to older people? Urban dimensions of placelessness and attachment. International Journal of Ageing and Later Life, 6(2), 73–102.

41.

Phinney

Kelson

Baumbusch

O’Connor

Purves

(2016). Walking in the neighbourhood: Performing social citizenship in dementia. Dementia, 15(3), 381–394. https://doi.org/10.1177/1471301216638180

42.

Przydatek

(2014). Remembering community settings: Exploring dementia-friendly urban design in British Columbian municipalities [Master's Thesis, University of Victoria]. https://dspace.library.uvic.ca//handle/1828/5540

43.

Rantakokko

Portegijs

Viljanen

Iwarsson

Kauppinen

Rantanen

(2016). Changes in life-space mobility and quality of life among community-dwelling older people: A 2-year follow-up study. Quality of Life Research, 25(5), 1189–1197. https://doi.org/10.1007/s11136-015-1137-x

44.

Sandberg

Rosenberg

Sandman

P.-O.

Borell

(2017). Risks in situations that are experienced as unfamiliar and confusing – The perspective of persons with dementia. Dementia, 16(4), 471–485.

45.

Schneider

I. E.

(2013). Quality of life: Assessment for transportation performance measures [Report]. Minnesota Department of Transportation. http://conservancy.umn.edu/handle/11299/149260

46.

Sheehan

Burton

Mitchell

(2006). Outdoor wayfinding in dementia. Dementia, 5(2), 271–281.

47.

Sorrows

M. E.

Hirtle

S. C.

(1999). The nature of landmarks for real and electronic spaces. In Freksa

Mark

D. M.

(Eds.), Spatial information theory. Cognitive and computational foundations of geographic information science (pp. 37–50). Springer.

48.

Teipel

Babiloni

Hoey

Kaye

Kirste

Burmeister

O. K.

(2016). Information and communication technology solutions for outdoor navigation in dementia. Alzheimer’s & Dementia, 12(6), 695–707.

49.

Wahl

H.-W.

Lang

F. R.

(2003). Aging in context across the adult life course: Integrating physical and social environmental research perspectives. In Annual review of gerontology and geriatrics, volume 23, 2003: Aging in context: Socio-physical environments (pp. 1–33). Springer Publishing Company.

50.

Wang

Burris

M. A.

(1997). Photovoice: Concept, methodology, and use for participatory needs assessment. Health Education & Behavior, 24(3), 369–387.

51.

Ward

Clark

Campbell

Graham

Kullberg

Manji

, Rummery, K., Keady

(2018). The lived neighborhood: Understanding how people with dementia engage with their local environment. International Psychogeriatrics, 30(6), 867–880.

52.

Wilkinson

(2002). Including people with dementia in research: Methods and motivations. In H. Wilkinson (Ed.), The perspectives of people with dementia: Research methods and motivations (pp. 9–24). Jessica Kingsley Publishers.