Applying the Innovation Biodesign Framework to Promote Equity and Green Activity in Dementia Care


Lassell et al present a use case demonstrating the process of moving an unmet need to the “solution space” of the Innovation Biodesign Framework for addressing a healthcare challenge in a specific at-risk population: Alzheimer disease and AD-related dementias.

From left: Becca Lassell, PhD, OTR; Katherine Wang, MD; Ada Metaxas, BSE-C; Sara Hantgan, BSI-C; Proby Gottipati; Sarah Zwerling; and Sunit P. Jariwala, MD, FAAAAI

From left: Becca Lassell, PhD, OTR; Katherine Wang, MD; Ada Metaxas, BSE-C; Sara Hantgan, BSI-C; Proby Gottipati; Sarah Zwerling; and Sunit P. Jariwala, MD, FAAAAI

Alzheimer disease (AD) and AD-related dementias (ADRD) are 1.5 times higher for people who identify as Hispanic or Latino than non-White Hispanics.1 Across the United States (U.S.), AD/ADRD is projected to see the greatest increase in Hispanic/Latinos among racial and ethnic groups, from 430,000 cases in 2012 to 2,383,000 in 2050.2 The Bronx, New York, ranks among the top 3 counties in the U.S. with the highest prevalence of AD.3 Approximately, 56% of Bronx residents identify as Hispanic/Latino and 29% of older adults live in poverty.4 Many older Hispanic/Latino adults in the Bronx face multiple risk factors for cognitive decline including risk factors that can be modified later in life such as physical inactivity, heightened stress, social isolation, and depression.5

Engaging in an active lifestyle is a key modifiable risk factor for cognitive decline and memory challenges later in life.5 Activity in contact with nature can lower anxiety6 and perceived stress7,8 more than indoor physical activity9 or outdoor physical activity without greenery.10 Visiting a green space or park at least once per week is associated with higher physical activity and social cohesion,10 which can address sedentary behavior and social isolation that are risk-modifiable factors for cognitive decline.5 A recent dose-response analysis indicated that visits to outdoor green spaces of 30 minutes at least once per week could reduce depression and high blood pressure by 7-9%.10 High blood pressure and depression are risk factors for cognitive decline31 and often co-occur with AD/ADRD. Green activities are any type of activity a person enjoys that involves nature and a social context and include walking, gardening, and tree planting. Green activities can be a cost-efficient way to build brain health and decrease risk of accelerated cognitive decline.

Gaps & Opportunities: Innovation Biodesign Framework

The innovation biodesign process is a well-suited approach to identifying unmet healthcare needs through clinical observation and patient feedback for the development of user-centered solutions.11 This approach can particularly be used to address health disparities and modifiable risk factors among underserved populations. In this article, we present a use case demonstrating the process of moving an unmet need from the “problem space” to the “solution space” of the published Innovation Biodesign Framework for addressing a healthcare challenge in a specific at-risk population.12 In particular, we seek to address modifiable risk factors of cognitive decline such as social isolation and physical inactivity through the development of a sustainable solution, the Green Activity Program. The Innovation Biodesign Framework is a helpful approach for clinicians and researchers seeking to solve problems identified by their patients, community, and healthcare partners (FIGURE).

Figure. Applying the Innovation Biodesign Framework to the development of a Green Activity Program for patients with Alzheimer’s disease and related dementias.

(Click to enlarge)

Figure. Applying the Innovation Biodesign Framework to the development of a Green Activity Program for patients with Alzheimer’s disease and related dementias.

(Click to enlarge)

Problem Space

Needs Assessment

People who identify as Hispanic/Latino with MCI and AD/ADRD, called memory challenges herein, have been historically underrepresented in research. Currently, few programs exist that have been codesigned with this population to improve their well-being and stave off cognitive decline. While some countries have undergone similar initiatives to prescribe green activities to improve a person’s health and well-being, many have not incorporated these communities in the design process, resulting in challenges with buy-in.13,14 To our knowledge, individuals with memory challenges have not been included in green prescribing models in other countries and require additional tailoring to safely access and participate in green activities.

