Gunnar Gunnarsson Master thesis, Friluftsliv And Health

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Gunnar Gunnarsson Master thesis, Friluftsliv And Health

  1. 1. What is the potential of Norwegian Outdoor Life Tradition (Friluftsliv) in the Maintenance phase (III phase) of Cardiac Rehabilitation? A literature review with emphasize on selected theories and empirical studies. Supervisor: Prof. Yngvar Ommundsen Norwegian School of Sport Sciences Gunnar Gunnarsson European Master in Health and Physical Activity Norwegian School of Sport Sciences 2008
  2. 2. 2 ABSTRACT: Background: In Norway, as in the rest of the world there is a high prevalence of cardiovascular diseases (CVD). The main risk group of CVD is elderly people, and their proportion in the society is growing. Due to increased knowledge and new technology, there is an increasing survival rate after cardiac events, creating a growing need for Cardiac Rehabilitation. However, due to economical and organizational reasons, the rehabilitation period at hospital and rehabilitation clinics is shortening. This diminishes the chances that patients adapt to a new lifestyle during rehabilitation, and they are therefore in danger of abandoning the active lifestyle when returning back to their home. Norway has a tradition for outdoor life, called “Friluftsliv”, which is highly valued and is a popular form of recreational activity. Friluftsliv (Norwegian outdoor life tradition) consists of dwelling and being physical active in natural environment. Friluftsliv has developed through the years in a blend with the Norwegian culture and identity. Together with its pedagogic and mentoring tradition, Friluftsliv seem to represent an interesting context of experience and activity in terms of cardiac rehabilitation. Aim: The main aim of this literature review is to examine the health effects of participating in Friluftsliv. To this end I search out for the health potential of Friluftsliv for patients who return back home from rehabilitation clinics, e.g. during the Maintenance phase of Cardiac Rehabilitation in Norway.
  3. 3. 3 Method: There is a lack of studies in Friluftsliv focusing on the health effects. Hence, it was necessary to also build upon relevant literature from the fields of Physical Activity and Health in general, and upon Agriculture and Landscape Architecture (“Nature and Health”), when examine the health potential of Friluftsliv. The literature review is focused on published evidence based research identified in PubMed and Cochrane, plus publications and reports from The Swedish Agricultural University, and from the European Cooperation in the field of Scientific and Technical Research (COST). Conclusion: Friluftsliv seems able to not only support involved patients’ physical and psychological development, but also their social development. With its own tradition of pedagogy, mentoring and its cultural heritage, Friluftsliv can be a good alternative in Cardiac Rehabilitation in Norway. Theoretical and empirical insight from the fields of Physical Activity and Health and from “Nature and Health” adds validity to this conclusion. Keywords: Friluftsliv, outdoor life, leisure time activities, outdoor recreation, cardiac rehabilitation, occupational therapy, horticulture therapy, Ecopsychology, public health intervention, community-based rehabilitation.
  4. 4. 4 TABLE OF CONTENTS: 1 INTRODUCTION: ................................................................................7 2 THEORETICAL AND EMPIRIC BACKGROUND ......................... 10 2:1 CARDIOVASCULAR DISEASES:........................................................... 10 2:1:1 Mental health: .......................................................................... 13 2:1:2 Cardiac Rehabilitation: ............................................................. 14 2:1:3 Cardiac Rehabilitation and Physical activity: ............................ 14 2:1:3:1 Development of Cardiac Rehabilitation: ............................ 17 2:1:3:2 Rehabilitation duration and adherence: .............................. 18 2:1:3:3 Social support and community settings: ............................. 20 2:2 NORWEGIAN OUTDOOR LIFE TRADITION (FRILUFTSLIV): .................. 21 2:2:1 Development of Friluftsliv and its role in personal and social development...................................................................................... 23 2:2:2 Friluftsliv – instrumental approach: .......................................... 25 2:2:3 How people relate to Friluftsliv: ............................................... 27 2:2:4 Mentoring pedagogy in Friluftsliv: ........................................... 28 2:2:5 Friluftsliv phenomenology: ...................................................... 31 2:2:6 The potential of Friluftsliv in a rehabilitation setting: ............... 33 2:2:6:1 Physical Activity and Health: ............................................ 33 2:2:6:2 ” Nature and Health”: ........................................................ 35 2:2:6:2:1 Ecopsychology: .......................................................... 36 2:2:6:2:2 Horticulture therapy (HT): .......................................... 37 3 AIMS OF THESIS:.............................................................................. 38
  5. 5. 5 4 METHOD:............................................................................................ 41 4:1 SEARCH METHOD: ............................................................................ 41 4:1:1 Inclusion and exclusion criteria: ............................................... 42 4:2 LIMITATION: .................................................................................... 42 5 THE POTENTIAL OF FRILUFTSLIV IN CARDIAC REHABILITATION:.............................................................................. 44 5:1 THE BENEFITS OF FRILUFTSLIV: ........................................................ 44 5:1:1 Physical benefits of Friluftsliv: ................................................. 45 5:1:2 Psychological benefit of Friluftsliv: .......................................... 46 5:1:3 Friluftsliv in a rehabilitation setting: ......................................... 47 5:2 PHYSICAL ACTIVITY AND HEALTH:................................................... 48 5:3 “NATURE AND HEALTH”: ................................................................. 50 5:3:1 Ecopsychology: ........................................................................ 51 5:3:2 Horticultural Therapy ............................................................... 54 5:3:2:2 Viewing natural scenes: ..................................................... 57 5:3:2:3 Being in natural environments: .......................................... 58 5:3:3 The use of nature in rehabilitation: ........................................... 59 6 SUMMARY.......................................................................................... 61 6:1 “NATURE AND HEALTH”: ................................................................. 62 6:1:1 Therapeutic work in “Nature and Health”: ................................ 63 6:2 FRILUFTSLIV AND HEALTH EFFECTS: ................................................. 64 6:2:1 The use of Friluftsliv in rehabilitation setting: .......................... 65
  6. 6. 6 6:3 WHAT IS THE POTENTIAL OF FRILUFTSLIV IN CARDIAC REHABILITATION?.................................................................................. 66 6:4 THE LIMITATIONS OF THIS THESIS: .................................................... 69 6:5 FURTHER RESEARCH: ....................................................................... 70 7 CONCLUSION .................................................................................... 72 REFERENCE LIST................................................................................ 73 LIST OF TABLES:................................................................................. 83 LIST OF FIGURES:............................................................................... 84
  7. 7. 7 1 Introduction: In Norway as in the rest of the world there is a high prevalence of cardiovascular diseases (CVD) and is the number one reason for early death. The main risk group of CVD is elderly people and their proportion in the society is growing. Reports are also showing increasing incidences of CVD at adulthood. For both groups the main risk factors are inactivity and overweight, and studies show that these two risk factors are on the increase in modern society. This result in a growing need for Cardiac Rehabilitation (CR). Due to economical and organizational reasons the rehabilitation period at hospital and rehabilitation clinics is shortening. This diminishes the chances that patients adapt to a new lifestyle during rehabilitation, and they are therefore in danger of abandoning the active lifestyle when returning back home. Also, the long distances to rehabilitation clinics in Norway makes this even more likely to happen. The Norwegian Outdoor Life Tradition, or Friluftsliv is highly valued and is a popular form of recreational activity in Norway. Friluftsliv consist of dwelling and being physical active in natural or near natural environment. Friluftsliv has developed through the years in a blend with the Norwegian culture and identity. Together with it’s pedagogic and mentoring tradition makes Friluftsliv interesting in terms of rehabilitation. The aim of this thesis is to do a literature review in order to get a closer look at the potential of Friluftsliv when patients return back home from rehabilitation clinics e.g. the Maintenance phase or phase III of Cardiac Rehabilitation in Norway.
