Abstract
Introduction
Cycling Without Age (CWA) is an innovative activity in which trained volunteers take people out on specially designed trishaws to explore their local areas and communities (Figure 1). Those taking part in the initiative are predominantly older adults living in long-term residential homes, many of whom have mobility and/or cognitive impairments that can limit their independence (Gow et al., 2019). Since its inception in Copenhagen in 2012, CWA has expanded to over 50 countries (Cycling Without Age, 2020). Despite CWA’s global success, limited peer-reviewed research has examined the benefits of the initiative. The current study therefore examined the immediate impact that engaging with the CWA activity has on older adults’ mood and wellbeing.
Cycling without age trishaws out on a ride, each piloted by a volunteer (seated at the rear) with up to two passengers seated up front. Photo credit: A. Gow. Image cannot be reproduced without permission.
A mixed methods approach found three common themes that older care home residents participating in the initiative in Wisconsin appreciated about CWA: fresh air, socializing and relaxing (McNiel & Westphal, 2018). A quantitative follow-up study revealed that after four months of participation (two rides per week), older adults displayed significant improvements in mental wellbeing (McNiel & Westphal, 2018; McNiel & Westphal, 2019). Similarly positive results have also been reported in relation to self-reported quality of life; for example, following a 12-week intervention programme in Barcelona in which participants took part in regular trishaw rides, there was a significant improvement in quality of life. Participants placed particular emphasis on the relationship that had been built with their CWA pilot (Salas, 2018). Although both the Wisconsin and Barcelona findings are positive and highlight the benefits of CWA, neither studies employed a comparison in which people who did not take part in the activity were measured.
CWA was introduced in Scotland by the Communities Along the Carron Association (Gow et al., 2019). During an initial trial in one town (Falkirk), qualitative research consisting of focus groups and interviews with care home residents, staff, CWA volunteers and family members/carers were conducted. Consistent with the research from other CWA locations (McNiel & Westphal, 2018; McNiel & Westphal, 2019; Salas, 2018), findings suggested benefits for care home residents in relation to a sense of freedom, enjoyment of fresh air and social interaction (Gow et al., 2019). Staff and family members also identified benefits in terms of mood, alertness and general wellbeing. Following the successful trial, Cycling Without Age Scotland was formed with support from the Scottish Government to enable the formation of CWA chapters nationwide.
In view of the lack of peer-reviewed research specific to CWA, it is useful to examine research related to the elements the initiative seeks to provide. These are predominantly access to outdoor spaces and socialization, both of which have been highlighted by older adults in qualitative reports (Gow et al., 2019; McNiel & Westphal, 2018; McNiel & Westphal, 2019; Salas, 2018). First, socialization appears to be important for older people living in long-term care homes in maintaining or enhancing positive mood and wellbeing. A recent survey found that the greatest predictor of positive wellbeing in care homes was the number of friends within the residence (Wolff, 2013). There may be several reasons for this, but one that is common in the literature, and something that CWA highlights in their principles, is the act of reminiscing. Following a 6-week intervention study in which participants were placed in either a group reminiscence activity, individual reminiscence, or control group (playing skittles), there was a significant main effect of group; those in the reminiscence group (and control group) experienced significant improvements in wellbeing, with group reminisce showing the most marked improvements (Haslam, et al., 2010). It has been suggested that in care homes, thinking about the past was far more frequent than talking about it. Reminiscence was commonly used to escape boredom and loneliness, though these residents were most likely to think about bitter memories. Those who displayed more depressive symptoms reminisced in a ruminative fashion, thinking more about lost loved ones (Henkel et al., 2016). The evidence highlights the need for facilitated reminiscing and to keep residents active so as to avoid negative forms. Arguably, CWA presents a way to achieve this by offering care home residents the chance to explore areas together that are likely to encourage memories, while being accompanied by a volunteer who rides the trishaw, referred to as a pilot. Pilots are not necessarily trained to encourage reminiscence as training focusses on health and safety, although qualitative reports suggest that pilots and passengers talk to one another throughout, regularly about the “back story” of the passenger (Gow et al., 2019). Further evidence also supports the positive impact socializing within volunteer schemes have on the wellbeing of older adults (Hill, 2016).