To address this gap, the Green Activity Program was designed to meet the preferences and needs of Hispanic/Latino community members with memory challenges.15 Furthermore, there is a need to involve local healthcare and nature organizations when developing and implementing the program. Adopting a collaborative participatory approach to involve all partners—community members, outdoor organizations, healthcare providers—can help to gain institutional and community support and may mitigate challenges with buy-in among healthcare and outdoor organizations.

Needs Screening

Co-design was informed by existing evidence-based programs and participant feedback.15 Participants included Hispanic/Latino persons living with memory challenges and their care partners, outdoor activity professionals, interdisciplinary healthcare providers, and dementia experts. Through iterative codesign, Hispanic/Latino participants living with memory challenges and their care partners identified preferred green activities and needs for frequency, duration, and delivery mode of the green activity program. They also identified preferred terms to describe their community (Hispanic/Latino) and empowering language for recruitment materials (eg, memory challenges instead of dementia). Outdoor professionals and people living with memory challenges provided input on local green activities. Healthcare providers and dementia experts provided guidance on referral pathways and fit within clinical care. All participants identified outcomes that mattered to them–including connecting with others and being in nature–and potential program barriers and solutions. Participants with memory challenges and their care partners emphasized the importance of program flexibility with a range of options for participation that could be tailored for each person’s situation (eg, 4-8 sessions between 30-90 minutes long) and were based on prior evidence-based programs.14,16

Solution Space

Invention: Green Activity Program

To promote an active lifestyle and well-being within a cohort with memory challenges, an occupational therapist-led 12-week Green Activity Program was co-designed with Hispanic/Latino and care partners, local outdoor professionals, and interdisciplinary healthcare providers.15 The program involves an occupational therapy (OT) evaluation, goal-setting, program sessions, and a tailored green activity plan. The care administered through the Green Activity Program holds potential to be reimbursed as part of clinical care. The Green Activity Program utilizes the evidence-based principles derived from the Tailored Activity Program and applies them to green activities. Green activity selection, delivery mode (in-person/phone check-ins), frequency, and program outcomes were designed to meet patient needs. An emphasis is also placed on using local resources to increase access for homebound participants and sustainable use of resources that exist in the community.

Implementation & Validation

To better align with the Innovation Biodesign Framework, the Green Activity Program exhibits flexible tailoring to the cultural preferences and values of the Hispanic/Latino community. Research is conducted with a high level of community engagement to better understand patient needs and receive feedback regarding program implementation. The Green Activity Program has significant potential to be embedded into current healthcare applications, where green activity-focused OT services could be covered under the existing Medicare/Medicaid plans.15 The success of in-home care delivered by OTs further demonstrates the utility of having flexible, personalized care as part of green activity implementation.

Anticipated Outcomes and Sustainability

Priorities for the implementation of this program include the promotion of health equity, improving patient outcomes within the Hispanic/Latino community, and increasing overall satisfaction of care between caregivers and patients.15 The use of codesign in program development can help guide implementation with community input on inclusive language, preferred methods of outreach, and appropriate cultural tailoring. The Green Activity Program is designed to be sustainable through its use of readily available local resources that can be directly integrated into clinical care. The sustainable use of local green resources may also increase social cohesion within the community. This can be achieved through partnering with advocacy groups, and nonprofits at the local level to directly disseminate this program.

The Innovation Biodesign Framework highlights the application of co-design in creating the Green Activity Program to be responsive to older Hispanics'/Latinos’ preferences and needs. This use case highlights the benefits of the Innovation Biodesign Framework in rapid cycle iterations utilizing codesign to receive input from multiple partners across sectors, including the end-user vulnerable Hispanic/Latino older adults with memory challenges, moving from a “problem space” to a “solution space.” Multipartner involvement is an inclusive innovation process involving and valuing input from partners across sectors, including a community that is truly living with memory challenges, in the design process. Notably, this approach to design with flexible interview methods allows individuals with memory impairments to continue engaging in the development process, ensuring that their perspective is included in the final result. Similarly, multipartner involvement in codesign ensures cultural sensitivity regarding language to represent the user’s communities or identities, such as gender, social roles, age, geographic location, religion, race, ethnicity, and AD/ADRD terminology.

