We identified a need for nature programs to meet the unmet need of physical inactivity and related risks of decreased well-being, dementia, and subsequent cognitive decline for Hispanic or Latino individuals living with memory challenges.

Physical inactivity is defined as failing to meet physical activity guidelines [17] and is attributed with 2% of the risk for developing dementia [1]. However, physical activity can also impact other modifiable risk factors, such as decreasing depression (3% risk reduction), hypertension (2%), and high low-density lipoprotein (7%) in midlife, and social isolation (5%) later in life [1], which collectively can contribute to a 19% reduction in the risk for developing dementia. In fact, the American Heart Association endorses physical activity as a critical component of a lifestyle approach as a first line of treatment for hypertension and high low-density lipoprotein [18]. Additionally, a recent meta-analysis with 191,130 participants found that if adults met physical activity guidelines, 11.5% of depression cases could be prevented [19].

Yet, physical activity alone is not enough to reduce risk for dementia and cognitive decline. A longitudinal study of 404 community-dwelling older adults who were free from dementia at baseline found that despite having high levels of physical activity, individuals with high sedentary behavior had neurodegeneration and worse cognition over 7 years [2]. Individuals with apolipoprotein E ε4, a well-established genetic risk factor for AD [20], were associated with high sedentary time and demonstrated faster hippocampal atrophy and decline in naming and information processing speed despite being physically active [2].

Sedentary behavior is an important risk factor for dementia [2]. Sedentary behavior is defined as exerting 1.5 metabolic equivalents in sitting, reclining, or lying down [17]. The World Health Organization recommends replacing 30 minutes of sedentary behavior a day with any kind of physical activity [21]. Replacing 30 minutes/day of leisure-time sedentary behavior with an equal amount of time with different types of physical activity was associated with a 7%-18% decreased risk of dementia incidence and a 12%-21% risk reduction in mortality from dementia for adults with a diagnosis [22].

One promising approach to reduce sedentary time and promote physical activity is using nature activities that a person enjoys and are meaningful to them. Nature activity is physical activity in contact with nature. Nature activity can lower anxiety more than physical activity without contact with nature (indoors or outdoors) [23,24]. Simply visiting a park or natural space for 30 minutes at least once a week can reduce hypertension and depression by 7%-9% [25], which are risk factors for dementia [1]. Moreover, visiting parks or green spaces is also associated with higher physical activity and social cohesion [25].

Nature or “green” prescriptions are integrated into health care systems in New Zealand, Australia, and the United Kingdom for middle-aged and older adults to reduce risk for cardiovascular disease, diabetes, and improve mental health [15,26,27]. Green prescriptions describe the process of prescribing nature experiences or activities to improve a person’s health and well-being. Green prescribing provides an enjoyable means to engage in physical activity at a low cost and is rapidly growing [15,26-31]. These interventions are particularly beneficial for people who lack access to nature [29] or experience lower resources [32]. However, there are many different types of nature prescriptions that are implemented in varied settings and with different populations. Components of these prescriptions show promise for people at risk for or living with dementia (Table 1).

As depicted in Table 1, nature prescriptions for other populations come with potential benefits and challenges. Benefits include increased physical activity, health, cognition, and well-being with sustained behavior change for middle-aged and older adults. While nature prescriptions have not been studied for populations with dementia, nature activities involving gardens and animals add potential benefits of reduced behavioral symptoms (eg, anxiety or depression) and improve well-being [44-46]. Moreover, nature prescriptions contain beneficial components of social engagement, nature, and meaningful activities, which can support function and stave off decline in persons living with dementia [47,48]. Plausible explanations for positive outcomes include (1) regulation of immunological and physiological (stress) responses, (2) enhancement of psychological states (mood and attention), and (3) facilitation of health-promoting behaviors (exercise and social contact) [36], with a central biological pathway of immune functioning by Kuo [49] encompassing all. Despite the potential benefits, a formal nature activity prescription program for this population has yet to be developed and tested.