  8. 8. 8 Friluftsliv is included in health’s “White papers” of the Norwegian state and is also popular as a method in rehabilitation clinics. Most of the studies in Friluftsliv focus on pedagogic, cultural heritage and tourism, but there are only few Friluftsliv studies focusing on the health effects of dwelling, or being physically active in nature. Therefore by including literature of other related professions, like the field of Physical Activity and Health and the field of Agriculture and Landscape architecture, it seems warranted to examine the potential of Friluftsliv. This field of Agriculture and Landscape Architecture, which focus on the health effects of nature, have I chosen to call “Nature and Health”. The main contribution comes from Ecopsychology, with the active and holistic view of the human-nature relationship. Ecopsychology emphasizes direct experience of nature by being bodily active in contact with nature. The studies focuses on the practical work in Ecopsychology, and examines the health effects of working at farms and out in the countryside. The most common therapeutic form of Ecopsychology is Horticultural Therapy (HT), which ranges from the cultivation of plants to the appreciation of landscape. In a rehabilitation setting, the results from HT studies are helpful when working with people in need for rehabilitation, people with different physiological and psychological disabilities, mental illness and mental fatigue. The vast majority of the Friluftsliv activities, as in HT concern direct contact between humans and natural environment. Therefore HT is of
  9. 9. 9 interest when examining the potential of Friluftsliv in a rehabilitation setting. Figure 1 includes the fields that are examined in this thesis to illustrate the potential of Friluftsliv in Cardiac Rehabilitation in Norway. Chapter 2 will focus on the status of Friluftsliv and Cardiac Rehabilitation and chapter 5 will examine empirical studies focusing on the health effects when participating in Friluftsliv, both in leisure time and in a rehabilitation setting. Supplemented by theory and empirical studies from the fields of Physical Activity and Health and “Nature and Health” The potential of Friluftsliv in rehabilitation setting Cardiac Friluftsliv: with pedagogy and Rehabilitation cultural heritage in the Maintenance phase (Norway) “Nature Physical Activity And Health” And Health Ecopsychology Horticultural Therapy Figure 1: a “bird’s eye view” of the topics of this thesis, which will be examined to enlighten the potential of Friluftsliv in Cardiac Rehabilitation
  10. 10. 10 2 Theoretical and empiric background 2:1 Cardiovascular diseases: The definition for health by WHO is the following: “A state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity” (World Health Organization, 1946, p. 303). It emphasize that it is not enough to cure diseases, but it is important to take into account the person as a whole. The increasing prevalence of lifestyle diseases (Stene- Larsen, 2006) will be a burden for both the patient himself and, will also have a impact on his activity level, mental health, social life, work and family (Satterfield, Volansky, Caspersen, & Engelgau, 2003). This is taken into account in the International Classification of Function, Disability and Health (ICF). The classification system does not only focus on the illness, but also the patients surroundings, like family, work, leisure activities and how the patient can manage to function in his own environment. Worldwide there is an increasing prevalence of chronic diseases, as for example Type II diabetes, overweight, cardio vascular diseases (CVD). There are risk factors of these diseases, which are connected to people’s lifestyle. CVD is globally the number one reason for early death, and two of the main risk factors for developing CVD are inactivity and obesity. There is a high level of physical inactivity reported in most industrialized countries (Pratt, Macera, & Blanton, 1999), including Norway (Søgaard, Bø, Klungland, & Jacobsen, 2000). In the case of obesity, a recent review
  11. 11. 11 reported that the proportion of obese (BMI >30kg/m2) Norwegian adults has doubled over the last two decades and the situation is described as an epidemic (Ulset, Rut, & Malterud, 2007). In Norway, as in the rest of the Western countries, there has been a reduction in mortality caused by CVD since the 80`. But still in 2004 Cardiovascular Disease was the main cause of death (Figure 1) and Heart Attack and Stroke were the leading cause of mortality (38%) in Norway (Nasjonalt Folkehelseinstitutt, 2006) Cause of death 2004 Mental illness Pulmonary diseases Diseases External reason Mortality Cancer Unknown or undefined reason Cardiovascular diseases 0 4000 8000 12000 16000 Mortality Figure 2: In 2004 Cardiovascular diseases were the main cause of death in Norway (Statistics Norway, 2006) New statistics from 2006 show that since 2000 there has been 14,6% increase in hospitalizing caused by CVD. Especially Heart Attack is increasing (60%). There may be two reasons for this. First, a change was made in the diagnostic system in 2000, which may have lead to an increase in registered heart attacks. The other reason is probably reflecting an
  12. 12. 12 increase of the group at risk or those who have passed the age of 60. In the case of Heart Attack, 3 out of 4 hospitalizations where patients older than 60 year old, and 2 out of 3 were men (Statistics Norway, 2007). In many industrialized countries, the percentage of the population that is elderly is rising; more people are surviving with conditions that in the past were fatal, and the prevalence of obesity and a sedentary lifestyle are still increasing. Due to increasing obesity and sedentary lifestyle, CVD is no longer a disease only among the elderly but also among the younger generations. As a result, the number of people living with a chronic illness is rising rapidly. In Norway there is no registration of how many live with morbidity as a result of CVD, but in the UK the proportion of people living with a chronic condition has risen from 21% in 1972 to 35% in 2002. And 17% of those with a chronic condition, have a cardiovascular illness or hypertension, and approximately 25% have three or more chronic health problems (Pattenden & Lewin, 2007). This means that more people are in need of care. Atherosclerotic cardiovascular diseases are the major cause of death in middle-aged and older-adults in most western countries, including Europe. In addition, atherosclerotic diseases, of which coronary artery disease is the most common, result in substantial disability, a loss of productivity, and contribute considerably to the escalating costs of health care, especially in regard to an ageing population. For those patients already identified as having cardiovascular diseases, the prevention of subsequent cardiovascular
  13. 13. 13 events while maintaining adequate physical functioning and independence, and a good quality of life, are thus major challenges. The results of EUROSPIRE II (EUROASPIRE II Study Group, 2001) study show that too many patients are not receiving appropriate therapeutic interventions (cardiac rehabilitation) or health behaviour advice. 2:1:1 Mental health: Acute cardiovascular events strongly affect people’s psychological condition. After a myocardial infarction, about 70% of patients report fatigue or lack of energy and are concerned about issues like physical health, return to work, sex life, the possibility of engaging in physical activities, and of living an enjoyable life in all aspects (Doerfler, Pbert, & DeCosimo, 1997). Around 15-20% of patients develop signs of depression, which increases the risk of future cardiac events (Carney et al., 1987; Welin, Lappas, & Wilhelmsen, 2000), and this is especially the case if there is also lack of social support (Horsten, Mittleman, & Wamala, 2000). But it has been shown is several studies that patients, who participate in cardiac rehabilitation programs, report improvement in well-being, health, and physical abilities. They also consume less tranquillisers and are less depressed compared to patients not enrolled in cardiac rehabilitation (Lavie & Milani, 1997; Milani, Lavie, & Cassidy, 1996).
  14. 14. 14 2:1:2 Cardiac Rehabilitation: The Rehabilitation of cardiac patients, is the sum of activities required to influence favourably the underlying cause of the disease, as well as to gain the best possible physical, mental and social conditions, so that they may by their own efforts, preserve or resume when lost, as normal a place as possible in community (World Health Organization Expert Committee, 1993). Cardiac Rehabilitation is by WHO been divided into 3 phases (ibid): (I) The Acute phases (II) The Reconditioning phase (III) The Maintenance phase. The aims of Cardiac Rehabilitation phase I-III is to facilitate recovery (Cardiac Rehabilitation) and to prevent future cardiac illness (“secondary prevention”) (Vanhees, McGee H, Dugmore, Schepers, & Van Daele P, 2002) 2:1:3 Cardiac Rehabilitation and Physical activity: Therapeutic exercise training is an accepted adjunct to medical therapy in the management of many chronic diseases. There is evidence that exercise training leads to potential central (cardiac) and peripheral (skeletal muscle) beneficial adaptation and can give significant improvements in exercise tolerance and symptoms in cardiac patients (Belardinelli, Georgiou, Cianci,
  15. 15. 15 & Purcaro, 1999). A Cochrane review, confirmed a 27% reduction in all cause mortality with exercise based cardiac rehabilitation (Jolliffe et al., 2008) Moreover, systematic physical activity may reduce anxiety and enhance well-being, and quality of life in these patients (Belardinelli et al., 1999; Willenheimer, Erhardt, Cline, Rydberg, & Iraelsson, 1998). In a literature review evaluating the evidence-base of exercise therapy the authors estimated that physical training has strong or moderate positive effect on disease pathogenesis in 50% of chronic diseases included in their review (9 of 18). They documented that physical fitness or strength can be increased in most diagnoses (strong or moderate evidence in all 18 diagnosis). This shows that good fitness level often means less symptoms and less disability in daily activities (Pedersen & Saltin, 2006). Also during maintenance phase (phase III) in Cardiac Rehabilitation, physical training is favourable because it leads to reinforcement of physical condition and healthy lifestyle(Vanhees et al., 2002). Studies in CR show that exercise training of lower intensity can produce improvements in functional capacity comparable to those produced by higher-intensity exercise. The lower-intensity exercise is characterized by greater safety, which is particularly important if exercise sessions are unsupervised; it causes less discomfort and is more enjoyable, and thus makes adherence to the recommended exercise regime more likely. Also the largest benefit in terms of mortality (30-40% reduction), does appear to accrue though engaging in moderate activity levels. That means activity
