M. Adam Malekzadeh - MA urban design - Research Proposal - Spring term - April Entry 2014 Research Title: Creating dementia-friendly urban environment to promote social inclusion, independent living and reducing risk of dementia amongst older Londoners: urban health and social intervention ABSTRACT Dementia is a major challenge we are facing in our society. This research investigates the effect of street mobility and network accessibility on people living with dementia in early stage and their carers. These will focus on the impact of community severance (traffic or volume) on leisure time physical activity and social interaction amongst older people living with dementia and their carers. Community severance occurs where road traffic (speed or volume) inhibits access to goods, services, or people. The aim of this research is to consider how social and lifestyle changes may help to reduce the risk of dementia and disability amongst older Londoners who are living with dementia in early stage. The study will be assessed and identify community severance within Older and Disable Lo do er s Developments where proposed by Great London Authorities in 2013 (GLA 2013). Although community severance diminishes social contacts, the implications of community severance for morbidity and mortality have not been empirically established. There is empirical evidence that traffic speed and olu e redu es physi al a ti ity, so ial o ta ts, hildre s play, a d a ess to goods and services. However, no studies have investigated mental or physical health outcomes in relation to community severance. 1. BACKGROUND There are 800,000 people living with dementia in the UK (Department of Health 2013); and the financial cost of dementia in the UK is £23 billion and globally it is approaching $600 billion. Prime Minister David Cameron led G8 Dementia Summit last December to set out plans for supporting people with dementia- and their carer and to develop co-ordinated global action on dementia, stimulating greater investment and innovation in dementia research. Dementia is the loss of intellectual ability. The early stage of dementia is often overlooked, because the onset is gradual. Common symptoms include: forgetfulness, losing track of the time, becoming lost in familiar places (WHO 2012). Early dementia diagnosis and post-diagnosis support is increasingly a key element in supporting independence and quality of life for people with early stage dementia and their carers. As people with dementia receive an earlier diagnosis this presents challenges for the person and their carer about how they cope and the type of help they require (NHS 2008). With limited spaces available in care facilities, most older people with mild to moderate dementia live in their own homes. (Burton 2006). Research has shown that remaining in the familiar surroundings of home and the local neighbourhood can have beneficial effects cognitively, physically and emotionally. However, to live successfully in the community people with dementia need outdoor environments that are designed inclusively to help them to get involve physically and socially. If they are unable to enter or use their local neighbourhoods they will become effectively housebound. (Mitchell 2006). Social interaction and physical activity in outdoor environment offers physical, sociological and psychological benefits for older people with dementia. Various ways of promoting an alternative model focusing on social inclusion are explored by Cantley and Bo es 2004 . These i lude heari g the oi es of people ith de e tia a d their views and feelings about how they want to live. This approach is supported by Wilkinson (2002) who argues the case for including people with dementia in research to increase understanding of their quality of life so that we can reduce barriers to participation and bring them more inclusively into society. There is evidence that the more that older people walk and take exercise the less their risk of dementia (Abbott et al, 2004; Scherder et al, 2005; Larson et al, 2006). Longitudinal study has found that frequent participation (daily-weekly) in social activities is conducive to a decreased risk of dementia (Wang, Karp, Winblad, & Fratiglioni, 2002). In the UK, more than 80 percent of people aged between 65 and 74 years old do not meet the recommended level of physical activity (Joint Health Survey Unit, 2004; Scottish Executive, 2005). There is need to understand the impact of community severance on social interaction, leisure time physical activity and factors that contribute to quality of life amongst older people in the early stages of dementia from their own perspectives. The outcome would inform public health and urban transport policy makers, academic researchers and dementia friendly community agencies to design social intervention and creating dementia friendly environment and promoting independent living amongst older people living with dementia in early stage and their carers. Residents living on busy streets have smaller social networks; people with fewer social contacts have worse physical and mental health. This study considers community severance, dependent older people living with dementia and their carers, social isolation, physical inactivity, street mobility and network accessibility in outdoor environment as urban transport, public health problems, which cannot be solved by individuals themselves. Integrated and cross-disciplinary approaches can overcome these problems. This research will employ evidence informed model of potential determinants of sport/physical activity (Foster, 2005), Agefriendly environment approach (WHO, 2007), street for life concept Dementia-friendly environment audit (Burton, 2006), pedestrianfriendly approach, and Healthy