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Outdoor Space for Aging: Environmental Assessment and Survey of Assisted Living Residents and Staff

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Outdoor Space for Aging:

Environmental Assessment

and Survey of Assisted

Living Residents and Staff

Espacios abiertos para la vejez: contribución ambiental y la perspectiva de los residentes y el staff asistidos

Susan Rodiek (Texas A&M University)

PROJECT ABSTRACT

OUTDOOR SPACE is an important component of residential care settings, and may potentially benefit the health and quality of life of aging residents. How-ever, the usability of outdoor space depends largely on appropriate architectural design: where are the outdoor spaces located, how do they connect with indoor circu-lation routes, and how does the building envelope help shape the spaces? This study explored usable outdoor space from the perspective of assisted living residents and staff (N = 1490) at 68 randomly selected facilities, located in three climatically diverse regions of the U.S. Written surveys and videotaped interviews documented

outdoor usage and preference for specific environ-mental features. An environenviron-mental assessment tool was developed to evaluate the main outdoor spaces and indoor-outdoor transition zones at each facility. Results found that outdoor usage was significantly correlated with residents’ physical activity levels, overall health, and satisfaction with the environment.

PROBLEM STATEMENT

Why do older residents need outdoor space?

Recent research has found that spending time outdoors can have significant health benefits for older adults. Improvements in mood, sleep patterns, and hormone balance may be associated with outdoor usage, partly due to increased physical activity, exposure to bright outdoor light, and contact with nature elements (Babyak et al., 2001; Rodiek, 2006). For example, a large study in Tokyo found better health and significantly increased longevity in older adults with better access to outdoor green spaces (Takano et al., 2002). Seniors

have been found to value outdoor space, and it is likely that even moderate amounts of time outdoors may potentially improve physical health and psychological well-being.

Figure 1. Usable outdoor space can provide connectivity between buildings.

Why is outdoor space often under utilized?

In spite of known benefits and apparent interest in going outdoors, it is widely reported that many outdoor areas at existing facilities are under utilized (Cutler & Kane, 2005; Kearney & Winterbottom, 2005). While el-derly residents have been found to highly value outdoor access, they may be discouraged from going outdoors by poor facility design and layout. With little or no increase in cost, the senior housing industry could en-courage outdoor usage by using evidence-based design principles in planning outdoor space. Unfortunately, few studies have attempted to measure the relationship between outdoor space design, and subsequent usage by residents and staff. The following example shows how direct field observation helps us better understand residents’ needs and preferences:

“A story that illustrates this issue involves housing in an Eastern city. The architect concerned with noise and fumes from traffic along an adjacent street sited the building away from this potentially annoying source. (An enclosed courtyard was created that)…included bench seating and other activities. Residents, however, found the street activity far preferable to the passive, deadly inactivity of the courtyard. Every day residents would carry light aluminum chairs around the building and position them to take full advantage of the activity along the heavily trafficked street away from which the building had been carefully oriented.” (Regnier 1985, p. 4)

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PURPOSE OF THIS STUDY

Main objectives

This study focused on learning more about seniors’ needs for outdoor access, so that future facilities may be designed to encourage optimal use of the outdoors, in order to potentially benefit residents’ health and quality of life. A major goal was to complete a more comprehensive examination than was previously available on this topic. Specific objectives were:

- Assess a large number of facilities and residents in diverse climates

- Develop an objective tool that could be used to evaluate outdoor environments

- Examine how design affects outdoor usage and environmental satisfaction

- Develop strategies for applying evidence-based principles to design projects

This preliminary report provides descriptive find-ings and correlations between outdoor usage and satisfaction with 1) resident demographic factors, and 2) resident assessment of outdoor features and quali-ties, as well as correlations between staff and resident surveys.

Figure 2. Outdoor areas can support multiple behavioral goals: security, autonomy, social interaction, contact with nature.

