Study design of an interdisciplinary and participatory nature-based palliative rehabilitation intervention in a Danish nursing home for people with severe dementia.

BACKGROUND: A limited amount of research has examined how nature-based palliative rehabilitation can be implemented in nursing homes for people with dementia, even though evidence suggests that these gardens are underused. This paper will present the study protocol of an intervention study co-designed in an interdisciplinary collaboration with a nursing home for people with dementia, to develop a tailored nature-based palliative rehabilitation program to increase qualified use of garden with the purpose of promoting a range of health outcomes. METHODS: The study is a single-cased quasi-experimental mixed methods study. The intervention will be developed, designed, and implemented in collaboration with the nursing home, using different co-design tools and methods. The effect of the intervention will be evaluated using the The Neuropsychiatric Inventory Nursing Home version in combination with medication use, a survey on staff burnout, and cameras in the garden to register garden use. A process evaluation with single- and focus group interviews consisting of various stakeholders in the study will be used to gain knowledge on the intervention processes and implementation. DISCUSSION: The paper presents new approaches in the field of palliative rehabilitation for people with dementia using nursing home gardens, through interdisciplinary collaboration, participatory co-design approach and mixed methods design. Using both effect and process evaluation, the study will provide unique insights in the role and importance of participatory process, interdisciplinary collaboration, and tailoring palliative rehabilitation activities in gardens at nursing homes to local needs and wishes. These results can be used to guide other nursing homes and renewal projects in the future. TRIAL REGISTRATION: ISRCTN, ISRCTN14095773 . Registered 15 July 2022-Retrospectively registered.

A nationwide Danish survey on the use of green spaces by people with mobility disabilities.

BACKGROUND: There is increasing awareness of the importance and health benefits of living near green spaces. Research usually focuses on the general population's use of green spaces and there has been little focus on the use of green spaces by specific groups, such as people with mobility disabilities. This represents a significant knowledge gap with regard to facilitating access to healthy green environments by all population groups. This study aims to provide knowledge of the use of green spaces by people with mobility disabilities. METHODS: The study was based on data from the Danish Health and Morbidity Survey in 2005. The study participants consisted of 11,238 adult Danes, 383 of whom reported mobility disabilities, meaning that they were dependent on assistive devices for walking or moving around. Multiple logistic regression analysis was used to investigate the association between mobility disability and use of green spaces. RESULTS: The results show that respondents who reported mobility disabilities visited green spaces less often than respondents without mobility disabilities. The severity of the mobility disability was associated with the frequency of visits. Frequency of visits was also related to the respondents' health-related quality of life status. CONCLUSIONS: These results highlight the need for further research into the constraints faced by people with mobility disabilities with regard to visiting green spaces.

Nature-based biopsychosocial resilience: An integrative theoretical framework for research on nature and health.

Nature-based solutions including urban forests and wetlands can help communities cope better with climate change and other environmental stressors by enhancing social-ecological resilience. Natural ecosystems, settings, elements and affordances can also help individuals become more personally resilient to a variety of stressors, although the mechanisms underpinning individual-level nature-based resilience, and their relations to social-ecological resilience, are not well articulated. We propose 'nature-based biopsychosocial resilience theory' (NBRT) to address these gaps. Our framework begins by suggesting that individual-level resilience can refer to both: a) a person's set of adaptive resources; and b) the processes by which these resources are deployed. Drawing on existing nature-health perspectives, we argue that nature contact can support individuals build and maintain biological, psychological, and social (i.e. biopsychosocial) resilience-related resources. Together with nature-based social-ecological resilience, these biopsychosocial resilience resources can: i) reduce the risk of various stressors (preventive resilience); ii) enhance adaptive reactions to stressful circumstances (response resilience), and/or iii) facilitate more rapid and/or complete recovery from stress (recovery resilience). Reference to these three resilience processes supports integration across more familiar pathways involving harm reduction, capacity building, and restoration. Evidence in support of the theory, potential interventions to promote nature-based biopsychosocial resilience, and issues that require further consideration are discussed.