Urban Planning approach (Barton, 2006) to evaluate the environmental features and its impact on health and older age. Urban transport solutions informed by physical activity concerns and social and-psychological approach which will take more account of an i di idual s parti ular life history, life style, social, cultural terms and how it impacts on experiences of dementia in early stage. AIMS and Research Question(s) The aim of this research is to identify how the social and lifestyle changes may help reduce the risk of dementia and disability; and to consider to what extend street mobility and network accessibility can influence leisure time physical activity and social interaction of older people living with dementia and their carers. This research seeks evidence to answer the following questions: To what extend social and lifestyle changes may help to reduce the risk of developing dementia and disability in the early stages? How to enhance and extend the active participation of older people with dementia in their local community? What is the role of community severance on social interaction, leisure time physical activity and lifestyle change amongst older Londoner living in early stage of dementia? What features of the built environment facilitate or hinder leisure time physical activity and social interaction in outdoor places amongst older people with dementia? To what extend street mobility and accessibility network to public realm increase leisure time physical activity and social interaction amongst older people living with dementia? OBJECTIVES There are five objectives will be addressed: 1) to explore the priorities of older people with dementia in community severance, and their needs in outdoor environments where may enhance their active participation on their local community. 2) to explore how changes in individual lifestyle, social interaction and leisure time physical activity, may reduce risk of dementia amongst old people living in early stage. 3) to develop a method / questioner tools to measure community severance at individual level and design social intervention to assess the effect of social change, physical activity on older people living with dementia in early stage. 4) to evaluate effect of community severance, shared-space, busy street, home zone and car-free environment on social interaction, leisure time physical activity and quality of life amongst older people with dementia and their carers. 5) to evaluate and coordinate clinical trial of memory services across London to understand the effect of outdoor environment, social interaction and leisure time physical activity on older people living with dementia and their carers. 2. Literature review This based on health and transport literature and review the links and impacts of urban environment and community severance on social interaction, leisure time physical activity and quality of life amongst older people living with dementia. 2.1. Impact of travel on social interaction: Outdoor open spaces serve as a place for social interaction among older people. Several studies have confirmed the link between attributes of outdoor spaces and the formation of a social network among neighbours. Longitudinal study has found that frequent participation (daily-weekly) in social activities is conducive to a decreased risk of dementia (Wang, Karp, Winblad, & Fratiglioni, 2002). Another study in Ireland demonstrated that people living in mixed-use, pedestrianoriented neighbourhoods, which provide more opportunities for walking, and hence a greater chance for neighbours to meet each other outdoors, tend to know neighbours better and engage in social activities more often than those living in car-dependent neighbourhoods (Leyden, 2003). 2.2. Impact of urban environment on physical activity: Getting outdoors offers physical, sociological and psychological benefits for older people. Physical inactivity is a major underlying cause of disease and disability (WHO, 2003). Despite abundant scientific evidence of the multiple health benefits of physical activity, and national and local level strategies to promote an active lifestyle, the majority of older people are not sufficiently active to maintain good health. Some environmental attributes help people carry out activities, while others th art people s pla s or i te tio s. Studies indicates that environmental determinants of activity participation include: land-use diversity, street pattern (connectivity), access to shops, access to recreational facilities, qualities of the pavement, aesthetics, safety from traffic and crime are correlate with physical activity (Frank, Schmid, Sallis, Chapman, and Saelens, 2005; Humpel, Owen, Leslie, 2002; Owen, Humpel, Leslie, Bauman, Sallis, 2004; Saelens, Sallis, Frank, 2003). 2.3. Impact of urban environment on quality of life: Studies show older people living in low density areas are more positive about their quality of life than those in higher density areas. Participants in villages and small towns rated their quality of life highest and those in major city/town centres lowest. Quality of life was also rated higher in residential than in mixed-use neighbourhoods. (Burton 2009). Despite bad press, villages still seem to offer many advantages. It may be possible to make urban housing more attractive to older people by increasing amount of greenery, some much better than none, controlling non-motorised traffic effectively, creating predominantly residential areas that have facilities and amenities scattered within them, using distorted grid layouts, designing to encourage social interaction. (Burton 2006 and Dempsey 2005). 