Innovative solutions to enhance safe and green environments for ageing well using stakeholder co-design.

There is a need to develop innovative solutions to enhance safe and green physical environments, which optimise health, wellbeing and community participation among older adults. In order to develop solutions that meet the needs of a diverse ageing population, an interdisciplinary approach is needed. Our aim was to identify the needs of older people in relation to ageing well in the environment by bringing together knowledge from different stakeholder and interdisciplinary perspectives. An international consortium (Retrofit living For ageing well through Understanding and Redesign of Built environments consortium: ReFURB) was established in April 2018, including ten core members, to (i) explore cutting-edge solutions to safe living for ageing populations and (ii) develop innovative approaches to everyday physical environments, which bring about health benefits. We used a co-design, interdisciplinary framework involving older adults, carers, physiotherapists, geriatricians, engineers, human movement experts, geographers and psychologists from the UK and Australia. This engaged people in a one day workshop that comprised a series of presentations from international speakers on urban design, social connectedness, hazards and injury prevention, and the physical environment. Small group discussions (facilitated by consortium members) followed presentations to consider the opportunities, challenges and barriers encountered with ageing, which included the use of creative engagement activities (LEGO® Serious Play, mind maps, poster gallery walk), to help participants share personal stories and reflect on the issues raised. Thematic coding was used to synthesise the outputs of the small group work.

Five themes emerged across the workshops, comprising: access and transport; involvement of the whole community; restoration rather than redesign; assistive and digital technology; and intergenerational approaches. These dimensions related to the physical, social and nature-based qualities of everyday environments, as they pertain to ageing well.

Conclusions
Co-design was a valuable tool that helped understand the perceptions of stakeholders and essential to develop effective interventions and solutions. Participants highlighted several issues affecting people as they age and key environmental considerations to promote wellbeing, activity, and participation. The consortium identified gaps in the existing evidence base and are now planning activities to further develop research ideas in collaboration with our co-design participants.

