Toward a proposal for a national strategy for access to outdoor stays in residential care facilities for older adults in Sweden.

People worldwide are living longer than ever before in history, which calls for a new public health approach to population aging (). Extensive research shows that access to and contact with nature is of great importance for people’s health and wellbeing (; ; ), not least in old age and for those experiencing frailty (; ; ). Despite this knowledge, there is a lack of established strategies to ensure access to and contact with nature for older adults in residential care facilities (RCFs) (; ; ). The present study forms part of the Swedish research project OUT-FIT (), and is one of several studies examining how outdoor environments in residential care facilities (RCFs), as a form of urban nature, can promote health and wellbeing among older adults and care staff in their professional practice. Within the OUT-FIT project, outdoor environments are defined to include physical settings such as balconies, patios, conservatories, and gardens, as well as surrounding areas with natural elements, such as public squares, walkways, parks, and other green spaces. Further, outdoor stays refer to general outdoor exposure, without a predefined therapeutic or rehabilitative purpose. Such exposure may include recreational, restorative, or everyday interactions with outdoor or natural environments and is not necessarily structured, supervised, or goal-directed within a healthcare context. In contrast, outdoor care and rehabilitation refer to organized and purpose-driven care and rehabilitation activities in which outdoor settings are intentionally incorporated to support specific health-related or functional outcomes. These practices are typically characterized by therapeutic planning, professional guidance, and explicit rehabilitative objectives, where the outdoor environment could serve as an integrated component of the rehabilitation process rather than solely as the setting in which activities occur. As part of the project framework, an international overview has been conducted to gain information about how different countries are addressing the issue of older adults’ access to outdoor environments and outdoor activities in RCFs (). The results indicate a variation in the level of awareness, initiatives, and approaches in a selection of European countries, which is confirmed in a study by . The absence of a strategic approach in Sweden has, among other things, the consequence that even though care workers and older adults in RCFs see the value of outdoor environments and wish to use them, access is lacking both environmentally and organizationally (). This suggests that the implementation of nature-based approaches currently depends largely on local priorities, individual engagement, and available resources, resulting in unequal access between facilities and municipalities. The lack of national guidelines, long-term funding structures, and coordinated responsibilities may therefore constitute structural barriers to a more systematic and equitable integration of outdoor environments in RCF care practices. The present paper describes the development of a proposal for a Swedish strategy and gathers ideas for how to realize the proposal. This introduction presents evidence that both motivates the need for such a strategy and constitutes the evidence base for the proposal. This evidence base is general in nature and not specific to the Swedish RCF context. Firstly, the strategy proposal is based on evidence about health benefits from being in natural environments. According to , spending at least 2 h a week in a natural environment is associated with self-rated good health and wellbeing for people in general. Particularly large health benefits from exposure to natural environments (e.g. gardens and neighborhood greenness) have been demonstrated for vulnerable groups, such as older adults, persons experiencing stress, the sick, those socioeconomically disadvantaged, or persons going through some form of life crisis (; ; , ; ; ). The health effects are evident both through self-assessment and with objective measures (; ; ). Connectedness with nature as well as access to green areas seem to be crucial, since both aspects affect the number of outdoor visits per week as well as the number of minutes per week that people spend outside in green areas ().