Abstract
Objective:
This study explores assisted living residents' walking behaviors, locations where residents prefer to walk, and walking environments in and around assisted living facilities.
Background:
Regular walking is beneficial to older adults' physical and psychological health. Yet frail older residents in assisted living are usually too sedentary to achieve these benefits. The physical environment plays an important role in promoting physical activity. However, there is little research exploring this relationship in assisted living settings.
Methods:
The researcher visited 34 assisted living facilities in a major Texas city. Methods included walk-through observation with the Assisted Living Facility Walking Environment Checklist, and interviews with administrators by open- and close-ended questions. The data from 26 facilities were analyzed using descriptive statistics (for quantitative data) and content analysis (for qualitative data).
Results:
The results indicate that (a) residents were walking both indoors and outdoors for exercise or other purposes (e.g., going to destinations); (b) assisted living facility planning and design details—such as neighborhood sidewalk conditions, facility site selection, availability of seating, walking path configuration (e.g., looped/nonlooped path), amount of shading along the path, presence of handrails, existence of signage, etc.—may influence residents' walking behaviors; and (c) current assisted living facilities need improvement in all aspects to make their environments more walkable for residents.
Conclusion:
Findings of the study provide recommendations for assisted living facilities to improve the walkability of environments and to create environmental interventions to promote regular walking among their residents. This study also implies several directions for future research.
An assisted living facility (ALF) is a long-term care option that combines housing, supportive services, and healthcare for mentally and/or physically frail individuals (Assisted Living Federation of America, 2010). The majority of ALF residents are older people (in this article and according to the World Health Organization [2010], older people refers to those who are 65 years of age or older) (Hawes, Phillips, Rose, Holan, & Sherman, 2003). This industry has experienced its fastest growth during the past decade: The number of ALFs in the United States was 11,459 in 1998 (Hawes, Rose, & Phillips, 1999) and 38,373 in 2007 (Mollica, 2008). This article reports the results of a series of ALF visits conducted to evaluate walking environments for assisted living residents.
Introduction
Health promotion and healthcare provision to older people have become major societal concerns, because the aged U.S. population will increase from 35 million in 2000 to 70 million in 2030 (U.S. Census Bureau, 2004). In response to these concerns, various means of health promotion (such as physical activity interventions) and senior housing (such as ALFs) have been developed over the past decade.
In 2000, the U.S. Department of Health and Human Services (DHHS) published its landmark report, Healthy People 2010: Understanding and Improving Health, which advocates 30 minutes of exercise a day 5 days a week for all age groups. Physical activities in which older people engage include walking, golf, tennis, and swimming, among others (Kolt, Driver, & Giles, 2004). Walking is the most preferred activity (Belza et al., 2004; Booth, Bauman, Owen, & Gore, 1997; Kolt et al., 2004; Lee, 2005; McPhillips, Pellettera, Barrett-Connor, Wingard, & Criqui, 1989). Compared to other types of physical activity, walking may require less exertion and impose fewer barriers, making it easier to sustain on a daily basis.
Regular walking has multiple physiological and psychological health benefits for older adults. Regular walking has multiple physiological and psychological health benefits for older adults. It can help prevent heart disease (Simonsick, Guralnik, Volpato, Balfour, & Fried, 2005; Wannamethee, Shaper, & Walker, 2000), improve mobility and performance (Melzer, Benjuya, & Kaplanski, 2003; Rantanen, Era, & Heikkinen, 1997; Simonsick et al., 2005; Talbot, Gaines, Huynh, & Metter, 2003), increase physical fitness (Tanaka, Reiling, & Seals, 1998; Wong, Wong, & Shen, 2003), reduce symptoms of depression (Motel et al., 2005), delay cognitive function decline (Weuve et al., 2004), lower the risk of dementia (Abbott et al., 2004), and maintain social functioning (Taylor et al., 2004). Cousins (1998) suggests that frail older people should be encouraged to walk whenever and wherever they can.
