The aim of the present study was to investigate the association between FDCs and activity levels in order to shed light on their potential as environments for promoting physical activity in the target group for the services. We wanted to investigate this both in relation to regular day care and for the attendees compared with their everyday life.
As our results show, attending FDCs is significantly associated with more physical activity, and at higher levels than attending regular day care. For the group attending FDCs, days spent on the farms were significantly associated with less sedentary activity, more light and moderate activity, and with more steps taken compared to days not at the farm. This is in line with previous research on farms as care settings for people with dementia [25, 26].
The higher levels in physical activity at the FDCs compared with regular day care could potentially be explained by several factors. The same factors could also potentially explain why people attending FDC have higher levels of physical activity on days at the farm compared to days not at the farm. One factor could be that the farm setting, to a larger degree, invites to physical activity through supplying the space for such activity and by having tasks that necessitates physical activity (e.g. woodcutting, gardening, feeding animals). Ibsen, Eriksen, et al.  noted that, while organized similarly to regular day care, FDCs in Norway differed in type of care environment with a wide range of activities and available resources. This included activities such as working with plants, tending and harvesting crops, woodworking and animal-related activities. Further, they found that the service took place in several areas, both on and outside of the farms such as the yard, the barn, gardens, a greenhouse and the surrounding uncultivated areas like forests and trails . De Bruin, Oosting, et al.  also noted on the difference in activities between regular day care and FDCs. They found that activities at the FDCs were more often outdoors or in another building than regular day care. Additionally, activities at regular day care more often involved sitting, while activities at the FDCs more often involved standing or walking. de Boer, Hamers, et al.  observed similar results, but then in farm-based nursing homes. They found that the residents of farm-based nursing homes were more physically active, spent less time in passive activities, and were more engaged in their activities. Sudmann and Børsheim  found that the participants perceived the tasks at the FDCs as useful and meaningful, which could potentially increase their engagement in the task and the intensity. Further, Hassink, De Bruin, et al.  found that working with animals at care farms implicitly stimulated to physical activity. Lastly, de Bruin, de Boer, et al.  note that at FDCs activities are naturally incorporated into the environment and care provisions and are as such continuously present. Based on this previous research, activities at the FDCs, and especially the farm activities, seem to encourage higher levels of physical activity, than activities found at regular day care. The activities at, and inherent to, the FDCs can as such explain the higher levels of physical activity we found in our analyses. One avenue for future research could be to investigate if and how aspects of the farm setting could be transferred to other care settings for people with dementia.
Another factor explaining our findings could be the importance of the service providers as they are generally the ones who structure the day, and it is in many ways up to them how much focus there are on physical activity. While this is true for all types of day care services, the farmer has the added benefit of the farm resources and surroundings, and the knowhow that allows for their inclusion in the service. Sudmann and Børsheim  highlights the importance of the service provider as a facilitator for activities for the participants of FDCs, noting their roles as “work leader” and “host”. Within care farming in general the importance of the service provider has also been noted. Hassink, Elings, et al.  found that the personal and involved attitude of the farmer was considered a defining characteristic of care farms in general, and this is echoed in Steigen, Kogstad, et al.  which highlights the farmer as a significant important other to the participants. Pedersen, Ihlebaek, et al.  found that the participants, here people with clinical depression, reported that the farmers gave them tasks they could accomplish, leading to increased self-confidence and independence. Ellingsen-Dalskau, Morken, et al.  also note the positive effect of the involved farmer. In their study, the participants of a farm-based prevocational program reported that the farmers provided guidance, positive feedback and encouraged them to try new activities. The service provider’s engagement at the FDCs might facilitate increased physical activity through support, encouragement and the creating opportunities for the participants to experience coping. Low self-efficacy for going outdoors have for example been linked with restricting activities , and support from the service-provider could potentially alleviate this. Additionally, the service providers at farms could use their knowledge to facilitate and tailor activities more to the individual. De Bruin, Oosting, et al.  noted that activities at the FDCs were more often aimed at the individuals than at regular day care services, and that the regular day cares often had activities that included the entire group. Individualized activities have been noted as a facilitator for physical activity for people with dementia . While there is a focus on tailoring activities to the individual at regular day care services, Strandenæs, Lund, et al.  found that staff at regular day care would state that they gathered individual knowledge about the attendees and tried to offer individualized services. At the same time, observations showed that the staff seemed to have insufficient knowledge about how to translate the information on the individuals into individually tailored and structured meaningful activities for the attendees. Additionally, the study found that there was a potential to include the attendees more in ongoing activities. This is mirrored in Myren, Enmarker, et al.  which found that participants at an FDC were more included in the daily activities at the FDC, like preparing meals, while participants at the regular day care centre were more passive in the daily activities. Therefore, the reason why we see differences, both between types of day care services, and days on and off the FDCs might be because the service providers promote physical activity both through providing organized activities to promote physical activity, such as taking walks or labour-intensive tasks, but also through support guidance, and individualization so that the participants try out farm activities which they might enjoy and exert themselves.