METHODS: ENVIRONMENTAL ASSESSMENT TOOL

Creating a valid instrument

A focused literature review was conducted on published best-practice design guidelines and recent research in the fields of gerontology, therapeutic landscape design, and environmental design for aging, based on relevance to this topic. From this review, an

annotated matrix of specific design recommendations was developed, which was compared and correlated to develop themes. After cross-referencing and combining the design elements that appeared most frequently, several main categories emerged as being most important. These were then organized into seven categories according to the behavioral motiva-tion or “affordances” provided for residents, rather than by different types of environmental elements (Figure 2 exemplifies this approach). This would allow future studies to compare outcomes from environ-mental interventions with the behavioral goals that have been established for the overall well-being of older adults. While many of the published guide-lines used for reference were based on practitioner experience of designers and care providers rather than scholarly studies, the high levels of agreement between widely different sources helps to validate this information source and the resulting environmental assessment instrument. See Regnier (2002) for a com-parative overview of behavioral goals compiled from multiple sources.

Creating a reliable instrument

After repeated pre-testing and revision, teams of evaluators visited different long term care facilities, and used the instrument to evaluate the outdoor space and indoor-outdoor connections. Inter-rater reli-ability testing on the seven domains was surprisingly high, even when evaluators were included with no prior knowledge or experience in this field. Intra-class correlation coefficients (ICC) were well above .90 on many of the separate principles and overall ratings, with a mean overall correlation of .93 (correlation of .70 is often considered minimally reliable; higher scores are considered good).

Seven Principles of Outdoor Space for Aging

Based on analysis and categorization in the litera-ture review and matrix, the following “seven princi-ples” were developed as the main elements included in the assessment instrument. Data were also collected on several other potentially relevant issues at the facility-wide level (e.g., outdoor activity programs, children’s playgrounds, policies toward pets, staff at-titudes toward residents’ outdoor usage, ambient light, and noise levels in outdoor spaces). The underlying assumption is that all the environmental principles are hypothesized to encourage and support outdoor

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usage by residents. The principles are described below in terms of the features/ qualities they would have in ideal circumstances:

1. CONTACT WITH THE WORLD BEYOND THE FACILITY: This outdoor area provides contact with the larger world residents have left behind, by creating opportunities to watch and/or interact with people, elements, and/or activities beyond the facility – this may include mail deliveries, nearby roads, etc.

2. INDOOR-OUTDOOR CONNECTION: This outdoor area is extremely easy to see and reach, be-cause the doorway is very visible and convenient from the main indoor places where residents spend time. Comfortable transition zones are located both inside and outside the doorway, making it easy to linger near the doorway.

3. FREEDOM, CHOICE, and VARIETY: This outdoor space tends to foster a sense of freedom in residents. The physical environment supports their autonomy and independence by providing a variety of locations, activities, focal points, views, seating, etc., that allow residents to choose among alternatives.

4. COMFORTABLE AND ACCESSIBLE: Residents have little difficulty navigating and using this outdoor area in comfort, because it is designed and main-tained with their diminished physical, functional, sensory, and cognitive abilities in mind.

5. ENJOYMENT OF NATURE: This outdoor area allows residents to view, enjoy, and relate to a variety and abundance of nature elements, especially those found to be preferred by older adults, such as flowers, greenery, trees, water, and wildlife.

6. PLACE TO BE ACTIVE: This outdoor space provides well-landscaped, safe, and comfortable walk-ways. It may also provide places for feasible activities such as games, stretching/ exercise stations, swim-ming, etc.

7. SAFE AND SECURE: This outdoor area al-lows residents to feel safe and secure while outdoors, especially in terms of the risk of falling, because it is designed and maintained to minimize elements that may be hazardous or dangerous.

Figure 3. Resident getting exercise on outdoor walkways

Conducting environmental assessments

At each facility, the most heavily-used outdoor areas were identified and evaluated separately, using a checklist. Evaluators used a scale from 1-10 to rate sets of sub-principles (total = 63) listed under each of the seven main design principles (these scores were later averaged to obtain the overall rating for each principle, in each of the outdoor spaces). Two trained research assistants independently completed the assessments; their scores were averaged for the final ratings. The same two individuals conducted the environmental assessments at all facilities and regions throughout the study, to reduce confounding factors. Assessments were scheduled at the times of year determined to have the most favorable weather conditions for each region, according to recent NOAA weather records (National Ocean and Atmospheric Administration, 1997-2007), in order to increase the

likelihood of resident outdoor usage during the study. No assessments were conducted in extreme conditions such as rainstorms or weather that was locally consid-ered unseasonable.

