Abstract
Play is fundamental to a person’s well-being. However, cultural norms and ageism have negatively impacted this practice among older adults. This study explored to what extent medical clowning promotes play among older adults. Qualitative data were collected in weekly group sessions of medical clowning in an Israeli retirement home. Group medical clowning offered participants a new sort of playground, which combined body play, cognitive play, and role-play. The clown created an ambience that legitimized older adults’ loosening-up, expanding their space, feeling happy, and developing new creative interactions. He enabled participants to get involved in free play, thus freeing them of social constructions regarding older adults. The medical clown created a community of play and legitimized play among older adults, thereby breaking rules based on social stereotypes, the convention that older adults should not behave nonsensically and challenging the accepted social norms of the retirement home.
1. Introduction
Play has been found to be of crucial value for children’s development [1] and for a person’s well-being [2]. Despite the fact that cultural norms, combined with ageism, have negatively impacted this practice among older adults, studies have found that play is also of crucial value in the third age [3, 4]. Therefore, this study explored to what extent, if at all, group meetings with a medical clown promote play among older adults living in an independent retirement home.
1.1. Play
“Play” is an elusive term, which has been defined in various ways by Piaget [5], Vygotsky [6], and numerous other scholars. This study relies on Brown’s [7] (p. 412) broader definition.
“Play is an ancient, voluntary, inherently pleasurable, apparently purposeless activity or process that is undertaken for its own sake and that strengthens our muscles and our social skills, fertilizes brain activity, tempers and deepens our emotions, takes us out of time, and enables a state of balance and poise.”
Huizinga [8] (p. 8) claimed that “the contrast between play and seriousness is always fluid.” According to Eberle [9] play is comprised of six elements which include anticipation, surprise, pleasure, understanding, strength, and poise. Among the different kinds of play, which Sutton-Smith [10] (pp. 4-5) presents are solitary play, informal social play, performance play etc. Essentially there are two types of play those with rules, such as board games, and those without rules, which involve humor, improvisation, and spontaneous-free play. Although research mostly explores them separately [11], in some cases they are combined. Malaby [12], for instance, mentions computer games, in which the players start playing the game according to the rules, and gradually spontaneously get involved in free play, thus combining game and play.
Winnicott [13] considered play a central contributing factor in a person’s mental health, particularly among children, since for them it has also an important developmental function [1], which bridges between internal and external reality [14]. Play thereby acts as a means of control, education, self-discovery, emotional expressiveness, overcoming challenges, etc. [15]. It enables interpreting reality from other angles [16] and is connected to a process of change [17]. Play has been found to be a means of lowering stress and anxiety [18], and its use has recently been recognized by the medical community [19].
1.2. Older Adults and Playfulness
The increase of life expectancy in recent decades has led to the growth of an older adult population and has been accompanied by a discrimination against seniors, known as ageism since 1969. Based on negative perceptions of the role of older adults in society, this prejudice has led to excluding seniors from certain areas of social life [20]. Furthermore, studies show that ageism has exacerbated the two most common challenges faced by older people, loneliness and depression [21, 22]. In fact, among older adults there has been a steady increase in the prevalence of depressive symptoms [23] and late life depression (LLD).
The ways of coping with challenges caused by aging, range from traditional therapies—such as psychopharmacological, psychodynamic, and psychoeducational therapies among others [24]—to alternative and complementary therapies, including music therapy and yoga [25, 26]. In addition, animatronic pets are also a way of coping with loneliness and depression among older adults [27].
Play has been found to be an important additional way of coping with aging. It is a source of expressive activity among older adults [28], which allows a feeling of freedom and youthfulness, since it is a framework for having fun and being silly [4]. Play does not only keep the older adults mentally and physically fit but also helps to exercise endurance and concentration [3]. Depending on the nature of play, additional skills, such as fine motor, mathematical, logical, and strategic, can also be exercised. While play is considered to be a type of behavior, playfulness is a way of thinking, which Barnett [29] (p. 955) defines as “[…] the predisposition to frame (or reframe) a situation in such a way as to provide oneself (and possibly others) with amusement, humor, and/or entertainment.”