Additional significant outcomes as a result of the Innovation Biodesign Framework include improved health literacy and digital health literacy.12 The collaborative and inclusive nature of the innovation biodesign process can lead to improvements in clinical outcomes among participants. By actively engaging in the design and implementation of the program, people living with memory challenges may develop a deeper understanding of their health conditions, treatment options, and self-management strategies, ultimately empowering them to make more informed decisions about their care.

Rapid–cycle iterations within the Innovation Biodesign Framework ensure that the Green Activity Program evolves responsively to feedback and insights from the participants. This framework focuses on rapid cycle iterations and refinement of the Green Activity Program, ensuring that the program can adapt to the evolving needs and preferences of participants, enhancing its impact and accessibility for the users at hand. The next steps in this process are to rigorously pilot the program with outcomes that matter to the community and partners, leading to effectiveness testing, and maximizing outreach of the program.

1. Alzheimer’s Association. 2023 Alzheimer’s disease facts and figures. Alzheimers Dement. Published online April 14, 2023. doi:10.1002/alz.13016
2. Matthews KA, Xu W, Gaglioti AH, et al. Racial and ethnic estimates of Alzheimer’s disease and related dementias in the United States (2015–2060) in adults aged ≥65 years. Alzheimers Dement. 2019;15(1):17-24. doi:10.1016/j.jalz.2018.06.3063
3. Alzheimer’s Association. Researchers Reveal First-Ever U.S. County-Level Alzheimer’s Prevalence Estimates.; 2023.
4. Furman Center New York University. The Bronx Neighborhood Profile. Published 2019. Accessed January 30, 2022.
5. Livingston G, Huntley J, Sommerlad A, et al. Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. The Lancet. 2020;396(10248):413-446.
6. De Brito JN, Pope ZC, Mitchell NR, et al. Changes in Psychological and Cognitive Outcomes after Green versus Suburban Walking: A Pilot Crossover Study. Int J Environ Res Public Health. Published online 2019. doi:10.3390/ijerph16162894
7. Olafsdottir G, Cloke P, Vögele C. Place, green exercise and stress: An exploration of lived experience and restorative effects. Health Place. 2017;46:358-365. doi:10.1016/J.HEALTHPLACE.2017.02.006
8. Pretty J, Peacock J, Sellens M, Griffin M. The mental and physical health outcomes of green exercise. Int J Environ Health Res. 2005;15(5):319-337. doi:10.1080/09603120500155963
9. Thompson Coon J, Boddy K, Stein K, Whear R, Barton J, Depledge MH. Does participating in physical activity in outdoor natural environments have a greater effect on physical and mental wellbeing than physical activity indoors? A systematic review. Environ Sci Technol. 2011;45(5):1761-1772.
10. Shanahan, D., Bush, R., Gaston, K. et al. Health Benefits from Nature Experiences Depend on Dose. Sci Rep 6, 28551 (2016).
11. Luff MK, Zarrin DA, Zhou L, et al. Clinical Needs Discovery in Pediatric Urology: Utilizing the Biodesign Process. Front Urol. 2022;2.
12. Metaxas A, Hantgan S, Wang K, Desai J, Zwerling S, Jariwala S. A Framework for Social Needs-Based Medical Biodesign Innovation. Appl Clin Inform. 2024 Apr 24. doi: 10.1055/a-2312-8621. Epub ahead of print. PMID: 38657678.
13. Drinkwater C, Wildman J, Moffatt S. Social Prescribing. Vol 364.; 2019. doi:10.1136/bmj.l1285
14. Hamlin MJ, Yule E, Elliot CA, Stoner L, Kathiravel Y. Long-term effectiveness of the New Zealand Green Prescription primary health care exercise initiative. Public Health. 2016;140:102-108. doi:10.1016/J.PUHE.2016.07.014
15. Lassell R, Tamayo V, Pena T, et al. “When she goes out, she feels better:” Co-designing a Green Activity Program with Hispanic/Latino People Living with Memory Challenges and Care Partners." .Front Aging Neurosci (under review).
16. Gitlin LN, Marx K, Piersol CV, et al. Effects of the tailored activity program (TAP) on dementia-related symptoms, health events and caregiver wellbeing: a randomized controlled trial. BMC Geriatr. 2021;21(1). doi:10.1186/s12877-021-02511-4
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