METHODS: RESIDENT AND STAFF SURVEYS

Developing appropriate questionnaire forms

The pencil-and-paper survey forms were designed specifically with the needs of older adults in mind, so they would be easy to understand and respond to, and not have so many questions they would be fatiguing. The typeface, questions, and response formats were pre-tested extensively with residents in non-partic-ipating facilities; all were revised several times to make the survey as clear and effortless as possible for

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residents. Staff surveys were designed to be completed very quickly. The final surveys had 44 questions for residents, and 40 for staff; both included optional write-in response categories.

Choosing regions and facilities

Of the ten largest “megapolitan” areas currently emerging in the U.S., three were identified as having the greatest comparative diversity of climate: ‘Gulf Coast’, ‘Midwest’, and ‘Cascadia’ (Lang & Dhavle, 2005; Fovell & Fovell, 1993). As assisted living facili-ties are more prevalent in urban areas (Hawes, 2003), this study was conducted in the largest city at the core of each of these megapolitan areas: Houston, Chicago, and Seattle (see Figures 4, 5). This provided examples of: a warm-winter climate with very hot summers (Houston), a moderate-summer climate with very cold winters (Chicago), and a year-round mild-temperature climate with high levels of rainfall (Seattle).

Recruiting facilities, residents, and staff

Within each region, a two-hour driving diameter was established that included the majority of assisted living facilities found in that vicinity. From this area, the participating facilities were randomly selected from the state list of all registered assisted living fa-cilities with resident capacity of 50 or greater. Facili-ties were recruited by telephone, with a participation acceptance rate of about 70%. About 15% of partici-pating facilities were not-for-profit; the remainder were for-profit. A randomized selection process for individual participants was pre-tested and deter-mined to be unfeasible within the constraints facilities typically operate under, so residents and staff were recruited directly by facility administrators. About 80% of participating residents, and 90% of staff, were women. Staff were recruited from all levels, in fairly equal numbers. The average resident age was 84, and the average staff age was 44. A team of research as-sistants traveled to each facility, and helped residents fill out survey forms as needed.

Figure 4. Primary emerging megapolitan regions in different climates (Lang & Dhavale 2005)

Figure 5. Cities used in this study: Houston, Chicago, and Seattle

ANALYSIS AND RESULTS

Data preparation and analysis

Surveys were coded during data entry to protect the confidentiality of responses. Environmental assess-ments and surveys were aggregated into a database, so individuals and facilities could not be identified. De-scriptive statistics were prepared using SPSS software, and correlational analyses used Spearman rho and Pearson correlation coefficients.

Survey highlights

The surveys indicated that residents and staff had strong interest in using outdoor space at their residen-tial communities, with about 95% of both categories indicating they cared about spending time outdoors. About 65% of residents said that spending time outdoors made them feel “better than before”, and a surprising 95% of staff reported feeling better after being outdoors. Over 80% of residents preferred to do their walking “mostly outdoors” or “half indoors/ half outdoors”, but about 40% reported that walkways and

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outdoor areas were either “not very well-designed” or “partly well-designed” for seniors.

Residents’ survey results compared with their outdoor usage

The factors that were found to be associated with levels of outdoor usage are shown in Table 1, with the higher numbers showing stronger correlation.

It was found that residents who spent more time

outdoors: t)BECFUUFSTFMGSFQPSUFEIFBMUI t3FQPSUFECFJOHNPSFQIZTJDBMMZBDUJWF t%JENPSFXBMLJOHKVTUGPSUIFTBLFPGFYFSDJTF t)BEGBNJMZWJTJUPSTXIPBMTPVTFEUIFGBDJMJUZ outdoor areas

It was found that residents who spent less time

outdoors:

t8FSFNPSFDPODFSOFEBCPVUUIFQPTTJCJMJUZPG falling

t4BJEUIBUPVUEPPSBSFBTXFSFIBSEUPTFFBOESFBDI t3FQPSUFECFJOHNPSFCPUIFSFECZTNPLJOH Residents who went outdoors more often also reported that they stayed out longer, and were more satisfied with the outdoor spaces. Those who had lived at the facility longer, reported spending less time outdoors, but levels of outdoor usage were not found to be associated with gender, age, or the number of ADL’s (Activities of Daily Living) they needed help with. Residents with poor vision or a history of serious falls reported less outdoor usage than others, but the difference was not significant. Those who had spent more time outdoors in childhood were found to spend more time outdoors at their facility, and also had greater satisfaction with the outdoor areas.