  16. 16. 16 performed at an intensity of 3-6 MET’s, or like brisk walking for most adults (Paffenbarger, Hyde, & Wing, 1994). But maybe the most important is that for each 1 MET improvement in exercise capacity, which is achievable for most people, is associated with large (10-25%) improvement in survival (Myers, 2007). And among patients who can safely perform modest levels of dynamic exercise, the relative safety and substantial value of low-intensity isometric or resistive (strength training) exercise, have also been identified (Mathes, 2007). An increasing amount of recent research has demonstrated that resistance training not only improves both muscular strength and cardiovascular endurance, but it also has positive influence on existing conditions such as hypertension, hyperlipidemia, obesity, and diabetes (Graves & Franklin, 2001). There are studies showing that exercise-based CR not only increases exercise tolerance, as maximum oxygen consumption, but also health- related quality’s of life (HRQoL) (Friedman, Thoresen, & Gill, 1986; Rees, Bennett, West, Davey, & Elbrahim, 2004). But the patient’s own perception of health status does also have an influence on clinical outcomes; for example, the perceived ability to exercise correlates better with the resumption of work than the objective measurements of exercise capacity during formal testing. And there is substantial correlation between perception of health status and returning to usual family and community activities, and recreational and occupational pursuits. And most importantly, this perception can be favourably altered by education and counselling (Friedman et al., 1986)
  17. 17. 17 2:1:3:1 Development of Cardiac Rehabilitation: Initially physical activity in Cardiac Rehabilitation was done outdoors and the intension was to improve symptoms and physical capacity. For more than 200 years ago, Herberden observed the beneficial effects in a patient being advised to saw wood for 30 minutes daily over a 6-month period. And the first person to introduce exercise systematically into the therapy of cardiovascular disease was M. Oertel in 1875 (Oertel, 1891). He successfully treated a patient with overweight and shortness of breath with an increasing number of steps in a hilly terrain, the “Terrain-Kur”, which became popular in the ensuing years. In Europe the rehabilitation clinics were build in rural surroundings, but the tendency now a days is that when the economy is lagging, the number of rehabilitation centers decline, and are being replaced by ambulatory programs for outpatients (Mathes & Halhuber, 1982). The use of home-based rehabilitation programs is now also more frequently used after hospital discharge and sometimes even after an ambulatory program. The disadvantage of home-based rehabilitation is the lack of contact with other people. That is why specialized sports clubs or specifically designed heart groups may be better to facilitate long-term secondary/preventive lifestyle (Vanhees et al., 2002). But the use of home- based exercise training is safe, and studies even demonstrate higher symptomatic benefit after combined home- and hospital-based training
  18. 18. 18 programs, than in the hospital-based only programs (Piepoli, Flather, & Coats, 1998). The exercise training programs for cardiac patients have different level of supervision, depending on the time after the cardiac event and the risk for developing cardiac complications during exercise. For patients who are evaluated at low-risk at 12 weeks after the cardiac event, there is no supervision needed. The use of electrocardiographic monitoring may be appropriate during the first 6 to 12 sessions, but being gradually reduced to once a week or once a month. For patients, which are evaluated at low-risk 12 weeks after index may enter a gymnasium- or community-based program that offer controlled exercise in an enjoyable environment. This is the ideal setting to promote self-confidence and risk factor control. Patients have the opportunity to exchange experiences with each other, and group activities help them to increase exercise adherence. For low-risk patients, home exercise rehabilitation is an alternative to supervised group programs (Moraes & Ribeiro, 2006). 2:1:3:2 Rehabilitation duration and adherence: Despite the knowledge of beneficial effects of cardiac rehabilitation is there low adherence to cardiac rehabilitation programmes; in USA it is only 10- 20%, and in UK 14-23%. A study done among patients from one of the private cardiac hospitals in Norway, Feiringkliniken (n=398) reported similar percentage. Only 20% of patients after ACB or PCI did participate in
  19. 19. 19 cardiac rehabilitation (Grimsmo & Vold, 2005). Further, in addition to this, in 2006 there was a 16% reduction in rehabilitation capacity in Norway (Norsk Pasientregister, 2006). This fact together with other difficulties, such as lack of motivation, financial problems, the need for speedy job resumption or timetable conflicts also prevent patients from participating in a CR program - the first step in a lifetime intervention. Moreover, the Health care systems, insurance companies and financial restrictions have lowered the payment and reimbursement for CR in the last decades. Consequently, interventions have shortened from the typical 3-6 months to some weeks, a time period insufficient to promote long-lasting behaviour change. This was supported by the EUROASPIRE II study conducted in 15 European countries. Results showed that there was a large potential and need for secondary implementation, because many patients have not adopted appropriate lifestyle or are even not taking the medications as recommended (EUROASPIRE II Study Group, 2001). By being a long-lasting intervention with significant financial and personal costs, the maintenance phase (III phase) carries a significant risk of being quickly abandoned. Patients may be frequently asymptomatic, previously sedentary and not wishing to do any lifestyle changes (Ockens, Hayman, & Pasternak, 2002). This often results in progressive decay in program compliance by the patients. In a study by Dorn and coworkers, only 13% of the participants were still exercising 3 years after the program started (Dorn, Naughton, & Imamura, 2001). By being aware of the typical drop-out factors (Ockens et al., 2002) and at the same time organize the programmes in cooperation with the patients,
  20. 20. 20 enhanced compliance can be ensured. Performing the exercise in groups might be preferred for the maintenance phase as the patient will benefit from psychosocial support within the group (Donovan & Blake, 1992). 2:1:3:3 Social support and community settings: There is a good deal of evidence to support the use of peer mentors with at- risk patients. Peer Mentors can provide social support to decrease heart disease-related depression, encourage healthy recovery, and decrease hospital readmission rate (Cashen, Dykes, & Gerber, 2004). And peer support groups for people 12 months after a cardiac event, led to an increase in physical activity and smoking cessation (Hildingh & Fridlund, 2003). Not only do studies show positive results for the patient but also for the peer mentor/advisor (Whittemore, Rankin, & Callahan, 2000). Rehabilitation intervention are often implemented at a hospital or rehabilitation clinic (inpatient/outpatient) but emerging evidence support the safety and effectiveness of rehabilitation in other settings, such as community centres and homes (Marchonni et al., 2003). Three decades ago the World Health Organisation (WHO) introduced the community-based rehabilitation (CBR) strategy, and in a modern health care system encouraging cost-effective methods, CBR is becoming an attractive method because of the low cost profile (Sharma, 2007). The primary aim of CBR is to provide primary care and rehabilitative assistance to persons with disabilities, by using human and other resources already available in their
  21. 21. 21 communities. In most countries CBR has been connected to the health care system but most of the success histories comes from where CBR is connected to private institutions or organisations (Ingstad, 2001). In Scandinavia it is especially private organisations that has used CBR in their organisations, adapting the CBR to the ideology of Scandinavian rehabilitation of normalisation, integration and equal opportunities for everybody (Ingstad & Eide, 2007). 2:2 Norwegian Outdoor Life Tradition (Friluftsliv): In this thesis the focus is on rehabilitation and secondary prevention. Hence, the spectrum of Friluftsliv will be limited to daily activities in local outdoors environments, or tours varying no more than one day (Norwegian: Nærmiljø Friluftsliv). The definition for Friluftsliv used in this thesis is: “Friluftsliv includes both dwelling and being physically active in the outdoors in leisure time, to achieve a change of environment and to experience nature”(my translation) (White Paper no 39 (2000/2001), 2001, p. 11) This is a vast and open definition, which includes almost every form of recreation in leisure time but the emphasis is on experiencing nature. The main issue is to regard Friluftsliv as a simple and ecologically responsible way of spending time outdoors. It should be practised in an environmentally responsible way, where ecological diversity is cared for. The emphasis is also on non-competitive activities and use of non-motorised
  22. 22. 22 and simple equipment. The essence is the good balance between man and nature, as well as the social fellowship between people when spending time outdoors (Westersjø, 2007). Norway has a population of 4.6 million people and Friluftsliv has enormous popularity and is highly valued by the nation. For example, more than 80% of the Norwegian population practice some kind of outdoor activity at least 10 times a year (Vaage, 2007). And the strongest reason for why people like to be active in Friluftsliv is experiencing nature and silence, and contemplation (MMI/FRIFO, 1993). But also the excitement of mastering Friluftsliv activities, playing and having fun, the social aspect and the feeling of responsibility when participating in Friluftsliv (Vorkinn M., Vittersø, & Riese, 2000). When asked about what is necessary for living a good and healthy life and what is important for the individual identity, 19 out of 20 Norwegian mentioned “nature”(White Paper no 39 (2000/2001), 2001). In White Paper nr. 39, the Norwegian government has stated that Friluftsliv may be the road to a better quality of life (White Paper no 39 (2000/2001), 2001). Also the white paper called “Prescription for a healthier Norway”, an official document on Norwegian Health Policy, includes Friluftsliv in the chapter called “To choose a healthier lifestyle” (White Paper no 16 (2002/2003), 2003) Given this common acceptance and statements from the state of Norway, Friluftsliv is often used as a part of rehabilitation interventions(Bischoff, Marcussen, & Reiten, 2007). This seems the case
