Abstract
Background
Population ageing is a growing public health concern. Parks can play a central role in promoting healthy ageing by offering accessible spaces for physical activity, social interaction, and mental restoration. However, little is known about how older adults use parks across seasons, what activities they engage in, and who they visit with and how this differs according to season and health status. Associations between older adults’ park visitation and health are not well explored, and little is known about reasons for non-visitation. This study among older adults aimed to (1) describe park visitation (frequency, duration, accompaniment, activities) across all seasons and by health status; (2) examine associations of total park visitation frequency and duration with self-reported physical, mental, and social health; and (3) describe reasons for non-visitation.
Methods
Older adults (n = 235) in Belgium reported their park visitation, health, and demographics. Using the Public Participatory Geographic Information Systems tool “My Green Place”, participants indicated the park that they visited most often or that they did not visit parks. Those who indicated that they were park visitors, completed questions concerning their park visitation and non-visitors reported reasons for not visiting. Descriptive statistics, Mann-Whitney U tests, and chi-square tests were performed (aims 1 and 3). Logistic regression models were fitted to examine associations of total year-round park visitation frequency (# visits/year) and duration (hours per visit/year) with physical, mental, and social health and loneliness (aim 2).
Results
Most participants (61%) visited year-round, especially in summer and spring. Park visitation frequency and duration were highest among participants who visited year-round. At least half of the sample visited parks alone across all seasons. Walking, sitting, listening to nature, and socialising were the most common activities. Reasons why non-visitors did not visit parks were primarily personal (e.g., physical disability, health reasons) or park related. There were limited associations observed between park visitation and health.
Conclusions
Our findings may help with planning park programming activities and informing important park features that cater to older adults’ needs, ensuring that parks support older adults’ healthy ageing.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12889-026-26924-1.
Keywords: Parks, Public spaces, Older adults, Physical health, Mental health, Social health
Background
Population ageing is critical for public health as the proportion of older adults (aged ≥ 60 years) is rising, with the number expected to double from 2019 to 2050 worldwide [1]. Given that ageing is generally linked to a higher risk of various health conditions, this may have significant implications for the aged care and health sectors. For example, 15% of older adults (aged ≥ 60 years) suffer from a mental or mood disorder [2] and 25% report experiencing social isolation and loneliness [3]. Additionally, the global prevalence of chronic diseases is higher among older adults compared to other age groups [4]. Consequently, there has been increased focus worldwide to foster healthy ageing and support older adults’ physical, mental, and social health.
There are many influences on older adults’ health and wellbeing, including neighbourhood built environments [5]. Neighbourhood parks offer opportunities for recreation, relaxation, social interaction, physical activity, and contact with nature [6, 7]. This can yield physical, mental, and social health benefits [8, 9] and promote wellbeing and healthy ageing [10]. Additionally, public parks are often free-to-access and located in many communities, making them well-placed to serve large populations [9, 11] including those at risk of poor health [12]. Thus, there is scope for park visitation to promote older adults’ health, potentially combatting challenges presented by population ageing.
Despite these benefits, little is known about park visitation according to season, activities performed in the park, and accompaniment during visits among older adults. This is an important gap to address because such contextual information can inform park policy and programming to promote older adults’ park visitation for enhanced health by targeting seasonal patterns of use, the activities they commonly perform during visits, and who they primarily visit with.
Most observational studies of park use, including older adults, are limited to data collection in one or two seasons, which limits understanding of annual visitation rates [13, 14]. To date, a quantitative study that explored park visitation (frequency and duration) among older adults in China among separate samples for winter (n = 211) and non-winter seasons (n = 240) found that 78% and 83% visited the park two or more times per week in winter and non-winter, respectively [15]. However, this study did not examine frequency and duration of park visitation across all seasons [15]. Another research gap concerns whether the frequency and duration of park visits vary according to physical, mental, and social health status or year-round (i.e., in all four seasons) visitation. This is critical for identifying sub-groups of older adults who are less frequent users of parks and should therefore be targeted in tailored interventions aiming to increase their park use for healthy ageing.
Further, quantitative studies conducted indicated that sitting/resting, exercising, walking, and chatting with others were the usual activities performed by most older adults during park visits [16–18]. These activities may vary according to health status and/or year-round visitation. Additionally, a cross-sectional study conducted in Hong Kong found that 61% of older adults visited parks alone, followed by friends or neighbours (32%) [17], while an Australian study found that 56% of older adults visited parks with another adult family member or friends, followed by grandchildren (19%), a dog (17%), and alone (11%) [19]. It remains unclear whether usual accompaniment to the park differs according to health status or year-round visitation. Gaining a better understanding of these variations may help with planning appropriate activities and park features that cater to diverse health needs.
Quantitative studies have shown that self-reported green space use (i.e., forests, gardens, parks) was associated with improved psychological health [20], social ties [8], and physical activity [21] among older adults. However, these studies did not examine frequency and duration of park visitation specifically. Therefore, further research exploring associations of park visitation frequency and duration with health outcomes is required to better understand what “dosage” of park visitation is associated with favourable physical, mental, and social health among older adults.
Relatedly, cross-sectional studies have indicated that self-reported visitation duration to green spaces (including parks) was associated with greater perceived wellbeing [22] and lower blood pressure [23] and that self-reported frequency of visitation to green spaces was associated with greater wellbeing [17, 24–26], better cardiovascular health [25], decreased feelings of loneliness [27], greater social cohesion [27, 28], and better self-estimated overall health [25, 29] among adults and older adults. However, only three of these studies focused on older adults exclusively [23, 25, 29], who have unique social and health needs compared to other age groups, and these studies generally only reported the frequency or the duration of visitation as opposed to both. Additionally, most of these studies focused on green space visitation [17, 27–29], which was not limited to parks. Thus, associations between park visitation (frequency and duration) and physical, mental, and social health, and loneliness among older adults are not well known, requiring further research to better understand the potential link between park visitation and healthy ageing.
Lastly, limited qualitative studies have explored reasons for not visiting parks among older adults, indicating that not feeling safe, limited access, and inadequate amenities were common reasons for non-visitation [30–32]. Further exploration of the reasons for non-visitation may inform targeted strategies to promote visitation among non-visitors as a means for promoting healthy ageing.