However, many older people fail to meet the DHHS exercise standard. According to a Centers for Disease Control and Prevention report (2008), levels of physical activity among two thirds of U.S. older adults were found to be either insufficiently active (36.9%) or inactive (23.7%). Situations in long-term care facilities are even more serious. On the basis of an observational study, Ice (2002) reported that nursing home residents spent only 0.9% of their time walking or 2.0% moving their wheelchairs; very few engaged in more rigorous activities. In addition, other researchers found that it was difficult for older people to change sedentary lifestyles or to adhere to long-term activity programs (Resnick, Nahm, Orwig, Zimmerman, & Magaziner, 2001).
ALFs provide care in home-like settings, which allow people with cognitive impairments or physical deficits to retain their privacy, autonomy, dignity, independence, safety, and choices (Regnier, 2002). Physical activity programs are important ways to involve ALF residents in exercise to maintain their physical functions. In a national survey (Hawes et al., 1999), most ALF administrators (91.4%) reported that they offered exercise programs. However, the effectiveness of these programs in terms of health promotion is not clear, because of a lack of detailed information such as types of physical activity, participation rates, and the frequency of programs offered.
Research on neighborhood environments indicates that safety, aesthetics, the convenience of facilities, land-use mix, and the quality of microscale urban design elements (e.g., sidewalks) influence older people's walking behaviors (Cunningham & Michael, 2004). One study by Joseph and Zimring (2007) reveals that continuing care retirement community (CCRC) residents were more likely to choose walking paths with certain physical characteristics. These characteristics include well-connected routes, good views, multiple destinations along the way, and no stairs. In addition, researchers found that some older people like to walk indoors (e.g., mall walking and corridor walking). Protection from crime and inclement weather, the opportunity to meet with friends, and easy walking surfaces are major reasons for choosing indoor walking (Duncan, Travis, & McAuley, 1995; Joseph, 2006).
The design of walkable ALF environments has become more important because frail older people are increasingly averse to nursing homes and seek a higher quality of life and greater independence living in an ALF. However, it is unclear what kind of environment supports ALF residents' walking. The lack of knowledge in this field impedes the efforts of designers who wish to create activity-friendly ALFs. Therefore, this research topic is timely.
This article presents the results of a series of visits to ALFs and interviews with administrative staff members. Facility visits represent one method to study issues regarding the planning, design, and operation of healthcare facilities (Zimring, 1994). A successful visit, as defined by Zimring, has three components: clear goals, thorough preparation (e.g., site and interviewee selection), and structured examination procedures (e.g., with a checklist or a survey questionnaire).
As part of a larger project, this study explores walking environments for ALF residents. The primary goals were to reveal current situations (e.g., indoor and outdoor walking environments) in ALFs and help develop hypotheses and research instruments for future research. The secondary goal was to provide recommendations for walkable ALF design and renovation. Thus, the scope of the study is broad, covering issues such as: (1) how walkable the environments are in and around existing ALFs; (2) how the design of ALF environments influences walking behaviors; and (3) how ALFs make use of existing environments to promote walking among residents.
Methods
Facility Selection
Facility visits were conducted in a major city in Texas. All facilities listed in the Texas Department of Aging and Disability Services Assisted Living Facility Directory (2006) in the research area were pooled for selection. Additional criteria for inclusion were established according to the research goals, namely that ALFs provide services to older people and have more than 10 licensed beds. (Hawes and colleagues [2003] suggested that facilities with fewer than 10 beds could not be labeled as ALFs.) These criteria were critical because they ensured that research findings would apply to the targeted population and settings. Of the facilities that met these criteria, 47 were contacted by telephone and 34 agreed to participate. However, after the visits, five ALFs were found to be psychiatric institutions with few older residents. An additional three ALFs failed to provide adequate information that was needed for the study (i.e., they would not allow the researcher to evaluate the environment, take photographs, or conduct interviews). These eight facilities were excluded from the data analysis. Thus, this article reports the results of visits to 26 ALFs.
Interview Participants
In each facility, an administrative staff member (i.e., an administrator or the activity director) familiar with facility operations and residents' activities was interviewed. A total of 26 people participated in the interviews.
Instruments
The instruments used in the study were a set of unstructured questions and the Assisted Living Facility Walking Environment Checklist (ALF-WEC) (see Appendix 1).