As the CWA mantra “the right to wind in your hair” suggests, another key element is access to outdoor spaces, the importance of which is evident in the wider literature. Care home residents place a high value on outdoor spaces being accessible, with the need to be around greenery of particular importance (Kearney & Winterbottom, 2008). Lack of access to outdoor spaces has also been reported as the main environmental variable predicting depressive symptoms in care home residents (Potter et al., 2018). Despite this, there are several barriers such as physical limitations, lack of assistance and design issues that can prevent care home residents from enjoying the outdoor environment. When these barriers are overcome even for a short while, there appears to be a positive impact on health and wellbeing (Astles, 2013; Dahlkvist et al., 2016). In people at different stages of dementia, significant improvements in agitation and sleep, as well as general wellbeing, were reported as a result of supported access to outdoor spaces. This was even the case for simple garden usage (Heliker et al., 2001; Whear et al., 2014). The frequency of access to outdoor spaces has been associated with feeling more cheerful and alert, as well as improvements in emotional well-being and the alleviation of some depressive symptoms (Rappe & Linden, 2005).
The current study explored short-term changes in the mood and wellbeing of older adults as a result of participation in the CWA activity. As CWA includes elements of socialization and access to the outdoors, both suggested to have benefits in terms of wellbeing and mood for older adults in care settings, we predicted that participation in the CWA initiative would be associated with significant immediate improvements in mood and wellbeing.
Methods
Participants
Participants were only included in the study if they were able to provide informed consent. Care home staff provided guidance on residents who would be unlikely to provide this, or be unable to complete the relevant measures, including participants who would only be able to respond to questions with yes/no rather than using the fuller response options. Participants were included, however, if they were able to respond to the questions but needed some support in physically completing them (for example, should they have difficulty with writing, holding a pen, etc). Forty-nine older adults were recruited from across Scotland within areas where the CWA scheme was active; 20 lived in supported housing, with the other 29 participants residing in long-term care home facilities. The group consisted of 34 females (69% of the sample) and 15 males aged 67 to 100 years old (
Materials
The Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS): The Warwick-Edinburgh Mental Wellbeing Scale (Tennant et al., 2007) consists of 14 items measuring hedonic and eudaimonic aspects of mental wellbeing. The measure covers positive affect (feelings of optimism, cheerfulness and relaxation), satisfying interpersonal relationships and positive functioning (energy, clear thinking, self-acceptance, personal development, competence, and autonomy). Participants are required to tick the box that best describes their experience of each statement using a five-point Likert scale (none of the time, rarely, some of the time, often, all of the time). The overall score is calculated by totaling the responses for each of the statements, ranging from 14 to 70. A higher score on the WEMWBS indicates a higher level of wellbeing.
The UWIST Mood Adjective Checklist (UMACL): The UWIST Mood Adjective Checklist (Matthews et al., 1990) consists of 24 adjectives describing mood. The adjectives are grouped into three mood factors (Hedonic Tone, Tense Arousal and Energetic Arousal) with eight adjectives in each subscale. Hedonic Tone is characterized by the balance between feelings of pleasantness or unpleasantness, Tense Arousal ranges from states of anxiety to states of calmness, and Energetic Arousal is characterized by feelings ranging from vigor to fatigue. Participants are required to tick the response that best describes their momentary feelings using a four-point Likert scale (definitely not, slightly not, slightly, definitely) with factor scores ranging from 8 to 32. A higher score in each scale indicates higher levels of that factor.
Procedure
The study adopted a repeated-measures design in part due to the difficulties of recruitment within care homes and also so that participants provided both “active” data and data for comparison (essentially each participant acted as their own control). This is advantageous in studies in real-world settings, as no participant is excluded from receiving the active condition during the study.
All participants were recruited by contacting residential homes and supported housing units via CWA Scotland. The care homes who were interested in taking part then contacted The Ageing Lab at Heriot-Watt University directly to arrange a suitable time for the researcher to visit the site and introduce the study to the residents. Residents who volunteered to take part in the study after this meeting were given an information sheet detailing the procedure. All introductions (and subsequent completion of measures) took place within the participant’s residence so that a trained support network would be present.
After providing written, informed consent, participants were asked to provide their age, gender, length of residence to date, and how many CWA rides they had been on prior to the study.