Therefore, this study among older adults aimed to: (1) describe the total park visitation frequency and duration per visit per season and in a year overall and according to health status (i.e., high/low physical health, mental health, social health, loneliness) and whether visitation was year-round (visiting in all four seasons or not); (2) describe usual accompaniment and usual activities performed in a park overall and according to health status and year-round visitation; (3) examine associations of total year-round park visitation frequency and park visit duration (aggregated annual hours) with physical, mental, and social health, and loneliness; and (4) describe reasons for not visiting parks among non-visitors.
Methods
This study analysed cross-sectional survey data collected via the Public Participatory Geographic Information System tool “My Green Place” [33] from a sample of older adults (60 + years) residing in Ghent, Belgium. The “My Green Place” tool has been used in previous research in Ghent and Woluwe, Belgium [33–35]. Ethical approval was received from the Ethics Committee of the University Hospital of Ghent University (2019/1873; BC-06738).
Study setting
Data collection occurred in the city of Ghent (Flanders, Belgium) with an area of 158 km2 and over 267,000 inhabitants (population density: 1,709/km2; annual population change: 0.74%), and the 83% are Belgian citizens [36, 37]. Of the population, 21% are under 20 years, 62% are 20–64 years, and 17% are 65 + years [36]. Of those aged 60 years and above, 26,170 are 60–69 years, 19,061 are 70–79 years, 10,432 are 80–89 years, and 3,009 are 90 + year [37]. There are 160 parks across Ghent.
Participant recruitment
Older adults were recruited through three main strategies. Firstly, the research team visited several public locations, such as one city library and local service centres in Ghent (n = 11), to notify centre users about the study and provide an invitation to participate. A local service centre is a community centre located in many of the 25 neighbourhoods in Ghent that has health personnel onsite (e.g., social worker, occupational therapist, psychologist), daily organised activities (e.g., games, drawing classes, library, organised sports), a cafeteria with food at concession prices, and provides administrative help. Interested persons had the option to complete the online survey, which included a consent form, at the location on a tablet or laptop with support from a researcher if needed. The research team also distributed flyers at the public locations (city library, local service centres) during their visits, so participants could receive a flyer with a link to the online survey to complete in their own time. The second strategy involved including a link to the online survey in print and online in local city magazines targeting older adults and these magazines’ Facebook pages. For the third strategy, emails with the weblink to the online survey were distributed to six assisted living facilities located in Ghent requesting staff to share the link with the residents.
Protocol
From August 2021 to February 2023, older adults completed an online survey in Flemish that included five components. The first component included providing informed consent (digital), where interested persons confirmed they had read the Plain Language Statement and agreed to voluntarily participate in the study. The second part prompted participants to indicate their residential statistical sector [38] on a digital map of Ghent in the “My Green Place” tool embedded within the survey [33]. Further information about the tool can be found elsewhere [33–35]. Additional file 1 includes screenshots of the online survey (Flemish) with the embedded “My Green Place” tool.
Participants were then asked to indicate that they did not visit parks or select the park they visited most often in general on an interactive map, which displayed all 160 parks (including neighbourhood parks, pocket parks, etc.) located across Ghent. Participants, who did visit parks, were presented with a series of questions in relation to the park they visited most often including usual activities performed in the park, the season(s) in which they visited, usual accompaniment to the park according to season, and frequency and duration of park visits according to season. They also were asked questions about demographics and health outcomes. Participants, who did not visit parks, were presented with questions about possible reasons for not visiting parks.
Measures
Physical, mental, and social health and loneliness
In three separate questions, participants indicated their physical health, mental health (degree to which they felt good about themselves), and social health (satisfaction and quality of their social contacts), respectively, on a five-point Likert scale (1 = very good to 5 = very bad). These items were conceptually aligned with the World Health Organization’s definition of health [39, 40] and adapted from items used in previous research [41, 42]. To ensure comprehensibility of these items, cognitive interviews were conducted with eight older adults, and item wording was adapted accordingly. Responses were reverse coded so that a higher score indicated higher physical, mental, or social health and dichotomised as follows (coding in parentheses): low health (0 = very bad, bad, not good/not bad) and high/favourable health (1 = good, very good). Participants were also asked to self-report the extent to which they felt lonely: never (1); rarely (2); sometimes (3); often (4); very often (5); and always (6). Responses were dichotomised as low loneliness (never, rarely) and high loneliness (sometimes, often, very often, always). Responses were dichotomised given the unequal distribution of frequencies across the different response categories for these variables.
Total frequency of visiting parks per season and year
In an initial question, participants were first asked to indicate whether they visited their most frequently visited park during spring, summer, fall and/or winter, and the response options included ‘yes’ or ‘no’. For each season that participants selected ‘yes’, they were then asked to indicate their usual frequency of visitation for that season from the following response options: every day; 4–6 times a week; 2–3 times a week; about once per week; about 2–3 times per month; about once per month; and less than once per month. If participants did not select a season or were a non-visitor, then their frequency was treated as zero for that season. A score of zero for all four seasons indicated non-visitation. Responses were recoded to create a continuous variable that reflected the frequencies of the response options in a given month (coding in parentheses): [28] every day; (21.5) 4–6 times a week [4.3 weeks/month multiplied by 5 as an average of visiting 4–6 times per week]; (10.8) 2–3 times a week [4.3 weeks/month multiplied by 2.5 as an average of visiting 2–3 times per week]; (4.3) about once per week [based on 4.3 weeks per month]; (2.5) about 2–3 times per month [average of 2–3 times visited per month]; [1] about once per month; (0.5) less than once per month; and (0) zero times per month. Then, this variable was multiplied by three (i.e., representing ‘months’) to calculate the total frequency of visits to the most frequently visited park for that season. All four total seasonal frequency of park visitation variables were summed to calculate a separate variable for the year-round park visitation (total number of park visits in a year).
Total duration of park visits per season and year
For each season that participants indicated that they visited their most frequently visited park, they were asked to indicate the average time spent per park visit in hours and minutes. This was converted into total hours per park visit per season. To calculate the total park visit duration per season (hours), the average frequency of visits per season were multiplied by the total time (hours) spent per park visit during each season (e.g., total frequency of park visits for fall multiplied by total hours spent per park visit during fall). To calculate the total year-round park visit duration (hours), the four variables for totals of park visit time per season were summed.