The unstructured questions queried administrators for their opinions regarding the promotion of walking among residents. The ALF-WEC consists of 53 items regarding facility information (e.g., activity programs), resident characteristics (e.g., number of residents using assistive devices and number of residents walking indoors or outdoors), the presence and the quality of neighborhood environment features (e.g., land-use mix), outdoor walking areas (e.g., sidewalk conditions), and indoor corridors (e.g., floor material, lighting levels, and amount of seating). There are two types of scoring methods: the dichotomized scale (i.e., yes or no) and a continuous scale that uses a 5-centimeter line segment. On the continuous scale, the evaluator places a mark on the segment to indicate the score for an environmental feature.
The ALF-WEC is based on the literature and the results of architectural case studies. The literature search was conducted using three online databases: MEDLINE, ISI Web of Knowledge, and Active Living Research References. Sixteen pertinent peer-reviewed articles were identified. The search was also extended to case studies presented in relevant books (e.g., Regnier, 2002) and conference presentations (e.g., Zimring, Joseph, Nicoll, & Tsepas, 2004). Only the features consistently found in the literature or case studies to be relevant to the walking behaviors of older people were included in the ALF-WEC. This instrument has some limitations. First, it was developed specifically for this project, and its reliability has not been tested. Second, the researcher found that the evaluations that used the continuous scale were not reliable. The reasons are twofold: (1) the measures are subjective, and (2) the ALFs were visited on different days. Therefore, in the data analysis, the researcher changed the continuous scales to dichotomized scales and in this article reports only the presence of certain features of neighborhood environments, outdoor walking areas, and indoor corridors.
Visit Procedure and Data Collection
The visit and data collection proceeded in three steps. First, the researcher walked around the campus and the surrounding neighborhood. Second, he walked through the facility. Third, the administrative staff member was interviewed. In the first and second steps, the ALF-WEC was used to collect facility information (e.g., physical activity programs offered, the number of residents using assistive devices, and the number of residents who walk indoors or outdoors) and to evaluate features of the physical environment (e.g., land-use mix and sidewalk condition). Photographs were taken to record the environment with as many details as possible. Interviews lasted 15 to 20 minutes. The unstructured questions were asked and notes were taken to document facts and opinions reported by the administrative staff.
Data Analysis
Two types of data were collected during the visits: quantitative and qualitative. The quantitative data were analyzed using descriptive statistics such as frequency, percentage, mean, and standard deviation. The content analysis method suggested by Lincoln and Guba (1985) was applied to analyze the qualitative data. This analysis was processed in four steps. First, interview notes were reviewed and grouped into several categories based on “look-like” or “feel-like” grounds. Second, information in the categories was evaluated, and the main theme of each category was identified. Third, another researcher who had not participated in previous phases of the project critically reviewed the analysis procedure, themes, and result interpretations. Then, in accordance with the review, some portions of the data were reanalyzed, and the themes were redeveloped.
Results
The descriptive results include general descriptions of facility and resident characteristics and features of the overall walking environments in and around the facilities. Analysis of the interview notes produced two main themes: residents' walking patterns and administrators' concerns regarding the impact of the environment on the promotion of walking.
General Description
Facility Characteristics (See Table 1)
Of the 26 ALFs studied, half (n = 13) were located in urban areas; nine (34.6%) were in a suburban setting, and four (15.4%) were in a rural setting. The dominant type of ALF was a free-standing facility (n = 16; 61.5%). Some were co-operated with nursing homes (n = 2; 7.7%) or independent living facilities (n = 2; 7.7%). CCRCs also provided assisted living services (n = 6; 23.1%). The size of the ALFs varied widely: the majority (n = 18; 69.2%) were medium-size facilities with 50 to 99 units (apartments); less than one fifth (n = 5; 19.2%) had fewer than 50 units; and large facilities (more than 99 units) were relatively rare, accounting for only about 11.6% (n = 3) of the facilities studied.