Indeed, playfulness is an important component of healthy aging in older adults [30, 31], it is positively related to happiness [32], and it contributes to their mental and emotional well-being [33]. There are various ways to make older adults play actively and become playful, from play therapy, which helps to resolve psychosocial difficulties [34], to therapeutic play, which generates emotional dialog [35]; from playful physical exercise, which moves the body and helps with loosening up [36], to video gameplay, solving cognitive and creative challenges [37]. Other ways involve having a kindergarten in a nursing home, as well as other intergenerational programs, which create an opportunity to come in contact with the younger generation [38, 39], including programs on online platforms [40]. However, none of the aforementioned techniques are similar to the play offered by medical clowns.
Medical clowns’ play is different from play therapy and from therapeutic play, in that it may be therapeutic, but it is neither based on a therapeutic contract [41] (p. 127), nor accompanied by a defined purpose. The clowns play with time and space by reversing “real” time and overcoming “real” space [42] (p. 139). Their play is shaped according to the people involved and their specific situation [43].
1.3. Medical Clowning
Clowns have often played various prominent roles in society. Not only as entertainers, performers, or players, as court jesters or circus clowns but also as healers. The modern phenomenon of medical clowning started with Hunter “Patch” Adams (M.D) in the 70’s in the United States, and since then it has spread to many countries worldwide. While at first, medical clowns worked mainly with children in hospital, they can now be found working with different populations and in different institutions, such as nursing homes, community medical centers, and children’s day care.
Studies on medical clowning portray it as based on a positive psychology approach [44]. Unlike approaches which seek a remedy for symptoms of a particular pathology, medical clowning focuses on the cultivation of psychological resilience and good mental health. To this end, it uses play techniques [43, 45, 46] and uses a combination of elements from many disciplines, including theater, drama therapy, and psychology [47]. Through their interventions, medical clowns manage to evoke different emotional states from the person with whom they interact [48], thus contributing to mental and physical health [49].
The praiseworthiness of medical clowning has been noted in studies involving different populations, children, adults, and older adults. Most of these studies focused mainly on medical clowning in children’s wards in hospitals [50] and have observed a positive impact on the children’s physiology and emotions [51, 52]. Interactions with medical clowns are noted to ameliorate symptoms and relieve pain [53], to have a positive impact on children undergoing invasive examinations [54] and to significantly reduce levels of stress in children prior to surgery [55, 56].
Studies which showed that medical clowning also has a positive impact on adults were conducted among children’s parents, caregivers and medical staff [57, 58], women undergoing IVF treatment for pregnancy [59], and patients coping with psychiatric disorders [60]. However, there is little research on medical clowning with older adults residing in specialized institutions, such as residential care facilities, assisted living facilities, and nursing homes [61, 62]. While studies on this population have focused on medical clowns working with older adults living with dementia [63, 64], the current research explores how play and playfulness are promoted by means of medical clowning with independent older adults.
2. Methodology
Based on a qualitative approach, this study explored medical clowning group sessions conducted in an independent retirement community in Israel. For 10 weeks, a professional medical clown (alias C), who also was a psychodramatist, worked once a week for 45 minutes with two groups of 10 participants each. The medical clown used medical clowning techniques, within the framework of the three phases of a classical psychodrama session, warm-up, action, and sharing.
The participants included 20 residents, 16 females and 4 males. 8 were between the ages of 70 and 79, 6 were between 80 and 89 and 6 were over 90 years old. The average age was 83 years. All residents were independent and mostly in good physical and mental health. Most residents had higher education degrees (70%). The house matron asked the residents whether they would like to participate in a research study involving group meetings with a medical clown. From the residents who signed up, the matron chose those who were able to attend on a regular basis. Then, she explained the study to them and upon their agreement they received a registration form which included informed consent. Participants were grouped according to their mother tongue and their command of Hebrew. The first group spoke Russian with basic Hebrew (therefore, was accompanied by a translator), while the second group spoke fluent Hebrew.
Data were collected by means of a combination of qualitative methods. Observations were conducted in each of the 20 sessions, including the interactions that took place before and after the sessions themselves. More data were collected by means of semistructured interviews which were held alongside the project, weekly interviews with the clown (10 in total); 28 interviews with participants, some of which were held after 5 sessions and some after 10 sessions (some participants were interviewed twice); and interviews with the matron, the social worker, and 2 family members. Interviews were recorded upon agreement and transcribed afterward. The average duration of the interviews was around 30 minutes. The data collected by the different qualitative tools contributed information from various perspectives, enabling us to capture a holistic picture of the medical clowning sessions. All data were analyzed according to grounded theory [65].