Both WHOs “Global Recommendations on Physical Activity for Health”  and Norwegian National Guidelines for physical activity for older people  gives recommendations on how much physical activity is necessary to maintain physical function and health. Additionally, the Norwegian guidelines recommend regular walks in varying terrain to maintain balance, range of motion and walking ability. Our findings indicate that attending FDCs could facilitate following these recommendations more so than attending regular day care. Further, our findings indicate that for those attending FDCs, the days on the farm are significantly more active and less sedentary. Given the high amounts of sedentary behaviour among people with dementia reported in previous research [7,8,9,10], the increased levels of physical activity on days with FDCs would seemingly be a valuable contribution towards less sedentary behaviour. That the participants are less sedentary are also in line with the WHO recommendations, as they highlight the need to avoid physical inactivity, as this has been identified as the fourth leading risk factor for global mortality . Breaking up sedentary behaviour can also be important to maintain physical function in elderly people as Fujita, Fujiwara, et al.  and Shimada, Ishizaki, et al.  found when looking at the association between frequency of leaving the home and instrumental and basic activities of daily living. On the other hand, de Bruin, Oosting, et al.  found no significant difference between regular day care and FDCs in maintaining functional performance. Still, Blankevoort, van Heuvelen, et al.  found that physical activity improved physical functioning and basic activities of daily living among people with dementia. Additionally, they noted that higher levels of physical activity seemingly led to higher impact on physical functioning and activities of daily living. Based on current recommendations and previous research, our findings indicate that FDCs can potentially facilitate adherence to the recommendations and improve physical functioning.
Strengths and weaknesses
The data for the present study were taken from two different projects, both with several data collectors, meaning we cannot discount inter-rater discrepancies with some of the measurements. However, the CDR [33, 34] and TUG  are both validated instruments with clear instructions. Also, the main measurement, the actigraphy, was assessed using the same software in both projects and data included in analyses based on the same guidelines, minimizing any discrepancies.
Further, the participants were not randomly select from among the relevant population. Recruitment was conducted by intermediaries, service providers and staff, in both studies. They might have screened their participants based on other criteria than the inclusion criteria, such as social or health status. This means that we might have a sample who are not representable for the whole population, potentially limiting the generalisability of the findings. The group attending regular day care and the group attending FDCs differed across several variables, such as gender, age, level of dementia and physical functioning. Additionally, it could be that participants attending FDCs are more physically active or have higher physical functioning, than people attending regular day care. To account for some of these differences we included age, gender and assessment of physical functioning in the statistical models as covariates as we believed these could influence levels of physical activity.
Last, one drawback with actigraphy, is that it does not give any information on the types of activity being conducted. As such, we do not know exactly what types of activities they are doing at the different types of day care services and which ones that contribute to physical activity. This means that we cannot preclude that the activities that contribute to physical activity at the FDCs are not specifically farm-related. Additionally, the way the actigraph measures activity means some forms of activity might be physically demanding, but not show up as physical activity with higher intensity . This might be applicable for both groups, but more so for the ones attending FDCs due to the nature of the activities at the farms, for example carrying fodder for farm animals. However, a strength of using actigraphy is that it gives objective data on the participants physical activity and has been shown to be feasible for people with dementia , as relying on self-reported data alone has been shown to be unreliable [49, 50]. Non-wear can also be a challenge with actigraphy, but we conducted wear-time analyses and included requirements for what constituted a valid day to be included in the further analyses (minimum 8 h recorded activity in a 12-h time span), effectively minimizing the potential impact of non-wear.
The present study is cross-sectional, as such we do not have data about the participants baseline activity levels before attending day care, nor about the progression over time. This means we cannot infer causality based on the present study, but the results from the linear mix-model supports the assumption that attending FDCs is a main contributor to the higher levels of physical activity among their participants.