Accompaniment and park activities
Participants reported their usual accompaniment to the park per season [alone, with dog(s), with partner, with adult family members(s), with child(ren), with grandchild(ren), with friend(s) or organised group, other]. An accompaniment variable was created with responses categorised as: visit alone, visit with others (not alone), and visit alone and/or with others. From a list of activities, participants also selected the usual activities performed when in the park (in general irrespective of season) and could add activities not listed (see top 10 in Table 1).
Table 1.
Sample characteristics
| n=235 | |
| Age groups, n (%) | |
| 60-69 years | 113 (48.1) |
| 70+ years | 122 (51.9) |
| Sex, n (%) | |
| Male | 102 (43.4) |
| Female | 133 (56.6) |
| Education level, n (%) | |
| No higher education diploma | 86 (36.6) |
| Higher education diploma | 149 (63.4) |
| Nationality | |
| Belgian | 233 (99.2) |
| Household, n (%) | |
| Live alone | 115 (48.9) |
| Live with other people | 120 (51.1) |
| Visit park ina, n (%) | |
| Spring | 183 (77.9) |
| Summer | 184 (78.3) |
| Fall | 174 (74.0) |
| Winter | 143 (60.1) |
| Number of seasons of park visits, n (%) | |
| 0 | 42 (17.9) |
| 1 | 12 (5.1) |
| 2 | 12 (5.1) |
| 3 | 28 (11.9) |
| 4 | 141 (60.0) |
| Top 10 activities performed in the parka , Mean(SD) | |
| Walking | 161 (68.5) |
| Sitting/relaxing | 88 (37.5) |
| Listening to nature | 69 (29.4) |
| Socialising with acquaintances (e.g., neighbours) | 41 (17.5) |
| Biking | 41 (17.5) |
| Meeting with friends/family | 35 (14.9) |
| Socialising with people they do not know | 31 (13.2) |
| Supervising (grand) children | 30 (12.8) |
| Photography | 30 (12.8) |
| Visiting a café/restaurant | 22 (9.4) |
| Total duration spent visiting parks (hours), Mean (SD) | |
| Winter | 9.4 (24.5) |
| Spring | 16.2 (29.7) |
| Summer | 21.7 (44.2) |
| Fall | 14.1 (26.4) |
| Year-round | 61.4 (111.0) |
| Total frequency (number of park visits) of park visitation, Mean (SD) | |
| Winter | 10.8 (20.8) |
| Spring | 15.7 (23.3) |
| Summer | 17.0 (24.1) |
| Fall | 14.4 (21.7) |
| Year-round | 57.9 (85.5) |
| Physical health, n (%) | |
| Low physical health | 66 (28.1) |
| High physical health | 169 (71.9) |
| Mental health, n (%) | |
| Low mental health | 35 (14.9) |
| High mental health | 200 (85.1) |
| Social health, n (%) | |
| Low social health | 33 (14.0) |
| High social health | 202 (86.0) |
| Loneliness, n (%) | |
| Low loneliness | 168 (71.5) |
| High loneliness | 67 (28.5) |
aCould select more than 1
Reasons for not visiting parks
Participants who reported not visiting parks, were presented with a series of questions concerning personal reasons (11 questions; e.g., having a physical disability that makes it difficult to visit parks), transportation (4 questions; e.g., no good footpaths or cycle paths to parks), and park-related reasons (19 questions; e.g., not feeling safe in parks) for non-visitation. For each question (see Additional file 2 for all questions), these participants indicated whether the reason applied to them (yes, no).
Demographic characteristics
Participants reported age (years), sex (male, female), and the highest diploma attained, which was dichotomised as no higher education diploma (none, primary school, secondary school) and higher education diploma (college, university). Participants also reported their nationality (open-ended) and household composition (living alone, married/cohabiting with children, married/cohabiting without children, sharing house/apartment with relatives/friends, staying in a nursing home/assisted living, other), which was dichotomised as: living alone and living with other people. Participants indicated their area of residence on a map, which was used to derive a statistical sector code [38] to determine the neighbourhood level income using a welfare index for the neighbourhood. The welfare index is a comparison of the average income per resident of a neighbourhood with the average income per resident in Belgium. Belgium’s average income/resident is set to 100. If a neighbourhood’s welfare index value is lower than 100, it indicates that it is lower than the national average income/resident. The welfare index of the city of Ghent equals 103, ranging between 68 and 138 across neighbourhoods.
Data analysis
Descriptive statistics, specifically frequencies, means, and standard deviations, were used to describe the sample characteristics, park visitation [usual activities performed in parks irrespective of season, the season(s) in which participants visited, usual accompaniment to the park according to season, total frequency of visiting parks per season and year, and total park visit duration per season and year], and health outcomes, specifically physical/mental/social health and loneliness (research question 1). Mann-Whitney U tests were run to compare total frequency of visiting the park in a year and total park visit duration in a year according to health status and whether participants visited year-round (research question 1). Mann-Whitney U tests were used given that the data did not meet the assumptions of normality (determined by Shapiro-Wilk test) and of equal variances between groups (determined by Levene’s test), requiring a non-parametric statistic test. Chi-square tests were run to compare usual accompaniment to the park and usual activities performed according to health status, specifically high/low physical/mental/social health and loneliness, and whether participants visited year-round (research question 2).
Complete case analyses were performed, with 12 participants excluded from the analyses due to missing data for the following outcome variables: physical health (n = 5); age (n = 4); loneliness (n = 2); and mental health (n = 1), reducing the sample from 265 to 253 participants. Eighteen further cases were dropped for implausible values (e.g., indicating the frequency of visiting the park but not providing any data for the visit duration and vice versa), reducing the final analytical sample to 235.
Logistic regression models were fitted to examine associations of year-round park visitation (total frequency and duration of park visits in a year) with physical health, mental health, social health, and loneliness among older adults separately (research question 3). This resulted in eight models (four outcomes each separately examined with the two exposure variables). All models adjusted for age, sex, household composition, education level, and socio-economic status of residential neighbourhood. Additionally, the dichotomised health variables (i.e., high versus low physical health, mental health and social health and loneliness) were treated as covariates, except for when one of these was treated as the outcome variable in a model. For example, statistical models fitted to examine associations of year-round park visitation with loneliness among older adults adjusted for physical, mental and social health. Statistical significance was set at p < 0.05, and all analyses were performed using Stata/BE 18.0 (Stata Corp., College Station, TX, USA). Descriptive statistics were used to describe possible reasons for not visiting parks among older adults who indicated that they were non-visitors (research question 4), and chi-square tests were used to determine if there were differences according to health status.