Participants were required to complete the Warwick-Edinburgh Mental Wellbeing Scale (Tennant et al., 2007) and the UWIST Mood Adjective Checklist (UMACL) (Matthews et al., 1990). This was done by either providing a hard copy of the measures for participants to complete themselves, or by the researcher or a member of staff who read out the questions and statements, so that participants could verbally provide their answers. Once completed, participants were left to continue their usual routine for approximately 60 min, though this varied depending on the home and staff requirements. Participants were then asked to complete the WEMWBS and UMACL again. These measures comprised the “No Ride Day” baseline and follow-up scores respectively.
On the next visit, participants were asked to complete the WEMWBS and UMACL before going out on a CWA ride. Upon completion of their ride, which usually lasted 40 to 60 min, participants were asked to complete both measures again. These measures comprised the “Ride Day” baseline and follow-up scores respectively. The study was approved by the School of Social Sciences Ethics Committee at Heriot-Watt University.
Statistical Analyses
The data satisfied the assumptions for parametric testing. Separate mixed analyses of variance (ANOVA) were conducted for the WEMWBS and each of the UMACL factors using SPSS. For all ANOVA, 35 participants provided data at baseline and follow-up on both ride and no ride days. The ANOVA assessed the main and interaction effects of the within-subjects factors Day and Baseline/Follow-up. Age (grouped as below 85 and 85 and above) and gender were included as between-subject factors. Where significant interactions were observed, post-hoc analyses were conducted with alpha set at 0.0125 to correct for multiple comparisons.
Results
Dropout
Of the 49 participants who consented to the study and provided demographic information, 47 completed No Ride Day measures and 35 completed Ride Day measures. Reasons for dropout between No Ride and Ride Days were predominantly health-related: five participants were subsequently too unwell to take part in a ride, one was admitted to hospital, and one participant died. Other reasons included people not wanting to participate in a ride on days coinciding with researcher visits (
Demographics and Baseline Mood and Wellbeing Scores.
Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS)
Figure 2a displays the wellbeing scores for No Ride and Ride Days. The WEMWBS mixed ANOVA revealed a significant interaction between Day and Baseline/Follow-up (
Changes in baseline and follow-up mood and wellbeing scores on ride and no ride days. (a) Warwick-Edinburgh Mental Wellbeing Scale. (b) UMACL Hedonic Tone. (c) UMACL Tense Arousal. (d) UMACL Energetic Arousal.
Two-Way Mixed ANOVA for Mood and Wellbeing (
UMACL Hedonic Tone
Figure 2b displays the Hedonic Tone scores for No Ride and Ride Days. The mixed ANOVA revealed a significant interaction between Day and Baseline/Follow-up (
UMACL Tense Arousal
Figure 2c displays the Tense Arousal scores for No Ride and Ride Days. The mixed ANOVA revealed a significant interaction between Day and Baseline/Follow-up (
UMACL Energetic Arousal
Figure 2d displays the Energetic Arousal scores for No Ride and Ride Days. The mixed ANOVA revealed a significant interaction between Day and Baseline/Follow-up (
Discussion
The current study highlights the immediate positive impact that participation in the CWA activity has on the mood and wellbeing of older adults living in care home and supported housing environments. Participants’ mental wellbeing, feelings of pleasure, and energy levels were significantly higher after they had taken a trip on the trishaw, while their stress levels were reduced. On days with no CWA ride, the mood and wellbeing measures remained stable over a period of time similar to that involved in a ride. Overall, the findings are consistent with the available literature specific to CWA, which also highlights the positive impact the initiative has on the mental wellbeing of older adults (Gow et al., 2019; McNiel & Westphal, 2018; McNiel & Westphal, 2019; Salas, 2018).
There is an important caveat when studying this kind of real-world intervention, which is the difficulty in breaking the activity down into the component parts that might be proposed as underlying those positive changes, and therefore measuring which specific factor influences mood and wellbeing, or whether it is the combination of factors. It is therefore important to note these findings should not be overstated, despite the evidence suggesting that the activity has a significant immediate effect on mood and wellbeing. Nevertheless, the qualitative data specific to CWA, and particularly CWA Scotland (Gow et al., 2019), suggests that older adults in care homes view socialization and access to the outdoors as being important elements of the activity; the findings will therefore be discussed in relation to those factors.