2.4 Impact of community severance on social contact: No study found related community severance, and its effects on behaviour (such as social contacts, older people with dementia , older people access to services), to short- or longterm mental or physical health outcomes, except for one related study that found reduced motor development in children not allowed to play outdoors. (Hüttenmoser 1995). Appleyard a d Li tell s results, sho i g a reduction in social contacts through the deleterious effects of traffic (Appleyard D, Lintell 1972, Appleyard D, Gerson 1981) have ee li ked ith Berk a a d Sy e s (Berkman, Syme 1979) a d others findings (Ellison CG. Race 1995) of increased mortality in those with fewer social contacts. None of these studies of morbidity or mortality have examined reductions in social contacts as a result of new roads or of increased speed or volume of traffic on existing roads: the chain of inference for the health effects of community severance does not currently extend to direct observation. It seems inherently likely that the effects of community severance do indeed impact on health, with adverse health consequences of reduced social contacts also occurring when this social disruption is due to road traffic (Mindell.J 2011). 3. Research Methods With the need to address the spiralling costs of health care in the United States and around the world, funders such as National Institutes of Health (NHI) and Centres for Disease Control and Prevention (CDC) and scientists are placing more emphasis on translational research. The logic of method in this research suggests a comprehensive set of qualitative and quantitative approaches, and employ translational research model which can generate the health and transport and physical activity data. The data will be analysing by NVivo. 3.1 Research Hypotheses The hypotheses, based on the urban transport and public health literature, were the people with dementia living in inaccessible pedestrians and busy roads with high volume of traffic avoid trip to local communities and they are 1) less physically active; 2) less socially interact within their community; 3) feel unsafe, 4) have higher prevalence of health problems linked to dementia, physical inactivity and social networking than those living in quite, car-free / pedestrian-friendly places. 3.2 Translational Model and collecting health and urban environment and transport data The translational model assess by developing seven-steps to facilitate stakeholder participation in research while building the capacity of the community to collaborate in research with multi-and interdisciplinary teams of social and medical science: 3.2.1 Partnership and Collaboration Step.1) Creating a research ready network of service which will collaborate with leading health and transport research centres and health organisation. This collaboration include: the Design and Engineering and Health Science and Social Care at Brunel University with Inclusive Design Getting Outdoor (I DGO), Dementia UK, Alzheimer Society, Living Street, Sport for England and Sustrans. The clinical memory trial will be organised to collect data by design medical trial and social intervention at primary care and UK Clinical Research Network UKCRN to evaluate the dementia amongst older people in early stage. 3.2.2 Health and Physical Activity Data Step.2) Recruiting older people with dementia in early stage and their carers for interview to assess parti ipa t s physical activity, life style, health and interaction with outdoor environment. Physical activity will be assessed by employing International Physical Activity Questionnaire (IPAQ). Parti ipa t s health a d lifestyle will be assessed by employing General Health Questionnaire (GHQ12) and Warwick-Edinburgh Mental Well-Being Scale (WEMWBS) which can identify predictors of positive mental health in a convenience sample of older people with dementia using a cross-sectional design. Health data for assessing individual older people with dementia come from National Dementia and Antipsychotic Prescribing Audit and Health and Social Care Information Centre (HSCIC). Data for measuring and mapping dementia coming from Department of Health, National Health Survey (NHS), Alzheimer Society, Dementia UK. 3.2.3 Study Areas Data to assess urban environment will be collected from study areas sites within Older a d Disa le Lo do er s Developments where proposed by Great London Authorities in 2013 (GLA 2013). The locations for study identified according to locations within inner and outer London where dementia is higher than above national average. Study areas Mapped by dementia on map and selected because of various locations within inner and outer London borough where level of dementia are above national average. The selected study areas start from highest to lowest percentage of dementia level in their boroughs which are includes: Islington (63%), Southwark (58%), Newham (58%), Camden (56%), Tower Hamlet (54%), Westminster (54%), Greenwich (52%), and Hackney (52%) Barnet (52%), Kensington & Chelsea (51%), Waltham Forest (51%), Lewisham (49%), Richmond Upon Themes (49%), Hounslow (46%), Lambeth (46%), Wandsworth (45%), Enfield (44%), Haringey (43%), Havering (39%), Hillingdon (37%), Harrow (33%) (Department of Health 2014). Furthermore, Barking & Dagenham had the greatest decrease (-19.5 per cent) followed by Tower Hamlets (-15.6 per cent). In all, 13 boroughs saw their older population shrink over the period. In the remaining boroughs population growth was greatest amongst people 65 and over in Camden, where 12.7 per cent more people were recorded in 2011 than in 2001 (Great London Authority 2013). 