Results
Table 1 presents the participant characteristics. Fifty-seven percent of participants were female, 99% were Belgian nationals, and most had a higher education diploma (63%). Roughly half were over 70 years (52%) and living with other people (51%). Parks were most frequently visited during summer and spring (both 78%), followed by fall (74%), and winter (60%). The majority of the sample visited parks in all four seasons (60%), although 18% did not visit parks at all. The five most common activities performed in the park were walking (69%), sitting/relaxing (38%), listening to nature (29%), socialising with acquaintances (18%), and biking (18%). The total mean duration of park visits was 61 h in a year, 22 h in summer, 16 h in spring, 14 h in fall, and 9 h in winter. The total mean frequency of park visitation was 58 visits in a year, 17 in summer, 16 in spring, 14 in fall, and 11 in winter. Most participants reported high/favourable physical health (72%), mental health (85%), and social health (86%) and low loneliness (72%).
Frequency and duration of park visits
Participants with high physical health reported a higher park visit duration (hours/visit) in winter and fall compared to those with low physical health, but there was no difference in the number of park visits according to health status (Table 2).
Table 2.
Total frequency of park visits and total duration of park visits per season and per year overall and according to health status and year-round visitation, mean (SD)
| Park visit frequency (# of visits) | Low physical health, mean (SD) | High physical health | z-statistic (p-value) | Low mental health | High mental health | z-statistic (p-value) | Low social health | High social health | z-statistic (p-value) | Low Loneliness | High Loneliness | z-statistic (p-value) | Visit less than year round | Visit all year rounda | z-statistic (p-value) | ||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Frequency of visitation in winter | 13.5 (22.5) | 16.6 (23.7) | -1.9 (0.0511) | 14.2 (20.2) | 16.0 (23.9) | 0.3 (0.7972( | 14.3 (23.0) | 16.0 (23.4) | -0.2 (0.8550) | 15.8 (24.1) | 15.6 (21.6) | 0.0 (0.9792) | 6.9 (17.7) | 21.6 (24.8) | -8.9 (< 0.001) | ||
| Frequency of visitation in spring | 8.5 (19.1) | 11.7 (21.4) | -1.9 (0.0509) | 9.3 (18.5) | 11.0 (21.2) | 0.2 (0.8628) | 11.7 (23.7) | 10.6 (20.3) | -0.0 (0.9793) | 11.0 (21.3) | 10.3 (19.6) | 1.0 (0.2994) | 0.1 (0.8) | 17.9 (24.4) | -13.2 (< 0.001) | ||
| Frequency of visitation in summer | 49.3 (81.6) | 61.2 (87.0) | -1.3 (0.2104) | 51.2 (74.5) | 59.1 (87.4) | 0.6 (0.5719) | 18.8 (24.8) | 16.7 (24.1) | 0.8 (0.4152) | 16.7 (24.9) | 17.7 (22.4) | -0.6 (0.5258) | 9.1 (20.4) | 22.2 (25.0) | -8.1 (< 0.001) | ||
| Frequency of visitation in fall | 12.2 (20.6) | 15.3 (22.1) | -2.0 (0.4666) | 11.4 (18.6) | 15.0 (22.2) | -0.5 (0.5874) | 13.6 (23.7) | 14.6 (21.4) | -0.8 (0.4194) | 14.7 (22.6) | 13.9 (19.4) | 0.5 (0.6169) | 5.5 (13.9) | 20.4 (23.9) | -9.3 (< 0.001) | ||
| Frequency of visitation in a year | 49.3 (81.6) | 61.2 (87.0) | -1.8 (0.0671) | 51.2 (74.5) | 59.1 (87.4) | 0.2 (0.8297) | 58.3 (92.2) | 57.8 (84.6) | 0.2 (0.8763) | 58.1 (89.1) | 57.5 (76.3) | -0.0 (0.9918) | 21.6 (50.0) | 82.1 (95.4) | -9.1 (< 0.001) | ||
| Park visit duration (hours) | |||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Total visit time in winter | 8.0 (29.1) | 9.9 (22.6) | -2.3 (0.0199) | 7.4 (15.2) | 9.7 (25.8) | 0.1 (0.944) | 8.1 (17.0) | 9.6 (25.6) | -0.3 (0.7470) | 7.6 (16.0) | 13.9 (38.1) | 0.8 (0.4413) | 0.1 (0.9) | 15.5 (30.2) | -13.1 (< 0.001) | ||
| Total visit time in spring | 17.5 (39.3) | 15.7 (25.2) | -1.7 (0.0834) | 13.5 (18.6) | 16.7 (31.3) | 0.2 (0.8415) | 12.4 (17.4) | 16.8 (31.3) | -0.3 (0.7951) | 14.0 (23.5) | 21.8 (41.2) | -0.2 (0.8245) | 9.1 (26.2) | 21.0 (31.0) | -7.9 (< 0.001) | ||
| Total visit time in summer | 24.7 (62.3) | 20.6 (34.8) | -1.3 (0.1848) | 20.8 (33.1) | 21.9 (45.9) | 0.6 (0.5654) | 23.6 (34.7) | 21.4 (45.6) | 0.8 (0.4274) | 18.6 (40.1) | 29.5 (52.7) | -1.0 (0.3096) | 17.0 (53.0) | 24.8 (37.0) | -7.5 (< 0.001) | ||
| Total visit time in fall | 13.5 (32.1) | 14.4 (24.0) | -2.1 (0.0392) | 9.7 (16.1) | 14.9 (27.8) | -0.7 (0.4811) | 10.3 (17.8) | 14.8 (27.6) | -1.3 (0.2006) | 12.4 (20.5) | 18.5 (37.2) | 0.5 (0.6180) | 6.1 (16.3) | 19.5 (30.3) | -8.7 (< 0.001) | ||
| Total visit time in a year | 63.7 (145.9) | 60.6 (94.4) | -1.8 (0.0663) | 51.4 (72.9) | 63.2 (116.4) | 0.2 (0.8140) | 54.5 (72.1) | 62.6 (116.2) | 0.2 (0.8074) | 52.5 (87.9) | 83.7 (153.0) | -0.3 (0.7404) | 32.3 (89.6) | 80.8 (119.6) | -8.2 (< 0.001) | ||
avisit all four seasons
Significant differences (p<0.05) are bolded
Park accompaniment
Across all seasons, most participants visited alone, followed by with a partner, friends/organised group, and grandchildren (Table 3). There were no statistically significant differences in park accompaniment according to health and visitation year-round (Table 4).