  23. 23. 23 despite of the shortage of evidence based studies evaluating the health effects of Friluftsliv and supporting the use of it in rehabilitation settings. 2:2:1 Development of Friluftsliv and its role in personal and social development. Friluftsliv is heavily influenced by the Norwegian culture of harvesting by Norwegian small –holders but also by English mountaineers, the explorer Fridtjof Nansen and the Deep Ecology movement of the 1970s. The Norwegian outdoor tradition is reputed for its holistic approach to living close to nature. The industrialisation came late to Norway and same with the urbanisation. There were few landowners and a negligible aristocracy. Hence huge tracts of common land were accessible to the Norwegian people. Furthermore, the judiciary which “advanced the land user rather that the landowner’s right” supported liberal land ownership, which encouraged people to journeying and harvesting in the woods, mountains and coastal waters (Tordsson, as cited in (Westphal, 2006, p. 134)). Due to this easy access to land, gathering berries, fishing and hunting for food this became one of the main strands of Friluftsliv. And in 1957 the Parliament ensured by the law: “Friluftsloven” (Outdoor Recreation Act), that Norwegians could continue travelling through both uncultivated and cultivated land when accessing recreational areas. This right is called: “Allemannsretten” (Mytting & Bischoff, 2001). In this way nature became a resource, and together with Friluftsliv became a part of the Norwegian identity. The explorer and scientist, Fridtjof Nansen (1861-1930) was one of the most
  24. 24. 24 important figures for Norwegian Friluftsliv. Nansen said in a speech to students in 1921: “In the wilderness, in the loneliness of the forest, with a view towards the mountains and a distance from glamour and confusion – this is where personalities are formed.” (Reed & Rothenberg, as cited in (Westphal, 2006, p. 144)). And in the years after World War I Friluftsliv was gradually perceived as means of smoothing or even solving society’s problems such as the moral and physical decay, which was prevalent at that time. Also, The Norwegian Trekking Association (DNT) started in 1932 to organize group tours into the mountains, which was increasingly acknowledged as an effective tool for personal and social development (Westphal, 2006). In the 1970s and 1980s came a massive protest against western societies and its excessive exploitation of natural resources (Breivik, as cited in (Westphal, 2006)). The modern society was believed to be on a collision course with nature. Friluftsliv acted as an antidote to this development and at the same time the “Deep Ecology” emerged. This branch of Ecological philosophy considers mankind as an integral part of its environment and gets its inspiration from the philosophical works of Spinoza, Buddhism and Gandhi (Næss, as cited in (Westphal, 2006)). It was acknowledged that Deep-Ecological Friluftsliv could offer its followers the opportunity to acquire life-skills that would “tackle life as such” and transfer systemic symbolic experience such as “the seasonal rhythm of the year, the rhythm with landscapes and waves” into holistic skills needed to support the work-
  25. 25. 25 life balance of daily routines (Myksvold, as cited in (Westphal, 2006, p. 151)). In the years after World War II Norway had enormous increase in wealth, resulting in massive demographic change. For instance in pre-war Norway only 30% of Norwegian lived in urban or populated areas, whereas this figure rose to more than 70% by the end of the century. As a result, the harvesting tradition in rural areas became less important and Friluftsliv became an outdoor activity for the “urbanized well-to do people from the cities” in their leisure time (Pedersen, as cited in (Westphal, 2006, p. 155)). Gradually Friluftsliv lost its political force to improve society (Tordsson, as cited in (Westphal, 2006)) at the same time the emphasis on deep-ecological Friluftsliv waned and the strands of Friluftsliv assumed a character of diversity. 2:2:2 Friluftsliv – instrumental approach: One of the new dimensions of friluftsliv that grew up was an instrumental approach, where Friluftsliv was used as an instrument or a pedagogic method to gain a goal. The working areas were therapeutic groups, management training, integration of ethnic groups, and personal development where teamwork (Bischoff & Odden, as cited in (Westphal, 2006)). At the same time Scandinavians (Norway, Denmark and Sweden) became introduced to the Anglo-American approach of using outdoor life to personal and social development (Sjong, as cited in (Westphal, 2006)). And
  26. 26. 26 some innovative rehabilitation clinics, like Beitostølen Helsesportsenter, Valnesfjord Helsesportsenter and Atføringssentret i Rauland embraced a Friluftsliv-inspired therapeutic approach to learning, and they demonstrated their faith and commitment to Friluftsliv as a worthy educational tool (Bischoff et al., 2007). But despite its apparently growing acceptance in Norwegian practice, the instrumental strands of Friluftsliv holds less sway as a solidly anchored concept compared to traditional Friluftsliv (Westphal, 2006). The Anglo-American personal and social development approach in outdoor life is far more consolidated and explicit in its practice than the Norwegian Friluftsliv, which favour the implicit nature of personal social development-related learning in the context of Friluftsliv (Norwegian: “Det kommer av seg selv” My translation: It will emerge by itself) (Sjong, as cited in (Westphal, 2006)). The Anglo-American approach utilises the outdoors in order to empower the individual (Wood, as cited in (Westphal, 2006)) by focusing on individual competence like `self-development`, `self- esteem` and `self-efficacy` (Bischoff, as cited in (Westphal, 2006)). However, this focus on individual competence does not fit so easily into the Norwegian tradition of Friluftsliv with its value and belief system which is historically rooted in ego suppressive and lateral thinking through its egalitarian tradition (Westphal, 2006). In the Friluftsliv’s tradition the potential as personal and social development instrument lies implicit in it. It is represented as values that may contribute to human development. It is possible to explore and utilise these values by selecting the proper environmental context and the challenge level of the tour. This is labelled
  27. 27. 27 “inherent pedagogy”, which is “pedagogy which builds on the ability to see the inherent qualities, potential and leadings in situations. The pedagogue has the job to find, pick up and clarify, structure and use situations which in their own way to communicate the message” (Tordsson, as cited in (Westphal, 2006, p. 209)). 2:2:3 How people relate to Friluftsliv: There are 3 different explanation models on how people relate to Friluftsliv: • The biological explanation is that we as human beings belong to the nature. When on hike we fall into a way of living, which we as human beings are adapted to and in which simple rules of surviving are ruling. The idea is that as a result of long evolution, we have developed and adapted to the environment in ways, which has given us the best possibility of surviving. • The second explanation, Friluftsliv is a socio-cultural phenomenon, is most commonly used one in Norwegian studies of Friluftsliv. According to this view, Friluftsliv is important as a cultural identity and cultivates important values in Norwegian society. Friluftsliv is something as we as a nation has sculptured, and we are proud of it. Friluftsliv is something that is learned, embedded in the culture and is taught from one generation to the next generation.
  28. 28. 28 • The third and last explanation model is more of an phenomenological perspective in the view of Friluftsliv as a phenomenon of its own. In this way Norwegian Friluftsliv is explained from the inside, from how we arrange Friluftsliv in a way, which is a contrast to our everyday living. And gives us the possibility to experience life in another way than in our routine life. This is where phenomenology and Merleau-Ponty enters the scene with the aspect of studying phenomenon from the inside and emphasize how the body and our behaviour are important for how we experience our environment. In Friluftsliv, this can be understood as every situation has its own possibilities, problems and pedagogic potential: each situation communicates different message, which we need to percept and the body will react to by adjust to the situation (for further details see chapter 2:2.5). In this way, Friluftsliv can give the feeling of meaningfulness where information, both conscious and unconsciously, is creative and reflectively processed. (Tordsson, 1999). 2:2:4 Mentoring pedagogy in Friluftsliv: Through the years Friluftsliv has developed its own mentoring didactic, which emphasize group development, situational and process orientated mentoring. At the same time it focuses on experiencing the nature, both as a goal on its own but also as a method to influence people with respect to environmental issues. The Norwegian Friluftsliv mentoring didactic is
  29. 29. 29 influenced by gestalt pedagogic, which emphasize experience of wholeness and relatedness between human being and the environment. The Deep Ecology movement, which has influenced the development of Friluftsliv, states that it is not possible to separate nature, consciousness, ego and the society surrounding us (Sendstad, 1992). When participating in Friluftsliv, everyone has the change to try out new roles as for example being a leader or having a role that includes responsibility. This is not only meant as an individual challenge but also as a part of a socialisation process in to the group, which they are apart of. In that way the participants are able to experience how their decision will affect others and try to predict consequences of their choices. The participants need to learn from their own decision-making, and the group as a whole, which will act as a reference on how well it worked. All group members are considered equal and have experience, knowledge and motivation, which is important for the group. The knowledge exchange often happens while being active, but will also happen automatically when sitting around the campfire. People experience situations differently and will therefore have different perceptions, which gives the participants the chance to learn from one another and make each other more conscious of different angles of view. The campfire is a context that invites participants to dwell, reflect and share experiences and knowledge. The situation is one where culture, language and context melt together and includes everybody sitting around the campfire.