The research project received the approval of the institutional ethics committee (IEC) of the university. Following the ethical rules in qualitative research, the participants were informed about the study and agreed to participate. Their names have been changed in order to protect their privacy and preserve their anonymity.
3. Results
In this section, we organize our findings in three parts. First, we present the importance of play for the participants (“Playing is life, it’s freedom”); next we display the participants’ connection with their inner child (“I never thought I’d play at this age”); and finally, we show the observed efficacy of medical clowning in obtaining the outcome of play (“The clown’s outfit leads to something different, it’s like magic”).
3.1. “Playing is Life, It’s Freedom”
“They actually played like children, full of enthusiasm and desire to win the game, paying attention to the points they collected and the mischievous behaviour of the opponent team. It was adorable to watch the 92-year-old “girl” get excited in order to lead her team to win.”
Playing was a crucial aspect in the group medical clowning sessions with older adults in the retirement home. With music in the background, dressed as a clown with a red nose but no make-up, huge clown’s shoes, colorful socks, shorts, a colorful jacket, and a funny hat; he used medical clowning techniques within the framework of the following three phases of a classical psychodrama session: (1) Warm-Up. Where participants were encouraged to move their bodies, particularly their arms and legs, by means of regular items used in a clownish style; (2) Action. Where participants were requested to play group games and as theater actors; and (3) Sharing. In which participants were invited to share a personal story, followed by a symbolic ceremony. Play was present in every phase of the sessions. The kind of play observed during the medical clowning sessions—body play, cognitive play, and role-play—will be analyzed hereinafter.
3.1.1. Body Play
In the first phase, “the warm-up,” always accompanied by music, the participants who were sitting in a circle received the same item from the clown. The clown used these regular items, such as long balloons, to encourage participants’ body play in a clownish style, as can be seen in the following observation:
““Now we are going to ballet dance,” announced the medical clown, after distributing white satin gloves to each participant. Cecilia stood up, ready to dance. What came next was a big surprise, as the clown only used his arms to create ballet movements. He also converted his satin gloved fingers into elegant dancing legs, and the participants, sitting comfortably in their circle, joyfully copied him.”
The way the clown used the satin gloves, is one example of how an item becomes a play element encouraging participants to move their body in a playful way. A further example was using big Lego bricks as drums or cymbals: instead of building something with the bricks, each participant used two Lego bricks to produce musical sounds by clapping them together. The medical clown also encouraged participants to use the items in other ways, such as using the swimming noodles for sword play with the clown and with the participants, or as rolling pins, with which they massaged themselves all over their stomachs, legs, and shoulders. Probably, they would not have massaged themselves on their own, but the music and the playful atmosphere encouraged them to do so. The creative thinking the clown disseminated broke the rules of how a certain object should be used. Once the passive object turned into a live and kinetic item, it became alive and enabled the initiation of play.
As part of the play with each item during the “warm-up,” the clown invited participants to choose a movement and lead the group for a few seconds, giving each person a moment of self-expression. These movements, with their own creative and funny dimensions, encouraged the participants to be actively involved in the play. The result was that the group enjoyed a variety of body movements which were presented by each participant, creating mutual body play within the group.
The activities with the different items invited the participants to activate their body as part of the play. Participants reported that some of the exercises in the first phase of the session were similar to the ones they have in gym classes, but with the clownish items they perceived these body movements as play; therefore, it was more fun to do them with the clown. Participants appreciated this unique contribution of the medical clown play, as Bella expressed “playing is movement and thinking; It helps us, at our age, to move more and not to go into decline.”
“The action” phase also involved body play. Daily life items once more were turned into interesting play tools for use in group games. For example, in one session the clown brought a walker which was transformed into a basket, by turning it over and attaching a plastic bag (Figure 1). Participants were divided into two groups, and each participant had one attempt at throwing the ball into the plastic bag. The clown explained “I brought a walker, knowing that some of the participants use one, in order to remove its ‘holiness and ceremony’ and turn it into something else, making it a play tool.”
In this “basket game” participants encouraged each other before throwing the ball and celebrated every point they won. It was notable that participants with different levels of limb disability were specially supported by the group, resulting in an extra body effort which surprised both themselves and the others. Despite the body’s inevitable aging process and society’s attitude toward the aging body, the clown gave it life through play, in an emotional, physical, and mental way.
