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Got the Blues, then find some Greenspace: The Mental Health Benefits of Green Exercise Activities and Green Care
 

Got the Blues, then find some Greenspace: The Mental Health Benefits of Green Exercise Activities and Green Care

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Got the Blues, then find some Greenspace: The Mental Health Benefits of Green Exercise Activities and Green Care

Got the Blues, then find some Greenspace: The Mental Health Benefits of Green Exercise Activities and Green Care

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    Got the Blues, then find some Greenspace: The Mental Health Benefits of Green Exercise Activities and Green Care Got the Blues, then find some Greenspace: The Mental Health Benefits of Green Exercise Activities and Green Care Document Transcript

    • Mind report 1.0, Feb 2007Got the Blues, then find some GreenspaceThe Mental Health Benefits of Green Exercise Activities and Green CareMind week report, February 2007Jo Peacock, Rachel Hine and Jules PrettyCentre for Environment and Society, Department of Biological Sciences, University of EssexWivenhoe Park, Colchester CO4 3SQ Photographs courtesy of Cyrillia Francis and Steph Berns of Mind 1
    • Mind report 1.0, Feb 2007BackgroundMind commissioned Professor Jules Pretty, Jo Peacock and Rachel Hine, lead researchers ofthe green exercise programme at the University of Essex, to investigate the mental healthbenefits Mind members derive from participating in a range of green exercise activities. Onehundred and eight Mind members took part in our research looking at the effects of existinggreen exercise activities which they are already engaging in locally. In addition, a further 20members participated in a smaller study which compared the mental health benefitsexperienced from participating in a green walk outdoors, with an equivalent walk indoors. Boththe statistical findings from this process together with the qualitative narrative are included in thereport.Mind and the University of Essex would like to thank all Mind members for their assistance withthe research published in this report. We are very grateful to all the people who completed thequestionnaires and those who took part in the walking study and agreed to share details abouttheir experiences. 2
    • Mind report 1.0, Feb 2007Contents1. Key findings 42. Introduction 83. Review of existing literature 10 3.1 The value of greenspaces and contact with nature 10 3.2 The value of exercise 11 3.3 The emergence of green exercise 12 3.4 What do we know so far? 14 3.5 What are we yet to fully understand? 16 3.5.1 Application of green exercise in the mental health population 3.5.2 Green exercise as a treatment for mild to moderate depression 3.5.3 Green care for marginalised populations 3.5.4 Limitations of research to date4. Assessment of existing Mind green exercise activities 23 4.1 Findings - green exercise activities 23 4.2 Findings - people involved in the activities 245. A Mind study to compare a green outdoor walk and an indoor walk 32 5.1 Backgound and methodology 32 5.2 Results 356. Conclusions and recommendations 41 6.1 Issues affecting progress of research 41 6.1.1 Ethical issues 6.1.2 Evaluation issues 6.2 Key issues for policy 42 6.2.1 Amount of greenspace 6.2.2 Accessibility issues 6.2.3 Barriers to participation 6.2.4 Acceptance from service providers 6.2.5 Working in partnership 6.2.6 The need for further research7. References 47 3
    • Mind report 1.0, Feb 20071. Key findings The current health status of the UK population is becoming problematic due to our increasingly sedentary lifestyles, our poor diets and the prevalence of mental illness. Mental ill health severely compromises quality of life and sadly, sufferers of anxiety and depression are all too commonplace today. The total costs of mental illness in England have been reported to be has high as £77.4 billion. This includes the human costs of mental illness due to reduced quality of life, suffering, pain, disability and distress; and the costs of output losses in the economy due to peoples’ inability to work and costs of health and social care. Therefore, mental illness is a burgeoning concern and public spending on mental health services is continually rising. Perhaps it is about time we started to question the cost- effectiveness of existing treatment options, such as therapy and drug prescriptions? Should we be thinking about preventative treatments and if so, what should we be prescribing? Is it inconceivable to think that we might already have a solution on our doorstep, which is available to everyone at minimal cost? The simple answer might exist in encouraging people to interact with nature and greenspace and to get active outdoors? A myriad of persuasive evidence demonstrates the positive relationship between exposure to nature and an individual’s health and well-being. Nature and greenspaces are often perceived as places to relax, escape and unwind from the daily stresses of modern life. This opportunity for relaxation and recreation has a positive influence on our emotional and physical well-being. Equally, participating in physical activity is known to result in positive physical and mental health outcomes. Therefore, engaging in physical activities whilst simultaneously being directly exposed to nature (“green exercise”) could offer an alternative preventative and curative option to address the worrying problem of mental illness. There is an emerging and compelling argument for green exercise therapy to be advocated as preventative medicine or the primary treatment option for some mental illnesses, as exercise has less negative side effects than many traditional drug therapies and it can positively treat patients experiencing a combination of physical and mental health problems. However, at present, there is limited evidence concerning the application of green exercise in the mental health population. With incidences of mental illness and especially depression on the increase how much do we know about green exercise as a potential treatment? There has been little research conducted which compares green exercise with more traditional treatment options, such as antidepressants or cognitive behavioural therapy but from initial findings we can confidently anticipate that green exercise is likely to be equally as effective. Some may argue that the option of green exercise therapy or green care may prove to be an even more effective treatment response than exercise alone as it encourages people to re- connect with nature and experience the additional positive health benefits that are associated with this. Contact with nature and greenspace is often uplifting and restorative, helps to reduce stress and improve mood and combining this with physical activity will offer a very efficacious treatment option. Green exercise also promotes social inclusion and enables people to make healthier choices and adopt a sustainable healthier lifestyle. 4
    • Mind report 1.0, Feb 2007 However, the robust scientific evidence to support this hypothesis is still lacking. For the idea to gain credibility and influence government policy and the health sector, more detailed research needs to be undertaken. Some of these research limitations were addressed in this study. 108 Mind members took part in our research and completed a specifically designed questionnaire, which assessed the positive physical and mental health benefits people derived from engaging in a range of green exercise activities. It was found that the combination of exercising outside in the presence of nature (i.e. green exercise) was the most influential factor, with 89.6% of respondents stating that this was very important or important in determining how they felt. This supports the idea that it is the synergistic amalgamation of the exercise in a green environment that produces added health benefits, rather than either one alone. Many key themes emerged when assessing how taking part in these activities made participants feel. They enjoyed becoming part of a group and socialising with likeminded people. They took pleasure in the conversation and company and the activities left them feeling refreshed. They felt less stressed, more alert and alive, happier and more relaxed. Many people stated that they felt mentally healthier and a lot more motivated and positive. They felt that the activities helped to lift their depression levels and instil a feeling of calm and peacefulness. Their overall mood improved as did their confidence levels and self- esteem. Many spoke of the benefits to their fitness levels and how they felt stronger, less lethargic and more energetic. Others commented on the changes to their body profile through losing weight, easing stiffness in their joints and becoming more agile, so there were a range of physical health benefits reported. The findings from this assessment clearly showed that participating in a range of green exercise activities provided substantial social, health and well-being benefits. The contact with nature and greenspace is a necessity in enriching the experience and creates a restorative environment which people can seek pleasure in escaping to. A lot of enjoyment was derived from getting out into the fresh air, admiring the scenery and taking pleasure in the wildlife, plants and trees. Participating in these activities was often perceived as therapeutic and engendered feelings of relaxation and peacefulness. The whole process was very calming; it reduced stress levels and encouraged people to feel good about themselves by improving their self-worth, confidence and self-esteem. It inspired people to embrace their problems and start to deal with them and learn how to cope. There was a great sense of achievement when an activity was completed, as participants felt they had achieved something worthwhile and therefore felt useful. Figure 1: The change in self-esteem following participation in the In addition, 20 local Mind group members walks participated in a separate small study which 18 addressed the research question: “Will Green outdoor walk exercising outdoors in a green environment 19 Index of self-esteem significantly improve participant’s mental health and well-being (using standardised 20 and well-recognised mood and self-esteem measures) compared to the equivalent 21 exercise indoors?” They took part in two Type of walk 22 Indoor walk 5
    • Mind report 1.0, Feb 2007 separate walks, a green outdoor walk and an indoor walk at a local shopping centre. Figure 1 clearly shows the significant improvement in self-esteem following the green outdoor walk and the detrimental effect after the indoor walk. Participating in a green outdoor walk also Figure 2: The change in feelings of anger following participation significantly reduced feelings of anger in the walks (Figure 2), depression (Figure 3) and 43 tension (Figure 4) in comparison to the 42 indoor walk. In fact, after the indoor walk participants were left feeling tenser than Indoor walk Index of anger 41 when they had started. Feelings of fatigue also reduced even though they had been 40 walking for an hour. Participants also felt 39 more active and energetic, so it offers an Green outdoor walk ideal way of getting rid of those blues. 38 Type of walk The findings undoubtedly showed that exercising outdoors in a green Figure 3: The change in feelings of depression following environment is a lot more effective in participation in the walks enhancing your mood and improving your 42 self-esteem compared to the equivalent amount of exercise indoors. 41 Indoor walk Index of depression Participating in the green outdoor walk 40 was a lot more effective in reducing feelings of anger, depression, tension and 39 confusion, in comparison to the indoor Green outdoor walk walk. It also increased feelings of vigour and left participants feeling more active 38 Type of walk and energetic. The enjoyment of engaging in green Figure 4: The change in feelings of tension following participation exercise activities in groups was a in the walks Indoor walk valuable part of the experience, as well as 39 the opportunity to breathe in fresh air, 38 admire the scenery and enjoy the wildlife. 37 Index of tension The findings add significant value to the 36 ever expanding green exercise research 35 programme as it focuses on individuals experiencing mental health issues and 34 separates the elements that constitute the Green outdoor walk 33 Type of walk green exercise experience. In today’s world, where sufferers of mental ill health are more commonplace, nature can act as a vital health resource. With significant costs incurred due to lost outputs, increased expenditure in the provision of care and the inestimable cost to the individual, the importance of access to nature and greenspaces is paramount. 6
    • Mind report 1.0, Feb 2007 Green exercise and green care therefore have implications for many sectors, suggesting the need for cross-disciplinary and sectoral strategies and action. Increasing support for and access to, a wide range of green exercise activities for all sectors of society should produce substantial economic and public health benefits. Such support could include the provision and promotion of healthy walks projects, green exercise on prescription, healthy school environments, green views in hospitals, care farms, city farms and community gardens, urban green space, and outdoor leisure activities in the countryside. 7
    • Mind report 1.0, Feb 20072. IntroductionThe current health status of the UK population is becoming problematic due to our increasinglysedentary lifestyles, our poor diets and the prevalence of mental illness. It is believed that atleast one in six individuals suffer from a “significant” mental health problem at any one time andsome reports quote this figure as high as one in four.Mental ill health can severely compromise an individual’s quality of life and it is a leading causeof disability. Sufferers of anxiety and depression are commonplace and by 2020 it is predictedthat depression will be the second most common cause of disability in the developed world.Mental ill health is therefore a major issue and sadly problems surrounding social exclusion,vilification and discrimination of the mentally ill are still real challenges to overcome.Mental illness is not solely a challenge for the health sector to address as it inflicts additionaleconomic and social costs. It is estimated that the total costs of mental illness in England in2002-03 were approximately £77.4 billion (The Sainsbury Centre for Mental Health, 2003). Toput this in perspective, the cost of crime for our society in the same period was substantiallyless, so mental illness is costing us more than crime. The costs of mental illness can besegregated into three key areas, impacting upon human costs, health and social care andoutput losses (Box 1).Box 1: The burden of mental illness in the UK  At least 1 in 6 individuals are affected at any one time  10% of children aged 5-15 yrs suffer from a mental disorder  Instances of depression and mixed anxiety rose from 7.8% in 1993 to 9.2% in 2000  £41.8 billion represents the human cost of mental illness due to reduced quality of life, suffering, pain, disability and distress  £23.1 billion is the cost of output losses in the economy due to peoples inability to work  £12.5 billion is the cost of health and social care provided by the NHS and Local Authorities and informal care given by family and friends  £4.9 billion is spent on NHS hospital and community health services  £1.4 billion is spent on Local Authority social services  £898 million is spent on GP consultations  £754 million is spent on drug prescriptions  £3.1 billion per year represents the net saving across the government as a whole if better mental health care is introduced (Wanless, 2002). This conservative estimate does not include the additional savings gained from promoting mental health and preventing problems in the first instance.It is evident that mental illness is a burgeoning concern and public spending on mental healthservices is continually rising. It is estimated that £7.9 billion was spent in England in 2002-03 onmental health services including £754 million on drug prescriptions. The cost of antidepressantshas risen dramatically. In 1992, the number of antidepressant prescriptions dispensed was 9.9 8