Demographic and preference variables associated with resident outdoor usage

Variable Frequency of outdoor usage Duration of outdoor usage Satisfaction with outdoors Tenure -.172(**) -.123(*) .025

Self-reported health status .159(**) .060 .140(*)

Childhood experience of outdoor use .119(*) .064 .167(**)

Care about outdoors .379(**) .322(**) .217(**)

Feelings from being outdoors .351(**) .344(**) .168(**)

Satisfaction with outdoors .279(**) .302(**) 1.000

Family stay duration .060 .188(**) .125(*)

Frequency of family outdoor usage .263(**) .173(**) .281(**)

Physical activity .350(**) .141(*) .105

Walking frequency .283(**) .200(**) .088

Walking duration .301(**) .340(**) .211(**)

Residents’ opinions on outdoor space associated with resident outdoor usage

Variable Frequency of outdoor usage Duration of outdoor usage Satisfaction with outdoors

Well-designed for seniors .120(*) .060 .389(**)

Walkways well-designed .096 .023 .248(**)

Amount of greenery -.074 -.040 .117(*)

Lack of access/ visibility -.100 -.012 -.180(**)

Comfort of outdoor areas .096 .138(*) .299(**)

Adequate seating .089 .051 .238(**)

Worried about falling -.165(**) -.192(**) -.053

Bothered by smoking -.060 -.063 -.070

Table 1. Significant associations of variables with outdoor satisfaction and outdoor usage (by frequency and duration) ** Correlation is significant at the 0.01 level (2-tailed).

* Correlation is significant at the 0.05 level (2-tailed).

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Papeles Seleccionados Residents’ statements on how they felt after going

outdoors

A strong majority of residents reported experiencing positive effects from spending time outdoors. Sample comments include statements that they typically felt:

tiJOWJHPSBUFESFGSFTIFENPSFBMJWFw ti*DBOCSFBUIFCFUUFSw

tiZFBSTZPVOHFSw

tiGFFMMJLF*IBWFIFMQFENZIFBMUIw tiDMFBSFSJODPOUBDUXJUI(PEw

What residents liked least about the outdoor areas

Residents described many elements they found less than satisfying in outdoor areas; most of these fell into the categories addressed in the environmental as-sessment, and further layers of analysis will determine how closely researcher’s assumptions aligned with residents’ opinions. Typical comments included:

tiOPUFOPVHIDPNGPSUBCMFDIBJSTw tiOPUFOPVHITIBEZBSFBTGPSTJUUJOHw tiOPUUPPDPOEVDJWFUPXBMLJOHw tiQMBDFTBSFVTVBMMZGVMMw tiOPUFOPVHIBSFBDMPTFUPUIFFOUSBODFw tiXJTIUIFSFXBTBĘPXFSHBSEFOw

What residents would like to add to existing outdoor areas

While many residents were satisfied with existing conditions, a surprising number made suggestions for improvement, when asked if they “could add one thing, what would it be?” Most suggestions related to one or more of the environmental assessment prin-ciples; typical comments included saying they would like to see: tiDPNGPSUBCMFDIBJSTGPSJOEJWJEVBMOFFETw tiBQMBDFXFDBOGFFEUIFCJSETBOEEVDLTw tiMBSHFUSFFBNQMFTIBEFw tiNPSFBSFBGPSGBNJMZNFNCFSTUPCBSCFDVFPS have fun” tiNPSFCFODIFTUPTJUPVUTJEFXJUIGSJFOETw tiNPSFQMBDFTXJUIBXOJOHPWFSIFBEUPBMMPXVTUP stay out but protected”

Comparing resident and staff outdoor usage

Staff members reported going outdoors nearly as often as residents, but stayed a shorter time. Figures 6 and 7 show the relative differences between staff and residents, in terms of how often they went outdoors, and how long they stayed there. It was somewhat sur-prising to see how often staff used the outdoor spaces; however, they did not stay out as long as residents, presumably due to work pressures.