Background
Over a decade since the World Health Organization's recommendation for 'age-friendly cities' [1], the built environment continues to pose major hazards (e.g. falls due to uneven terrain) to older adults [2], which contribute to reduced community participation.
Characteristics of the outdoor environment -such as uneven and wet surfaces, hazards on pavements and kerbs -have been identified as risk factors for falls in middle-aged and older adults [3]. Physical inactivity is also a major public health concern, with older adults being one of the most sedentary age groups [4], which heightens their risk of mortality, metabolic disease and obesity. Emerging evidence suggests that outdoor physical environments pose significant challenges across the adult lifespan, and may not be fit for purpose to support active and independent living into later life [5,6].
Redesign of the built environment, informed by new knowledge of how older adults engage with their surroundings, is attracting growing attention as a means through which to improve health and wellbeing in old age [6]. Worldwide, new urban design initiatives are emerging to transform public spaces, increase physical activity, participation, and social interaction, and reduce the growing burden of chronic diseases, in older adults. Notable recent developments include exercise parks fit for older people's purpose [7,8], smart home technology [9], dementia villages [10], and scoping of 'walkable' neighbourhood design features [11]. Sales et al. [8] reported that short-term use of a novel exercise park improved physical function in older adults, and was associated with high rates of adherence and participation. However, safety aspects of purpose-built outdoor exercise areas -for example where there is limited control over climatic and environmental changes -require further consideration [7]. Other groups have reported that the immediate physical environment surrounding an older person's home, and opportunities to participate in exercise within a social setting, are most important to support physical activity participation [12].
Related to this, social connectedness is a major factor underpinning older adults' community participation, and therefore, environments designed to encourage interaction with others may be most effective in supporting healthy, active ageing. Several studies have explored the concept of 'active transport' and evaluated the key features of 'walkable' and pedestrian-friendly neighbourhoods, as a potential route by which to encourage physical activity in older adults [11,13,14]. Street connectivity, mixed land use [15], ease of access to destinations and transport and shared routes for walking and cycling are critical factors to consider in urban planning in order to help increase pedestrian activity at concentrated areas (e.g. shopping centres) which are meaningful to, and frequently visited by, older people [11]. As important as utilisation of those spaces is people's sense of connectedness, identification and belonging to the community within which those spaces exist (i.e., their neighbourhood or community identity). Such community belonging -reflected in people's sense of social identification as us Glaswegians or us East Enders, for example -enables access to a range of psychological resources (support, control, resilience, self-esteem, etc.) that have recognised benefits for health and well-being [16]. Particularly relevant to the present context is the positive role that such identification plays in supporting mobility [17]. Thus, finding an optimal balance in land mix, specifically urban infrastructure and green space (such as parks, gardens, woodlands and green trails), and community identification is critical. Overload of environmental stimulation, including neighbourhood retail destinations and high urban density, may negatively impact on psychological wellbeing and cognition in later life [18,19].
Connecting with nature within and beyond our built environments, including green and blue spaces, can also play a major role in promoting healthy ageing [20], with reported mental health benefits for middle-aged and older adults [21][22][23][24]. Evidence suggests that people who live in the 'greenest' communities are at lowest risk of presenting with psychological distress, and tend to adopt more physically active lifestyles, allowing them to experience nearby nature [21]. Novel strategies have been implemented to facilitate interaction with green spaces including community walking maps [25] and social walking groups [26], to discourage sedentary behaviour and help older adults reap the health benefits from these surroundings and social interactions. Having a greater abundance of parks, located within close proximity to older people's homes may be one solution to increase physical activity [27]. However, overcoming challenges in maintaining parks that are safe, accessible, clean, attractive and nuisance-free, may determine the extent to which public green spaces are utilised [6]. For older adults with a cognitive impairment, such as dementia, sensory gardens may offer therapeutic effects on psychological wellbeing and behaviour, if well thought through and carefully designed [28]. Similarly, blue spaces (e.g. lakes, oceans, coastal regions) may also contribute to therapeutic landscape experiences, which can promote wellbeing in older people [29]. Participation in water-based activities such as surfing [23], or simply exposure to a visible blue space [30], have been shown to reduce psychological distress, specifically anxiety and depression, in middle-aged and older adults.
Whilst evidence suggests there are multiple factors that play a major role in 'healthy and active ageing', it is not clear which factors are considered most important by older people.
The thoughts and personal experiences of older people are critical to inform the development of research agendas and projects that address the current and future needs of ageing populations. Without knowledge of older people's priorities, concerning their interaction with everyday outdoor environments, it is unlikely that any solutions (exclusively designed by researchers) to enhance 'ageing well' would be effective or attract user engagement. Our aim was to identify the needs of older people in relation to ageing well in the environment by bringing together knowledge from different stakeholder and interdisciplinary perspectives.
To undertake this and wider research, the National Institute for Health Research (NIHR) recommends that patients and members of the public should be involved in identifying and prioritising topics, and in designing, monitoring and evaluating their outcomes [31].
An active partnership with patients and publics, initiated at an early stage in the research process can provide researchers with critical insight of lived personal experiences (e.g. what it is like to be an older person), which are used to inform the development and implementation of health research that is more relevant to the end-user. Patient and Public Involvement (PPI) can therefore be highly beneficial in developing, clarifying and affirming the importance of meaningful research questions, prior to seeking research funding. In this paper we report on the impact that stakeholder engagement and PPI had on identifying the research priorities for an international consortium, whose objective is to develop cutting-edge solutions to enhance safe, green everyday environments for ageing well. Key stakeholders including members of the public were specifically involved in the 'Identifying', 'Prioritising' and 'Design' stages of the research process, as a means to help plan the consortiums' future work. Creative engagement activities were implemented during the PPI process to facilitate communication of tacit knowledge and shared understanding. Our use of creative activities, over other forms of engagement activities (e.g. involvement in steering committees), overlook power and epistemic injustice, where the knowledge (and voices) of non-academics are typically underprivileged in such 'coproduction' settings. Creative methods can assist in rebalancing this injustice by offering an 'alternative' mode of sharing and communicating that is familiar to all, yet uncommon in research settings, which typically use written and spoken 'jargon filled' words in ways that are often exclusive [32].

Conception of an International Consortium
In April 2018, an international consortium of academics from The University of Queensland The planning meeting included facilitator training in several creative engagement activities, specifically LSP, goal-directed personas, and mind maps. Upon using LSP for the first time, the group were instructed in how to conduct 'creative warm-up exercises' for familiarisation purposes. This included building a model that represented a concept, to which all could relate (e.g. your home town). LSP methods were then used in a similar manner, to consider 'challenges to ageing well'. The group also experimented with the use of goal-directed personas, whereby each person created a persona using a male or female body silhouette that represented themselves as an older adult (20 + years in the future).
This model was used to help the group reflect on the perceived physical, psychological, environmental or social relational needs of older adults. However, given that workshop participants represented a breadth of ages across the lifespan (and so older delegates would need to create personas that captured their current self, rather than future needs), it was agreed that LSP would be a more widely accessible engagement tool.