Despite the benefits, there are challenges to implementing nature programs. Challenges include appropriateness of the activities to meet the person’s needs, institutional policies, and a lack of available natural (green) resources, as contributing to low referral rates in primary care [36]. Difficulties with participant engagement also present a challenge to implementing nature prescriptions, as many of these programs grew from a bottom-up approach in the United Kingdom, resulting in challenges with buy-in [15,50].

Critiques of current nature prescriptions include challenges with referrals in primary care settings, varying terminology [36], and overlooking groups who have historically been excluded from research. Limitations of nature prescriptions include a lack of testing in persons living with dementia and a lack of culturally congruent programs for individuals who have been minoritized in the United States. A recommended strategy to engage underrepresented groups in physical activity interventions is to promote social cohesion and use local resources to increase participation and sustain behavior change [51].

Despite the potential benefits of nature activities to improve well-being and reduce risk for dementia and cognitive decline after a dementia diagnosis, a comprehensive nature activity program for this population has not been developed. Prior models of nature programs have often overlooked communities that are minoritized in the United States, who are at higher risk for developing dementia, such as Hispanic or Latino populations [4]. Additionally, most nature prescribing models are commonly implemented with community workers, who are often unequipped to tailor activities to a person’s fluctuating levels of function and decline associated with dementia [52]. Occupational therapists are uniquely positioned to address this need as tailoring and matching valued activities to a person’s function, preferences, and needs are central to their scope of practice [53]. There is a need to design an occupational therapist-led comprehensive nature activity program to safely tailor and implement nature activities for people with MCI as a precursor to AD and those living with dementia.

A nature program has not been developed for Hispanic or Latino individuals with memory challenges in the United States, and culturally adapted programs for this population in general are scarce [54]. There is a need to develop a comprehensive nature program that prioritizes the values and human experiences of Hispanic or Latino people living with memory challenges. In line with human-centered design principles, key Hispanic or Latino values that impact the use of supportive programming include familismo (responsibility to family), personalismo (relationships with others), respeto (respect), and dignidad (dignity and self-respect) [55].

Additionally, there is a need to use a partner-driven approach to develop a nature-prescribing program. Particularly, prior nature prescribing programs have lacked input from Hispanic or Latino individuals with memory challenges, care partners, local health care providers, and outdoor organizations. Using a partner-driven approach to develop and implement a nature intervention could mitigate challenges with buy-in and cohesion [36]. To address these gaps, the NATURE program was designed with input from multiple partners, including Hispanic and Latino individuals with memory challenges, care partners, outdoor professionals, and health care providers.

Feedback from partners was elicited during 5 focus groups and 2 interviews to co-design the NATURE intervention. End user engagement through iterative co-design was as described in Lassell et al [12] to inform key elements of the program and research design of the ongoing pilot study. Co-design occurred with Hispanic or Latino individuals living with memory challenges, care partners, outdoor professionals, and interdisciplinary health care providers using a community-based participatory action research [56] approach with human-centered design principles. A community-based participatory action research approach involves an iterative cycle of acting, assessing, reflecting, and refining. People living with memory challenges and their care partners were empowered to contribute to each phase of the research process. Community-based participatory action research principles of empowerment, capacity building, and resource use were applied throughout the development and implementation process. Actions supporting these principles occurred with identifying outcomes relevant to community partners and end users (all groups) with program co-design, implementing the protocol, assessing its acceptability and feasibility, and refining based on their input.

Co-design enabled key elements of the program to align with participant preferences and needs. Co-designed elements of the research design were recruitment strategies, including preferences for terminology and language from the end users (eg, people living with memory challenges vs dementia and Hispanic or Latino vs Latinx). The NATURE program was designed to align with the cultural preferences and values of the Hispanic or Latino community. Particularly, the values of the design of the program also incorporated Hispanic or Latino values of respeto and dignidad were built into the occupational therapy assessment by asking what matters most to the person. Additionally, the values of personalismo and familismo were incorporated with options to include family or friends in the Nature Activity Plan and intervention sessions [12].