Facility Characteristics
Note: N = Total number of ALFs
ALF = Assisted living facility
NH = Nursing home
IL = Independent living
CCRC = Continuing-care retirement community
Resident Characteristics (Walking- or Physical Activity-Related) (See Table 2)
Resident Characteristics
Note: SD = standard deviation
Nearly half of the residents (46.2%; SD = 20.1) used walkers—almost twice as many as those who used wheelchairs (23.8%; SD = 13.5). [Note: some residents used both devices.] Physical activity programs were the dominant means of exercise, followed by walking indoors and walking outdoors. Four of 10 residents in a facility participated in these physical activity programs (38.6%; SD = 16.4). More residents walked indoors (22.7%; SD = 19.5) for exercise than outdoors (15.8%; SD = 16.2).
Walking Environments
Neighborhood Walking Environment (See Table 3)
Walking Environments
Note: N = Total number of ALFs
Land use patterns and neighborhood infrastructure (e.g., sidewalks, roadways, traffic lights) may be two important factors that affect ALF residents' neighborhood walking behaviors. The former determine the number of destinations (e.g., grocery store, mall, restaurant) that residents can walk to; the latter influences walking safety and comfort. The dominant land use patterns were residential (n = 11; 42.3%) and mixed-use (n = 10; 38.5%). Four ALFs (15.4%) were surrounded by business and office buildings. One facility (3.8%) was located in a commercial area. The majority of ALFs (n = 20; 76.9%) were close to roadways with peed limits greater than 30 miles per hour (mph); in Texas, 30 mph is the speed limit for most roadways in urban residential areas. Fifteen such roadways (57.7%) had traffic lights; no traffic-calming devices (e.g., speed humps) were found. Slightly less than three quarters of the ALFs (n = 19; 73.1%) had sidewalks in their neighborhoods.
Outdoor Walking Environment (On-Campus)
As Tale 3 indicates, seven facilities (26.9%) provided looped walking paths encompassing main buildings, which enabled residents to walk around the facility outdoors. On 12 (46.2%) campuses, people could walk on the low-speed driveways or parking lots. Gardens with walking paths were one of the prevalent features of the ALFs surveyed (n = 2; 84.6%). However, destinations within gardes, such as gazebos, pools, and water fountains that could stimulate an interest in walking were found in only half of the 13 facilities (n = 13; 50%). In addition, three facilities (11.5%) had covered walkways to connect different buildings or different portions of a building.
A looped corridor, comfortable seating, continuous handrails, and attractive window views are features that could make indoor walking safer and more enjoyable.
Indoor Walking Environment (See Table 3)
The indoor corridor was a principal place for people to walk. A looped corridor, comfortable seating, continuous handrails, and attractive window views are features that could make indoor walking safer and more enjoyable (Regnier, 2002; Zimring et al., 2004). Only one third (n = 9; 34.6%) of the ALFs had looped corridors where residents could walk continuously without having to turn back. A plurality of the ALFs (n = 18; 69.2%) offered seating along the corridors. Seven of them (26.9%) provided alcoves for seating, which not only avoided obstructions (i.e., chairs) along the walking path but also protected sitters' privacy. Handrails, an important feature that assists frail older people's walking, ere installed in most of the ALFs (n = 24; 2.3%). However, less than half of the corridors (n = 12; 46.1%) provided window views.
Walking Patterns
Walking as a Facility-Level Program
All administrators reported that they had regular group physical activities, yet most of these activities were performed while sitting or standing. Only three facilities offered walking programs. One of these walking programs was called “Morning Community Walk Around,” in which residents walked along an on-campus walking path under the surveillance of staff members. Another facility carried out a similar program. The absence of a sidewalk, however, caused residents to walk on the low-speed driveway and parking lots surrounding the facility building. One facility promoted indoor walking with a program called “Hallway Walk & Roll.” During this activity, people could walk or roll their wheelchairs through the corridors. In two other facilities, administrators reported sending their residents to the local supermarket or the mall to walk once a week. However, the number of participants was small (i.e., 6–8 people), because of the limited capacity of the vehicles. The long distance between the facilities and supermarkets/malls also made it impractical to drive back and forth to deliver additional residents to join in the walking activities. Finally, one administrator reported a “walking to eat” program. Led by the activity director, residents walked to a restaurant on an adjacent block to have meals.