3.1.2. Cognitive Play
The second phase, “the action,” started with semicompetitive group games in which participants were divided in two groups which competed one against the other. These games, mostly “cognitive games,” used unusual sized objects, such as an enormous board game. The huge size of the board game, which itself broke the rules, encouraged the participants to join in, play, and have fun. One example was a Trivia game introduced in a clownish style. In that session the clown brought a huge carpet board of the game snakes and ladders (Figure 2). Two porcelain clowns served as counters, and the dice was made out of a big white styrofoam box with disproportional angels and uneven numbers 3, 4, 7, 8, 9, and 11. Everything was so different from the regular game, but it was mainly the strange size of the accessories which provoked the participants’ curiosity and invited them to play. A representative from each group tossed the dice and this was followed by trivia questions which encouraged cognitive thinking. It was very impressive to see the collaboration during the play, and the group interaction of small talk based on the trivia questions and their personal memories. The trivia game challenged the participants and allowed them to demonstrate their cognitive capabilities.
In each group game, it was important for the participants to follow the counting of the points and make sure that their group was in the lead. This involvement in the game and desire to win, was clear in one of the sessions when Kobi had to leave the meeting for a while, and the first thing he inquired when he came back, was the number of points his group had gained. Similarly, when in one of the sessions the clown brought a huge 3D car maze, the involvement of the participants even reached the point at which one of them decided to break the rules, by taking the car out of the board to win the game. This caused a scornful reaction from the members of the second group. This episode demonstrates not only the importance that participants gave to the group scores but also their wish to resolve the cognitive challenge posed by this game (Figure 3). Furthermore, despite their interest in the scores, they appreciated the play itself, as Betty stated in one of the sessions “playing is life, it is freedom, and it doesn’t matter who’s winning.”
3.1.3. Role-Play
The second type of activity in “the action phase” was role-play. The clown placed different kinds of hats, such as sombreros and turbans, on a table. Each participant was invited to choose one of them. Then, the clown asked them to select a character that they would like to be that day, explaining that it does not necessarily have to do with the hat they had picked. Subsequently, each participant announced their chosen character, and the clown interacted with each character by asking them several questions, as in the following example:
“Sarah, wearing an engineer’s hat, chose to be a singer. She was asked, which kind of songs she sings. Sarah selected a Tango, and the clown played it. Following this episode, other participants, in character, although they did not choose to be singers, asked the medical clown to play songs they liked.”
It was noticeable that this spontaneous act of choosing a song, gave the participants a way to express themselves and share their personal tastes with the members of the group. In addition, the above description of the role-play revealed some hidden traits of each individual. This was possible because they were in play mode, and thus opened up and felt free to share. In some cases, participants even prolonged the role-play by interacting with each other in their adopted characters. For instance, while still wearing a Chinese hat, Nina announced that she was a Chinese teacher, Rachel asked her, as part of the play, how much she charged per lesson. The hats and the characters enabled the participants to spontaneously role-play with each other, even without the intervention of the clown.
Acting was also present in the third phase, “the sharing,” in which every week a different participant was invited to share a story from the past with the group. Once the story ended, a theatrical ceremony was held, in which the clown awarded the storytellers a plastic gold medal on a ribbon necklace, whilst emphasizing some strong aspects of their lives. Thereupon, a short victory march was performed by the storyteller accompanied by applause from the participants. Every participant who received the medal began marching willingly, displaying their excitement and happiness, waving one hand toward their audience and showing off the medal. The participants were completely immersed in this ceremony as part of the role-play, as Fortuna said:
“The medal ceremony was exciting, since receiving a medal is a symbol of pride, joy and confidence. Personally, I imagined that I was on a sports field, receiving a medal after winning, it was an honorary moment.”
3.2. “I Never Thought I’d Play at This Age”
Clowning was something new to the residents, it introduced them to two main practices which were formerly considered out of bounds to people of their age playing and laughing. At the beginning, there were sessions in which they felt uncomfortable and embarrassed about laughing and having a good time, especially in the presence of the social worker (who came to watch) and the house matron (who came to assist). Later on, they realized that it was legitimate for them to play and enjoy themselves, to the point that they started to suggest their own kind of play. For example, this occurred in one session in which the warm-up phase involved an activity with a huge parachute held by all the participants together while sitting in a circle.