Table 3.
Usual accompaniment when visiting the park per season, n(%)
| Usual accompaniment | Winter | Spring | Summer | Fall |
|---|---|---|---|---|
| Alone | 101 (52.1) | 121 (62.4) | 126 (65.0) | 122 (62.9) |
| Partner | 42 (21.7) | 50 (25.8) | 54 (27.8) | 49 (25.3) |
| Friends or organised group | 30 (15.5) | 34 (17.5) | 38 (20.0) | 34 (17.5) |
| Grandchild(ren) | 16 (8.3) | 32 (16.5) | 35 (18.0) | 29 (15.0) |
| Adult family member(s) | 9 (4.6) | 14 (7.2) | 18 (9.3) | 11 (5.7) |
| Dog(s) | 8 (4.1) | 9 (4.6) | 9 (4.6) | 8 (4.1) |
| Child(ren) | 4 (2.1) | 9 (4.6) | 11 (5.7) | 7 (3.6) |
This table only includes the park visitors
Table 4.
Accompaniment when visiting the park in a year and according to health and visitation year-round
| Usual accompaniment to the park across the year, n(%) | Low physical health | High physical health | X2 (p-value) | Low mental health | High mental health | X2 (p-value) | Low social health | High social health | X2 (p-value) | Low loneliness | High loneliness | X2 (p-value) | Visit less than year round | Visit all year round | X2 (p-value) | ||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Visit alone | 19 (40.4) | 49 (33.3) | 1.4 (0.495) | 9 (32.1) | 59 (35.5) | 0.3 (0.848) | 7 (25.9) | 61 (36.5) | 4.2 (0.125) | 52 (36.9) | 16 (30.2) | 1.6 (0.444) | 15 (28.3) | 53 (37.6) | 4.3 (0.117) | ||||
| Visit with others (not alone) | 15 (31.9) | 44 (29.9) | 1.4 (0.495) | 8 (28.6) | 51 (30.7) | 0.3 (0.848) | 6 (22.2) | 53 (31.7) | 4.2 (0.125) | 44 (31.2) | 15 (28.3) | 1.6 (0.444) | 22 (41.5) | 37 (26.2) | 4.3 (0.117) | ||||
| Visit alone and/or with others | 13 (27.7) | 54 (36.7) | 1.4 (0.495) | 11 (39.3) | 56 (33.7) | 0.3 (0.848) | 14 (51.9) | 53 (31.7) | 4.2 (0.125) | 45 (31.9) | 22 (41.5) | 1.6 (0.444) | 16 (30.2) | 51 (36.2) | 4.3 (0.117) | ||||
This table only includes the park visitors
Significant differences (p < 0.05) are bolded
Park activities
A high proportion of participants who engaged in walking and biking during their park visits reported better physical health compared to their counterparts and visited year-round (Table 5). A higher proportion of participants who engaged in photography during their park visits reported better/higher social health (Table 5), and a higher proportion of participants who engaged in sitting and listening to nature reported lower levels of loneliness (compared to those with high loneliness) (Table 5).
Table 5.
Top 10 activities performed during visitation overall and according to health status and year-round visitation n(%)
| Activities performed in the parka | Low physical health | High physical health | X2 (p-value) | Low mental health | High mental health | X2 (p-value) | Low social health | High social health | X2 (p-value) | Low Loneliness | High Loneliness | X2 (p-value) | Visit less than year-round | Visit all year-round | X2 (p-value) | ||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Walking | 34 (51.5) | 125 (75.2) | 3.9 (0.049) | 22 (62.9) | 137 (69.5) | 0.3 (0.614) | 20 (60.6) | 139 (69.8) | 1.3 (0.251) | 116 (70.2) | 43 (64.2) | 0.0 (0.854) | 37 (41.5) | 122 (86.5) | 7.2 (0.007) | ||||
| Sitting/relaxing/readings | 29 (43.9) | 59 (34.9) | 2.6 (0.109) | 15 (42.9) | 73 (36.5) | 0.9 (0.345) | 16 (48.9) | 72 (35.6) | 2.4 (0.118) | 57 (33.9) | 31 (46.3) | 5.1 (0.024) | 29 (30.9) | 59 (41.8) | 2.6 (0.109) | ||||
| Listening to nature | 15 (22.7) | 54 (32.0) | 0.4 (0.548) | 11 (31.4) | 58 (29.0) | 0.2 (0.657) | 12 (36.4) | 57 (28.2) | 1.1 (0.299) | 44 (26.2) | 25 (37.3) | 4.2 (0.038) | 19 (20.2) | 50 (35.5) | 0.0 (0.960) | ||||
| Socialising with acquaintances (e.g., neighbours) | 12 (18.2) | 28 (17.2) | 0.9 (0.339) | 6 (17.1) | 34 (17.5) | 0.0 (0.909) | 8 (24.2) | 32 (16.3) | 1.6 (0.212) | 11 (12.8) | 29 (20.6) | 0.2 (0.669) | 12 (12.8) | 28 (20.6) | 0.0 (0.977) | ||||
| Biking | 4 (6.1) | 37 (21.9) | 5.9 (0.015) | 3 (8.6) | 38 (19.0) | 2.1 (0.144) | 5 (15.2) | 36 (17.8) | 0.1 (0.720) | 34 (20.2) | 7 (10.5) | 2.7 (0.097) | 6 (6.4) | 35 (24.9) | 4.2 (0.040) | ||||
| Meeting with friends/family | 8 (12.1) | 27 (16.0) | 0.1 (0.835) | 4 (11.4) | 31 (15.5) | 0.3 (0.576) | 5 (15.2) | 30 (14.9) | 0.0 (0.945) | 23 (13.7) | 12 (17.9) | 1.0 (0.307) | 7 (7.5) | 28 (19.9) | 1.2 (0.283) | ||||
| Socialising with people they do not know | 9 (13.6) | 22 (13.0) | 0.5 (0.496) | 4 (11.4) | 27 (13.5) | 0.1 (0.791) | 2 (6.0) | 29 (14.4) | 1.7 (0.190) | 23 (13.7) | 8 (11.9) | 0.0 (0.837) | 8 (8.5) | 23 (16.3) | 0.0 (0.837) | ||||
| Supervising (grand) children | 5 (7.6) | 25 (14.8) | 1.1 (0.293) | 3 (8.6) | 27 (13.5) | 0.6 (0.452) | 5 (15.2) | 25 (12.4) | 0.2 (0.636) | 18 (10.7) | 12 (17.9) | 2.9 (0.090) | 10 (10.6) | 20 (14.2) | 0.6 (0.421) | ||||
| Photography | 7 (10.6) | 23 (13.6) | 0.0 (0.901) | 2 (5.7) | 28 (14.0) | 1.7 (0.188) | 0.0 (0.0) | 30 (14.9) | 5.6 (0.017) | 20 (11.9) | 10 (14.9) | 0.6 (0.421) | 7 (7.5) | 23 (16.3) | 0.3 (0.594) | ||||
| Visiting a café/restaurant | 8 (12.1) | 14 (8.3) | 0.4 (0.539) | 4 (11.4) | 18 (9.0) | 0.3 (0.595) | 4 (12.1) | 18 (8.9) | 2.0 (0.158) | 18 (10.7) | 4 (6.0) | 1.0 (0.307) | 5 (5.3) | 17 (12.1) | 0.3 (0.608) | ||||
Significant differences (p < 0.05) are bolded; chi-square test performed
Associations between park use and health outcomes
As shown in Table 6, for every 1-hour increase in park visitation duration/time, the odds of being lonely were 0.2% higher (OR = 1.002; p = 0.032). There were no significant associations between total year-round park visit duration and physical, mental, or social health or between total year-round visitation frequency and physical, mental, and social health and loneliness.