3.2.4 Urban Environment Data Urban environment data will be assessed by urban design and street design appraisal and Age-friendly environment approach (WHO, 2007), Dementia-friendly environment audit which survey areas according to Familiar, Legible, Distinctive, Accessible, Comfortable, Safe built environment (Burton, 2006), pedestrian-friendly approach, and Healthy Urban Planning approach (Barton, 2006) to evaluate the environmental features and its impact on health and quality of life amongst older people living with dementia and their carers. 3.2.5 Transport and Community Severance Data Data to assess Community Severance, Transport and Urban Environment come from Department for Transport (DfT) traffic counts data, such as total number of vehicles, percentage of heavy goods vehicles (HGV) and average speeds. It can also be assessed by the characteristics of the road (such as number of lanes and lane width) and by the number and type of pedestrian crossings. It will assess the change in the infrastructure and in traffic levels over time. In addition to assess community assessment the another concept could be identified to measure three elements from community severance which are: 1. Existing of barriers to the mobility of pedestrians; 2. Mobility needs of older people with dementia and their carers living by; 3. Characteristic of the environment and its effect on social interaction amongst older people with dementia (street volume, busy road, clean and safe place). Further framework which are includes: 1) the suitability of surfaces for walking/cycling; 2) street width, curb type and the presence of vehicle parking; 3) traffic volume, speed and the presence of management and control devices; 4) the nature of traffic crossings and crossing aids and verge widths; 5) street design and the design and distance of intersections and other access points; 6 issues of personal safety such as lighting, surveillance and path/lane obstruction; and 7) aesthetic factors such as the presence of trees, street maintenance, cleanliness and pollution (Pikora 2003). 3.2.6 Collaborating Between University Research Units and Service Agencies Step.3) Developing a pool of investigators, in resear h u it at U i ersity s Depart e t of Health Science and Social Care and Engineering Design to collaborate with service agencies such as Dementia UK, Alzheimer Society, etc. Step.4) Developing pilot study programs on linking community severance and dementiafriendly environment to physical activity such as leisure time walking to utilities, green spaces and connect investigators to research opportunities involving community agencies. Step.5) Developing and training investigators and researchers who is willing to collaborate within research areas about bridging transport, health and dementia friendly environment. Step.6) Facilitating researcher-community partner interaction through educational events. Step.7) Engaging researchers and practitioners on critical issues related to ageing with dementia by developing a research to practice consensus workshop model. 4. Research Timeframe The research will commence in April 2014 and research completion will be in April 2017. Year 1: Develop literature review; seek ethical approval; gather transport, health and physical activity data; simulate older adult with dementia and starting interviewing older people with dementia and their carers to collect data on their mental health, leisure time physical activity, social interaction outdoor, community severance and their sense of belonging in their community; measure sample to validate dementia estimates; describe and map dementia and social change interview data. Year 2: Gather urban environmental and transport by site survey, urban design appraisal and audits to collect community severance, transport and urban environment study areas; organise social data in intervention and physical activity events to measure before and after effect of social interaction in outdoor environment; to better understanding of the link between social interaction and dementia and develop a community severance and dementia friendly model. Year 3: Predictive analyses/evaluate intervention impact; and employ NVivo to analyses data. 5. Outcomes and Dissemination The research will provide academic and policy outputs and it will produce peer-reviewed publications that ill uild o the super isor s research on the relationships between community severance, leisure time physical activity and social interaction amongst older people living with dementia and their carers. The results will feed into Department for Transport s a d Depart e t of Health s ongoing review of the role of social change on reducing the risk of dementia in the community severance. The research findings will have implications for urban design, street design and spatial planning locally, nationally and internationally. This research project fills a gap in academic knowledge, offering a multi-disciplinary evidence-based approach to studying dementia-friendly and community severance. The research will be valuable to policy makers, practitioners and local communities and it focuses on reducing dementia in early stage and making older people's lives healthier and happier and to promotes dementia friendly environment. The research outcome will be disseminate across the many users in the UK and abroad such as practitioner and academic journals such as Lo al Go er e t Chro i le , ur a studies , The La et , Pu Med , BMJ , Ashgate . 6. REFERENCE Appleyard D, Gerson MS, Lintell M. Livable streets. Berkeley: University of California Press; 1981. Appleyard D, Lintell M. The environmental quality of city streets: The residents' viewpoint. Am Institute Planners J. 1972;38(3):84-101 Department of Health, London Berkman L, Syme SL. Social networks, host resistance, and mortality: A nine-year follow-up study of Alameda County residents. Am J Epidemiol. 1979;109(2):186-204. 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