    • Mind report 1.0, Feb 2007million but by 2003 this figure had increased to 27.7 million. This represents a cost of £395.2million and implies an increase in cost of 2,083% in only 11 years.The government is also currently spending more money on training therapists to co-ordinatecognitive behavioural therapy (CBT) sessions, so mental ill health is emerging as a costlypredicament. Perhaps it is about time we started to explore alternative preventative and curativetherapies which, while comparable in their success rates, are cheaper to employ. Theimportance of the health of the individual and affected family members involved in careprovision supersedes any financial cost, but if there is a potential solution which addresses bothissues, this could significantly reduce public spending and human costs.Is it inconceivable to think that we might already have a solution on our doorstep, which isavailable to everyone at minimal cost? The simple answer might exist in encouraging people tointeract with nature and greenspace and get active outdoors? The positive relationship betweenexposure to nature and greenspace and an individual’s health is continually being evidenced.The quality and quantity of nature and greenspace in the surrounding environment transforms aperson’s mental health, both at home, at work and at the places they visit. This concept is notrevolutionary but it has yet to significantly influence the planning of urban and ruralenvironments or public health and social care priorities. However, nature and greenspaces areoften perceived as places to relax, escape and unwind from the daily stresses of modern life.This opportunity for relaxation and recreation has a positive influence on our emotional andphysical well-being. Therefore, in today’s world, where sufferers of mental ill health are morecommonplace, nature can act as a vital health resource. With significant costs incurred due tolost outputs, increased expenditure in the provision of care and the inestimable cost to theindividual, the importance of access to nature and greenspaces is paramount. 9
    • Mind report 1.0, Feb 20073. Review of existing literature3.1 The value of greenspaces and contact with natureThere is a myriad of persuasive evidence which connects regular contact with the naturalenvironment and greenspace to enhanced physical health and mental well-being. Thisincorporates a variety of outdoor settings, from the open countryside, fields and forests, remotewildlands, parks and open spaces, to street trees, allotments and gardens. The key messageemerging is that contact with these greenspaces improves psychological health by reducingstress levels, enhancing mood and offering a restorative environment which enables you torelax, unwind and recharge your batteries. Greenspaces also provide an ideal opportunity andincentive for exercise and can be especially valuable in urban areas for facilitating social contactand helping to bring people together.A significant relationship between the proximity of urban open green spaces, visiting frequency,duration of stay and the level of self-reported stress experienced has been reported (Grahn andStigsdotter, 2003). The quantity of available greenspace has also been correlated with longevityand a reduced risk of mental ill health (Takano et al., 2002; De Vries et al., 2003). Open spaceis also vitally important for children and studies have shown that children with Attention DeficitDisorder worked better and their concentration improved after participating in activities in greensurroundings (Taylor et al., 2001).So, if research strongly indicates that exposure to nature and greenspace positively affects ourphysical health and mental well-being, do we fully understand why? What are peoplesmotivations for engaging with nature? With a multitude of choices available, why do so manypeople still seek out green places (both rural and urban) on a regular basis? As hominids werehunter-gatherers for over 300,000 generations, having daily contact with nature and the land,are the reasons co-evolutionary? In comparison, the increasingly urbanised and industrialisedenvironment we currently live in has only emerged in the past six to ten generations.Many of us already recognise and appreciate the health benefits we derive from spending timeengaging with nature. In the UK we make 1.2 billion day visits to the countryside each year, witha further 5 billion visits to urban parks. 5 million people are regular anglers, and some 15 milliongarden regularly; 6 of every 10 households have a pet; and many millions of others are birdwatchers, wild-fowlers, pigeon-racers, dog-walkers, ramblers, runners, horse-riders, cyclists andgame shooters. Why do we do all these things? What motivates us to take the trouble to be inthe presence of green nature and living things, when we can now easily stay at home and watchit on the television? Why do we say that we feel great after green activities? And if we feel sogood doing it, why do we not spend more time visiting greenspaces and put time aside to enjoyit?Equally, we may question what consitutes a green experience? Do artificial plastic trees andplants have the same effect as rainforest trees or hay meadows in the spring? In what way doesnature affect us emotionally as opposed to intellectually – is the experience different if you areaware the nature is simulated? What difference does spending five minutes a day in contactwith nature make to two weeks in the wild? Does an individuals personal history affect theirexperience? Is there a contrast between urban and rural dwellers, or someone visiting their ownlocal environment compared to someone coming from another culture? Does the culture oforigin affect the experience, or is the desire to connect with nature the same irrespective of 10
    • Mind report 1.0, Feb 2007cultural context? These thought-provoking questions need to be explored so that we can beginto shape our reasons for engaging with nature and greenspace.3.2 The value of exerciseParticipating in regular physical activity is generally accepted as a highly effective method forpreventing illness and offers a therapeutic intervention for tacking existing illness. Physicalactivity has been evidenced to be an important determinant of both physical health andpsychological well-being. Moderate regular exercise reduces morbidity rates by 30-50% and hasa particularly protective effect against maturity onset Type II diabetes, coronary heart disease,musculo-skeletal diseases and cancer. It lowers blood pressure, improves blood lipid andglucose profiles and boosts the immune system. It also enhances mental health by improvingmood and self-esteem, reducing stress, enriching an individual’s quality of life and diminishingthe chance of depression. We are now gaining a better understanding of the intimate inter-relationship between mental and physical health, as the status of one considerably affects theother. Therefore, exercise can be used as a successful tool to ensure preferable health statesare experienced.Throughout the last fifty years, the UK has witnessed a dramatic fall in the levels of dailyphysical activities, despite the robust evidence for staying active. On average, adults expend500 kcal less energy per day in comparison to their ancestors fifty years ago. This iscomparable to undertaking a marathon a week on top of current activity levels, just to restorethis reduction in energy expenditure. This is primarily because people have become increasinglysedentary in all aspects of daily life, including during leisure time, in travelling to and from workand during work itself. Home life has also become more sedentary and although gym andfitness club membership has risen (although many have a low adherence rate) in the pasttwenty years, there are indications that people are becoming less likely to engage in organisedsports and leisure activities.The level of weekly physical activity required to achieve general health benefits has led to thedevelopment of a universal recommendation. It advises that individuals should participate in “atleast 30 minutes a day of at least a moderate intensity on 5 or more days of the week”(Department of Health, 2004). However, it is estimated that only 35% of men and 24% ofwomen actually meet this recommendation. The major problem is the misconception thatcurrent physical activity levels are sufficient to avoid ill-health. 80% of individuals are aware thatregular exercise is beneficial for their health, but most inaccurately believe that they participatein enough exercise to reap these rewards. For these targets to be met a dramatic modification isnecessary and perceptions need to be revolutionised.Due to this activity transition, populations have suffered very significant public healthconsequences. The annual costs of physical inactivity in England are reported to beapproximately £8.2 billion (Department of Health, 2004). This figure excludes individuals whoare obese due to inactivity, which contributes an extra £2.5 billion annual cost to the economy.These figures incorporate both costs to the NHS and costs associated to the economy (e.g.work absenteeism). This rise in inactivity levels and the associated problems with obesity are apriority on the government’s agenda and although there is a general acknowledgement thatgreenspaces rich in biodiversity encourage physical activity, the relationship needs furtherinvestigation to develop a deeper understanding. Undertaking physical activities in outdoorgreen environments seems to be a more sustainable option in maintaining long-term activitylevels, as it is the interaction with the environment and the social contact that are the main 11
    • Mind report 1.0, Feb 2007incentives. In this situation, the health benefits derived from the exercise are not the sole focusand become a secondary outcome. With the current inactivity predicament, exploring the use ofrural and urban greenspaces as ideal locations to encourage physical activity could prove to bea benefit for all.3.3 Emergence of green exerciseThere is a growing body of empirical evidence which proclaims that exposure to nature inducessubstantial mental health benefits. Equally, participating in physical activity is known to result inpositive physical and mental health outcomes. Therefore, at the University of Essex we havecombined these ideas into a programme of research which investigates the synergistic benefitsof engaging in physical activities whilst simultaneously being directly exposed to nature. Werefer to this as “green exercise” (Figure 5). This programme addresses current concerns aboutthe adverse health effects of modern diets and sedentary lifestyles, along with growing evidencethat stress and mental ill-health have become substantial health problems for many people inindustrialised societies. Figure 5: The concept of green exercise and the health benefits it engenders Engaging in Exposure to nature physical activity and greenspaces Green Exercise 1. Improves 2. Generates 3. Facilitates social psychological well- physical health networking and being benefits connectivity Healthier communities and avoided public health costsFrom a wide variety of University of Essex research involving more than three thousand people,we have discerned three key outcomes from participating in green exercise activities: 1)improvement of psychological well-being (by enhancing mood and self-esteem, whilst reducingfeelings of anger, confusion, depression and tension); 2) generation of physical health benefits(by reducing blood pressure and burning calories) and 3) facilitation of social networking and 12
    • Mind report 1.0, Feb 2007connectivity (by enhancing social capital). Box 2 shows a selection of qualitative comments thathave been collected during the research which supports this idea.Box 2: A selection of comments collated during our research programme supporting the keyhealth outcomes identified1: Improves psychological well-being“It is relaxing mentally where I can get away from responsibilities of a managerial job and being a parent. I find itrefreshes me for everyday life and its problems. A great day”“I feel it helps my well being and I feel more healthy”“In good spirits and very relaxed”“Good to be out and meet people. Boosts your ego and makes you feel good”2: Generates physical health benefits“Exercise, being outdoors, enjoying the environment”“Relaxing, exercises the body, clears the head”“Fun to do, great exercise and in a beautiful location which helps keep me fit and happier”“To try to keep fit and lose weight, good company”3: Facilitates social networking and connectivity“Enjoyment especially the social interaction and meeting and talking to people we wouldn’t ordinarily meet!”“Feel refreshed – better for taking part, enjoy social aspect”“I feel much more alive and my spirits have lifted by the walk and the company of other walkers”“As a retired person it is valuable for me to meet other people for recreation and conversation”Our research has also enabled us to gain an insight into some of the underlying reasons forengaging in green exercise activities. Table 1 illustrates these ideas by identifying four keyprinciples and separating these into ten sub categories, which describe some of the pleasureswe commonly refer to.Green exercise seems to be effective in generating a variety of health benefits which lead tohealthier communities and avoided public health costs. With the understanding of the closeinter-relationship between mental and physical health gaining acknowledgement, engaging ingreen exercise activities presents an ideal way of advancing collective health states.Three of the government’s six key priorities in their recent Public Health White Paper were to“reduce obesity”, “increase exercise” and “improve mental health”. Therefore, encouraging morepeople to adopt green exercise behaviour may contribute to the compliance of these objectiveswhilst also enhancing the health of the nation. 13