Stakeholder Engagement Workshop (Day 2)
Day two was the main co-design event that involved a wide range of participants.
Workshop participants were recruited by invitation only, to ensure attendance from individuals with complementary expertise, from across a range of disciplines, professional and public sectors. The delegate list was compiled by two consortium members (VG, ALH) with input from the wider group, and included 44 individuals or organisations who received an invitation to attend the workshop (or identify a relevant person) via email. PPI representatives were identified through the local University of the Third Age and the Peninsula Patient Involvement Group. We aimed to recruit 40 participants, who could be divided into four groups of ten for each of the small group discussions. Refreshments were provided and members of the public who attended the workshop were reimbursed for their time and travel expenses, in accordance with INVOLVE guidelines (a UK government funded programme which supports active public involvement in National Health Service, public health and social care research) [33]. Ethical approval was not required [34].
The workshop was opened by a keynote presentation on Active Ageing given by a senior figure from Age UK (the UK's largest charity for older people). This was followed by four key themed presentations, to which the subsequent small group discussions would be anchored: Theme 1) Urban design and active ageing; Theme 2) Built environment: hazards and injury prevention; Theme 3) Natural and sensory environments; Theme 4) Social identity and connectedness.
The facilitated small group discussions allowed participants to share their perspectives on concepts presented within each themed talk. The small groups each had two facilitatorsone being the speaker who delivered the talk linked to the theme, and the second a ReFURB consortium member, with at least one having attended the facilitator training session. The discussions commenced with the facilitators re-defining the relevant workshop theme, for example, clarifying what is meant by the term 'urban design' or 'social connectedness' and asking participants how they interpreted these terms, in light of their own personal experiences. Within each group, the following initial question was posed; "What are the challenges or barriers [for example, concerning the built environment]?" Using LEGO®, participants were then asked to build a representation of one challenge they had identified, and to write their idea on an accompanying label. Once all participants had constructed their LEGO® model, each member of the group described the challenge, and explained what different elements of the model signified (e.g. layered LEGO® blocks representing uneven terrain). Extended discussion of the LEGO® models was facilitated using the following standard questions across all the small groups: "Can the challenges be grouped or joined?"; "Where are the similarities in the challenges?" and; "What do you think will be the greatest challenge in the future?" Where possible, the facilitators encouraged participants to share practical examples, for example, "loss of memory" was considered a generic idea, whilst "not being able to remember my grandchildren's names" provided greater specificity.
Following the LEGO® design activity, each group was asked to collaboratively create a mind map detailing the perceived 'needs' and main issues within the theme. To engage all participants in the discussion of the four workshop themes (rather than just the theme to which they had self-assigned), a 30-minute poster gallery walk was conducted, during which the mind maps created by all four small groups were displayed. Participants were encouraged to add additional thoughts and ideas to the posters, and to place a mark next to existing comments with which they strongly agreed. One of the small group facilitators thematically coded data captured on the mind maps that were created by participants during the small group discussions (Table 1), along with any other written materials collated throughout the day.