End users of Hispanic or Latino people living with memory challenges identified a range of nature activities they enjoyed (eg, walking, dancing, or feeding squirrels) and preferences for program frequency, duration, and delivery-based on prior evidence-based programs [15,25]. They underscored the need to offer a range of options for flexible participation that could be tailored according to individual needs and preferences (eg, 4-8 sessions between 30-90 minutes long). Outdoor professionals provided input on local nature activities and how they would prefer to be supported by the occupational therapist to participate in the program. Health care providers advised on clinical referral pathways, including primary care and community-based organizations. See Lassell et al [12] for iterations of the program before and after the co-design process.

The NATURE intervention was informed by the Theory of Cognitive Reserve [57], the Attention Restoration Theory [58], and the environmental press model by Lawton [59], with the assumption that tailoring nature activities that are meaningful to a person (matching the activity demands to their context, preferences, and needs) can support a person’s participation in nature activities and well-being. The co-design process incorporated options for session duration and frequencies based on previously successful programs such as the Tailored Activity Program for people living with dementia [60-62] and 2 green prescribing models [15,63]. Co-design resulted in the creation of a 12-week NATURE intervention that incorporated the preferences and needs of Hispanic or Latino and care partners, local outdoor professionals, and interdisciplinary health care providers [12].

The goal of the NATURE intervention is to promote an active lifestyle and well-being by mitigating risk for dementia and cognitive decline. The intervention advances the US Department of Health and Human Services “National Plan to Address Alzheimer’s Disease” Goal 3 [64] as a support for people living with AD and their families and is driven by outcomes that mattered to Hispanic or Latino individuals living with memory challenges [12]. The program involved an occupational therapy assessment, goal-setting, and a tailored green activity plan that could be built into a person’s daily routine to address physical inactivity and sedentary time throughout the day. The program emphasizes using local community resources to increase access for homebound participants and to promote sustainability (Table 2).

Function was assessed with the Functional Activities Questionnaire, fall risk. The Fall Risk Assessment Tool and the World Health Organization fall risk clinical algorithm were conducted by a trained research assistant before the program. Individuals who were at high fall risk were required to have a care partner present for program sessions and green activities.

NATURE was implemented by 2 licensed occupational therapists with a minimum of 4 years of experience in geriatrics and dementia care. The occupational therapists were trained using a training manual of NATURE with templates for session notes and evaluation forms. The occupational therapists delivered NATURE either virtually using a secure Zoom platform or in-person, based on participant need and preference, in alignment with co-design [12]. NATURE involves 3 phases: assessment, coaching, and self- or care partner–monitoring and sustained behavior change.

The assessment phase informed how the nature activities were tailored in a participant’s NATURE plan (Table 3). The assessment phase involved 2 sessions, ranging from 60-90 minutes. Based on the assessment which included clinical interviews, functional assessments, and validated questionnaires, tailoring occurred on 3 levels: the person and family, the nature activity, and their daily contexts (environmental modifications based on accessibility, safety, weather, equipment needed, level of social support, socioeconomic resources, and the nature resources available to the person in their home, neighborhood, and community). As part of the assessment, participants engaged in collaborative goal-setting using Goal-Attainment Scaling to develop 3 goals for 3 separate individual nature activities that the person wanted to do. Local nature activities were selected from a list compiled through co-design [12]. The local nature list included cost and whether there were virtual options. The participant worked with the occupational therapist to select 3 nature activities they would prefer to do. Goals to engage in the 3 selected nature activities were based on the person’s level of function and incorporated the World Health Organization’s guidelines for physical activity. Goals could be made to engage in a nature activity or to safely access a nature activity (eg, learning a new bus route to a park) and had options for good days and hard days, and virtual options for inclement weather.