Walking as a Resident-Initiated Activity
Administrators consistently reported residents who walked on their own for exercise. Three facilities indicated that they had walking clubs that had been organized by the residents; club members walked together once or twice a week. In one facility featuring three separate small buildings, a walking path was built on campus. Two covered walkways connected the buildings. Originally, they were used mainly as paths to transfer food from one building to another. Unintentionally, the walking path, the indoor corridors, and the covered walkways formed a continuous walking route. The administrator found that residents used this route for exercise.
In another ALF, which was a six-story facility, different wall colors, furniture, and carpet that offered varying visual experiences were assigned to different floors. A group of residents walked together along the corridors on one floor, took the elevator to another floor, and then continued walking. Walking promotion signage was seen in another facility; it stated that “12 rounds of this hallway equal 1 mile.” The administrator reported that some residents walked every day and actually counted how many miles they walked. Many facilities had courtyards, but administrators mentioned that very few residents used them for walking exercise. They could not account for this.
Concerns Regarding the Walking Environment
Most administrators were concerned primarily about security and safety. Therefore, in most ALFs, residents were advised not to walk off campus. Walking with staff surveillance helps mitigate worries about attack by strangers or being left unattended after a fall. Two facilities reported they had installed wireless alarm systems, providing “unseen” surveillance of residents. If an accident occurs, the resident can push the button on a small device that she or he carries and signal his or her location to the control center. Staff can then quickly locate the resident and provide immediate help.
Overexposure to sunlight was another concern. Too much sunlight can be dangerous to older people, especially those taking medications (such as haloperidol, chlorpromazine, and phenothiazines) that may have sun-related side effects. Thus, some facilities suggested that their residents walk outdoors either early in the morning or at dusk.
Additionally, one administrator suggested that the current design and planning of ALFs may need change in the near future to accommodate Baby Boomers, who may have healthier lifestyles and be more active than the generations currently living in ALFs. Many people wish to maintain their routine activities (e.g., walking) when they move to retirement homes. Thus, as this administrator predicted, a walkable environment may be one criterion of future customers when choosing among ALFs.
Discussion
Results of this study are consistent with previous research that suggests physical environment characteristics, such as safety, land-use pattern, and quality of design elements (e.g., sidewalks) are important for older people's walking behaviors. Previous research on healthier or younger populations, nonetheless, may fall short when conceptualizing walkable environments for ALF residents, who are on average 86.9 years old (National Center for Assisted Living, 2010).
On one hand, the majority of ALF residents have some degree of difficulty with mobility. Most of them are incapable of walking for a long distance; some are prone to falling. As administrators reported, ALF residents' activities are generally confined to the facility campus; they are not encouraged to walk outdoors without surveillance. On the other hand, a small number of residents who are physically healthy and have a desire to walk in the neighborhood remain. Thus, it is necessary to provide diverse walking environments to meet residents' differing needs.
Compared to healthier or younger populations, frail older people need more support from the physical environment for walking. According to Lawton's (1977) theory, people with low competence may have difficulty adapting to a relatively challenging environment. This kind of environment should be modified appropriately, which allows less competent people to function as normally as possible, like their more competent counterparts. For example, some ALF residents may not be able to walk up to higher-level ground by taking the stairs. However, if a ramp with a gradually rising slope is provided, they may be able to accomplish this task, because walking on a ramp requires less strength than walking up stairs.
Facility designers and planners have to take into account the fact that a large percentage of ALF residents use assistive devices (i.e., walkers and wheelchairs). These residents need more space to accommodate such devices. The width of a walking path, for instance, should be sufficient for two people with walkers to walk abreast. Otherwise, a path that is too narrow may discourage walking exercise, because it potentially impedes social interaction, which has been found to be a strong motivator of physical activity (Taylor et. al., 2004).
Walkable Environments for ALF Residents
In accordance with the results of this study, the following discussion of walkable environments for ALF residents focuses on two aspects: neighborhood environments and environments in and around facilities.