Small Group Work
During the LSP activity, workshop participants created a range of models, which represented their perceived challenges or barriers to ageing well (Fig. 1). Following this, each small group created a mind map, which pooled the 'needs' identified by participants within each of the four themes (Fig. 2). Table 1 summarises the main points documented within the mind maps. During the group activities, participants were asked to consider whether there were any similarities in the challenges identified, and if any challenges could be grouped together. This discussion process subsequently led to the creation of subthemes within each of the four themes ( Table 1). The four main priorities, with accompanying possible solutions, identified during the small group discussions are presented in Table 2. Notably, the four priorities within each core theme represent the initial ideas from participants in each respective small group. These initial ideas were then expanded by other workshop participants during the poster gallery walk, as a means to encourage a wider collaborative approach to ideas generation. The final priorities were subsequently selected by the original small group discussion members within each core theme. Over the course of the workshop, the artist in attendance captured ideas and discussions during the talks and small group work to produce an infographic (Fig. 3). sharing of ideas between groups. Although the day was structured around four initial themes, activities identified five cross cutting themes which should be considered when planning research and policy changes to promote active ageing.
The first cross-cutting theme was 'Access and transport'. At the outset of the workshop, there was a strong emphasis on how to enhance the design of specific locations (e.g. houses, parks, shopping malls), overlooking the means by which these spaces are accessed in the first instance. Participants' feedback demonstrated a common trend pointing to the need to consider how people 'travel to and from', and 'access' diverse everyday environments, in order to interact with them. Accessible transport options impact on social inclusion and independence [35]. Ensuring older people, including those living with illness, impairment, and disability, can remain active within and beyond their own communities requires a rethink in current transport strategies [36]. Proportionately more older people live in rural communities, when compared with their urban counterparts and this poses challenges for transport services to meet the needs of geographically unequal population distribution [37].
Whilst the consortium had acknowledged the critical role of 'social connectedness' within healthy and active ageing, this was largely confined to interaction with other people.
Priorities for workshop participants indicated that the concept of connectedness should extend beyond friends and family to the 'Involvement of others/community' [38][39][40]. It was recommended that the consortium also consider the role of, and interactions with, animals, pets, transport personnel (e.g. bus drivers who facilitate access to the environment), shared-living to address loneliness, and the need for a sense of purpose and social responsibility.
A primary aim of the consortium was to develop innovative solutions to enhance green diverse outdoor environments, for example through the creation of novel assistive devices and state-of-the-art interior design. Contrary to this assumption, participants indicated that 'Restoration rather than re-design', of such environments in the short-term was of greater importance to ageing well. There was a strong emphasis on making use of "what we already have" rather than attempting to reinvent the wheel, with recommendations that we focus on developing strategies that facilitate 'adaptation' to the existing environment and one which supports a sense of agency, independence and autonomy for the older adult. Large scale urban design projects often involve rapid physical transformation of city and community environments which can impact on local identity and social networks [41].
Workshop participants supported the high potential for new 'Assistive and digital technologies' to enhance the safety of older adults. Specific recommendations from participants included the development of technologies that address 'hazard awareness' (e.g. pedestrian safety). As well as being used for safety, assistive technology can affect where and how people live for example, driverless cars and smart homes [35]. Technology can also be used to reduce social isolation [42] and can improve care and quality of life [43], yet concerns were also identified around privacy, monitoring and digital exclusion.
Throughout the workshop talks and small discussion groups, the consortium had presented ideas that were exclusive to older adults. Whilst this approach was rooted in the overarching theme of the workshop, being 'healthy and active ageing', it became apparent that we should extend our focus to consider adults across the lifespan and experiences across different age cohorts. Interactions between younger and older adults were viewed by participants as being critical for physical and social wellbeing [44], and a recent review has highlighted that intergenerational contact can reduce ageism [45]. With no real understanding as to when 'ageing' begins [46], there is no strong rationale to limit the consortium's remit to older adults but to have an inclusive approach that enables all to realize their potential for physical, social, and psychological well-being throughout the life course [47]. It is also important that our future work adopts an intersectional approach, which additionally considers how experiences across different genders and ethnicities impact ageing well.

Strengths And Limitations
One of the strengths of our approach was using creative methods that have been shown to facilitate the articulation of tacit knowledge [48] and develop a shared understanding through co-production [49]. Creative engagement activities, as part of the PPI process, can also help to rebalance power and epistemic injustice between academics and nonacademics [32]. Further strengths of this work include our interdisciplinary learning approach, which sought to bring divergent perspectives together, to create a shared vision concerning solutions to enhance ageing well.
There were, however, several limitations to this work. First, it is important to acknowledge that stakeholder engagement activities attract a self-selecting group of participants, who may not be representative of the wider population [50]. Our participant recruitment strategy was by invitation only, and predominantly included individuals within the consortiums' established networks. It is possible this approach to participant selection may have attracted individuals who were supportive of the consortium's work and research agenda. Second, whilst the ReFURB consortium includes core members from the UK and Australia, the workshop was only delivered in the UK. Findings from the workshop may not be applicable to older adults living in other countries, such as Australia, in light of urban, social, cultural, and geographical differences. Third, the workshop talks and small group discussions were not audio or video recorded, in order to ensure participant anonymity and confidentiality, and protection of intellectual property. Whilst the facilitators did take notes during all sessions, and workshop participants were encouraged to document their thoughts and ideas on paper during the LEGO®, mind map and poster gallery walk activities, it is possible that some data may have been lost in the absence of recordings. Details of in-depth conversations and discussions, offering rich data concerning participants' perceptions, may not have been captured within the abbreviated mind maps and posters. We also felt that recording the small group discussions may have made group members more reluctant to share their views. Fourth, the workshop was designed around four a priori themes, which the consortium deemed to be important for ageing well. Whilst participants did not have the opportunity to create their own individual themes, their perspectives did contribute to the shared outcomes of the workshop.

Conclusions
The engagement work reported in this paper provided critical insight into the personal experiences of ageing participants from different perspectives, the challenges encountered when interacting with diverse everyday environments, and possible solutions.  Example of a LEGO® Serious Play design innovation created by participants during the small group discussions.

Figure 2
Example of a mind map capturing participants' perceived challenges and needs within the workshop themes. Infographic of the key themes, discussions, and feedback from the workshop.

Supplementary Files
This is a list of supplementary files associated with the primary manuscript. Click to download.