    • Mind report 1.0, Feb 2007Table 1: Four key principles describing why people enjoy engaging in green exercise activities Sub-Principles Descriptors categories Being with friends and family, companionship and social interaction, a. Social creation of collective identity, making new friends, conviviality Direct bonding with companion animals (e.g. dogs, horses) and wild b. Animals animals (both observing and hunting), feeding birds, recognising, counting1. Natural and wildlife and collecting (greater value of rarities)and socialconnections c. Memories Visiting special places where memories and stories are provoked and and recalled (childhood associations), story-telling, personal identity, links to knowledge myths, stimulation of imagination, ecological literacy Large scale and longevity of nature in contrast to humans, transformative d. Spiritual capacity of green nature, oneness with nature and animals Diverse colours of nature and landscapes, views of landscape, beauty of a. Colours scenery, bird-song and sounds of other animals, light (especially sunrise / and sounds sunset), visual and aesthetic appreciation of landscapes2. Sensory Smell and other senses, being outdoors, exposed to all types of weather,stimulation b. Fresh air changing of seasons, a contrast to indoor and city life, escape from urban pollution c. Adrenalin rush, exhilaration, fun, arising from a physical activity or Excitement experience of risk (e.g. rock climbing, mountain biking), sense of adventure Learning a skill and completing a manual task (e.g. conservation activity), a. Manual challenging, fulfilling and rewarding, sense of achievement, leading to a tasks3. Activity sense of worth and value b. Physical Enjoyment of the activity itself and the physical and mental health benefits activity associated with it, makes people feel good, more energetic, less lethargic Getting away from modern life, relaxing (as a contrast), time alone or with a. Escape family, a time to think and clear the head, peace and quiet, tranquillity and4. Escape from freedom, privacy, escape from pressure, stress and “rat-race”, recharging modern life batteries3.4 What do we know so far?Even just viewing nature through a window or in a painting can positively influence people’swell-being. Research has shown this in hospitals, prisons, the workplace and whilst travelling towork1. Green views from the window help to buffer stresses, reduce frustration and enhanceconcentration. Viewing green landscape paintings aids recovery from illness, improves mood,reduces stress and improves mental well-being. At the University of Essex we havedemonstrated that engaging in physical activities whilst viewing a series of green rural or urbanpictures reduces blood pressure and enhances mood and self-esteem (Pretty et al., 2005).Incidental exposure to nearby nature whilst engaging in some other activity also assists inreducing stress, enhancing mood status and promoting relaxation. This nearby natureincorporates countryside and neighbourhood greenspaces, parks, grounds of hospitals and carehomes, along with healing gardens2. Healing gardens are designed to aid recovery from stressand are often present in hospitals and care homes, whereby stressful experiences areencountered by patients, visitors and staff. Therefore, outdoor natural settings are often1 (Verderber and Reuman, 1987; Tennessen and Cimprich, 1995; Leather et al., 1998; Parsons et al., 1998; Kaplan, 2001;Laumann et al., 2003)2 (Cooper-Marcus and Barnes, 1995, 1999; Wells, 2000; Whitehouse et al., 2001; Ulrich, 2002; Wells and Evans, 2003) 14
    • Mind report 1.0, Feb 2007perceived as therapeutic “healing places” and a wide range of research has demonstrated thiseffect (Pretty, 2007).Direct participation in some green exercise activity, such as gardening, walking, running, cyclingor fishing also yields a series of unequivocal physical and psychological health benefits. Studieshave looked at the benefits of wilderness experiences, adventure therapy, forest schools, socialand therapeutic horticulture (which is based on the value of gardening for mental and physicalhealth), care farming and private and community gardens.The University of Essex has undertaken research involving 263 participants which measuredthe effects of ten green exercise activities (including walking, cycling, horse riding, fishing, canalboating and conservation activities) in four countries of the UK (Pretty et al., 2006; Pretty et al.,2007). We found that participants felt significantly less angry, depressed, confused and tenseafter engaging in the activities and their self-esteem levels all significantly improved. Theseimprovements were not affected by the type, intensity, or duration of the green exercise activity,indicating the potential for a wider health and well-being dividend from green exercise.It is often argued that the underlying reasons for nature’s ability to help people recover fromstress and mental fatigue is due to its restorative powers. Terry Hartig has pioneered the notionthat nature can restore deficits in attention arising from overwork or over-concentration, makingpeople both feel and think better. He has found that sitting in a room with tree views promotesmore rapid blood pressure decline than sitting in a windowless room, and also that walking in anature reserve reduces blood pressure more than a walk along an urban and non-green street.In both contexts, the green room and green walk, people recover more rapidly from attention-demanding tasks and the long-term effects may be important. Another five-year study of olderpeople found that access to green space in which they could walk was an accurate predictor forlongevity, as those who walked in green places lived longer (Takano et al., 2002).It has been suggested that spending time in ecologically restored areas and having aheightened knowledge of nature can encourage more frequent visits outdoors for longer periodsof time. Young people are currently becoming more and more disconnected with nature and,therefore, are currently making fewer visits to the countryside than ever before, and engagingchildren with nature from a young age can encourage them to participate in more outdoorexercise and make more frequent countryside visits throughout adulthood leading to theassociated health benefits.It is apparent that there is an emerging body of evidence supporting green exercise and greencare and it is becoming increasingly recognised as an idea which can be linked to currentgovernment health and social care policies. The research holds implications for human health,environmental protection and national policies alike. Engaging in green exercise activitiesconveys substantial mental, physical and social health benefits, even from relatively shortexposures. These health benefits will lead to avoided public health costs, which will ultimatelysave the NHS money. Although there are many opportunities already available, they areaccessed predominantly by reasonably healthy individuals. The cohorts of people studied todate are those already choosing to engage in green exercise activities and therefore can beconsidered healthy. We are yet to engage and research the harder to reach sedentarypopulation or those experiencing mental ill-health. If we can develop a methodology forengaging these populations, the potential financial savings are immeasurable. 15
    • Mind report 1.0, Feb 20073.5 What are we yet to fully understand?3.5.1 Application of green exercise in the mental health populationThere is limited evidence concerning the application of green exercise in the mental healthpopulation. Initial steps are being taken to try and engage individuals experiencing mentalillness in green exercise activities. For example, greater participation by the public in greenexercise has led to the introduction of new initiatives, such as the “Green Gym’s” set up by theBritish Trust of Conservation Volunteers (BTCV). These outdoor gyms encourage participationin local nature conservation activities to improve health and well-being and establish socialnetworks. The projects vary, including creating community gardens, managing local woodlands,tree-planting and maintenance of public footpaths. These Green Gym groups often attractindividuals experiencing mental illness and initial evaluation findings have reported significantincreases in mental health state scores, a reduction in depression and a trend towards weightloss (Reynolds 1999, 2002). A further national evaluation of the health benefits of participatingin Green Gyms was conducted by the School of Health and Social Care at Oxford BrookesUniversity during 2006 and is expected to be published shortly.Another example of a green exercise initiative for people suffering from mental health problemsis the Stepping Out project. This is funded by Natural England (formerly the CountrysideAgency) and supports and enables both informal carers of people suffering from mental illhealth, and those that they care for, to explore and discover green spaces and the countrysidein and around Coventry. The project is managed by Warwickshire Wildlife Trust in closepartnership with Coventry Carers and the Asian Mental Health Action Project and through aseries of confidence building and awareness activities forming a ‘stepping stones’ journey,Stepping Out supports and encourages participants to access the local environment3.Findings of research suggest that therapeutic applications of green exercise could therefore beeffective and this is termed “green care”. There is a growing movement towards green care inmany contexts, ranging from green exercise activities, social and therapeutic horticulture,animal assisted therapy, eco-therapy and care farming. Green care in agriculture or “carefarming” is defined as the use of farms and agricultural landscapes as a base for promotingmental and physical health (Hassink, 2003; Braastad, 2005). Farming is used to provide mentaland physical health benefits for a wide range of people. These may include those with definedmedical or social needs (e.g. psychiatric patients, those suffering from mild to moderatedepression, people with learning disabilities, people with a drug history, disaffected youth orelderly people) as well as those suffering from the effects of work-related stress or ill-healtharising from obesity. Care farming is a partnership between farmers, health care providers andparticipants, and so combines the care of people with the care of the land. Care farming is partof a growing recognition that the land is multifunctional, providing a range of environmental andsocial goods and services. Green care on farms is thus part of a movement to reconnect peopleto the land, and to the food produced by domestic farming.There are now several hundred green care farms in Norway, the Netherlands, Italy, Germany,Austria, Belgium and Slovenia4. Such green care farms are formally tied to local social servicesand hospitals, and provide a new component of care in the community. Farmers are paid forproviding a kind of “health service” whilst continuing with agriculture. This can help to maintain3 http://www.warwickshire-wildlife-trust.org.uk/SteppingOut/index.htm4 See Farming for Health (Europe) www.farmingforhealth.org 16
    • Mind report 1.0, Feb 2007the economic viability of farms, farmers benefit from the extra labour and they can still sell theirproduce.There are many different terms for green care in agriculture across Europe including Farmingfor Health, Care Farming and Social Farming but all essentially refer to the same concept. Muchof the research into Green Care had until recently been largely qualitative and anecdotal, butresearch initiatives are currently underway examining the physical, mental and social healthbenefits of green care for various populations and groups. Research which is particularlyrelevant for people with mental health issues includes a Dutch study for example. Researchersat Wageningen University in the Netherlands are looking at the effect of green care farms onquality of life of demented elderly and for people with a psychiatric and/ or drug addictionbackground5. Studies in Norway (Norwegian University of Life Sciences) are looking at thehealth benefits of animal assisted therapy on farms for people with mental health disorders andsimilar studies with animals assisted interventions are being conducted in the Netherlands(Wageningen)6.While the term “care farming” is well-recognised in Europe, here in the UK, the concept isrelatively new. There is an increasing amount of interest from many sectors including farmers,health care professionals and social care providers, the prison and probation services and thereare a number of care farms already operating throughout the UK. However the numbers of carefarms are thought to be small and the movement is very embryonic at present, with no nationalframework. The National Care Farming Initiative (UK)7 aims to promote and support theexpansion of care farming throughout the UK and is currently undertaking research to establishthe scale of care farming in the UK.Like the UK, Denmark, Finland, Italy, Austria and Germany have also initiated research into thehealth benefits of care farming and this is expected to combine with the research underway inthe Netherlands and Norway to produce evidence to support the use of care farming for healthbenefits. The European Farming for Health Community of Practice(CoP) 8 , a network of thoseinvolved with care farming in Europe and beyond recognised the need for a sound body ofevidence to support the health and “therapeutic” benefits of care farming in order to influencehealth and social care professionals and policy-makers alike (Hassink and van Dijk, 2006). TheFarming for Health CoP has been instrumental in developing a COST Action on green Care inAgriculture9 which is an EU funded action to increase the scientific knowledge on the bestpractices for implementing green care in agriculture with the aim of improving human mentaland physical health and the quality of life. In particular one of the areas of priority for the actionis to coordinate research in this field by the comparison and discussion of ongoing projectsrelated to health effects on people and the establishment of a set of good researchmethodologies.There has been most research into another form of green care, social and therapeutichorticulture (STH). Social and therapeutic horticulture has been used as a therapy or as an add-on to therapy for many years and in the UK there has been a steady rise since the 1980s in thenumbers of garden projects that offer horticultural therapy to many different groups of people.The associated health benefits to those who participate in STH are well documented and also5 Simone de Bruin, Marjolein Elings, Nicole van Erp, Jan Hassink, Eric Baars6 Bjarne Braastad and Bente Berget (Norway) and Reina Ferwerda and Jorine Rommers (Netherlands)7 See National Care farming Initiative (UK) website www.ncfi.org.uk8 see www.farmingforhealth.org for more information9 www.umb.nor/greencare 17