Neighborhood Environments
Neighborhood sidewalk systems
Results indicate that a number of ALFs were located in neighborhoods without sidewalks. This makes off-campus walks impossible, because it is unsafe for residents to walk in the road with vehicles or—for those using walkers or canes—to walk on lawns as most younger people do in this situation. A continuous sidewalk system is a prerequisite to promote neighborhood walking among assisted living residents.
Moreover, in this study, the roadways closest to most ALFs had speed limits of greater than 30 mph; traffic lights were found in only about half of the roadways; and no traffic-calming devices (e.g., speed humps) were installed around any of the ALFs visited. In such cases, neighborhoods can still offer enjoyable walking environments if their sidewalks have certain features, such as green buffers (e.g., lawns, flowerbeds, or bushes) between the path and the roadway and noticeable signage (e.g., stop signs and “yield to pedestrian” signs) where older people may cross the street.
Site selection
Facility site selection is important. Locating ALFs in areas with high population density and high land-use mix provides residents with easy access to destinations such as restaurants, supermarkets, cinemas, and the like. Residents can—as the results show—walk as a group accompanied by staff or family members, which may mitigate concerns about crime and accidents (e.g., falls and traffic accidents). Facilities located adjacent to destinations may also engage more residents in group activities, such as mall walking. For example, if a mall is nearby, the facility van, which can accommodate only 8–12 residents, can go back and forth to deliver more residents to the activity. Thus, with the assistance of a few staff members, residents may have to wait only a short time to get together and walk.
Environments in and Around Facilities
Walking under staff surveillance
Unattended falls are dangerous to older people. Research reveals that falls are the most frequent cause of injury-related morbidity and mortality among community-dwelling older people (King & Tinetti, 1995). One way to avoid unattended falls is to build walking paths close to the building, where staff can oversee residents from indoors (see Figure 1). One technology that administrators mentioned—a wireless alarm system—allows some degree of flexibility in ALF site planning: It provides extended surveillance while not requiring staff members to actually see residents. However, the system does not work if a resident walks beyond its range or the resident does not know how to operate the device correctly.
Building a walkway close to a facility can help prevent unattended falls. It allows staff members to oversee the walkway from indoors and provides surveillance for residents who are walking outdoors.
Outdoor walking areas
The results indicate that ALF residents walk on walking paths or walking spaces (e.g., low-speed driveways and parking lots) for exercise. Looped walking paths/spaces, shade, and seating are critical to ALF residents' outdoor walking. Looped walking paths/spaces support continuous footsteps, where residents are able to keep walking without having to turn back. Shade from trees or structures (e.g., trellises) can protect older people from overexposure to sunlight (see Figure 2).
A covered walkway can protect older people from overexposure to sunlight.
Seating along walking paths is important in three respects: (1) It provides a rest area for those who are too tired to continue walking; (2) it affords a sense of control to those who are unsure how far they can walk; and (3) it encourages outdoor social interactions. Among the ALFs studied, only a small number of facilities had looped walking areas; some had seating along the paths/walking areas; and a very few facilities had covered walkways or well-shaded walking areas.
Indoor walking areas
Corridors are the main venue for indoor walking. As with outdoor walking, a looped walking path and seating are important. As mentioned earlier, placing chairs in alcoves can clear the walking path and protect people's privacy (see Figure 3). In addition, window views can make indoor walking more attractive: They provide indoor walkers with a pleasant visual experience and a sense of connection with the outside world (see Figure 4). Unfortunately, fewer than half of the ALFs studied had window views from the corridors. Another crucial feature is handrails, which were found in most of the ALFs. Handrails help residents who use a cane or have no assistive device to maintain balance while walking. Although walking promotion signage was seen in only one facility, it proved to be a good incentive for walking by informing residents how many miles they had completed.
Placing chairs in alcoves can clear the walking path and protect people's privacy.
Window views provide indoor walkers with a pleasant visual experience and a sense of connection with the outside world.
Locations Where ALF Residents Like To Walk
The results show that ALF residents walked both indoors and outdoors. The percentage of residents who walked indoors was higher than the percentage of those who walked outdoors. However, this should not be interpreted simply as residents' preference for walking indoors. When analyzing the data, the authors found that where residents chose to walk depended on (1) weather conditions; (2) the quality of the indoor and outdoor environments; and (3) residents' physical and psychological health status. Nevertheless, it is worth noting that walking indoors is one of the major modes of exercise for ALF residents. This finding has practical implications for both designers and administrators, especially those designing or operating facilities in areas with long hot and/or cold seasons.