  30. 30. 30 One definition of mentoring in Friluftsliv is: “a special process orientated mediation method, which focus on groups activities and direct contact with nature” (My translation) (Tordsson, 1993) Mentoring in Friluftsliv is meant to help people with individual problem solving, and by working in groups find solutions to challenges. And at the same time by using the context of Friluftsliv, participants experience joy, teamwork, satisfaction, quality of life, responsibility for them self and nature. The goals by mentoring in Friluftsliv have been formulated by Tellnes as: • Mediate the experience of untouched nature, which can give the feeling of happiness and quality of life • Developing deeper connection to the untouched nature, which may lead to the feeling of responsibility in environmental issues • Develop the ability of critical analyse of the way of living in modern society, and be aware of the consequences these may lead to. • Inspire to change lifestyle; to more simple and “richer” life • Mediate the individual ability to cooperate, responsibility and to personal development (Tellnes, 1992) Friluftsliv has developed some pedagogic principles, like “tur etter evne” (my translation: adapted tour to ones ability). This means the abilities of the participations should always be attuned to the demand of the tour. This is not only meant as to secure a pleasant hike but is an important security principle which will allow the mentor and the participants to accomplish their tour goal. The mentor needs to be experienced to accomplish this, and
  31. 31. 31 by doing so this will train the participant in their ability to evaluate if they have the ability to sustain the demands of the nature. By following this principle of “tur etter evne” (adapted tour to ones ability) there will be a progression in the ability by the participations by every tour they do. An all to soon progression will act as guiding and leave out the support that enables the participant for self-help (Tordsson, 1993). 2:2:5 Friluftsliv phenomenology: It is a common belief in Norway that Friluftsliv includes everyone who wants to participate and gives the opportunity to explore nature, not only by being physically active but also by dwelling and experience the nature. Friluftsliv is a holistic physical activity, which includes people physically, psychologically and intellectually. When in nature you need to be active, not only with your body but also intellectually when experiencing/sensing the natural environment. Mother Nature can be friendly and hostile, warm or cold, beautiful or horrific and more, all at the same time. At the same time as we explore and react to the nature, we do explore our self, how we react both physically and psychologically. The interaction between people and nature in Friluftsliv has been explained as: 1. In Friluftsliv we perceive the nature by its different qualities. To experience the nature is to acknowledge these qualities and accept them.
  32. 32. 32 2. In Friluftsliv we belief that the nature communicates with us. Nature approaches us as a whole person; our body with it’s capacity to perceive intellectually and emotionally. 3. We express our understanding of nature by specific bodily action where we interact with the nature 4. In the fundamentals of Friluftsliv lies the belief that the experiences in nature add in a valuable way to us as human beings. Not only do we explore the nature, but also our self in the interaction with nature, which can give us the experience of happiness as well as contribute to personal and social development (Tordsson, 1999). Friluftsliv often seek to the philosophic ideas of Merlau-Ponty, because one of the key elements of his phenomenology is that it is not possible to separate body and mind. The one can’t work without the other. Or as Merleau-Ponty says: “We are our bodies” and for him consciousness was not just something that goes on in our heads. Rather, our intentional consciousness is experienced in and through our bodies (Duesund, 1995, p. 31). We experience our body, both as subject when we are physically active and as object when reflecting about our self. The objective body is visible when we reflect over the body. Such visibility is not possible without the subjective body. The body cannot be only subject or object and it is not possible to make them independent of one another. Merleau-Ponty argued that it is when being physically active that we come close to experience of the subjective and objective body at the same time. We are being active
  33. 33. 33 without thinking about what we are doing or in other words we forget our bodies and are just active (Duesund L., 1999). 2:2:6 The potential of Friluftsliv in a rehabilitation setting: Traditional Friluftsliv includes many different activities as hiking, canoeing, cross-country skiing, climbing, gathering berries and mushrooms, which require different levels and type of physical activity. In some form of Friluftsliv, physical activity is important but in other not so important. In traditional Friluftsliv experiencing nature has been key elements (Hegge, 1990) and from a phenomenological perspective this is only possible through the use of body. Physical activity is a important part of Friluftsliv and the arena is the nature, but there are only few studies of the health benefits of physical activity and nature in participating in Friluftsliv. Therefore, will this thesis now introduce the fields of Physical Activity and Health and “Nature and Health”, but chapter 5 will look closer into the research question. 2:2:6:1 Physical Activity and Health: Physical activity is a fundamental means for improving physical and mental health. But as the case for too many people, has the physical activity been removed from everyday life, with dramatic effects for health and well- being. Physical inactivity is estimated to account for nearly 600 000 deaths per year in the WHO European Region. Tackling this leading risk factor
  34. 34. 34 would reduce the risks of cardiovascular diseases, non-insulin- dependent diabetes, hypertension, some forms of cancer, musculoskeletal diseases and psychological disorders. In addition, physical activity is one of the keys to counteracting the current epidemic of overweight and obesity that is posing a new global challenge to public health (World Health Organization Europe, 2006). Over the past decades, knowledge has been accumulating concerning the significance of exercise in the treatment of a number of chronic diseases. Today, exercise is indicated in the treatment of a large number of medical disorders. In the medical world, it is traditional to prescribe the evidence- based treatment known to be the most effective and entailing the fewest side effects or risks. The evidence suggests that in selected cases, exercise therapy is just as effective as medical treatment – and in special situations more effective – or adds to the effect (Pedersen et al., 2006). Table 1: Summary of the health effects associated with physical activity (World Health Organization Europe, 2006) Condition Effect Heart disease Reduced risk Stroke Reduced risk Overweight and obesity Reduced risk Type 2 diabetes Reduced risk Colon cancer Reduced risk Breast cancer Reduced risk Musculoskeletal health Improvement Psychological well-being Improvement Depression Reduced risk
  35. 35. 35 Physical activity has major beneficial effects on many chronic diseases (Table 1). These benefits are not limited to preventing or limiting the progression of disease, but include improving physical fitness, muscular strength and the quality of life. The strongest evidence indicates that the greatest benefit of physical activity is in the reduction of CVD risk. Inactive people have up to twice the risk of heart disease of active people. Physical activity also helps to prevent stroke and improves many of the risk factors for CVD, including high blood pressure and high cholesterol (World Health Organization Europe, 2006). 2:2:6:2 ” Nature and Health”: One of the main issues in the Norwegian definition of Friluftsliv is experiencing nature, and surveys conducted in Norway show that this is one of the main reason why people join Friluftsliv. For the purpose of this paper, nature is defined as an organic environment where the majority of ecosystem processes are present (e.g. birth, death, reproduction, relationships between species. This includes the spectrum of habitats from wilderness areas to parks in urban environment. To get closer look at the interaction between human beings and nature, and health benefits of nature will the thesis now turn to Ecopsychology and Horticultural Therapy. Ecopsychology is more the theoretical and the philosophical background and Horticultural Therapy is the practical
  36. 36. 36 application of how plants in healing garden and landscape in more natural environment, can benefit the human health. 2:2:6:2:1 Ecopsychology: “Human sanity requires some less-than-obvious connections to nature as well as the necessity for food, water, energy, and air. We have hardly begun to discover what those connections may be....” (Sherpard and McKinley, as quoted in (Fisher, 1999, p. 2)). Ecopsychology can be described as a synthesis between ecology and psychology, placing human psychology in an ecological context, and mending the divisions between mind and nature, humans and earth. A fundamental concept for Ecopsychology is that it is psychologically damaging for humans to live disconnected from their ecological context, as most of us do in contemporary urban industrial cultures. Nature is not supposed to serve humans instrumental purpose and be separated from us human beings (Schroll, 2007). Ecopsychology emphasizes direct experience of nature by being bodily active in contact with nature. The Ecopsychology elevates phenomenology as a useful philosophical foundation for thinking about the connection or disconnection between humans and their ecological context (Fisher, 1999). Theodore Roszak was the first one to use the term Ecopsychology and defined it as:
  37. 37. 37 1) The emerging synthesis of ecology and psychology. 2) The skilful application of ecological insights to the practice of psychotherapy. 3) The discovery of our emotional bond with the planet. 4) Defining “sanity” as if the whole world mattered. (Roszak, 1992) 2:2:6:2:2 Horticulture therapy (HT): Most of the studies concerning nature health effects, which are referred to in this thesis is originated from Horticulture therapy. HT is defined as “a process utilizing plants and horticultural activities to improve social, educational, psychological and physical adjustment of persons thus improving body, mind, and spirit of people.” (Relf, 2005, p. 3). Traditionally has Horticulture therapy been associated with plant cultivation as a tool of occupational therapy, but nowadays a broader definition is recognised, ranging from plant cultivation to appreciating landscape (Braastad & Bjørnsen, 2006). Such therapy is used in rehabilitation and vocational centres, youth outreach programs, nursing homes and senior centres, hospitals, hospices, war veteran centres, homeless shelters, penitentiaries, mental health facilities, schools, community gardens, and botanic gardens. In cases when non-professional therapists lead these activities, they are considered as activities with a therapeutic value.