Figure 6. Comparing resident and staff usage: How OFTEN they go outdoors

Compare resident and staff outdoor usage "How long do you usually STAY outdoors?"

0 5 10 15 20 25 30 35 zero 5 minutes or less about 15 minutes about 30 minutes about 45 minutes about one hour about one & half hours tw o hours or more Percentage

Resident outdoor usage Staff outdoor usage

Compare resident and staff outdoor usage "How OFTEN do you use the outdoor spaces?"

0 5 10 15 20 25 30 never seldom or almost never every month tw ice a month every w eek 2-3 per w eek every day more than once a day Percentage

Resident outdoor usage Staff outdoor usage

Figure 7. Comparing resident and staff usage: How long they STAY outdoors.

Staff confirmation of residents’ levels of outdoor usage

In addition to collecting information about the staff themselves, staff surveys were used to confirm the self-reported responses of residents. Although self-reports are often considered to be of questionable accuracy, the

staff reports of how often residents went outdoors and how long they stayed, in most cases closely mirrored what residents themselves had reported (see Figures 8 and 9).

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DISCUSSION

Limitations of the study

This study had numerous limitations, some of which could be corrected in further studies, and some of which are characteristic of the populations and is-sues being explored. It was found to be unfeasible to randomly select either residents or staff, as the process even without randomization was somewhat burdensome to administrators assisting with the project. As the main level of environmental analysis is at the facility-wide level, even the relatively large sample of 68 facilities is not sufficient to overcome the effects of confounding variables that certainly exist. By choosing the larger urban areas, this study represents more affluent facilities and residents than if it had been conducted in rural areas and small towns. Finally, although strong correlation was found that linked outdoor usage to better health and higher physical activity levels, this does not determine the direction of causality. Further analysis of this data at the individual level will make it possible to control for individual variables such as age, health, functional ability, poor vision, and history of falling; this may yield more conclusive results on the association be-tween environmental factors and outdoor usage.

Future research directions

An intervention study could be designed, based on these findings, to help determine the direction of causality: “Does better health lead to increased outdoor usage, or does increased outdoor usage lead to better health?” The causality likely operates in both directions, and a well-constructed study could help strengthen theory on this topic. Behavior-mapping could be conducted as a further confirmation of the

levels, types, and locations of usage reported in this study. It would be worthwhile to extend the present study to other residential facility types, different climates, and non-urban areas. Further research on the role of the outdoors for staff health and well-being would also be valuable, especially with current and projected staffing shortages.

Application to practice

A chief advantage of this study is that the principles are intended to be applied directly to practice settings, by both providers and design practitioners. After extensive layers of factor analysis, the environmental assessment instrument will be revised to reflect the design elements that are most significant in affecting levels of outdoor usage and satisfaction with outdoor space. From this, a useful and practical checklist will be revised and made available to the industry. To assist in disseminating this information, a multimedia educational program currently under construc-tion will also be made available, to present the most important principles in an easily-applied format. By making it easier and faster to obtain evidence-based information, this educational tool will facilitate ap-plying research to actual design situations. Because the principles presented will be based on the docu-mented needs and desires of residents, application of these principles is expected to increase outdoor usage in assisted living settings. This in turn may lead to potential benefits for residents, such as improved mood and hormone balance, higher levels of physical activity, and better sleep patterns. It may also pro-duce benefits in market appeal and occupancy levels for assisted living providers. Design practitioners may benefit from greater client satisfaction, and increased

Compare resident and staff perception of resident outdoor usage: "How OFTEN do RESIDENTS use the outdoor spaces?"

0 5 10 15 20 25 30 35 never seldom or almost never every month tw ice a month every w eek 2-3 per w eek every day more than once a day Percentage

Resident self-reported usage Staff report of resident usage

Figure 8. Comparing resident and staff perceptions of HOW OFTEN residents go outdoors

Com pare resident and staff perception of resident outdoor usage: "How long do RESIDENTS usually STAY outdoors?"