Some administrators mentioned that courtyards were not used for walking. There are several possible reasons for this. First, most courtyards had only one or two short paths, providing limited choice and distance for walking. Second, some courtyards were not visible from inside the buildings, which may not have engaged potential users. Third, courtyard entrances were removed from the main indoor walking routes. In addition, most courtyards were surrounded by windows, affording little privacy (see Figure 5). Last but not least, smoking areas were generally located near one of the entrances to the courtyards. Nonsmokers tended to avoid these areas.
This courtyard was surrounded by windows, offering little privacy.
Implications for Current Practice in ALFs
The findings of this study suggest two ways for existing facilities to involve more residents in walking: Institute a walking activity program, and improve the quality of indoor and/or outdoor walking environments.
Integrating Walking Into Exercise Programs
According to administrators' reports, walking programs could motivate many residents to walk. Facilities can make use of existing environments (outdoor walking paths; on-campus, low-speed driveways; or indoor corridors) to integrate indoor or outdoor walking into their routine exercise programs. Walking as a group can reduce the incidence of falls, increase positive social interaction among residents, and create a sense of community. These benefits may, in turn, help improve residents' adherence to the program.
Improving the Walkability of an Environment
Changing the physical settings of ALFs requires more time, funds, energy, and determination than creating activity programs. However, it may fundamentally alter people's lifestyles by providing activity-friendly environments. This study suggests that even a small change in the environment (e.g., posting signage that promotes walking) can effectively encourage people to walk. Inside buildings, adding chairs at appropriate locations and installing handrails will increase frail older people's confidence in walking. Outdoors, constructing looped walking paths will support continuous footsteps, and planting more trees will not only provide shade along the path but also improve the visual quality of the whole environment.
Limitations
The research design limited the generalizability of the findings. For example, the results would be different if alternative facilities and interviewees had been selected; and other researchers may have interpreted the qualitative data analyzed by the content analysis method differently. In addition, the goal of the study was not to test specific hypotheses but to reveal the current situation in ALFs and generate research questions for future studies. Therefore, the results are presented by means of descriptive statistics and qualitative interpretations, which should be further examined by empirical research. Another limitation is that the reliability of the research instrument (i.e., the ALF-WEC) has not been tested, which could generate unreliable findings. Moreover, the data were collected during the summer, when temperatures were around 85–95°F. This also may have biased the results. Additionally, residents' characteristics (such as the number of people who walked regularly indoors and outdoors) were reported by administrative staff members, not collected through direct observation. There may be discrepancies between the reports and actual behaviors.
Conclusion and Directions for Future Research
Residents of ALFs walk both indoors and outdoors for exercise or other purposes (e.g., to reach destinations). ALF planning and design details—such as neighborhood sidewalk conditions, facility site selection, availability of seating, walking path configuration (e.g., looped/non-looped path), amount of shading along the path, presence of handrails, signage, etc.—may influence residents' walking behaviors. Current ALFs need improvement in all these aspects to make the environments in and around facilities more walkable for residents.
This study contributes to the conceptualization of walkable environments for frail older people and the accumulation of evidence for creating environmental interventions to facilitate active living in ALF settings. Furthermore, several topics worthy of future research emerged: (1) residents' perceptions of their walking environments; (2) the physical features of walkable indoor corridors in ALFs; (3) the physical features of walkable outdoor spaces at ALFs; (4) the integration of activity programs and existing walking environments; and (5) physical environmental interventions to improve exercise adherence.
Footnotes
Acknowledgment:
The author thanks Drs. Mardelle Shepley, Susan Rodiek, Louis Tassinary, and Michael Duffy for their suggestions on research design, and Dr. Mardelle Shepley for reviewing this manuscript. This project was supported by the Nurture by Steelcase—Center for Health Systems & Design Dissertation Grant.
Appendix 1. The Assisted Living Facility Walking Environment Checklist