    • Mind report 1.0, Feb 2007include studies which focus on those who are suffering from mental health problems inparticular.A recent collaboration between the Centre for Child and Family Research at LoughboroughUniversity and Thrive called “Growing Together” has concluded a major piece of researchexamining the physical, mental and social health benefits of STH (Sempik et al., 2003, 2005). Inthis study Sempik et al., (2003) carried out a comprehensive survey of literature of STH anddiscovered a wealth of descriptive literature on horticulture, health and well-being. STH projectsare widely used for patients suffering from Alzheimer’s disease and a study of over 2000 olderpeople living in the Gironde area of France conducted by Fabrigoule et al., (1995) found that it isalso possible that regular participation in gardening may offer some protection against thedevelopment of dementia. In a prospective study showed that those who took part in gardening(or who travelled, carried out odd jobs or knit) were significantly less likely to develop dementiathan those who did not. Later studies have shown that the exercise provided by gardeningactivities may also be significant in delaying the onset of dementia and Alzheimer’s disease(Rovio et al., 2005 and Larson et al., 2006).However, as is the case with green care and Green exercise projects in general although thereis much descriptive and qualitative data available there is a relative scarcity of quantitativeresearch. Sempik et al., (2003, 2005) concluded that there was also a need for more “hard”evidence to support the findings.Green care, care farming, SHT, green gyms and other green exercise projects are worthyexamples of how engaging in green exercise and care activities can help people with mentalhealth problems. Therefore, the initial successes of green care in Europe combined withinnovative green exercise initiatives poses the question – should people experiencing mentalillness be prescribed “green care” such as green exercise therapy, social and therapeutichorticulture or time at a care farm instead of, or in addition to, traditional medicine?3.5.2 Green exercise as a treatment option for mild to moderate depressionWith incidences of mental illness and especially depression on the increase how much do weknow about green exercise as a potential treatment? It is estimated that 25% of women and10% of men in the UK will experience a period of depression requiring treatment, at some pointin their lives (Halliwell, 2005). Often, visiting their GP is the first step they take in addressing thesituation and it is usually the GP who is primarily responsible for organising their treatment.A recent report conducted by the Mental Health Foundation reported that in cases of mild tomoderate depression, 55% of GP’s prescribe antidepressants as their first choice of treatmentresponse (Halliwell, 2005). However, only 35% actually believe that antidepressant medicationis the most effective intervention in these situations. It was reported that although GP’s deemedalternative treatments to be more suitable, 78% of them had still prescribed antidepressants asthe treatment option in the last three years. In comparison, only a minority of patientsexperiencing mild or moderate depression are offered the choice of exercise therapy as aprimary treatment response. A mere 5% of GP’s offer exercise therapy as one of their threemost common treatment responses, in comparison to 92% of GP’s who commonly prescribeantidepressants as a treatment response.Yet, research has demonstrated that a supervised programme of exercise can be equally aseffective as antidepressants in treating mild to moderate depression (Halliwell, 2005; 18
    • Mind report 1.0, Feb 2007Richardson et al., 2005). In a report by the Chief Medical Officer it was stated that “physicalactivity is effective in the treatment of clinical depression and can be as successful aspsychotherapy or medication, particularly in the longer term” (Department of Health, 2004).Therefore, a compelling argument for exercise therapy to be advocated as the primarytreatment option can be formulated. Exercise has less negative side effects and can positivelytreat patients experiencing a combination of physical and mental health problems. A commonconcern is that people experiencing a period of depression will not have the desire or motivationto exercise, but compliance rates are often much better than for medication, especially if theyare receiving adequate support and encouragement.The option of green exercise therapy or green care may prove to be an even more effectivetreatment response than exercise alone as it encourages people to re-connect with nature andexperience the additional positive health benefits that are associated with this. Contact withnature and greenspace is often uplifting and restorative, helps to reduce stress and improvemood and combining this with physical activity will offer a very efficacious treatment option.Green exercise is very cost effective and participation is often free or at a minimal cost. Unlikefitness centres and gymnasiums it does not require an initial joining fee or a monthlysubscription, as you can walk around your local park or woodlands at no cost. Exercising intraditional gyms often incurs an extremely low adherence rate due in part to lycraphobia (a fearof undertaking physical activity in a commercial fitness industry setting). Outdoor exerciseprovides the opportunity to escape this setting and the additional confinements of indooractivities. Green exercise also promotes social inclusion and enables people to make healthierchoices and adopt a sustainable healthier lifestyle.However, to date, there has been little research conducted which compares green exercise withmore traditional treatment options, such as antidepressants or cognitive behaviour therapy. Weanticipate that green exercise will be equally as effective, but the robust scientific evidence tosupport this hypothesis is still lacking. For the idea to gain credibility and influence governmentpolicy and the health sector, more detailed research needs to be undertaken. Therefore, at theUniversity of Essex we have collaborated with South Essex Partnership NHS Foundation Trustto design a feasibility study which compares a green exercise programme with a series of CBTsessions as treatment options for patients suffering from mild to moderate depression. A total ofsixteen participants will be recruited to the study and eight will be randomly allocated to thegreen exercise group and the remaining eight to the CBT group. Each group programme willconsist of a two hour session, once a week for a period of six weeks and we will evaluate andcompare the effectiveness of the two different programmes. The green exercise programme willinvolve one hour of moderate walking in the local countryside and woodlands. This will be a ledwalk and a certain level of social interaction will be encouraged but monitored. The CBTprogramme will follow the traditional pattern and involve small group discussions and a mini-lecture. A series of standardised psychological instruments will be used to measure levels ofdepression, mood, self-esteem, social adaptation and general mental health. These will beadministered at regular intervals over the six week period to monitor any changes. The initialfindings from the feasibility study will be used to obtain further funding to conduct the study on alarger scale and generate a wider interest.Colleagues in Australia have also initiated some research into the participation in forest andwoodland management as a treatment for depression (Townsend, 2006). Their pilot projectengages people experiencing depression in nature-based activities in a woodland environment.The project is on-going but initial findings suggest encouraging improvements to physical andmental health, along with a reduction in social isolation. 19
    • Mind report 1.0, Feb 20073.5.3 Green care for marginalised populationsThere is also limited evidence concerning the use of green exercise therapy for populationsmost marginalised in mental health, for example, those residing in hospitals, prisons andinstitutions whereby mental ill health is problematic. Two classic studies from the 1980’s (Moore,1981; Ulrich, 1984) initiated research into the health benefits for both prisoners and hospitalpatients of windows overlooking greenspace compared to those facing brick walls. The firstfound that prisoners in Michigan whose cells overlooked farmland and trees reported 24% lesssick cell visits compared to those in cells facing the prison yard. The second was a ten yearcomparative study of post-operative patients in Pennsylvania whose rooms either overlookedtrees or a brick wall. The hospital stay for those patients with tree views was significantly less,they also required fewer painkillers and used less strong or moderate medication and nursingstaff reported fewer negative evaluation comments in the medical records.An initial study in a Swedish psychiatric hospital reported the amount of damage to paintings onwalls over a 15 year period. Damage was only ever inflicted on abstract paintings and therewere no recorded attacks on paintings depicting nature and landscapes. In a more recent studyof hospital patients, (Diette et al., 2003) demonstrated the clear value of a landscape pictureaccompanied by the sounds of nature. Prior to their operation, a group of bronchoscopy patientsoverlooked a large landscape picture present at their bedside whilst listening to sounds ofbirdsong and a babbling brook. This group’s level of good or excellent pain control was 50%higher in comparison to those without access to the picture or sounds. This simple interventionhas financial implications if it suggests that less money can be spent on pain killing drugs forpatients. These studies imply that greenspaces and nearby nature should be seen as afundamental health resource.One of the nine major reasons that cause ex-offenders to re-offend has been identified as poormental and physical health (SEU, 2002) and a significant number of prisoners in the UK sufferfrom a variety of mental health issues. “Offender and Nature” (O&N) schemes can addressseveral of the underlying factors contributing to re-offending and are another example of aninitiative to improve mental and physical health and well-being by using green exerciseactivities. O&N initiatives involve partnerships between offender-management organisations10and natural-environment organisations11.Offenders and Nature schemes involve offenders working as volunteers on nature conservationand woodland sites, carrying out tasks such as creating and maintaining footpaths, opening updense vegetation to create more diverse habitats, establishing ponds and building boardwalks.O&N schemes are seen as reparative work that benefits the public, while providing experienceof teamwork, life and skills training to offenders and also boosting their confidence and self-esteem (Carter and Hanna, 2007). Many offenders and supervisors have observed a ‘calming’and ‘focusing’ effect in volunteers. Some O&N schemes explicitly apply ‘ecotherapy’, whichuses working in natural environments to support people with mental health issues and addictionproblems, specifically drawing on the capacity of nature to calm, heal and inspire (Hall, 2004;Burls, 2005; Burls and Caan, 2005). As is the situation for many other green exercise and greencare initiatives, although there is much qualitative and anecdotal evidence supporting theseprojects, there is a lack of “hard” or quantitative data and there is a need for further evaluation ofthese schemes.10 Such as National Offender Management Service, Her Majesty’s Prison Service and National Probation Service11 For example Natural England, Forestry Commission, BTCV and National Trust 20
    • Mind report 1.0, Feb 2007Traditionally hospitals have been renowned for their surrounding beautiful gardens and array ofplants (Nightingale, 1860, 1996). Similarly, monasteries often designed intricate gardens to offera pleasant relaxing environment for the ill to visit for a respite (Gerlach-Spriggs et al., 1998).Sadly, over time, hospital funding has become more concerned with reducing the risk ofinfection and focusing on efficiency and this has been reflected in design and lack of greenery.Consequently, they have evolved into stressful establishments which do not fulfil the emotionalneeds of patients, their families and staff (Lindheim and Syme, 1983; Ulrich et al., 1991;Horsburgh, 1995). This problematic transformation needs to be addressed as research impliesthat gardens and nature in hospitals enhance mood, reduce stress and improve the overallappreciation of the health care provider and quality of care.Healing gardens are designed to aid recovery from stress and are often present in hospitals andcare homes, where stressful experiences are often encountered by patients, visitors and staff.Sempik et al. (2002) comprehensively reviews studies that analyse positive effects of thesetypes of gardens. In addition, Cooper Marcus and Barnes (1999) extensively review researchinto the positive impact of healing gardens on the patient’s health and well-being. Whitehouse etal. (2001) found that a healing garden in a children’s hospital in California had numerouspositive effects on users. 54% stated that they felt more relaxed and less stressed, 24%refreshed and rejuvenated, 18% more positive and able to cope and only 10% had experiencedno difference in mood. Nearly half of all observed visitors spent less than 5 minutes per visit inthe garden, so even vary short visits were beneficial. Visitors to the garden want to “escape thestresses of the hospital and enjoy the relaxing and restorative elements of nature”.A lot more research needs to be conducted within the area of marginalised populations,especially targeting those with mental health problems in addition to those populations inhospitals and prisons in general. However, the findings do suggest that perhaps those involvedin hospital design and planning should consider the value to patients and visitors of pleasantviews from windows, of landscape artwork in wards and of hospital gardens. The majority of theresearch has been conducted in the USA and Scandinavia, so we need to learn from this andinitiate our own research here in the UK.3.5.4 Limitations of research to datei) Type of evidenceIn the fields of Social and Therapeutic Horticulture, Green care, Care Farming and GreenExercise there are several similarities to the limitations of research to date. Although there ismuch valuable qualitative evidence describing the physical, mental and social health benefits ofexposure to exercise and nature there remains a shortage of scientifically robust, quantitativeevidence. This “hard” data is necessary to convince healthcare professionals, social careproviders and sceptics of the merit of green exercise and green care.ii) Exposure time to green exerciseThe research has also not yet fully addressed the issues of exposure time and sustainability.Research has demonstrated that short or occasional exposures to nature and physical activityare potentially highly beneficial in improving mental health and physical well-being. However, weare yet to establish whether cumulative short exposures, such as viewing nature out of awindow or taking a short walk equate to longer, less frequent exposures to nature, such as aweekend trekking in the hills (Hartig et al., 2003). We do not know if short exposures alone willlead to long-term improvements, but there is some evidence to suggest that behavioural andlifestyle changes can be provoked by such activities, leading to continuing re-exposure which 21