Table 6.
Associations of park visitation frequency and duration with physical, mental, and social health and loneliness
| Physical health | Mental health | Social health | Loneliness | |||||
|---|---|---|---|---|---|---|---|---|
| OR (95%CI) | p-value | OR (95%CI) | p-value | OR (95%CI) | p-value | OR (95%CI) | p-value | |
| Total year-round park visitation frequency | ||||||||
| Total number of visits per year (visits/year) | 1.001 (1.00, 1.01) | 0.424 | 1.001 (1.00, 1.01) | 0.697 | 1.000 (0.99, 1.00) | 0.648 | 1.000 (0.99, 1.00) | 0.832 |
| Total year-round park visitation duration | ||||||||
| Park visit duration (hours per park visit/year) | 1.000 (0.99, 1.00) | 0.940 | 1.001 (1.00, 1.01) | 0.386 | 1.000 (0.99, 1.00) | 0.658 | 1.002 (1.01–1.02) | 0.032 |
Significant differences (p < 0.05) are bolded
All models adjusted for: age, sex (male, female), household composition (living alone, living with others), education level (no higher education diploma, higher education diploma), socio-economic status of residential neighbourhood, and other health-related variables that were not the outcome [i.e., logistic regression models fitted to examine associations of park visitation (e.g., total frequency of park visitation in a year with loneliness among older adults adjusted for physical, mental and social health)]
Reasons for not visiting parks
The majority of the top 10 reasons for not visiting parks among older adult non-visitors (n = 41) were either personal or park-related, notably five of the ten main reasons were personal, including wanting to do other things during free time, having a disability, health limitations, having a garden at home, or not having energy. There were four park-related reasons for non-visitation, which concerned safety, lack of amenities (e.g., toilets, place to eat), or having few parks in the area (Table 7).
Table 7.
Top 10 reasons for not visiting parks among non-visitors (n = 38)
| Number | Reason category | Reason for not visiting parks a | Overall n (%) |
|---|---|---|---|
| 1 | Personal | I prefer to do other things in my free time. | 17 (44) |
| 2 | Personal | I have a physical disability that makes it difficult for me to visit parks. | 15 (38) |
| 3 | Personal | My health (physical/mental) does not allow me to visit parks. | 14 (36) |
| 4 | Personal | I have a garden at home. | 12 (31) |
| 5 | Park-related | I do not feel safe in parks. | 12 (31) |
| 6 | Park-related | There are no public toilets. | 12 (31) |
| 7 | Transport | There are no good footpaths or cycle paths to parks. | 11 (28) |
| 8 | Personal | I do not have enough energy to visit parks. | 10 (26) |
| 9 | Park-related | There is nowhere to buy something to eat or drink. | 10 (26) |
| 10 | Park-related | There are few parks, if any, in my area. | 9 (23) |
aParticipants selected whether the reason applied to them (yes, no)
There were some statistically significant differences in the proportion of older adult non-visitors who selected certain reasons for non-visitation according to health status (Additional file 3). Briefly, a higher proportion of older adult non-visitors, who did not indicate a physical disability or health (physical/mental) limitations as reasons for not visiting parks, reported having higher physical health compared to their counterparts.
Additionally, a higher proportion of older adults, who did not cite the absence of good footpaths or cycle paths as reasons for not visiting parks, reported higher physical health compared to their counterparts.
Discussion
This study provides new insights on park visitation among older adults. It is one of few studies to describe older adults’ park visitation (frequency and duration) per season and across the year, whilst also describing usual accompaniment and activities performed. It is the first study, to our knowledge, to describe whether these park use patterns differ by health status and year-round visitation. While some previous studies have investigated older adults’ park visitation patterns and associations with health indicators [23, 25, 29], they have not examined differences according to health status and year-round visitation. Therefore, this study provides a more detailed examination of the context of older adults’ park use than prior cross-sectional studies, particularly in the Belgian context. It is also the first study to examine associations of total annual park visitation frequency and park visit time with physical, mental, and social health and loneliness among older adults. This differs from previous studies, which have predominantly examined older adults’ park visitation in one or two seasons as opposed to annual visitation [13, 14]. This is important as it enables a more comprehensive understanding of their park use behaviour. While our findings regarding older adults’ park use generally align with previous research, there was limited evidence linking year-round visitation frequency and duration with health and loneliness outcomes. This study also explored several reasons for non-visitation, generating a richer understanding why older adults may not use parks. These novel insights can inform more inclusive and targeted park design and programming for older adults to encourage park use.