“At first, they made small and big waves with the parachute. Then the clown suggested that one person at a time should choose an animal and the group should imitate its movement, changing the size of the parachute waves accordingly. Suddenly they created their own new game: they stretched the parachute, said “one-two-three freeze, no laughing,” and then they stayed frozen until someone laughed, and so they all laughed loudly and started joking.”
As can be seen from the above example, older adults not only participated in the play proposed by the clown but they also suggested their own new game. The parachute, which was being used in a clownish style, facilitated the development of spontaneous play. Occurrences like that were rare at the beginning, but as the weeks passed the residents felt much more comfortable in the presence of the clown and in the group.
Little by little they discovered the multiple advantages of play, which they experienced in the clowning sessions. Dov, for example, emphasized how play encouraged him use his brain “we must think, and change our daily routine. It was playing which gave my brain an opportunity to work.” Fortuna explained that playing during the sessions made her feel younger “playing is returning to childhood, and feeling like a young soul.” In addition to these feelings, playing during the sessions with the clown made the participants feel treated as human beings and free of social constructions, as Yafa shared.
“Playing filled an empty space in me. I go to a club for the elderly, but there they treat us like objects, because we are “just old people.” I want to feel like a human being, not another older person. During the clowning sessions we were people, human beings, not older adults. Clowning gave me the opportunity to participate in a group and do silly things and enjoy them, like children do, even at my age.”
This issue was further explained by the clown.
“Other professionals do similar activities to those done by medical clowns. However, the clown’s presence and the “language of play” used during the sessions, are what make people not think about what is not acceptable at any moment, but they do it and are amazed that they actually do.”
In the end, playing during medical clowning sessions made the participants enjoy themselves to such an extent that they did not think about their usual preoccupations. As Gadi described: “people went into a nonsense state […] Medical Clowning took them out of their current state of mind. Even those who felt sad when they came in, became joyful when they were there.”
While being engaged in play the participants didn’t think about their problems and enjoyed the moment. Play occupied their mind and created a place free from worries. As Katerina explains:
“I never thought I’d play at this age. After every session I look forward to this time next week, to hang out with the clown. Clowning gives me an hour in which I don’t think about myself, about my pain and loneliness […] I just go along with what the clown wants.”
3.3. “The Clown’s Outfit Leads to Something Different, It’s Like Magic”
The clown’s outfit was found to be crucial for making play possible for older adults. If someone led those sessions without being dressed as a clown, it would not be enough to lead the participants into play mode. This was clearly expressed by the participants: “the clown’s outfit leads to something different, it is like magic,” said Yaffa. The clown’s unique outfit, unusual and out of the norm in a retirement home, caught the participants’ attention, aroused their emotions and made them open to the idea of play. As Katerina declared: “the clown’s outfit helps us to fool around.”
In fact, medical clowning does not just consist of a funny outfit or a red nose but is the gate way to interaction by means of play. It gives the person an opportunity to behave contrary to accepted social correctness and provokes a response both from the clown and the people around him. In the words of the medical clown:
“The clown’s role is to bring the place of play back into the reality of older adults, through group interaction. Its aim is to return to spontaneity, to create active participation, connect to the past and empower the participants.”
The clown’s presence helped the participants “live the moment” as Yafa stated. Similarly, Natasha explained that “after every session we feel in a good mood, we are happy and laugh a lot. We had fun and we obtained good energy.” Laughing was an important element for the participants, as Vera described “I had fun and I laughed like a child. At our age it is healthy to laugh and not cry. It helps us to reach such an age: not 20, not 30, but over 90.” In addition, the participants realized that laughing within the group made them open up and feel positive, as Diana elaborated “there was an opening up process, it did us good since it extracted positive feeling from us […] who said that older people should only be serious?”
4. Discussion
This research explored medical clowning practices in group sessions for independent older adults living in a retirement home. These practices differ from the work medical clowns do in hospitals, which mainly focuses on children. The difference is not only in the age of the recipients and the composition of the sessions (one-to-one in hospitals and group sessions in the retirement home) but also in the role of “play” during the encounters. While all children are encouraged to play as part of their development, hospitalized children find playing a challenge due to their health. The clown is the conduit that recaptures the element of play the children had in their life outside the hospital [45]. Older adults, following cultural and social norms, are not expected to play since this practice is not considered appropriate for serious older adults. However, the clown gives legitimacy to the world of play, offering them a new colorful playground to enjoy, combining body play, cognitive play, and role-play.