  38. 38. 38 3 Aims of thesis: There is a high prevalence of cardiovascular diseases (CVD), not only in Norway but also in the rest of the world. The main risk group of CVD is elderly people and their proportion in the society is growing, which means increased incidence of CVD. Reports are also showing increasing incidences of CVD at adulthood. For both groups, the main risk factors are inactivity and overweight, and studies show these two risk factors are on the increase in modern society. And together with higher survival rate, results in a growing need for Cardiac Rehabilitation (CR). Due to economical and organizational reasons, the rehabilitation period at hospital and rehabilitation clinics is shortening. This diminishes the chances that patients adapt to a new lifestyle during rehabilitation, and they are therefore in danger of abandoning the active lifestyle when returning back to home. The distance from south to north in Norway is the same as the distance from Oslo, the capital of Norway, to Rome in Italy. And due to long distances to hospitals and rehabilitation clinics there is a need for activity- form/method/intervention in the home community of the patient. Since Friluftsliv is a widespread form of physical activity in Norway and is highly valued both by the state and the population of Norway it might have an unrealised potential when it comes to be included in cardiac rehabilitation in Norway. Hence, the aim of this thesis is to conduct a literature review to examine the potential of Friluftsliv to be used as a method in Cardiac rehabilitation. To get a closer look at the potential of Friluftsliv, studies
  39. 39. 39 focusing on health benefits of Friluftsliv will be included, supplemented with studies from the fields of Physical Activity and Health and “Nature and Health” (figure 3). Given that the short in-hospital period is beneficial for the patient but does not give the patient enough time to adapt new lifestyle. Moreover, it is hard for the patient after in-clinic rehabilitation to keep on exercising on his or her own. That is why this thesis will focus on the Maintenance phase (Phase III) in rehabilitation and try to discover if Friluftsliv can play a role in this phase of the rehabilitation after Cardiovascular Diseases. The potential of Friluftsliv in rehabilitation setting Cardiac Friluftsliv: with pedagogy and Rehabilitation cultural heritage in the Maintenance phase (Norway) “Nature Physical Activity And Health” And Health Ecopsychology Horticultural Therapy Figure 3: studies focusing on the health benefits of nature and physical activity are included to enlighten the potential of Friluftsliv in Cardiac Rehabilitation
  40. 40. 40 The research question is: What is the potential of Norwegian Outdoor Life Tradition (Friluftsliv) in the Maintenance phase (III phase) of Cardiac Rehabilitation?
  41. 41. 41 4 Method: 4:1 Search method: This thesis is based on literature review of studies related to cardiac rehabilitation, Friluftsliv, Ecopsychology and Horticultural Therapy. My interest is on how Friluftsliv can been used in the health care sector. There is almost non-existing literature or studies on the health effects of participating in friluftliv1. Therefore I found it necessary to search for evidence-based research from Agricultural and Landscape Architecture studies. Both in Friluftsliv and Agricultural studies, the nature is as an arena and there are published high quality studies in Horticulture therapy. I have searched for published literature on Pubmed and Cochrane but it has also been useful to search for work on www.google.com and http://scholar.google.no/. In search for literature on databases I used the following search words: Friluftsliv, outdoor life, leisure time activities, outdoor recreation, cardiac rehabilitation, comprehensive cardiac rehabilitation, horticulture therapy, ecotherapy, Ecopsychology, rehabilitation intervention, community-based rehabilitation and health promotion in community setting. I have also searched for thesis publications from the universities of most relevance. In this case for Friluftsliv, it has been Norwegian, Swedish and Danish universities of sports. In the case of Ecopsychology and Horticultural 1 In order to get a closer look at the area of this thesis I participated in workshops focusing on Cardiac Rehabilitation (www.feiringklinikken.no) and Friluftlsiv and Mental health (www.nakuhel.no)
  42. 42. 42 Therapy, has publications and reports from The Swedish Agricultural University, and the European Union project COST Action 866: Green Care in Agriculture, been a helpful source. 4:1:1 Inclusion and exclusion criteria: Inclusion criteria: • Published literature in scientific journals • Thesis published by universities in the area of Physical Activity and Health, Ecopsychology and Horticulture Therapy. • Studies with adult participants • Studies focusing on rehabilitation or secondary prevention after cardiovascular diseases or their risk factors. Exclusion criteria: • Theoretical and empirical studies conducted on Wilderness therapy and Adventure therapy, as these therapy forms of outdoor life usually are a trip done over 2-4 days or more. The focus in this thesis is on daily activities in nearby natural or near natural environment. 4:2 Limitation: This thesis search for theories and empirical studies from 4 different areas: physical activities and health, Friluftsliv (Norwegian Outdoor Life Tradition), Ecopsychology and Horticulture. Comparing and using studies from different technical perspective is a challenging task. I have tried to be
  43. 43. 43 true to both the aims of this thesis and of each of these areas, while at the same time be open for new evidence based research, which might add to the knowledge of Friluftsliv in Cardiac Rehabilitation.
  44. 44. 44 5 The potential of Friluftsliv in Cardiac Rehabilitation: More than 80% of the Norwegian population practice some kind of outdoor activity at least 10 times a year (Vaage, 2007). The government has stated in a White Paper nr. 39 that Friluftsliv may be the road to a better quality of life (White Paper no 39 (2000/2001), 2001). And Friluftsliv is regarded as a popular method in rehabilitation clinics and as a tool to promote physical activity in public health interventions. This is a paradox, because little research evidence exists supporting directly that Friluftsliv promote better health. 5:1 The benefits of Friluftsliv: In traditional Friluftsliv, nature is considered as a partner and not just as a background for one’s recreational activities. The arena is commonly remote wide-open nature, but with increased urbanisation there is increasing utilisation of nearby nature areas for recreational purpose. The strongest reason for why people like to be active in Friluftliv is experiencing nature, experiencing silence, excitement, mastering, play and having fun, responsibility, social aspects (Vorkinn M. et al., 2000) and contemplation and peace (MMI/FRIFO, 1993). Participating in Friluftsliv has not only a physical component but also involves the possibility of improving psychological and social wellbeing (Table 2).
  45. 45. 45 Table 2: The benefits of Friluftsliv on physical, psychological and social well-being (White Paper no 39 2000/2001, 2001) Category of health Benefits of Friluftsliv • Physiological improvement (endurance, strength, motor skills) Physical well-being • Loss of weight • Prevention of illnesses and injuries • Experience of nature and culture Psychological • Reaching or overcoming ones individual boundaries wellbeing • Silence, (self-) reflection, room for philosophy • Experience Social wellbeing • Interacting and sharing with others 5:1:1 Physical benefits of Friluftsliv: There are only few studies, which have focused on the physiological benefits of Friluftsliv, but two are worth mentioning. Both of them deal with participants, which were tested both pre- and post-hunting season. The first study concluded, after comparing result based on interviews and tests of pulse and cholesterol from the test group (n=22) and the control group (n=16), the increased activity level during preparing for and under hunting season, had positive effect on the physiological health of the participations (Okstad, 1994). The other study showed that the participants (n=22) had a significant increase in VO2 max, or 46,81 ml/kg pr. min. from pre-hunting season compared to post-hunting season, 48,21 ml/kg pr. min. (Kleiven & Bekkevold, 1994). Given that physical activity is a part of the definition of Friluftsliv, it is natural to look at research studies on the health benefit of physical activity. And evidence based research show that physical activity has diverse
  46. 46. 46 beneficial physiological effects to the muscle- and skeleton system, cardiovascular system and energy metabolism(Pedersen et al., 2006). I will come back to this in 5:2. 5:1:2 Psychological benefit of Friluftsliv: It is well known that moderate physical activity improves mental health like the feeling of being calm, relaxed and improved cognitive functions (Martinsen, 2004) (Moe, Retterstøl, & Sørensen, 1998). When speaking of psychological benefits of Friluftsliv, this has not been studied in great detail. However, there are some studies which point to psychological benefits of Friluftsliv. A study conducted back in 1994 indicated that the everyday level of mental distress was a lot higher for inactive people in comparison to active participants in Friluftsliv (Ingebrigtsen, 1994). Further, in a study published in 2002, only 30% of the participants who did exercise training reported positive psychological health effects of their participation compared to 60% of those who where active in Friluftsliv (Myrvang, 2002). In Sweden, where Friluftsliv has similar status and popularity as in Norway, a study with 10.000 participant was conducted on how leisure time activities, work, place of residence, economy and their social network influenced their quality of life (Norling, 2001). Results from the study showed that involvement in leisure time activities correlated strongly with subjective evaluation of quality of life. And participants placed Friluftsliv as second most important leisure time activity (60%). In Norway, several
  47. 47. 47 projects has been conducted in which Friluftsliv have been used as a method with the objectives of increased physical and psychological health. These projects have been argued to be successful, but studies with evaluation of the outcome has not been conducted (Bischoff et al., 2007). 5:1:3 Friluftsliv in a rehabilitation setting: As mentioned earlier Friluftsliv is often used at rehabilitation clinics as a method in a comprehensive rehabilitation in the case of as obesity, orthopaedic and amputation, rheumatism, mental disorder and cardiovascular diseases (Bischoff et al., 2007). Further, the fruitfulness of using Friluftsliv has been supported by showing that Friluftsliv activities in a rehabilitation setting, help patients with Rheumatism mastering their perception of pain (Hobbelstad, 2004). Studies also indicate that Friluftsliv may be a good alternative when working with patients dealing with challenges of modern society (Bjørnå, 2005) or overweight (Marcussen, 2006). Further, for patients with mental disorders has outdoor life as walking/ light tour been shown to be a good alternative to exercise training in particular, because it results in lower drop out rate compared to jogging (Martinsen, 2000) and increases social capacity (Eikenes, Gude, Hoffart, Strumse, & Aarø, 1999).