The coaching phase involved either 1:1 virtual, phone, or in-person visits with a trained and licensed occupational therapist lasting between 30 and 90 minutes. The occupational therapist developed a personalized NATURE plan for each participant. Care partners were invited to join but were not required unless a participant was at high fall risk or if they required a legally authorized representative to attend. Each session involved the following components: greeting or introduction, reviewing progress toward each goal, testing at least 1 nature activity related to their goal, making adjustments as needed, reviewing the weekly behavioral activation worksheets, planning their nature activities for the next week, educational materials (nature activities, depression, reduction of fall risk during plan, and participant-specific education), reviewing session points and scheduling the next session. Behavioral activation worksheets involved weekly goal-setting using SMART (Specific, Measurable, Achievable, Relevant, and Time-Bound) goals, planning their activity, telling their team (occupational therapist, family, or friend), reflecting on how the nature activity went, and problem-solving with the occupational therapist afterward. Care partners completed the behavioral activation form for individuals who had greater cognitive impairment. Participants also mapped out their nature activities for each week using a dry-erase calendar. They planned their nature activities embedded into their daily schedules while considering the weather and air quality. There was an option to include an additional 3 in-person or virtual visits as needed, based on participant need.

The self-monitoring phase involved 2 phone check-ins that were at least 15 minutes with the occupational therapist. Check-in sessions involved a greeting, discussing progress toward goals, and problem-solving any challenges that arose with their NATURE plan, with additional adjustments as needed. Additional education was also provided in relation to each participant’s NATURE plan.

NATURE sessions are being implemented virtually or in-person with 1:1 sessions by a licensed occupational therapist. Two occupational therapists are implementing NATURE and received 4 hours of training guided by the NATURE training manual.

The pilot study is being implemented through continued community engagement with local aging organizations that provide services in the Bronx; Indianapolis; and Burlington. Participant feedback regarding program feasibility (retention, feasibility of outcome measures, or fidelity) and acceptability (questionnaires and interviews) is being gathered. Planned outcomes of the program include promoting health equity and an active lifestyle, mitigating risk factors for cognitive decline related to physical inactivity and social isolation. Additionally, health outcomes related to self-reported physical activity using the Quick Physical Activity Rating [65] scale and well-being, such as the PROMIS measures of Social Participation, Mental Health, and Physical Health [66,67], are also being collected among other health outcomes (Table 4).

Using human-centered design principles, we are incorporating multiple methods to measure preferred outcomes of well-being, sleep, and social connection. We are using the ActiGraph LEAP to measure physiological data related to well-being (heart rate and activity), sleep, and validated questionnaires. We are also piloting the CentrePoint Connect mobile app (ActiGraph, LLC) sync ActiGraph data in real-time and assess the usability of these technologies using Holden Systems’ Usability Scale [68]. Additionally, qualitative data will be gathered to learn about each participant’s experience during the program to iteratively refine the intervention and measurement of outcomes before efficacy testing.

The NATURE intervention is designed to be sustainable through its use of local resources that are accessible by participants (eg, ongoing nature activities in their community, recommending nature activities they can still access after the intervention) with tailored strategies to adapt and integrate nature activities into the person’s daily routine. Using local natural resources may also contribute to social cohesion for participants and their communities. This can be achieved through continued partnerships with local outdoor organizations and our local health care partners.

If determined effective in the future, the NATURE intervention has the potential to be embedded into current health care systems, with potential reimbursement under Medicare with skilled home health care (part A) and home-based outpatient services covered under part B [69]. However, before being implemented in other contexts with other groups, context-specific adaptations will need to be made by identifying local nature activities and referral pathways for local community-based organizations and hospital systems. Additional refinements may also be needed for language preferences to describe AD and related dementias to successfully recruit participants from other cultural groups, and have members of the group assist in implementation. Additional adaptations may also be needed to align with cultural values.