Evaluating the Impact of Community Gardening on Sense of Purpose for Persons Living with Dementia: A Cluster-Randomized Pilot Study

Design

Ten residents at a skilled care facility in Grand Haven, Michigan were assigned to one of two groups: a control group that received a basic gardening intervention (n = 5), and an experimental group (n = 5) that received the gardening intervention with an added charitable component through which participants cultivated produce for donation to food insecure community members. Due to logistical necessity, group assignment was determined by location of residence; those living in the “general” wing, which houses both people who do and do not have dementia, were assigned to the control group, and residents living in a discreet dementia care unit were assigned to the experimental group. Eighteen gardening sessions were scheduled through the Life Enrichment Program at Grand Pines from July 1 to September 4, 2019. These sessions were supervised by the PI (ACS), Grand Pines staff, and community volunteers, and were one-hour in length, with two sessions held per week. Gardens with tomatoes, peppers, zucchini, squash, and cucumbers were planted in wheelchair-accessible raised beds located on patios accessible to residents. Due to logistical necessity, researchers and Grand Pines staff assembled the raised beds and did the initial planting without resident assistance. Activities in each session included watering, weeding, fertilizing, and harvesting the crops. Participants were encouraged to self-direct their activities during each session, taking part in whichever tasks they most enjoyed. Participants in the experimental group were reminded each time they went into their garden that the produce they were growing would be donated to a local food pantry that serves food insecure community members. A poster saying “Donation Tally” was placed on the patio when participants gardened and recorded the amount of each type of vegetable grown, harvested, and donated. Participants in the control group kept the vegetables they grew for personal use.

Study site

The study was conducted in Grand Pines Assisted Living Center, a residential living community offering varying levels of care including independent senior living, assisted living, and specialized dementia care. Residents from any level of care were eligible to participate in the study, provided they had an established diagnosis of Alzheimer’s disease (AD) dementia.

Recruitment

Eligibility for participation was based on permanent residence at Grand Pines Assisted Living Center, a physician-documented diagnosis of AD dementia, age greater than 50 years old, and the physical ability to garden (based on subjective evaluation by Grand Pines staff members). Additionally, Grand Pines uses Teepa Snow’s GEMS Brain Change Model to stage residents with AD dementia [42]. This model focuses on the skills and abilities retained by those living with dementia (e.g., a person in the early “diamond” stage is “clear and sharp,” and may simply need some additional time and repetition to absorb new information, while a person in the later “amber” stage may retain a strong drive to independently satisfy their desires, even if it means crossing others’ boundaries to do so). Residents who were in the last two stages according to this model (i.e., the “ruby” or “pearl” stages), as determined by Grand Pines staff, were excluded from this study, due to lacking the functional status necessary to participate in gardening activities. As participants’ GEMS stages were used only as exclusion criteria, the participants’ individual stages were not recorded by researchers as part of the study.

Potential participants were identified by Grand Pines staff members, and interested residents met in person with the PI to discuss the research. Verbal consent was sought from participants and/or a legally authorized representative.

Caregivers of residents were also recruited for participation in interviews at the end of the study. Grand Pines caregivers were required to spend at least ten hours per week providing care for one or more of the participants. No incentives were offered for resident or staff participants.

Ethical approval

Approval for all aspects of the study was obtained from the Penn State College of Medicine Institutional Review Board and Human Subjects Protection Office (#36459) and the LH Ethics Committee.

Data collection

Semi-structured, qualitative interviews were held by ACS with participants at the end of the study to seek reflection on the experience. Interviews lasted an average of 10 min. Exit interviews were also conducted with caregivers who worked at Grand Pines to explore any changes they noticed in the participants. These interviews lasted an average of 5–10 min. All interviews were digitally-recorded and transcribed by the PI with identifiers removed.

Qualitative analysis

A thematic analysis approach was used to analyze qualitative data. In order to capture the full spectrum of effects of this intervention, a coding framework was established which included biological, psychological, social, and spiritual aspects. Using this framework, the transcripts from each interview were independently coded by the investigators until data saturation (when no new codes emerge) was achieved. Two analysts (ACS, DRG) used the codebook and applied constant comparison method to analyze data. Throughout the process, coding meetings were held to iteratively discuss discrepancies. Once themes and subthemes were identified, representative quotes were selected. All participants and caregivers were randomly assigned a pseudonym (Participant A-H, Caregiver A-C) in order to demonstrate the representation of a diversity of speakers while still protecting the participants’ identities.

Participant characteristics

The control cohort included 5 white/non-Hispanic women, and the intervention cohort included 4 women and 1 man, all of whom were white/non-Hispanic. Three caregivers on staff at Grand Pines participated in interviews.

Qualitative results

Analysis of transcripts from interviews with the participants revealed four main themes relating to the biopsychosocial wellbeing of participants (Table 1).

Theme 1: Gardening outdoors provided specific physical benefits that improved quality of life

Participants identified discreet physical benefits associated with hands-on gardening activities, with basic exposure to the outdoor elements serving as one means of improving QOL. As one participant said:

Another participant noted specific aspects of the outdoor setting improving QOL:

A third participant (Participant G) repeated four times during their interview that their favorite aspect of gardening was that “it got me outdoors!” Other participants identified similar enjoyable elements associated with being outdoors, including “being out in the open, in the fresh air” and “seeing the beautiful flowers,” (Participant A), “I always had a garden, um ...  and I love flowers” (Participant C), and simply “I like to be outside” (Participant D).