  48. 48. 48 5:2 Physical Activity and Health: Physical activity is an important part of Friluftsliv and studies show that physical activity has beneficial effects on both physical and psychosocial health. Regular physical activity increases the exercise capacity and the degree of change depends primarily on the initial stage of fitness and intensity of training. The training increases exercise capacity by increasing both maximal cardiac output and the ability to extract oxygen from the blood. And these physiological benefits of a training program can be classified as morphologic, hemodynamic, and metabolic (Table 3). Table 3: Physiological adaptations to physical training in human (Perk J et al., 2007) • Hemodynamic adaptations: Increased cardiac output Increased blood volume Increased en-diastolic volume Increased stroke volume Reduced heart rate for any submaximal workload • Metabolic adaptations: Increased mitochondrial volume and number Greater muscle glycogen stores Enhanced fat utilitzation Enhanced lactate removal Increased enzymes for aerobic metabolism Increased maximal oxygen uptake • Morphologic adaptations Myocardial hypertrophy (likely only in younger individuals)
  49. 49. 49 For patients with heart disease, the most important physiological benefit of training occur in the skeletal muscle. That is the metabolic capacity of the skeletal muscle is enhanced through increases in mitochondria volume and number, capillary density, and oxidative enzyme content. These adaptations all together, enhance perfusion and the efficiency of oxygen extraction. In addition, exercise training has positive influence on the cardiovascular risk profile (Table 4) and a improvement in both insulin sensitivity and endothelium function. Recent studies also suggest that programs of regular exercise have favourable effects on plasma concentrations of inflammatory risk markers like C-reactive protein and homocysteine (Myers, 2007). Table 4: Changes in risk factors influenced by exercise training (Perk J et al., 2007) • Decrease in blook pressure • Increase in high-density lipoprotein cholesterol level • Reduction in plasma inflammatory risk markers (C-reactive protein, homocysteine) • Augmented weight reduction efforts • Psychological effects: Less depression Reduced anxiety • Improved glucose tolerance • Improved fitness level Empirical studies show that exercise-training result in both lower morbidity and mortality, but there are also other benefits of exercise training. Those who get exercise cardiac rehabilitation, have higher event-free survival rate and a lower hospital readmission rate compared to the controlled
  50. 50. 50 group(Belardinelli et al., 2001). But for more empirical studies on the outcome of exercise training in cardiac rehabilitation go to chapter 2:1:2. 5:3 “Nature and health”: As stated in the Norwegian definition of Friluftsliv, nature is an important part of Friluftsliv: “Friluftsliv includes both dwelling and being physically active in outdoors environment in leisure time, to achieve a change of environment and to experience nature”(my translation) (White Paper no 39 (2000/2001), 2001, p. 11). Here the words “outdoors environment” and “experiencing nature” have the connection to nature. For the purpose of this paper, nature is defined as an organic environment including both wilderness areas and parks in urban environments. Most of the studies in this field focuses on the benefits of contact with nature in park environments for urban-dwelling individuals, and explores the potential of contact with nature for promotion of health. In 1986 WHO published the Ottawa Charter, which identifies the importance of environments supportive of health. The charter also states that the inextricable links between people and their environment represents the basis for a socio-ecological approach to health. The Charter advocates for protection of natural and built environments, and conservation of natural resources as essential in any health promotion strategy. And the central theme has been promotion of health by maximizing the health value of everyday settings, which includes places where people live, work and play (World Health Organization, 1986). This
  51. 51. 51 includes how people in urban, rural and more out in the countryside areas relate to their environment. The idea that contact with nature is good for human health and wellbeing, has been the subject of research in diverse disciplines such as psychology, environmental health, psychiatry, biology, ecology, landscape preferences, horticulture, leisure and recreation, wilderness, and public health policy and medicine. The central notion is that as well as being totally dependent on nature for material needs (food, water, shelter, etc.) is the interacting with nature beneficial, perhaps even essential, to human health and wellbeing (Maller, Townsend, Brown, & Leger, 2002; Wilson, 1984) 5:3:1 Ecopsychology: Ecopsychology integrates ecology and psychology. Among its contributions are the application of psychological principles and practices to environmental education and action. By also bringing ecological thinking and the values of the natural world to psychotherapy and personal growth, it would seem easier to aim for fostering lifestyles that are both ecologically and psychologically healthy. Most of its practitioners and theorists are based in the USA, with a growing movement in Australia, South Africa and the UK. Ecopsychology suggests that there is a synergistic relation between planetary and personal wellbeing. Although only relatively recently adopted in modern western society, Ecopsychology is essentially modern
  52. 52. 52 interpretation of ancient views of humans and nature held by many indigenous peoples. Ecopsychologists believe that disconnection from nature has a heavy cost in impaired health and increased stress (Schroll, 2007). In Ecopsychology there are 3 different models, which explain the positive health effects nature has on people: • The “evolutionary theory” states that, visual patterns of the natural environment are easiest to interpret, because people use their involuntary attention (Kaplan & Kaplan, 1989). This form of attention is preferable and may release negative stress. This assumption is explained by the brain’s pre-programmed preparedness to sort out different stimuli in a natural environment, where man was originally meant to live. The opposite is directed attention, which occurs when humans are bombarded by information from the urban, artificial, environment, which has to be sorted out. This attention requires much energy leading to overloading and negative stress, i.e. easy distraction, difficulties in planning and implementing and to feeling of impatience and irritability (Jernberg, 2001). • The “cultural learning theory”; individuals adapt to the natural environment where grown up, leading to a preference for familiar trees and flowers (Relf, 1992). This statement contributed to the
  53. 53. 53 formulation of the theory of “the living environment” (Grahn, as cited in (Söderback, Söderström, & Schälander, 2004, p. 249). This theory prompted the suggestion that environments should be created to facilitate memories of competence and experience among people with dementia. • The “psycho-evolutionary theory” states that, humans have long adapted positively to nature for survival, and therefore react with positive emotional physiological responses when in natural or nature-related environments (Ulrich, Simons, & Losito, 1991b). This theory has been proved acceptable through several studies (Ulrich et al., 1991b; Ulrich, 1981; Ulrich, 2000; Ulrich, 1984). Many Eco-psychologists have turned to the phenomenology of Merlau- Ponty as a philosophical source for Ecopsychology. One perspective is that Merleau-Ponty’s phenomenology can be used to make people aware of their direct, embodied being in the world. As such, we may well discover more emotional and/or spiritual experiences of the natural world around us (de Jonge, 2002). The American Eco-psychologist, Andy Fisher, emphasizes on being present in our experiences, “…pay attention both to our experience of nature and to the nature in our experience;…)(Fisher, 1999, p. iv). Fisher states that modern society “… lack the contexts necessary to bear our pain and suffering, and so to stay above the healing threshold.”(ibid, p. 299) In his work he refer to the nature as the context, which can enable healing. “Bearing pain is always a matter of placing it in a larger context so that it
  54. 54. 54 both loses its overwhelming power and is given the space it needs to move.”(ibid, p. 303). 5:3:2 Horticultural Therapy Eco-psychologists use different types of practical methods when working with patients. The most used method is Horticultural therapy, but other forms comprise Wilderness therapy, Nature-guided therapy and Animal assisted therapy (Schroll, 2007). The most studied method is Horticultural therapy. Therefore, studies originating from Horticultural Therapy are considered here. Studies from Horticultural Therapy have showed that the experience of nature affects people differently and is largely depending on their life situation (Ottosson & Grahn, 1998a). Figure 4 shows that a person in a life crises is in need for peaceful and non-demanding environments when processing fundamental questions about his life. At the bottom of the pyramid is the directed inwards involvement level where mental power is very weak. The type of physical activity that can be undertaken tends to be private, like walking, picking berries, or collecting wood a short distance into the forest, and disturbances are disliked (Ottosson, 2001).
  55. 55. 55 Figure 4: The x-axel shows the human need for nature and the y-axel shows humans mental state (Stigsdotter & Grahn, 2002) Studies done at the Swedish Agriculture university in Alnarp, show that those green-marked areas who have number of spatial qualities or basic characteristics (table 5) are generally more popular, more appreciated and is visited more often than a green-marked area with only one or few of the basic characteristics (Berggren-Bärring & Grahn, 1995). And the most valuable and health beneficial for stressed and vulnerable people, is if the living environments has the basic character of serene, space, wild, rich in species (plants, trees and animals) and in some cases essence of culture (Grahn, 2005).
  56. 56. 56 Table 5: The eight basic characteristics, which influences the popularity of green areas (Grahn, 1991a) The eight basic Character of the garden room Sketches showing characteristics what the garden rooms might look like 1. Serene Peace, silence and care. Sounds of wind, water, birds and insects. No rubbish, no weeds, no disturbing people. 2. Wild Fascination with wild nature. Plants seem self-sown. Lichen- and moss-grown rocks, old paths. 3. Rich in Species A room offering a variety of species of animals and plants. 4. Space A room offering a restful feeling of “entering another world”, a coherent whole, like a beech forest. 5. The Common A green, open place providing vistas and inviting you to stay. 6. The Pleasure An enclosed, safe and secluded Garden place, where you can relax and be yourself and also experiment and play. 7. Festive A meeting place for festivity and pleasure 8. Culture A historical place offering fascination with the course of time People with access to nearby natural settings have been found to be healthier overall than other individuals. The long-term, indirect impacts of nearby nature also include increased levels of satisfaction with one’s home, one’s job and with life in general (Kaplan et al., 1989). Access to nearby natural setting means to be in interaction with nature on a daily bases, ether by viewing or by being in natural environments.