    • Mind report 1.0, Feb 2007would result in a healthier population. Secondly, the findings do not explore enhanced ordifferent effects of exposure to specific places for certain people because they hold memoriesand stories which are associated with them. It could be hypothesised that some environmentsmay me green and beneficial, but anonymous, whereas others may evoke pleasant memorieswhich affect the experience (Tuan, 1977; Gallagher, 1994).An important unanswered question for those concerned for sustainability is to what extent dothe benefits of such green experiences continue off-site? How long do the physical andpsychological benefits last once you return to your urbanised more stressful environment? Dothe benefits last for the day, the next day or for the next week? Does contact with natureprovoke long-term changes in thinking, which could lead to deep social and politicaltransformations?iii) Economic considerationsThe full economic benefits of promoting nature and greenspaces as a health resource are notyet fully understood. We still lack the health economic data to accurately estimate the totalsavings that a public mental health strategy could yield. A recent report written by Willis andLiesl (2005) highlighted four major gaps in the current evidence base which prevents a fulleconomic assessment of the health benefits of greenspace being evaluated. These include: 1)quantifying the value of the psychological benefits from greenspace; 2) improved evaluation ofgreen exercise activity programmes; 3) the time profile of risks when exercise is continued ordiscontinued for different age groups and 4) assessing benefits from increased physical activitybetween the sedentary populations and those participating in intermediate or frequent activity.Therefore, large scale surveys are required which relate greenspace accessibility and use toimproved health outcome measures, to enable a full economic costing to be undertaken.The Department of Health (2004) has estimated that a 10% increase in adult physical activitywould benefit the UK by £500 million per year, saving 6000 lives. The potential economic impactof emotional benefits and improved mental well-being has not yet been quantified but would beadditional to these physical health benefits, and might indeed outweigh them. If these activitiesare achieved through “green activities” that might also provoke long-term changes in attitudes tonature and the environment in both rural and urban contexts, then wider support for pro-sustainability policies is more likely to arise.Can green exercise and green care, therefore, be considered a good buy for pubic health,providing physical, social and mental health benefits? Can green exercise and green care beused in a preventative way before we become ill to safeguard our mental well-being? Can carefarming provide another option for treating mental ill-health? Could some of the annual £10billion of costs of obesity, coronary heart disease and physical inactivity be avoided? Could the£77 billion annual cost incurred in 2002-03 for mental illness be significantly reduced in thefuture?One of the central needs now is to ensure that the assessment of the value of greenspace andthe countryside includes the potential mental and physical health benefits to those both workingand visiting those areas. The NHS budget is several hundred times more than current spendingon conservation and access to greenspaces, yet spending on these will help to prevent illnessand to save the UK money. 22
    • Mind report 1.0, Feb 20074. Assessment of existing Mind green exercise activitiesThere are a wide range of very successful green exercise activities and projects already inexistence amongst Local Mind Associations (LMA’s). These activities include walking,gardening activities (especially on allotments), social and therapeutic horticulture, gardendesign, conservation activities, bush craft (exploring local woodlands and building fires etc) anddog walking.A lot of the gardening activities encourage clients to grow and learn about the plants and flowerson local allotments in the community. Many conservation groups assist garden teams working atlocal formal gardens, woodlands and the open countryside. They always employ a sociallyinclusive approach, so the activities are open to staff, service users and volunteers alike.Many of the walks take place regularly in the open countryside, at local parks or woodlands,along the beach or canalside, in all weathers. Whilst participants are walking they are oftenencouraged to engage in other activities such as bird watching, photography, admiring thewildlife and enjoying the scenery.Therefore with this in mind, we designed a universal tool which could be used to evaluate thiswide range of green exercise activities to illustrate what positive effects they were having onparticipants’ physical and mental health.A specifically designed questionnaire was sent out to all Mind members who were engaging in aselection of green exercise activities and 108 completed questionnaires were returned from 19different Mind groups (see Box 3).Box 3: Mind groups included in the assessment of green exercise activities  Birmingham  Mid-Staffordshire  Brighton  Mid-Warwickshire  Dartford, Gravesham and Swanley  Redcar and Cleveland  East Berkshire  St Helens  Great Yarmouth  Tameside and Glossop  Havering  Taunton  Hull and East Yorkshire  Thurrock  Kensington and Chelsea  Wallingford  Lewes District and Wealden  West Cornwall  Maidstone4.1 Findings - green exercise activitiesThe green exercise activities were predominantly made up of gardening projects, conservationactivities and walking groups. 52% of the respondents were engaging in gardening activities onallotments or specific projects. These activities included weeding, digging, planting, grassmowing, watering, pruning and composting. A further 7% of participants were involved inspecific conservation activities including scrub clearances and laurel thinning. 37% ofrespondents were participating in regular walks around local gardens, along the river bank or“cross country”. The remaining 3% were running in greenspaces regularly and 1% had beencycling. 23
    • Mind report 1.0, Feb 2007The duration of a typical activity session varied considerably, ranging from a minimum of 15minutes to a maximum of 6 hours. The average length of a session was 2 ¾ hours (163.2 ± 89.4minutes) and the most common session duration was 2 hours. 29% of the activities lasted over4 hours.Respondents attended Figure 6: How often respondents attend the sessions 60sessions fairly frequently, withthe majority of people engaging 50in these activities on a weeklybasis (55%). A total of 26% of 40participants attended sessionsat least twice a week or more (%) 30frequently, whereas only 6% 20engaged in the activitiesoccasionally (Figure 6). 10Respondents were asked how 0 Daily Three times Twice a Weekly Fortnightly Monthly Occasionallylong they had been attending a week weekthe green exercise activity Frequencysessions. Responses variedfrom a minimum of one monthto a maximum of 16 years. The Figure 7: How long respondents have been attending the greenaverage time was just over 2 exercise sessionsyears (25.5 ± 35.7 months); 35with the most common answer 30also being reported as 2 years. 25Figure 7 categorises theanswers into specific groups 20 (%)which highlight the percentages 15calculated for each time period. 10 54.2 Findings - peopleinvolved in the activities 0 6 months or less 6 months - 1 year 1-2 years 2-5 years Over 5 years Length of timeOut of the 108 completedquestionnaires returned, 72% ofrespondents were male and Figure 8: Age categories of the respondents28% were female. Figure 8 1%reports the percentage of 2% 15%individuals within each age 11-18 yrsband. It is clear that the most 19-30 yrscommon age group was the 31- 31-50 yrs 35%50 years, closely followed by 51-70 yrsthe 51-70 year age group. 71+ yrsTogether this made up 82% ofthe sample population, with afurther 15% aged between 19-30 years. 47% 24
    • Mind report 1.0, Feb 2007Respondents were asked to Figure 9: Key qualities that respondents gain out of participatingreflect on the qualities they in the activityhoped to get out of What they hoped to get before starting the activity (%)participating in the activities 90 What they actually get now theybefore they started engaging 80 are doing the activity (%)in them and compare these 70to the qualities they actually 60get, now they have been 50 (%) 40participating in the activities 30on a regular basis (Figure 9). 20The most popular answer 10overall was to “get out in the 0fresh air” (83%), followed by Meet new people Learn new skills Get out in the Get fitter Other“meeting new people” (76%) fresh airand “getting fitter” (69%). The Qualitiespercentage of respondentsderiving pleasure out of the 4 aspects listed increased once they were engaging in the activitiesregularly in comparison to their initial expectations.17% of respondents stated “other” hopes that they anticipated getting out of the activities,before they started participating in them. These included improving their concentration,enhancing their self-esteem, keeping them occupied, keeping them sane, building theirconfidence, keeping them motivated, building friendships and losing weight.16% of respondents listed “other” qualities that they actually got out of participating in theactivities, since engaging in them on a more regular basis. These included improving theirconfidence, helping with their depression, a sense of achievement, contributing to organicgrowing and biodiversity, immense enjoyment and fun, socialising, friendship and keeping themoccupied.Participants were also asked the question “how does taking part in these activities normallymake you feel?” 103 respondents provided comments to address this question and theiranswers were grouped into 9 key themes:Key theme Examples of comments from respondents “Socialising and talking about your problems helps me a great deal”1. Becoming part of a group – enjoyment “It gives me company which I don’t have where I live” of socialising with “Being part of a team, getting out on a nice bright day, feeling refreshed. likeminded people, Often dont feel confident to be out alone. Dont have my own garden so having company and would otherwise stay indoors” conversation and “Refreshed and feeling more like facing things. Having been with likeminded feeling refreshed. people and had company and conversation” “Like being part of the workforce in the community, feeling good” 25
    • Mind report 1.0, Feb 2007Key theme Examples of comments from respondents “Pleased and a sense of achievement that I have done a task that I have2. Sense of been asked to do and finished it” achievement – completing a task “Better about myself, feeling a sense of achievement” and achieving “Feel good about doing an activity that has definite results” something worthwhile, feeling “That I have achieved something worthwhile” useful “It makes me feel I am doing something useful”Key theme Examples of comments from respondents “Before attending Mind I only went out if I had to, I now find it less stressful”3. Feeling relaxed and less stressed “Relaxed, peace of mind” “Relaxed, more focus of mind and greater co-ordination, greater self esteem”Key theme Examples of comments from respondents “Improves my depression, helps me be more motivated and gives me4. Feeling able to deal satisfaction in doing things. Since starting the project I have been able to with problems and improve on my quality of life. Coming here has helped me overcome most of begin to cope my problems” “Happier and able to cope again” “Less depressed, revitalised and more able to cope with my issues” “It takes me out of my depression for a while and gives me something to look forward to” “It takes my mind off my worries”Key theme Examples of comments from respondents “It improves my fitness and is very beneficial for my mental and physical5. Feeling healthier and health” fitter – both physically and “Healthier, more active, fitter” psychologically “Positive and healthy” “Healthier psychologically and physically” “Much fitter and I feel especially good immediately after a session. I feel able to chat to other runners easily and feel generally less anxious” 26
    • Mind report 1.0, Feb 2007Key theme Examples of comments from respondents “It makes me feel good about myself and it improves my confidence”6. Feeling good about myself – improving “A lot happier in myself, also there is a great sense of peacefulness here and self-worth, the nature is wonderful” confidence, self- “More positive about myself, better for being with people and out in fresh air” esteem “After being out in the fresh air and doing gardening I feel better in my self - eat well and sleep well” “It gives a feeling of self worth because you have made a difference / improvement no matter how small! Slowly builds confidence which in turn has a knock on effect and improves all aspects of life”Key theme Examples of comments from respondents “Great - lifes worth living, clears the mind”7. Feeling great – more alive and confident. “Alive and confident” The word “great” “More focused, feeling confident, much happier” was used very frequently “Makes me feel good, it is good, makes you get out of the house, look forward to all the activities”Key theme Examples of comments from respondents “It makes me feel good and happy and lifts my mood”8. Feeling “happy” – this word was also “I enjoy the fresh air and conversation, it makes me happy” used very frequently “It makes me happy”Key theme Examples of comments from respondents “Its nice to get out and go for a walk, to get out of the house”9. A sense of escape – getting out of the “I love to get away from the hustle and noise of the town and out into the house and having Chase wilderness, I feel great out there” something to do “It gives me something to do during the week which makes me happy to be out socialising. I don’t tend to go out much so it gives me something to do” “Sleeping better at night, gets me out of the house, socialising better, gaining new skills, coming to the project has given me new confidence and a belief in myself” “I enjoy being in the countryside away from the stresses of the town, traffic, crowds, noise etc and the people are nice and friendly and good company”Other comments included feeling a sense of satisfaction, feeling refreshed, at peace withnature, having a new lease of life and being set free and that it was a preferred option to sittingstaring at the walls. It is clear that engaging in a range of green exercise activities generates amyriad of positive healthy feelings. 27