According to the findings of this study, this playground also differs from accepted game playing for older adults, including digital games [66] and nondigital games [67]. While with gameplay, both in person or with computers, it is easy to discern and be aware that it is “play time,” with free play, as instigated by the clown, the presence of the clown with his outfit and accessories is the signal that play can legitimately begin. Once the participants in the retirement home entered and saw the clown, they knew that it was play time. Furthermore, the clowns’ spontaneity as well as their capacity to connect with each individual participant and create an organic whole with the group, and encourages an atmosphere of free play. Unlike any play activity organized by other professionals, such as social workers, the clown is not perceived to be a “serious” entity. This enables the participants to open up and feel free enhanced by the presence of the clown.
The clown’s introduction of free play made the participants feel liberated from the social constructions expected of older adults. This gave them an opportunity to expand their personal space, and share their play with others, enabling creative, interpersonal interaction. Thus, group medical clowning is a leisure activity which further contributes to the well-being and happiness of older adults.
The observed medical clowning sessions are different from other activities offered in retirement homes, such as music and dance, which have also been found to contribute to the well-being of older adults [68, 69]. While these activities focus their intervention on one discipline, medical clowning sessions use a variety of techniques and combine elements from varied disciplines [47] as part of the clown’s intervention. The clown’s presence and his “language of play” frees the participants from their inhibitions. Therefore, medical clowning sessions contribute in two unique ways. First, they create an atmosphere that enables the emergence of new social interactions through play. Second, the presence and intervention of the medical clown gives legitimacy to an elevated type of play, carefree interaction by means of silly actions. Therefore, the creation of this enhanced playful environment not only serves to transcend social boundaries and norms but also improves the well-being of older adults.
Medical clowning, as a type of “therapeutic play,” prioritizes obtaining the individual and social freedoms that characterizes it. Unlike “play therapy,” which aims at helping a person cope with psychosocial difficulties [34], medical clowning may not have a predetermined focus. It is directed specifically toward animating the individual and thereby loosening them up and giving them a feeling of freedom and release.
Playfulness is positively related to happiness [32]. It contributes to a person’s well-being, and enhances their ability to cope with stress [70]. Treating older adults as “older adults” rather than simply as human beings, deprives them of both playfulness and the activity of play itself, which provides them with the opportunity to be actively present and to experience a therapeutic encounter [71]. The presence of the clown encouraged participants to flow with him and develop their play and playfulness [72]. This was achieved due to the clown being a play incentive attuned to the participants, who facilitated their connection with each other, awakening a collective joy and engagement in play encounters.
The boundary between play and reality disappears with the clown’s appearance. The medical clown creates “a magical safe area” which is an intermediate area between fantasy and reality [73], connects between play and seriousness [41], opens up new affective realities [74], and “invites us to learn how to move in different spaces” [42] (p. 152). In the present study, the clownish style of play and the role-play, made the older adults feel free to move in new directions, both internally and externally.
Throughout the session with the clown the participants laughed heartily and had many opportunities to express themselves through play, choosing a character for role play or sharing a story from the past. This active play participation led the older adults to feel happy, alive, and free. Play allowed them to bond with each other, thereby creating new memories and meaningful life experiences. Furthermore, while in today’s world play between older adults and children is legitimate, between older adults it is not. Thus, the clown created a community of play, legitimizing play among older adults and breaking the cultural rules of seriousness and social stereotypes. He broke the convention that older adults should not behave nonsensically, challenging the social norms of the retirement home.
Future research should further explore the promotion of play in group session of older adults from various cultures, in order to better understand the relationship between play, happiness, and well-being in the different cultural reactions to medical clowning as a leisure activity. This will allow medical clowning group encounters with older adults to become culturally sensitive. Furthermore, studies should also explore how playfulness can be developed in one-to-one medical clowning sessions with independent older adults in retirement homes.
5. Limitation
The main limitation of this study derives from its focusing exclusively on older adults in one specific location, and not, for example, comparing it to other residential homes and day centers. Another limitation was the fact that the number of residents who were interviewed was small, since there were only relatively few residents in the study groups. Notwithstanding the significant value of our study, in which we relied on observation sessions and interviews, additional studies can be devised and conducted using a mixed methods approach to provide more robust results.
Data Availability
The data used to support the findings of this study are available from the corresponding author upon request.
Conflicts of Interest
The authors declare that they have no conflicts of interest.