Similar to previous studies [17–19, 30, 43], walking, sitting/relaxing, listening to nature, socialising, and biking were the most common activities performed by older adults during visits. Given their popularity among older adults, a valuable strategy may be incorporating such activities in organised programs (e.g., supervised/accompanied and focus on popular activities, such as walking, socialising) [44] and supporting the installation of facilities that support these activities. No significant differences in usual activities performed according to high versus low loneliness were observed, differing from results from a Dutch study, which observed that older adults who visited public spaces for passive activities (e.g., relaxing, sitting) were less likely to report feeling lonely than their counterparts [45]; however, that study did not focus exclusively on parks. Unsurprisingly, a high proportion of older adults, who reported higher physical health, engaged in walking and biking whilst visiting the park compared to those with low physical health. Relatedly, one of the main reasons why non-visitors reported not visiting the park was due to having a disability or health limitations, underscoring the importance of ensuring that parks are designed to support rather than restrict accessibility and use by persons living with disabilities [46]. In order to support older adults’ park visitation, park planners should consider universal-access strategies (e.g., handrails along sloped paths and stairs; anti-slip paths) and age-specific infrastructure and programming, in addition to involving older adults (including infrequent and non-visitors) in the decision-making process given that this is important for successful park design [47–49]. Promising design strategies identified from a recent study that investigated physical and social park features that were valued among older adults (e.g., regular and non-park visitors) included the provision of overhead lighting and open spaces with clear visibility, amenities that support socialising and intergenerational contact (e.g., benches, picnic tables), regular maintenance, multiple connected pathways that are clean and accessible for all (e.g., persons with mobility restrictions), pétanque courts in sheltered areas with surrounding seating, and shade [49]. More in-depth research is needed to explore specific strategies for supporting older adults with a disability or health limitations to visit parks. Further, our survey did not ask about whether the activities performed in the park were accompanied. Future studies should therefore explore accompaniment during park activities to better understand the nature of older adults’ activities during park visits and whether supporting accompaniment may be a strategy to motivate/assist non-visitors to visit parks more often.
Our results indicated that across all seasons, the highest proportion of older adults visited the park alone, followed by with a partner or friends. This aligns with the results from a study conducted in Hong Kong [17], but contrasts with findings from other studies in the USA and Australia, where most older adults visited with another person [19, 23]. It is plausible that older adults are content with spending time in parks without a particular companion; however, as nearly half of our sample were living alone, it is possible that older adults do not enjoy visiting alone but have no one to visit with. Targeted programs that promote social interaction and include supervised/structured exercise sessions, nature-based social groups, and park prescriptions may be further promising strategies for encouraging older adults’ park use [44, 50, 51]. Further, while older adults may choose to visit parks alone, their sense of community in the neighbourhood and their bonds to the place and its people may motivate or reinforce their park use [17, 52, 53]. The impact of sense of community, place, and belonging and social cohesion in the neighbourhood context [54] on older adults’ park use patterns requires further investigation.
Older adults’ year-round visitation was 58 visits per year, which is higher than the average frequency of 43 park visits in 12 months among older adults (n = 100) in the USA [23]. However, our results differ from previous studies conducted in China, Belgium and India, where most older adults (60 + years) visited urban green spaces daily [17, 30, 55] and where 83% visited parks two or more times per week (roughly 104 visits/year) [15]. These differences may be due to differing built environments (e.g., greater concentration of buildings in Hong Kong and India compared to Ghent). Additionally, older adults’ average park visitation duration was 61 h in a year, equating to roughly five hours per month. Previous studies have indicated that 24% to 44% of older adults spend an hour or less in parks [15, 17, 19]. However, they did not report on the park visit duration per month, season, or year, and it should be noted that the variables used in those studies were not directly comparable to those used in the present study. Greater consistency in the reporting of older adults’ park visitation frequency and duration is needed in future studies to draw clearer comparisons. Additionally, our findings are limited to a sample of older adults with relatively good health. Co-creating park developments and refurbishments with various older adult sub-groups to cater to their needs and provide suitable age- and ability-inclusive features may be a key strategy for supporting park use among a range of older adults, including those who may be less healthy and active [49, 56].
Over half of the sample visited in all four seasons, and the highest proportion of older adults who visited the park reported visiting during spring and summer. While not focused solely on older adults, a study conducted in the US also found that adults’ park use was higher in summer and spring compared to winter and fall [57]. Another study explored older adults’ perceptions of using outdoor environments year-round and found that accessibility is a key consideration, which may be viewed differently across the year [58]. For example, wet leaves from cold and rainy weather in autumn and winter may pose additional accessibility barriers (e.g., lack of slippery, wet leave removal on walking paths) to park visitation [58], potentially explaining why a lower proportion of older adults visited in fall and winter in the present study [30]. Given park visitation can vary by season, park planners may benefit from providing programming and amenities that cater to use across seasons (e.g., shelter for poor weather, non-slippery paths for fall and winter, guided walks or activities in seasons when use is lower, nature-based walking groups or social clubs) to support safe, habitual use year-round [44, 49–51]. Lastly, park prescriptions for year-round use and nature-based programs may be a practical, low-cost strategy for increasing older adults’ park use and supporting healthy ageing [50, 59].
Contrary to our hypothesis, we found limited evidence for associations between the total duration of park visits and older adults’ physical, mental, and social health and loneliness. Contrasting findings from a systematic review [27], which found that greater self-reported time spent visiting green spaces was associated with lower levels of loneliness, our results indicated that total year-round duration of park visits was significantly associated with higher loneliness (OR = 1.002; p = 0.032). Our findings also contrast those from a longitudinal cohort study, which observed that greater access to urban green spaces was associated with lower cumulative incidence of loneliness among city dwellers, which included older adults [60]; however, that study did not measure park visitation specifically. While our results were not in the expected direction, reverse causation cannot be ruled out. Thus, it is possible that older adults who experience higher levels of loneliness spend more time in parks. Additionally, the effect size was very small and unmeasured confounding variables (e.g., personal-level income) may explain this finding, so results should be interpreted with caution. Future research may benefit from conducting quasi-experiments to better understand the relationship between duration of park use and older adults’ health [61]. Further, physical, mental, and social health and loneliness were each assessed using a single item measure at one point in time, which may have limited measurement sensitivity and influenced our findings. This may partly explain the absence of statistically significant associations. It is important to acknowledge that the results are exploratory and may have differed if other measures had been used. Moreover, the health questions only concerned overall physical, mental, and social health and loneliness, which can be cultivated across different social domains and contexts [62]. Future studies may consider utilising both general and context-specific (e.g., unique to neighbourhood parks) measures when assessing these health outcomes [63]. Further, the proportion of older adults with high versus low physical, mental, and social health and loneliness differed (e.g., 72% reported never/rarely feeling lonely), although this is fairly comparable to older adults in previous research in other European countries [64], and the sample generally had favourable health and was highly educated, which may have biased the findings towards null associations due to restricted variance. Future studies are needed to further explore these associations.