    • Mind report 1.0, Feb 2007Respondents were then asked how important being outside with nature was in determining howthey felt and 88.1% stated that this was very important or important. Similarly, 88.8% felt thatparticipating in some form of exercise was very important or important in influencing how theyfelt. However, the combination of exercising outside in the presence of nature (i.e. greenexercise) was even more influential, with 89.6% of respondents stating that this was veryimportant or important in determining how they felt. This supports the idea that it is thesynergistic amalgamation of the exercise in a green environment that produces added healthbenefits, rather than either one alone.The next question in the questionnaire asked respondents to identify the differences thatparticipating in these green activities made to how they felt and they were asked to distinguishbetween the mental and physical aspects. 102 comments were received concerning the mentalhealth benefits and once again familiar messages emerged. Many respondents talked about thepositive effect on their minds and how it helped them to think more clearly, provided a focus forconcentration and offered overall peace of mind. They felt less stressed, more alert and alive,happier and more relaxed.Many people stated that they felt mentally healthier and a lot more motivated and positive. Theyfelt that the activities helped to lift their depression levels and instil a feeling of calm andpeacefulness. Their overall mood improved as did their confidence levels and self-esteem andsome of the key comments are listed in Box 4.Box 4: Participants comments concerning what differences the activities made to how they feltmentally “More stable, able to think for myself more” “Less worried, co-ordination of body and mind, better sense of well being” “It stimulates the mind and gives me something to concentrate my mind on” “Memory has improved and I think clearer and more positively” “I am more alert, less stressed” “Helps me to relax and stop worrying” “More relaxed and able to sleep at night” “I always feel better - more relaxed, less tense after a good session of exercise, more able to talk to people” “Lifts depression gives me a good feeling” “They help me focus on positive things rather than negative” “Makes you want to get out of bed and I’m not as low as I have been” “It feels calm and satisfying on my allotment, I look forward to going” “Improves my mood, more self-esteem and makes me feel good about myself” “Feel more confident (alive) not looking at four walls”97 comments were received concerning the physical health benefits of engaging in greenexercise activities. Overall, respondents felt a lot healthier, more alive and refreshed. Manyspoke of the benefits to their fitness levels and how they felt stronger, less lethargic and moreenergetic. Others commented on the changes to their body profile through losing weight, easingstiffness in their joints and becoming more agile (see Box 5 for examples of typical comments). 28
    • Mind report 1.0, Feb 2007Box 5: Participants comments concerning what differences the activities made to how they feltphysically “ I feel a lot stronger and fitter” “My fitness has improved, I feel refreshed and alive” “I feel fitter for getting out more often” “Feel lifted and less lethargic” “More energetic and less lifeless” “I feel as though I can do things without being tired. I am more active, less lethargic, I want to join in things and my body is looser and more agile” “More stamina and less physically restless” “I use my hands so it helps my hands to move better as they are painful and stiff due to arthritis” “Stops the stiffness in the joints, that I get when I just sit around doing nothing” “Lost weight, more agile, helps to keep my body moving” “Becoming involved in outdoor activities, also good therapy for body and soul” “Helped me to get more active” “Makes me feel good to get my heart pumping”Finally, participants were asked to comment on what they felt was special about the activity and102 responses were received. It was clear from the collated narratives that there were 5 mainaspects which were special about the green activities. These were the: 1) Social benefits; 2)Benefits from contact with nature; 3) Benefits from the activity itself; 4) Psychological benefitsand 5) Physical benefits. These findings clearly support the green exercise model and thefollowing tables illustrate some of the key comments supporting each feature.Key feature Examples of comments from respondents “Excellent teamwork, meeting new people to make friends, we are a family1. Social benefits – and look out for each other” meeting and socialising with “I think it is because I take part with people I know well, who enjoy doing the people out in the same things and nobody judges you or criticises you” fresh air, team work, “Everyone is friendly and I feel part of something collectively positive” companionship, “I have made new friends and am able to communicate better, staff members camaraderie, being are very helpful and listen to my problems, everybody is very friendly towards part of a group me” “It gives me the opportunity to be active and social, team work, being outside with others, making friends, enjoying their company” “The chance to meet people, plus a chance to exchange news and views”N.B: 44% of respondents made comments concerning social benefits 29
    • Mind report 1.0, Feb 2007Key feature Examples of comments from respondents “Being with nature, out in the fresh air and the peace and quiet”2. Benefits of contact with nature – fresh “Because I was out in the open air and was also interested in the birds and air, wildlife, trees, wildlife” plants, scenery “Being outside hearing and seeing wildlife watching your own plants grow. It gives me a good feeling” “Freedom, space, no one to judge you, view the scenes, keep fit, breathe in the fresh air. I love being in natures garden, thats how I see it” “You see lots of wildlife, get a feeling of space and tranquillity and see places I wouldnt normally see if travelling by car” “A closeness to nature is the most special feeling and it gives you acceptance of yourself”N.B: 21% of respondents made comments concerning social benefitsKey feature Examples of comments from respondents “The activity is good to look back at when completed. We have all worked3. Benefits of the very hard on our allotment, the results have been very rewarding activity itself - “It gets people out into a different environment other than what they would growing vegetables, usually do” learning new skills, new experiences “Learning new skills, growing vegetables from seed that you can eat” “Gardening is very therapeutic because it is stress free, outdoors, physical and you can see what you love achieved at the end” “Its fun, it costs nothing, no special equipment and the views are stunning”N.B: 17% of respondents made comments concerning social benefitsKey feature Examples of comments from respondents “Open air activity is good for my mental health. My confidence has improved.4. Psychological Also meeting others who have similar mental health problems helps” benefits – therapeutic, calming, “Takes my mind of the depression” sense of “Its therapeutic and calms me” achievement “It is special because it gives you a sense of achievement in all the jobs you do on the farm”N.B: 10% of respondents made comments concerning social benefitsKey feature Examples of comments from respondents “Keeps you active and mobile”5. Physical benefits “Being close to nature and doing physical activities” “Its easy physically but all counts helping towards my fitness for the future” “The exercise with nature”N.B: 8% of respondents made comments concerning social benefits 30
    • Mind report 1.0, Feb 2007The findings from this assessment clearly show that participating in a range of green exerciseactivities provides substantial social, health and well-being benefits. The contact with nature andgreenspace is a necessity in enriching the experience and creates a restorative environmentwhich people can seek pleasure in escaping to. A lot of enjoyment is derived from getting outinto the fresh air, admiring the scenery and taking pleasure in the wildlife, plants and trees (Box6).Participating in these activities is often perceived as therapeutic and engenders feelings ofrelaxation and peacefulness. The whole process is very calming; it reduces stress levels andencourages people to feel good about themselves by improving their self-worth, confidence andself-esteem. It inspires people to embrace their problems and start to deal with them and learnhow to cope. Participants feel healthier and fitter, more alive, refreshed and a lot happier. Thereis a great sense of achievement when an activity is completed, as participants feel they haveachieved something worthwhile and therefore feel useful.Engaging in green activities in groups also inspires new friendships to develop and enhancessocial capital, which supplements the range of health benefits experienced. Participants enjoybecoming part of a group, socialising with likeminded people and having companionship,camaraderie and conversation. Therefore, meeting and socialising with people out in the freshair is a key ingredient in the activities success.Box 6: Comments from a participant engaging in gardening activities at a local allotment A woman aged between 51 and 70 years has been working on a local allotment regularly for the past 11 years. She attends the sessions most weeks and typically spends around 6 hours on the allotment per session. Before she started helping out at the allotment she hoped that this would provide her with an opportunity to learn some new skills and get out in the fresh air. Since she has been attending regular sessions, she finds that not only does she learn new skills and get out in the fresh air, but she’s also enhanced her fitness, met new people and contributed to organic growing and biodiversity. “I enjoy gardening, seeing things grow and then picking, cooking and eating them and I feel a sense of achievement. Im interested in learning about gardening and about nature conservation and I love watching wildlife, birds etc. If I arrive at the allotments feeling low or preoccupied I feel my mood lift and I find a sense of well-being” “I have been interested in "green" activities all my life - gardening, walking, conservation, being close to nature, but the "extra" benefit of this is the sense of sharing and co-operating with other people. Also our allotment site is very beautiful and peaceful so I feel in harmony with the world there” “I enjoy the physical movement and effort and I appreciate the experience of all my senses - sight, sound, smell, taste and touch and I like working with the earth” “Its very creative - especially so since our allotment leader is not only a great gardener but also an artist so as well as producing great fresh food through working physically in the open air were also involved in making a beautiful place. Some would say a place of healing too, and everyone is kind and supportive of one another” 31
    • Mind report 1.0, Feb 20075. A study to compare a green outdoor walk and an indoor walk5.1 Backgound and methodologyAnother major gap in the evidence base is the comparison of indoor exercise to equivalentoutdoor green exercise activities. This would enable us to identify what extra health benefits arederived from the contribution of the green elements. When comparing innovative outdoorvoluntary activities, such as the green gyms to indoor sports, the adherence rates are a lot moresuccessful in the long term. Nearly half of the participants of indoor sports drop out within thefirst six months, whereas walking outside seems to be the most preferred form of exercise tomaintain adherence (Hilldsdon and Thorogood, 1996). Research analysing joggers alsoreported that running in a stimulating green environment detracted the mind from the physicaldiscomfort of exertion and fatigue. This enabled participants to continue jogging for longerperiods of time (Pennebaker and Lightner, 1980). However, there is a shortage of compellingevidence in this area, especially in the UK.To date the University of Essex has been involved in a series of studies and researchprogrammes that have analysed the physical and mental health benefits of participating in greenexercise activities. However, a key question which is yet to be addressed is: how does greenexercise compare to exercising indoors? If the type, intensity and duration of the exerciseremains the same, but it is conducted in two very distinct environments (indoors, with no greennatural elements and outdoors in a natural green space), we would be able to establish whatadditional benefits the “green” engenders. Therefore Mind approached the University of Essexfor advice and guidance to enable them to undertake some innovative research. This researchinvolved local Mind group members engaging in a green outdoor walk and a comparable indoorwalk and results were analysed by the University of Essex. This short study addressed theresearch question: “Will exercising outdoors in a green environment significantly improveparticipant’s mental health and well-being (using standardised and well-recognised mood andself-esteem measures) compared to the equivalent exercise indoors?”The locations for the indoor and outdoor walks were initially identified and then the walks tookplace in early January 2007. They occurred one week apart, at a similar time of day and bothlasted for an hour. Mini-buses were used to transport participants to the locations. The outdoorgreen exercise walk involved walking around Belhus Woods Country Park, which has a diverselandscape of woodlands, grasslands and lakes12. In contrast the indoor walk involved walkingaround Lakeside shopping centre. In both conditions continuous walking was preferred,although participants were allowed to stop briefly to admire the scenery or shop windows and acertain level of social interaction was also encouraged.Both of the group walks were led by the same Mind organiser and they were equivalent induration and intensity. The same leader was present at both walks to ensure consistency ofpersonality. The study was a repeated measures design, as the same group of subjectsparticipated in both walks to eliminate their diverse health states as confounding variables. 20members of various local LMA groups volunteered to take part in the research and they allattended both of the organised trips.12 Belhus Woods Country Park -http://www.essexcc.gov.uk/vip8/ecc/ECCWebsite/dis/guc.jsp?channelOid=14413&guideOid=16906&guideContentOid=14412 32
    • Mind report 1.0, Feb 2007A mixed method design incorporating both quantitative data and qualitative narrative wasutilised to collect data using a composite questionnaire. The questionnaires were administeredimmediately before and immediately after both of the walks to allow direct comparisons to bemade and to identify any changes in health parameters as a direct result of exposure to theenvironment. The questionnaires included standardised tools which measured participants’levels of self-esteem and mood and other qualitative questions were asked to allow us tocapture some detailed narrative. Participants were asked to complete the questionnairesindividually and not to compare or discuss their answers. Questions were answered accordingto how the participant felt at that particular moment in time.The standardised tools incorporated in order to determine any changes in psychological statesderived from the walks, measured self-esteem and mood. Self-esteem was measured beforeand after the walks using the one-page Rosenberg Self–Esteem Scale (RSE) (Rosenberg,1989), which is a widely used measure of self-esteem in health psychology. Mood change wasmeasured before and after the walks using the (McNair et al., 1984) Profile of Mood Statequestionnaire (POMS). This is a short form one-page version of the POMS test which has abackground of successful use for mood change post-exercise. The POMS subscales measuredwere anger, confusion, depression, fatigue, tension and vigour. In addition, a Total MoodDisturbance (TMD) score was calculated to denote an overall assessment of emotional state.This method is regularly used as it provides an indicator of overall mood. It involved summingthe POMS subscale T-scores of anger, confusion, depression, fatigue and tension and thensubtracting the T-score for vigour (McNair et al. 1992, p.6).Photographs from the green outdoor walk at Belhus Woods Country Park 33
    • Mind report 1.0, Feb 2007Photographs from the indoor walk at Lakeside shopping centre 34