0 10 20 30 40 50 60 zero 5 minutes or less about 15 minutes about 30 minutes about 45 minutes about one hour about one & half hours tw o hours or more Percentage

Resident self-reported usage Staff report of resident usage

Figure 9. Comparing resident and staff perceptions of HOW LONG residents STAY outdoors

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market share afforded by specialized knowledge in this topic.

CREDITS

Funding and assistance

This project was supported by SBIR Grant # R44AG024786 from the National Institute on Aging. The content is solely the responsibility of the authors

and does not necessarily represent the official views of the National Institute on Aging or the National Insti-tutes of Health. The author is also grateful to the as-sisted living organizations that provided access to their communities, to the many residents and staff members who took their time to participate in this study, and to the colleagues and research assistants whose ideas, time, and efforts made this study possible.

REFERENCES

Babyak, M., Blumenthal, J. A., & Herman, S. (2001). Exercise was more effective in the long term than sertraline or exercise plus sertraline for major

depres-sion in older adults. Evidence-based Mental Health,

4(4), 105.

Cutler, L. J., & Kane, R. A. (2006). As great as all outdoors: A study of outdoor spaces as a neglected resource for nursing home residents. In S. Rodiek & B.

Schwarz (Eds.), The Role of the Outdoors in Residential

Environments for Aging (pp. 29-48). New York: The Haworth Press, Inc.

Fovell, R. and Fovell, M. (1993). Climate Zones of the Conterminous United States Defined Using Cluster Analysis. 6: 2103-2135.

Hawes, C., Phillips, C., Holan, S., & Sherman, M.

(2003). Assisted Living in Rural America: Results from

a National Survey. College Station, TX:: Southwest Rural Health Research Center, The School of Rural Public Health, Texas A&M University System Health Science Center.

Kearney, A. R., & Winterbottom, D. (2006). Nearby nature and long-term care facility residents: Ben-efits and design recommendations. In S. Rodiek & B.

Schwarz (Eds.), The Role of the Outdoors in Residential

Environments for Aging (pp. 7-28). New York: The Haworth Press, Inc.

Lang, R. and Dhavale, D. (2005). “Beyond

Megalop-olis: Exploring America’s New “Megapolitan”

Geog-raphy.” Accessed online February 5, 2007 10:00 am http://www.mi.vt.edu/index.asp?page=4&id=44

Martin, J. L., Marler, M. R., Harker, J. O., Josephson, K. R., & Alessi, C. A. (2007). A multicomponent nonpharmacological intervention improves activity rhythms among nursing home residents with

dis-rupted sleep/ wake patterns. Journal of Gerontology:

Medical Sciences, 62A(1), 67-72.

National Oceanic and Atmospheric Administration.

(1997-2006). Climatological Data Annual Summary;

Texas. Retrieved March 29, 2007, from, http://www1. ncdc.noaa.gov/pub/orders/966FD87E-80BD-4691-E629-FD144FF034A2.PDF

National Oceanic and Atmospheric Administration.

(1997-2006). Climatological Data Annual Summary;

Illinois. Retrieved March 29, 2007, from, http://www1. ncdc.noaa.gov/pub/orders/F893BEAC-212B-54B1-DD45-6828CF68CE9C.PDF

National Oceanic and Atmospheric Administration.

(1997-2006). Climatological Data AnnualSummary;

Washington. Retrieved March 29, 2007, from, http:// www1.ncdc.noaa.gov/pub/orders/497B2BB5-D00E-9D38-CFF2-4EB2B43846C4.PDF

Regnier, V. (2002). Design for Assisted Living:

Guidelines for Housing the Physically and Mentally Frail. New York: John Wiley and Sons.

Regnier, V. (1985). Behavioral and Environmental

Aspects of Outdoor Space Use in Housing for the Elderly. Los Angeles: Andrus Gerontology Center, University of Southern California.

Rodiek, S. (2006). A missing link: Can enhanced

outdoor space improve seniors housing? Seniors

Housing and Care Journal, 14, 3-19.

Takano, T., Nakamura, K., & Watanabe, M. (2002). Urban residential environments and senior citizens’ longevity in megacity areas: the importance of

walk-able green spaces. Journal of Epidemiology and

References

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