  57. 57. 57 5:3:2:2 Viewing natural scenes: The healing effects of a natural view is increasingly being understood in stressful situations or environments such as workplaces, hospitals and nursing homes (Lewis, 1996). In these environments, as well as for people who work in windowless offices, studies show that seeing nature is important to people and is an effective means of relieving stress and improving well-being (Lewis, 1996; Kaplan, 1992a). A study examining recovery rates of patients who underwent gall bladder surgery found that those with a natural view recovered faster, spent less time in hospital, had better evaluation form nurses, required fewer painkillers and had less postoperative complications compared with those that viewed an urban scene (Ulrich, 1984). In another study by Ulrich colleagues they compared physiological effects of different natural and urban scenes on subjects who had just watched a stressful film. The physiological data measured in this study, suggests that natural settings elicit a response that includes a component of the parasympathetic nervous system associated with the restoration of physical energy (Ulrich, Dimberg, & Driver, 1991a). Evidence has also been presented to show that even by only watching nature, results in psychological responses like the feeling of pleasure, sustained attention or interest, and diminution of negative emotions, such as anger and anxiety (Rohde & Kendle, 1994).
  58. 58. 58 5:3:2:3 Being in natural environments: Early research found that in the act of contemplating in nature, the brain is relieved of “excess” circulation (or activity) and the nervous system activity is reduced (Yogendra, 1958). Experiencing nature can help strengthen the activities of the right hemisphere of the brain, and restore harmony to the functions of the brain as a whole (Furnass, 1979). Kaplan and Kaplan described restorative environments as those settings that foster recovery from mental fatigue (Kaplan, 1992b). According to their findings and other studies, restorative environments require four elements: • Fascination (an involuntary form of attention requiring effortless interest, or curiosity) • A sense of being away (temporary escape from one’s usual setting or situation) • Extant or scope (a sense of being part of a larger whole) • And compatibility with an individual’s inclinations (opportunities provided by the setting and whether they satisfy the individual’s purpose) (Kaplan et al., 1989; Hartig, Mang, & Evang, 1991). Empirical, theoretical and anecdotal evidence demonstrates that contact with nature positively impacts blood pressure, cholesterol, outlook on life and stress reduction (Kaplan et al., 1989; Ulrich et al., 1991b; Lewis, 1996; Kaplan, 1992a; Rohde et al., 1994; Hartig et al., 1991; Leather, Pyrgas, & Lawrence, 1998; Parsons, Tassinary, Ulrich, Hebl, & Grossman-Alexander, 1998). A study from Norway showed that walking in natural environment
  59. 59. 59 increased the parasympathetic activation, resulting in lower heart rate and lower blood pressure. But this was not the case after similar activity in an urban environment (Laumann, 2004). These outcomes have particular relevance in areas of mental health and cardiovascular disease, categories that are set to be the two biggest contributors to disease worldwide by the year 2020 (Murray & Lopez, 1996). 5:3:3 The use of nature in rehabilitation: There are many examples that natural environments/green areas are used in therapeutic activities. The participants are often elderly, people with different physiological and psychological disabilities, mental illness, mental fatigue or people in need of rehabilitation. Horticultural therapy is a therapy form which includes interventions mediated by nature-oriented views and spaces, such as gardens and everything associated with them, the plants and material related to them, garden tools and garden occupations performed among disabled people for healing and for restoring or improving health and wellbeing or for rehabilitation (Parr, 2005). An outdoor recreation provides an opportunity to increase quality of life and heighten social interaction, and thus helps to enhance community spirit and foster a more socially inclusive society (Scottish Natural Heritage, as cited in (Morris, 2003)). Ryan (1997 as cited in (Morris, 2003)) describes the impact of incorporating therapeutic gardening into reminiscence work for people with dementia, regaining mobility, dexterity and co-ordination after a stroke, to regain confidence and self-esteem.
  60. 60. 60 Studies show that interaction with plants and earth enables sensory stimulation, provides an opportunity to keep warm through activity, and exposes the body to fresh air. It can also help people gain basic and social skills, obtain qualifications, rebuild their lives, and maintain or improve quality of life. It provides something to talk about, a chance for enthusiasts to impart knowledge, it 'humanises' institutions, provides motivation, induces aesthetic satisfaction, status and self-esteem (Ryan, as cited in (Morris, 2003)). Studies have further shown that recreation in parks, healing gardens and in natural environments positively influence health. Moreover, it seems that particularly those with poor general health, benefits the most (Ottosson & Grahn, 1998b). A study composed on effects of Horticulture Therapy on mood and heart rate in patients participating in an inpatient cardiopulmonary rehabilitation program, showed significant lower heart rate and improved mood state after intervention. The study compared patient educational classes supplemented with Horticulture Therapy, and a group given only educational classes. They concluded that given that stress contributes to coronary heart diseases, findings support the role of Horticulture therapy as an effective component of cardiac rehabilitation (Wichrowski, Whiteson, Haas, Mola, & Rey, 2005)
  61. 61. 61 6 Summary The objective of this thesis is to study the potential of Friluftsliv as a method in Cardiac Rehabilitation. The starting point is the high prevalence of cardiovascular diseases (CVD) not only in Norway but also in the rest of the world. The main risk group of CVD are elderly people and their proportion in the society is growing, which means increased incidence of CVD. Reports are also showing increasing incidences of CVD at adulthood. For both groups, the main risk factors are inactivity and overweight, and studies show these two risk factors are on the increase in modern society. And together with higher survival rate, results in a growing need for Cardiac Rehabilitation (CR). Due to economical and organizational reasons, the rehabilitation period at hospital and rehabilitation clinics is shortening. This diminishes the chances that patients adapt to a new lifestyle during rehabilitation, and they are therefore in danger of abandoning the active lifestyle when returning back home. Also, the long distances to rehabilitation clinics in Norway, makes this even more likely to happen. Friluftsliv has developed through the years in a blend with the Norwegian culture and identity. Also the inherent pedagogic and mentoring didactical potential of Friluftsliv mixed with deep ecology, makes Friluftsliv potentially unique in terms of rehabilitation. Friluftsliv is an activity form and is practised in natural or a near natural environment. Friluftsliv is highly valued and is a popular form of recreational activity in Norway. Hence, it seems interesting to look closer at the potential of Friluftliv in CR when patients return back home, from rehabilitation clinics e.g. the Maintenance
  62. 62. 62 phase or phase III of CR. The literature review reveals some Norwegian Friluftliv studies, showing the potential physiological and psychological health benefits of practising Friluftsliv. There is however, a lack of good studies, in particular on the potentially physiological effects of practising Friluftsliv and on the physiological and psychological benefits of dwelling in nature. Therefore in including literature of other related professions like the field of Physical Activity and Health and “Nature and Health” (Figure 3), seem warranted to examine the potential of Friluftsliv. 6:1 “Nature and Health”: In a attempt to examine the field of “Nature and Health” has this thesis looked closely into Ecopsychology and empirical studies conducted on Horticultural Therapy. The main contribution from Ecopsychology in the scheme of this thesis is the active and holistic view of the human-nature relationship. The Ecopsychology states, that it is psychologically damaging for humans to live disconnected from their ecological context. But Ecopsychology also emphasizes direct experience of nature by being bodily active in contact with nature. Ecopsychology turns to Phenomenology in search for a philosophical foundation, and in order to explain the value of human interacting with their environment (Fisher, 1999). Similar statements can be found in Friluftsliv, which focus on the interaction between people and nature. That nature communicates with us, and the experience in nature has something valuable to give to us human beings (Tordsson, 1999).
  63. 63. 63 6:1:1 Therapeutic work in “Nature and Health”: The studies focusing on the practical work in Ecopsychology examine the health effects of working at farms and out in the countryside, and on how animals, plants, and the landscape can be used in recreational or work- related activities for different patient groups. These studies include participants such as psychiatric patients, mentally disabled persons, people with learning disabilities, with burnout problems, people with drug problems, young people, elderly people, and clients of social services. The most common therapeutic form is Horticultural Therapy, which ranges from cultivating plants to appreciation of landscape. Horticultural Therapy (HT) is the most studied therapeutic form within the context of Ecopsychology. Although Friluftsliv includes activities with animals, like horse riding, is the vast majority of the Friluftsliv activities as in HT, concerns direct contact between humans and natural environment. Therefore HT is of interest when examining the potential of Friluftsliv in a rehabilitation setting. Studies on Horticultural Therapy or therapeutic horticultural activities, reveal that it is possible to relieve stress, improve well-being (Kaplan, 1992b; Lewis, 1996) and elicit restoring physical energy (Ulrich et al., 1991a) only by viewing natural scenes. Also studies have shown that by experiencing nature, this can have positive effects on brain function (Furnass, 1979), cholesterol level, and people’s outlook on life (Hartig et al., 1991; Kaplan et al., 1989; Kaplan, 1992b; Lewis, 1996; Parsons et al., 1998) plus lowering heart rate and blood pressure (Laumann, 2004). In the case of

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