    • Mind report 1.0, Feb 20075.2 ResultsA total of 20 participants took part in both walks, of which 7 (35%) were male and 13 (65%)were female. 47% of the participants were aged between 31-50 years and the remaining 53%were aged between 51-70 years.Initially, a paired samples t-test was conducted to identify if there were any significantdifferences in the participants’ preliminary mood and self-esteem scores between the two walks.This did not reveal any significant findings, indicating that prior to both the walks participants’levels of self-esteem and mood were comparable.Secondly, paired samples t-tests were conducted to identify any significant changes in startingself-esteem and mood levels and those reported after each walk. Each walk was initiallyanalysed separately to distinguish any differences between the two walks.i) Outdoor Walk Figure 10: The change in self-esteem following participation in the green outdoor walkFigure 10 highlights the 19statistically significantimprovement in self-esteemfrom 21.3 to 19.0 (p<0.01)(Note - the lower the value, the Index of self-esteem 20higher the self-esteem). Scoresranged from a high of 12 to a Represents a significant increase in self-esteem oflow of 37 prior to the walk. After 2.31 (p< 0.01)the green outdoor walk, they 21ranged from the highestpossible self-esteem score of10 to a low of 35. 22 Before AfterThe change in the six subscalemood factors were alsoanalysed following participation Figure 11: The change in the subscale mood measurementsin the green outdoor walk. following participation in the green outdoor walk 44 BeforeFigure 11 illustrates the Significance tested with 1- 43 Aftersignificant reductions in feelings tailed t test (* p<0.05; ** 42 p<0.01; *** p<0.0005)of anger (from 42.6 to 39.2, 41p<0.05); confusion (from 39.5 Index of mood 40to 36.5, p<0.01); depression 39(from 42.1 to 39.4, p< 0.01); 38fatigue (from 43.4 to 37.1, p<0.0005) and tension (from 39.5 37to 34.4, p<0.01), so participants 36were feeling less angry, 35confused, depressed and tense 34 Anger * Confusion ** Depression ** Fatigue *** Tension ** Vigourafter the outdoor walk. Feelings Mood factorof vigour increased from 40.7 to42.1, so even though they hadbeen walking for an hour, participants felt less fatigued and more active and energetic. 35
    • Mind report 1.0, Feb 2007Therefore, Figure 12 shows thatthe total mood disturbance (TMD) Figure 12: The change in total mood disturbance (TMD) followingsignificantly improved after participation in the green outdoor walkparticipating in the outdoors green 140walk from 166.4 to 144.4 (p<0.01) 145(Note – the lower the score, thebetter the overall mood). 150 Index of TMD Represents a significantii) Indoor walk 155 improvement in total mood disturbance of 21.9 (p< 0.01)Figure 13 highlights the non 160significant decrease in self- 165esteem from 21.0 to 21.8 (Note -the lower the value, the higher the 170self-esteem). Scores ranged from Before Afterthe highest possible self-esteemscore of 10 to the lowest possiblescore of 40, both before and afterthe indoor walk. Figure 13: The change in self-esteem following participation in the indoor walkThe change in the six subscalemood factors were also analysed 20following participation in theindoor walk. Figure 14 illustratesthe only mood factor to be Index of self-esteemsignificantly reduced, which wasfatigue (from 42.3 to 39.0, 21p<0.05). Feelings of angerreduced slightly (from 41.6 to41.1) and depression levels alsoreduced slightly (from 41.3 to40.8, p<0.01). However, in 22contrast to the green outdoor Before Afterwalk, feelings of tension slightlyincreased (from 37.2 to 37.7) andconfusion levels also slightly Figure 14: The change in the subscale mood measurements followingincreased (from 39.2 to 39.5). participation in the indoor walkFeelings of vigour decreased from 4341.7 to 38.7, so after this walk, 42 Significance tested with Before 1-tailed t test (* p<0.05;participants were feeling less 41 ** p<0.01; *** p<0.0005) Afteractive and energetic and more 40 Index of moodtense and confused. 39Therefore, Figure 15 shows that 38the total mood disturbance (TMD) 37hardly changed after participating 36in the indoor walk from 159.9 to 35159.4 (p<0.01) (Note – the lower 34the score, the better the overall Anger Confusion Depression Fatigue * Tension Vigourmood). Mood factor 36
    • Mind report 1.0, Feb 2007Finally, we used a mixed between- Figure 15: The change in total mood disturbance (TMD) followingwithin ANOVA test to compare the participation in the indoor walkchange in self-esteem and mood 140levels between the two walks. Thiswould enable us to establish and 145confirm which walk was having the Represents a non 150 significant improvement inmost beneficial effect on their Index of TMD total mood disturbance ofpsychological health status. 155 0.5Figure 16 shows the changes in 160self-esteem after both walks, withstarting self-esteem scores 165averaged for both conditions. This 170graph illustrates the positive Before Afterimprovement in self-esteemfollowing the green outdoor walkand the negative effect after theindoor walk. Therefore, there was a Figure 16: The change in self-esteem following participation in the walksstatistically significant difference 18between the 2 groups (F= 6.3;p<0.05). Green outdoor walk 19Figures 17 to 22 illustrate the Index of self-esteemchanges in the six subscale moodfactors after both of the walks. Once 20again starting mood scores havebeen averaged for both conditions,to allow direct comparisons to be 21made. There was a statisticallysignificant difference between the 2 Type of walkgroups for anger (F= 4.2; p<0.05); 22 Indoor walkconfusion (F= 5.8; p<0.05);depression (F= 4.7; p<0.05) andtension (F= 8.0; p<0.01). There were no significant differences between the groups in feelings offatigue or vigour. Figure 17: The change in feelings of anger following participation Figure 18: The change in feelings of confusion following in the walks participation in the walks 40 43 Indoor walk 42 39 Index of confusion Indoor walk Index of anger 41 38 40 37 39 Green outdoor walk Type of walk Green outdoor walk 38 36 Type of walk 37
    • Mind report 1.0, Feb 2007 Figure 19: The change in feelings of depression following Figure 20: The change in feelings of fatigue following participation in the walks participation in the walks 42 44 43 41 Indoor walk 42 Index of depression Index of fatigue 41 40 40 39 Indoor walk 39 38 Green outdoor walk 37 Type of walk Green outdoor walk 38 Type of walk 36 Figure 21: The change in feelings of tension following Figure 22: The change in feelings of vigour following participation participation in the walks in the walks Indoor walk 43 39 Green outdoor walk 38 42 37 Index of vigour Index of tension 41 36 40 35 39 34 33 Type of walk Green outdoor walk Indoor walk Type of walk 38Therefore, when combining all of Figure 23: The change in feelings of total mood disturbancethe six subscale mood factors to following participation in the walks 140calculate the change in TMD Green outdoor walk(Figure 23), there was a significantdifference between the 2 groups Index of total mood disturbance 145(F=8.6, p<0.01) (Note – the lowerthe score, the better the overall 150mood). 155The findings clearly show thatexercising outdoors in a greenenvironment is a lot more effective 160 Indoor walkin enhancing your mood andimproving your self-esteem 165 Type of walkcompared to the equivalent amountof exercise indoors. Participating ina green outdoor walk can significantly reduce feelings of anger, depression, tension and fatigue,whilst also making you feel more active and energetic, so it offers an ideal way of getting rid ofthose blues. 38
    • Mind report 1.0, Feb 2007In addition to analysing changes in Figure 24: How much enjoyment participants derived frompsychological health states, we various aspects of the walks Green outdoor walkalso asked participants to use an 5.0 Indoor walkenjoyment scale to rate how much 4.5enjoyment they got out of various 4.0aspects of the walks. The short Index of enjoyment 3.5scale ranged from “did not enjoy at 3.0all” (1) to “enjoyed a lot” (5) and the 2.5mean answers are displayed in 2.0 1.5Figure 24. It is clear that 1.0participants enjoyed the scenery 0.5and the exercise more in the green 0.0outdoor walk. They also enjoyed The scenery Being with other The exercise Being outside / Doing somethingbeing in the company of other people shops differentpeople and doing something Featuredifferent more in the greenenvironment. Spending time outside in the fresh air was more enjoyable than walking aroundthe indoor shopping centre.Participants were also asked to comment on what they thought was special about both of thewalks (Box 7).Box 7: What did you feel was special about the walk? Comments from participantsGreen outdoor walk (12 comments received out of the 20 completed questionnaires)“It makes you feel good in the fresh air, looking at the water makes you feel relaxed. Joining in withother people. I like walking in the countryside”“Apart from meeting other Mind members, it was extremely good to take part and involve mymembers”“Good exercise and meeting up with other groups”“Very good exercise”“All different Mind groups getting together”“Meeting others, visiting different places, fresh air, exercise and talking to others”“Getting close to gods beautiful creation”“Scenery”“Made me forget how down I felt, whilst on the walk”“Being able to do something different”“Getting out of doors”“Meeting others in similar circumstances, fresh air, nice views, other peoples company”Indoor walk (11 comments received out of the 20 completed questionnaires)“It was not as good as the open air”“It is a good exercise and walking with other people makes you feel better in yourself”“Enjoyed being with people and getting to know other people from Mind groups”“Very good exercise and meeting other people”“Meeting with other Minds”“Very worthwhile”“Did see this as exercise”“It was better than being outside”“If it helps others its all worth it”“Great but on benefits so cannot enjoy fully the experience”“Being part of a group that seeks to counter problems engendered by mental health, the exercise” 39
    • Mind report 1.0, Feb 2007The comments were very focused on the enjoyment derived from spending time with otherpeople, especially during the indoor walk. However, narrative relating to the green outdoor walkdid mention the enjoyment gained from getting out into the fresh air, the scenery andparticipating in the exercise itself.A selection of participants provided reflective comments of their experiences a couple of weeksafter participating in both of the walks (Box 8). Many participants felt that the positive benefitsgained from taking part in the green outdoor walk lasted for a few days and in some cases wereespecially apparent the following morning.Box 8: Reflective comments received from participants a couple of weeks after the walks “I had my first nights sleep for a long time without sleeping tablets after the green outdoor walk. Also I made a call to a family member on return home from the woods, which I had been putting off as perhaps I was not in the right place” “Felt relaxed with nature, one to one with the creator, lifts your spirits and depression” “The outdoor walk was very nice and made me feel very uplifted and happy” “I enjoyed the walk and the scenery very much. It was nice to be with other people, it made me feel good to be out in the fresh air. It was lovely to breathe in your lungs. It was very good exercise and makes you feel good” “It was nice to browse around the shops with other people as it’s nice to do things together. I enjoyed the walk but preferred the walk outside, it made you feel great and like you had achieved something worthwhile” “It was very nice to have walked around with other people and been with other people. It was a cold day and very muddy but very good”The results from this small study support previous green exercise research findings reported bythe University of Essex, which refer to significant improvements in self-esteem, total mooddisturbance and enhanced social capital. Although there was no control condition to comparethe findings to (e.g. what activities members usually engage in, such as meeting for a coffee, artclasses etc), the significant findings generate some thought provoking questions.Participating in the green outdoor walk was a lot more effective in reducing feelings of anger,depression, tension and confusion, in comparison to the indoor walk. It also increased feelingsof vigour and left participants feeling more active and energetic. The enjoyment of engaging ingreen exercise activities in groups is a valuable part of the experience, as well as theopportunity to breathe in fresh air, admire the scenery and enjoy the wildlife. Therefore,exercising outdoors within a green environment has to be a preferred option to engaging incomparable exercise indoors. The findings add significant value to the ever expanding greenexercise research programme as it focuses on individuals experiencing mental health issuesand separates the elements that constitute the green exercise experience. 40
    • Mind report 1.0, Feb 20076. Conclusions and recommendations6.1 Issues affecting progress of research6.1.1 Ethical issuesMost evaluation work is considered as a type of research and in many settings this brings up theissue of ethics. Ethical dimensions should therefore be taken into account when consideringresearch into green care or green exercise especially if people with special needs or fromvulnerable groups are involved. Interviewing or surveying both members of the public andprofessionals, in terms of the right to privacy and protection from physical or emotional harmmust also be considered. For example, when dealing with children, the issue of parentalconsent should be thought of, informed consent is also necessary for adults and involvementwith GP referred patients may produce confidentiality issues.In healthcare settings in the UK, research is likely to be within the remit of NHS Research EthicsCommittees, and possibly NHS Trust Research and Development committees. Even if there areno formal healthcare links with the project, evaluation work may still fall under the remit of LocalAuthority or University ethical regulations. Although undeniably necessary, the extensive ethicalapplication procedures in the UK, often take several months before research can begin, thuscan limit the progress of the research and can make applying for ethical approval a very time-consuming and administrative chore.6.1.2 Evaluation IssuesThe evaluation of both green care and green exercise projects aimed at increasing participationin nature-based exercise in both rural and urban areas presents many interesting challenges. 1. the variety of projects and initiatives incorporated within the “green exercise” or “green care” definition 2. the complexity of relationships with different dimensions of health 3. the production of evidence of the effectiveness of health-related activitiesIn the field of healthcare evaluation, the robustness and effectiveness of evidence is traditionallyassessed using an idea of a ‘hierarchy of evidence’. In the traditional hierarchy, particularelements of evaluation design are seen as indispensable if the ‘scientific’ nature of evidence isto be preserved. Foremost among these are:-  the application of a comparative method including a ‘control’ sample  the use of randomness as a principle in the construction of samples  the use of ‘blinding’ (research participants and researchers are uncertain of which individuals have received an intervention and which a dummy or placebo)  the use of replicable methodology and standardised, validated instruments for the measurement of health gain and other outcomesBecause of the above, the ‘double-blind randomised control trial’ (RCT) is seen as the ‘goldstandard’ in effectiveness methodology. However, evaluation of green care and green exerciseinterventions may find it difficult to live up to this standard, as they, by their very nature, 41