QOL also arose from the physicality of gardening itself. As one participant said:

That same resident expressed that there was benefit not “Just being outside, [but] ...  getting to move around.” A caregiver also noted the physical benefits of gardening and harvesting fruits and vegetables:

Theme 2: Working on a project in a group setting improved mood and fostered a sense of community

Nearly all participants expressed that they enjoyed working on a project with others. In discussing her favorite aspects of the project, Participant C reflected on friendships made with other residents in the garden (“mingling with ...  the other people in here. You know, we’ve made friends”), while Participant F thought of the garden and said “Ooh yeah, they can go out with me, there!” and Participant D spoke of “ ...  just being outside with the others.” This participant, who was observed by a caregiver to have formed a particular bond with another resident in their group, commented:

Similarly, nearly every participant reported that they associated a positive mood with the garden, with three participants specifically sharing that it made them happier (“It makes me happy,”; “I think it, um, actually it makes you happier,”; “Well, I was happy out there”). One participant connected their positive mood with the charitable aspect of the garden, saying:

Another participant connected their positive mood with the opportunity to take on a new social role as the member of the group who helped maintain a cheery attitude and uplift the collective mood, saying that being in the garden “makes you happier ...  because you’re enjoying ...  well, what’s around us. And um ...  helping other-other people find what’s good about it.” (Participant A).

Theme 3: Gardening promoted reminiscence and reinforced a sense of self

Spending time in the garden prompted participants to reminisce about past experiences. In the interviews, four participants identified that they had formerly lived on farms or worked in gardens. One participant said:

In response to a question investigating whether gardening reminded her of anything from the past, Participant G shared: “Oh yeah, I used to love gardening.” A third participant shared a story connecting the gardening experience to when she had lived on a farm in her youth, saying:

Caregivers felt the mnemonic aspects of the activity had been beneficial as well. As one said:

Additionally, participants were able to draw connections between their experiences in the garden and other aspects of their lives that they remembered fondly. Participant D in particular spoke about how much they liked beautiful sunny weather and would connect this weather with memories of a boat they formerly owned. Nearly every time this participant was outside, they would share these memories with the other participants, and invite the others to go out on their boat with them sometime.

Gardening also helped one participant connect to her selfhood in a spiritual sense. In response to a question about whether she felt that gardening is an important thing for people to learn, the participant said:

Theme 4: Gardening provided participants with a sense of purpose and pride

Nearly all participants said that they looked forward to spending time in the garden, largely due to the abovementioned benefits to their QOL. In response to questions exploring whether they looked forward to spending time in the garden, participants variously responded:

Caregivers uniformly agreed that gardening had been a purposeful activity for participants. One caregiver said:

While another caregiver observed that “I just know after leaving the activity, they were happy” (Caregiver A).

A key component of feeling purposeful appeared to be the sense of pride participants felt toward the work they were doing. Three participants reported that they had brought up their work in the garden to their family members, with one reporting that they would “bring them around and show them.” Another participant felt that the tangible results of the work were especially meaningful:

One caregiver took particular note of the pride participants showed in their work, saying:

For those participants who experienced the added charitable component, this appeared—to some degree—to enhance the meaningfulness of the activity, though it was unclear whether all participants had retained memory of this aspect of the experience. One participant, when asked if it was important to them that their vegetables were donated, said: “Well, if they needed it, then yeah!” Another participant said: “[We] were proud that they had those to give to them, and that they were ...  vegetables” (Participant H).

One caregiver reported that participants did seem aware of that aspect of the project:

Limitations

This study had several limitations. The study population was small and restricted to a single facility, with the intervention occurring over a relatively short interval. Nearly all participants were female and lacked racial/ethnic diversity, which also limits generalizability. Moreover, randomization into groups was, out of logistical necessity, assigned based on the physical location of the participant within the facility, which could have biased the composition of control/intervention groups. Larger sample sizes with greater diversity of participants would improve depth of data and generalizability of future quantitative/qualitative studies. It is possible that the simple act of leaving the facility and being outside–rather than gardening specifically—is responsible for the benefits observed in the data.

With respect to qualitative data collection, there is a possibility that desirability bias could have affected interview responses from participants and staff, as the residents may have associated the PI with their time in the garden and felt pressured to give positive feedback during interviews (i.e., the “halo effect”). Future studies could control for this, and perhaps elicit greater candor from participants, by using an interviewer with whom those in the study are not acquainted, and who lacks an association with their time in the garden. Future studies may benefit by enabling staff to share subjective experiences more frequently throughout the study, rather than just at the end.

Researchers may also find an additional opportunity to support PIL by encouraging residents to participate in the early stages of planting, or even in assisting with the assembly of raised-bed planters when physically able. Future work might also evaluate how the degree of direct participation in charitable work influences the meaning of that activity for participants. This study did identify that the hands-on nature of gardening was enjoyed by the participants, but they did not participate in the physical act of delivering the vegetables to the food pantry. It is possible that strengthening the reinforcement of the charitable aspect of the intervention could improve outcomes. Indeed, in this study, caregivers discussed the donation with participants whenever possible, but, due to short-term memory loss, it was not always clear if participants remembered this. Further research into the benefits of charity work could investigate the benefits with gardeners at varying stages of dementia, to determine whether there are diminishing returns as the disease progresses.