It is difficult to attribute the potential impact of the socialization aspect due to the fact that the researcher was not present for the trishaw rides, and no measures of social contact were taken (on either day). Socialization is, however, a key principal within the CWA initiative and the findings from the intial trail in Scotland noted that care home residents highlighted how much they appreciated the element of socialization (particularly with the pilot) (Gow et al., 2019). The findings are in line with other research that points toward the positive impact of volunteer schemes on the wellbeing of older adults (Hill, 2016) and also the impact that forming new friendships has on the perspectives of those living in residential care (Lester et al., 2012).
As stated above, lower access to outdoor spaces has been highlighted as a predictor of depressive symptoms in older adults living in care homes (Potter et al., 2018), as well as a lack of environmental mastery (Knight et al., 2011). Participants’ significant improvement in mood and wellbeing immediately after getting outdoors and exploring their local communities is supported by a large body of literature that identifies the importance of being outdoors, and particularly the positive effects of access to, or viewing of, green spaces (Astles, 2013; Dahlkvist, et al., 2016; Gagliardi & Piccinini, 2019; Kearney & Winterbottom, 2008; Rappe & Linden, 2005). The participants in the current study were generally located in towns and villages in Scotland, meaning that trishaw rides often included easy access to green spaces. An avenue for future CWA research to explore would be whether there is any difference in the mood and wellbeing scores between older adults in CWA locations embedded in cities versus those in more rural areas. That would allow a more fine-grained sense of whether just being outdoors, versus being within green spaces, underpins the changes in mood and wellbeing observed.
Although not significantly different, the baseline scores on the WEMWBS, and the Energetic Arousal and Hedonic Tone factors of the UMACL were higher on days including a ride than those with no ride. This could suggest that the knowledge of a prospective CWA ride may have a positive impact on the wellbeing and energy levels of older adults in care homes, though a larger sample size would be required to explore that in more detail. Other research has found that positive prospective imagery can significantly influence the mood of older adults (Murphy et al., 2015) and so it may be that a similar mechanism is involved here.
Limitations & Future Directions
The current study has a few limitations. First, the sample size is small but considering that limited research has been done with the initiative, the current study provides a basis for further exploring the potential benefits in more detail. That said, given the sample comprised older adults predominantly living in care homes or supported environments, there were challenges to recruitment. To counter that, the repeated measures design was employed in the current study; future studies might consider a comparison of participants who are actively involved in the CWA initiative versus those that are not, for example.
As mentioned above, there are difficulties in measuring the individual components of a real-world activity such as this, though future CWA research should perhaps focus on attempting to compare the differing impacts of socialization and access to outdoors separately, as well as comparing this with the combination of the two. That will be complicated by not wishing to interfere with people’s access to the initiative. Future research should also compare mood and wellbeing changes between those with specific cognitive impairments, physical limitations or combinations of both. Furthermore, this study only focused on the immediate, or short-term, impact that the CWA ride had on mood and wellbeing. Although this approach is advantageous in real-world settings, it was also part of a planned strategy of building an evaluation of CWA within Scotland over time. The current study is the second stage of this evaluation, further extending the qualitative report conducted by Gow et al. (2019). The next step would be to continue to explore these short-term benefits and assess the longevity of the effects. This would include measuring mood and wellbeing later on the same day as the ride, and also measuring the long-term impacts of participation with CWA over a course of months, for example. Future research should also explore the wider impacts of CWA, including the measurement of other aspects of mental health, social isolation and loneliness, and cognitive and physical abilities, as well as a deeper understanding of the experiences of taking part in the scheme, for example including audio or video recording during participation for qualitative analysis.
Conclusion
The current study provides an insight into the effects of a novel initiative aimed at improving the lives of older adults in care homes and supported housing environments. This research provides useful findings in terms of the immediate impacts of the CWA initiative, and supports the implementation of the scheme more widely. There is a relationship between participation in this activity and positive short-term changes in mood and wellbeing that should be explored further, including the assessment of possible cognitive and physical changes.
Footnotes
Acknowledgements
We thank Cycling Without Age Scotland for their support. The authors specifically thank the staff of the care homes and supported housing that supported data collection on their sites, the CWA volunteers, and the participants.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The current study was supported by funding from the Scottish Government, disbursed via Cycling Without Age Scotland (CWAS). The sponsor (CWAS) played no role in designing, executing, analysing and interpreting the data, or writing this paper; CWAS facilitated contact with care homes/supported housing environments, but not participant recruitment.