    • Mind report 1.0, Feb 2007preclude the use of one (or several) desirable methodological elements. The main reasons forthis are:-  Green exercise does not involve the application of a discrete or defined ‘treatment’ such as a medicine  Green exercise is not applied to an identifiable population of ‘patients’ (therefore randomised samples of ‘treated’ and ‘untreated’ patients are not identifiable)  Green exercise is not amenable to placebo (e.g. it is not possible to design an activity that is just like a country walk, but isn’t a country walk at all.)  Green exercise activities can not be blinded as it would not be possible for a patient to be honestly unsure whether they had been on a country walk or not.  The outcomes being looked for are not discrete or easily measurable (e.g. feelings of improved general wellbeing, augmented social capital, “healthy communities”)Given that schemes promoting ‘green exercise’ are characterised by all of the above, we cansee that the ‘gold standard’ of a blinded and randomised control trial is not necessarily anappropriate (or even possible) choice. Researchers at Loughborough University are currentlyembarking on a feasibility study of a RCT approach in Social and Therapeutic Horticulture toexamine these very issues.Evaluation methodologies must therefore try to use as many elements of classic randomisedtrials as they can. They could also be specifically designed to include qualitative elements inaddition to quantitative elements, such as asking participants and users to reflect on theirexperiences of involvement with schemes, in their own words. This type of work does not figureat all in traditional approaches to proving effectiveness, but, in terms of attempting to illustratethe kinds of impacts that ‘green exercise’ schemes can have on the lives of participants, the useof qualitative methods is clearly one appropriate path to follow.6.2 Key issues for policyGreen Exercise and Green Care have important policy implications for a wide range of sectors.It is clear that a large number of people already use the countryside and urban greenspaces,from which they derive a health benefit, however, physical and mental health problems are onthe increase and many people do not access greenspaces at all. Exposure both to nature andgreen space and to physical activity should be a central part of the policies and strategies of alarge number of organisations.It seems evident then that promoting participation in both green exercise activities and greencare has important implications for public and environmental health. Therefore, increasingsupport for and access to a wide range of green exercise and green care activities for all sectorsof society should produce substantial economic and public health benefits as well as reducingindividual human suffering. However, for this promotion to be successful, we firstly need todiscuss and address some of the key issues that will be raised.6.2.1 Amount of greenspaceWe need both more quality greenspaces, (especially in very urbanised areas), and to activelyprotect and conserve existing green spaces in both rural and urban locations alike. There 42
    • Mind report 1.0, Feb 2007seems to be a distinct incongruity between the positive conclusions of green exercise reportedin this research document and the existing drivers of economic development in both rural andurban regions. In the regeneration of urban areas, green spaces are often removed to keepdown maintenance costs, and there is often a perception that well-vegetated places offer moreopportunities for criminals and drug-dealers to hide. In rural areas, modern agriculturaldevelopment and the need for new housing continue to put pressure on greenspaces wherepeople can enjoy green exercise opportunities.6.2.2 Accessibility issuesWe need to encourage access and recreation providers to ensure that more people have easyaccess to green areas within a short distance from their home. The availability of accessiblegreen space close to home is a well-known factor in levels of exercise participation, andparticularly if these areas are located within a few hundred metres or a 5 minute walk fromhome.The extensive amount of accessible green space already available to the public constitutes avery significant health resource for the country (the Natural Health Service), but at present toofew people make use of these opportunities, and those that do tend to be from only certainsocial groups. Groups with low participation rates in countryside recreation as a whole areyoung people; low-income groups; ethnic minorities and disabled people. We have also shownthat people suffering from mental ill-health particularly receive physical, mental and social healthbenefits from participating in green exercise activities.Given that many people who suffer from depression and stress can reap great benefits fromparticipating in green exercise activities, it would be interesting to map the areas of accessiblegreenspaces in the UK with the areas of highest mental health vulnerability to see if there is apositive correlation. People who are most disconnected from nature may be those who sufferthe most. The availability of accessible nearby nature as greenspaces in urban areas orcountryside in rural areas, has the potential to make us feel better or to make us feeldisconnected and so it can be argued that contact with nature is crucial to safeguarding themental health of the nation.Perhaps therefore, countryside agencies and greenspace managers should ensure that i)services at urban parks, country parks, recreation areas and other greenspaces are focused onencouraging socially-excluded groups and people with mental health concerns to access natureand ii) greenspaces are accessible to all in practice as well as in theory.6.2.3 Barriers to participationIf green exercise can have such a positive effect on health, why are more people not regularlytaking exercise and visiting green spaces? Firstly, it is apparent from current participation ratesthat a large proportion of the UK population already engages in various forms of green exercise.Thus, there is already a health dividend being experienced. On the other hand, recent dataindicates that another substantial proportion of the population is in danger of becoming obeseand too sedentary. It is clear that there are barriers to participation, which are affecting differentgroups of people in different ways (Table 3). How, then, can environmental and health policysectors overcome the challenge of finding ways to remove these barriers to participation? 43
    • Mind report 1.0, Feb 2007Table 3: Current potential barriers to participation in green exercise activitiesPotential Barriers Reasons Many people assume that in order to have any benefit to health, walks need to beTime available for at least an hour and because of this many people feel that they then cannot spare this much time to walk. Many people find it difficult to get the motivation to do any type of exercise and thisLack of motivation is accentuated even more for people suffering from mental ill health. They often state that they are too tired from a long day’s work. Public spaces are sometimes seen as ‘risky’ and associated with crime. The fear from personal attack, angry farmers, farm animals or fear of having a medicalPerceptions of emergency may affect people’s willingness and ability to make the most of thesepersonal safety natural places. The absence of safe pavements and walking and cycling paths is also a concern. Some groups of adults and children are not independently mobile and can’t get toLack of transport these places or there may be a lack of public transport which limits travellingoptions options. If there are busy roads to cross this often acts as a challenging obstacle. Many people do not know where footpaths start, finish or how to get to them. LocalLocation of rights Authorities and land managers should place a higher emphasis on rights of wayof way signage and maintenance to encourage access. A lack of knowledge about the terrain of an area can also act as a barrier to participation, if there is no information available on the type of surface, severity ofTerrain hills, maintenance standards of paths and hedges and potential obstacles. This is doubly worrying for those people suffering from joint and balance problems or those with generally low levels of fitness. A lack of information about facilities, such as toilets, that may available en routeFacilities may also act as a deterrent. Some people need a reason to go for a walk. These reasons include: walking withPurpose a pushchair, walking the dog, or social reasons such as meeting people or family time.6.2.4 Acceptance from healthcare and social service providersThe health sector needs to consider the contribution that green exercise makes to bothindividual health and public well-being. After all, a fitter, happier population has the potential tosave money for the National Health Service. Any forthcoming Physical Activity Plans shouldemphasise the value of nature and green space for formal and informal use, and also stress thetherapeutic value of the outdoors (both rural and urban) for delivering mental well-being.Health professionals at Primary Care Trust level, including GPs, should work closely with othersectors to link health and the environment more closely. Environmental, countryside, sports andplanning professionals and green care practitioners can all be involved in affecting the mentalhealth of local communities in partnership with PCTs. Exercise prescription should be increasedto encourage those with sedentary lifestyles and weight problems to become aware of thepersonal health benefits. A recommendation to take part in existing local “walking for health”schemes or other green exercise activities is a relatively cheap and effective way for primaryhealth care practitioners to encourage people to become more active.There is a lack of knowledge and acceptance of the benefits to be gained from using exercisereferral in treating depression among GPs, and providers of health and social care need to beencouraged to take the idea of “green care” more seriously. GP’s should be encouraged toconsider and recognise the value of “green prescriptions”. 44
    • Mind report 1.0, Feb 2007It is also important that the general public is made aware of the benefits of contact with nature.Those people who already appreciate the positive effect of a walk in the park or a stroll on thebeach for example would readily agree that nature is good for you, but people who aredisconnected from nature may not have had the chance ever to feel such benefits. A majorproblem in encouraging more “green prescriptions” is to overcome the patient’s perception ofwhether green exercise is as an effective treatment response. Sometimes, patientssubconsciously believe that taking a pill will automatically make them feel better, whereasleaving their doctor’s surgery with a recommendation to engage in regular outdoor walks maynot be deemed as effective or even a satisfactory treatment.Agencies responsible for providing social care services would also benefit from recognising thepotential of green care and green exercise activities to increasing the health and mental well-being of patients and clients. In the same way, the prison service, once well-renowned forrecognising the benefits to inmates of working on a prison farm or garden, should look intoincreasing this potential for a happier, calmer and more socially adjusted prison population.Probation services in some areas of the UK are already recognising the potential in CareFarming and horticultural projects to provide natural, green environments to deliver both mentalhealth and employment dividends to ex-offenders. In times with increasing prison populations, aprevalence of prisoners with mental health problems and concerns over the effectiveness ofcurrent probation services, there is great potential for green exercise activities and green care tobe used as an additional option in the rehabilitation of offenders into society.6.2.5 Working in partnershipGreen exercise has implications for many sectors, suggesting the need for cross-disciplinaryand sectoral strategies and action. The majority of countryside visits are informal, and so weshould consider how better to market the countryside as a health resource to a wide range ofsocial groups and encourage land managers, countryside agencies and farmers to advertise thehealth implications of their resources.Health agencies should advertise the mental health benefits of physical activities in rural andurban green spaces and the private sector, particularly the food manufacture and retail industry,could be engaged in partnerships for provision of both healthy food and healthy places wherethe food is raised and grown.All public and private agencies should consider the value to the mental health and well-being ofemployees and customers of a pleasant outdoor landscape, water, indoor vegetation and freshflowers, nature posters and paintings, which all can be readily incorporated into the localphysical environment with minimal expense.Often research institutions face problems in accessing people to engage in their research whichis vital in developing the evidence base. Therefore encouraging academic institutions, the healthsector and pubic and private companies to work in partnership will be a positive step forwards. 45
    • Mind report 1.0, Feb 20076.1.6 The need for further researchThere is a need for funding of further robust scientific research to be conducted and in particularwe need to understand more about the financial savings and economic costings of increasingparticipation in green exercise activities. A recent report highlighted the major gaps in theevidence base which prevents us placing a monetary value on the impact of green exercise(Willis and Liesl, 2005). Leading on from this, three proposals for further research wereidentified: 1) Valuing the provision of greenspace for health: The factors that would encourage sedentary and obese people to engage in physical activity in green spaces need to be assessed. 2) Estimating the health benefits from the supply of greenspace relative to where people live: Assess the possibility of using National Health Survey data to estimate the contribution of greenspace to mental health, quality of life and physical activity levels. 3) Enhanced monitoring and evaluation of green exercise and green care activity programmes: Demonstrate improved monitoring and evaluation methods for green exercise and green care programmes by assessing changes in physical activity behaviour, health outcomes and economic measures.Once again, this highlights the need for collaboration between academic research institutionsand health and social care professionals. A universal, standardised tool could be developed toimprove monitoring and evaluation methods for a range of green exercise activities, and allowcomparisons to be made. 46
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