A mixture of personal (e.g., physical disability, health matters) and park-related reasons why non-visitors did not visit parks were reported. This included not feeling safe in parks, limited amenities, and access to parks (i.e., there were few/any parks in their area). Our findings are consistent with previous studies conducted in Australia and Belgium, where older adults reported that amenities, such as a café and public toilets, were important for supporting their park visitation [30, 32, 65] and active and social park use [19, 31]. Park planners should consider equipping parks with these features to support visitation, physical activity, and social interaction in parks. Previous research has also found that older adults may not feel safe in parks due to social (e.g., fear of certain persons who appear threatening) or physical/environmental (e.g., poor lighting, slippery surfaces and fear of falling, shrubbery obscuring views) reasons [30–32, 66]. Lack of suitable paths to access the park were reported as a reason for non-visitation, aligning with research indicating the importance of paths for supporting park use [30, 31, 67] and access to, from, and through the park by offering off-road infrastructure to reach destinations [68, 69].
Strengths and limitations
There are several strengths of this study. These include the reasonably balanced split of males and females in the sample, the use of multiple health outcomes (physical, mental, and social health, loneliness), and the combination of the “My Green Place” Public Participatory Geographic Information System tool [33] with season-by-season self-reports to derive year-round measures of older adults’ park visitation frequency and duration.
However, there were limitations. Firstly, the current study utilised a cross-sectional design and reliance on subjective survey measures may have subjected the data to recall and social desirability biases [70, 71]. Participants’ responses were in relation to the most frequently visited park, so future studies should explore older adults’ park use in relation to their favourite park and nearest park as park visitation frequency and duration may vary depending on the context of the park to a person. The effect size for the significant association was very small and there were wide confidence intervals for the predictor variables, so results of this study should be interpreted with caution and warrant further research. Additionally, the health outcomes were measured using single-item self-report questions that had not been previously validated, although these items were adapted accordingly following cognitive interviews with older adults to ensure comprehensibility of wording. The limited sensitivity of these measures may partly explain the null findings observed in this study. Thus, the findings should not be interpreted as evidence that parks do not promote older adults’ health; rather the associations may not have been statistically significant or detectable given the measures used. Future studies should use more sensitive instruments to better explore the associations between older adults’ park visitation and health. There was a high number of logistic regression models fitted for the analyses, increasing the risk of type 1 error [72, 73]. As this study was exploratory and had several outcome variables, no adjustments were made for multiple testing in accordance with the literature [72, 73]. Additionally, the survey was only offered online in Flemish, thereby potentially excluding older adults who do not speak this language and who may have difficulty completing the online survey even with assistance from research staff. Future studies may benefit from more diversified data collection where the survey can be completed in different formats (e.g., digital, print) and other languages. Part of the data collection occurred during the COVID-19 pandemic (spring 2021) with some restrictions still in place, so it is possible that this influenced our findings. Lastly, the sample of adults generally had favourable health and were well-educated, which limits the generalisability of the findings more broadly and especially to more vulnerable older adult populations (e.g., culturally and linguistically diverse), who may have at higher risk of poor health [74].
Conclusion
Most older adults visited parks year-round with most visits during spring and summer. Older adults who visited parks year-round, visited more frequently and for longer per visit in each season and year compared to those who did not visit year-round. Over half of older adults visited parks alone, and accompaniment did not vary according to health status and year-round visitation. The most common park activities included walking, sitting, listening to nature, and biking, with certain activities varying according to older adults’ health status. These insights may help with planning appropriate park programming activities (e.g., offering year-round programs, targeting common activities like walking and biking) and park features (e.g., walking/cycling paths, adequate seating, etc.) that cater to older adults’ needs, ensuring that parks are inclusive and beneficial for this user group. The most common reasons for not visiting the park included wanting to do other things, physical or health limitations, having a garden at home, safety, lack of appropriate facilities (e.g., toilets, eating areas, paths), not having energy, and not having many parks nearby. Ensuring that parks are available, accessible, high-quality, and equipped with features that meet older adults’ park visitation needs may be critical for attracting older adult non-visitors to visit and thereby supporting associated health benefits. Further research is needed to better understand the complex relationships between park visitation and health outcomes among older adults, with a particular need for more consistent reporting of park use patterns and contextual factors. Additionally, associations between year-round park visitation frequency and duration and health outcomes among older adults were very limited. Quasi-experimental studies are needed to clarify causal associations of older adults’ park visitation (frequency, duration) with physical, mental, and social health, and loneliness among older adults [61].
Supplementary Information
Acknowledgements
The authors would like to thank all research staff involved in the study as well as the persons who participated in this research.
Authors’ contributions
ER drafted the manuscript and conducted the data analyses and interpretation of results. AVP contributed to the study design, data collection, and interpretation of results. BD, DVD, LP, AVP, and ER conceptualised the research question and study design. BD, JV and DVD secured the funding for this research. LP contributed to the study design and data collection. NERA and NVDW developed the “My Green Space” tool. All authors critically commented on drafts of the manuscript and approved the final version.
Funding
This project has received funding from the European Union’s Horizon 2020 research and innovation programme under the Marie Skłodowska-Curie grant agreement No 765389. This project was supported by a research grant from Research Foundation Flanders (3G068519). LP was supported by a Research Foundation – Flanders (FWO) Postdoctoral Fellowship – junior (12ZF122N).
Data availability
The dataset analysed during the current study are not publicly available due to ethical restrictions related to the consent given by participants at the time of study commencement. An ethically compliant dataset is however available from the corresponding author upon reasonable request and with approval of the Ethics Committee of the University Hospital of Ghent University.
Declarations
Ethics approval and consent to participate
This research was performed in accordance with the relevant guidelines and regulations in the Declaration of Helsinki. Ethical approvals were granted from the Ethics Committee of the University Hospital of Ghent University (2019/1873; BC-06738). Written informed consent (digital) for participation were obtained from participants.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The dataset analysed during the current study are not publicly available due to ethical restrictions related to the consent given by participants at the time of study commencement. An ethically compliant dataset is however available from the corresponding author upon reasonable request and with approval of the Ethics Committee of the University Hospital of Ghent University.