A Short Mindfulness Retreat for Students to Reduce Stress and Promote Self-Compassion: Pilot Randomised Controlled Trial Exploring Both an Indoor and a Natural Outdoor Retreat Setting.

Here, we developed and examined a new way of disseminating mindfulness in nature to people without meditation experience, based on the finding that mindfulness conducted in natural settings may have added benefits. We evaluated a 5-day residential programme aiming to reduce stress and improve mental health outcomes. We compared an indoor and an outdoor version of the programme to a control group in a pilot randomised controlled trial (RCT). Sixty Danish university students experiencing moderate to high levels of stress were randomised into a residential mindfulness programme indoors (n = 20), in nature (n = 22), or a control group (n = 18). Participants completed the Perceived Stress Scale and the Self-Compassion Scale (primary outcomes) along with additional secondary outcome measures at the start and end of the program and 3 months after. Stress was decreased with small to medium effect sizes post-intervention, although not statistically significant. Self-compassion increased post-intervention, but effect sizes were small and not significant. At follow-up, changes in stress were not significant, however self-compassion increased for both interventions with medium-sized effects. For the intervention groups, medium- to large-sized positive effects on trait mindfulness after a behavioural task were found post-intervention, and small- to medium-sized effects in self-reported mindfulness were seen at follow-up. Connectedness to Nature was the only outcome measure with an incremental effect in nature, exceeding the control with a medium-sized effect at follow-up. All participants in the nature arm completed the intervention, and so did 97% of the participants in all three arms. Overall, the results encourage the conduct of a larger-scale RCT, but only after adjusting some elements of the programme to better fit and take advantage of the potential benefits of the natural environment.

Health promoting outdoor environments--associations between green space, and health, health-related quality of life and stress based on a Danish national representative survey.

AIMS: To investigate the associations between green space and health, health-related quality of life and stress, respectively. METHODS: Data were derived from the 2005 Danish Health Interview Survey and are based on a region-stratified random sample of 21,832 adults. Data were collected via face-to-face interviews followed by a self-administered questionnaire, including the SF-36, which measures eight dimensions of health and the Perceived Stress Scale, which measures self-reported stress. A total of 11,238 respondents completed the interview and returned the questionnaire. Multiple logistic regression analyses were performed to investigate the association between distance to green space and self-perceived stress. RESULTS: Danes living more than 1 km away from the nearest green space report poorer health and health-related quality of life, i.e. lower mean scores on all eight SF-36 dimensions of health than respondents living closer. Respondents living more than 1 km away from a green space have 1.42 higher odds of experiencing stress than do respondents living less than 300 m from a green space. Respondents not reporting stress are more likely to visit a green space than are respondents reporting stress. Reasons for visiting green spaces differ significantly depending on whether or not respondents experience stress. Respondents reporting stress are likely to use green spaces to reduce stress. CONCLUSIONS: An association between distance to a green space and health and health-related quality of life was found. Further, the results indicate awareness among Danes that green spaces may be of importance in managing stress and that green spaces may play an important role as health-promoting environments.

Post-Occupancy Evaluation of a Crisis Shelter Garden and Application of Findings Through the Use of a Participatory Design Process.

OBJECTIVE: This study concerned optimization of an evidence-based crisis shelter garden as a setting for everyday activities and nature-based therapy. The study hereby tested the design guidelines that the garden is based on. BACKGROUND: Design guidelines for gardens intended to support health are becoming increasingly specialized, targeting different user groups. This study contributes to the knowledge concerning health-supporting garden design at crisis shelters for women and children who are exposed to domestic violence. METHOD: The study included a post-occupancy evaluation (POE) consisting of landscape analyses, observation of physical traces, and interviews as well as a subsequent participatory design process. RESULTS: The landscape analyses and the observation of physical traces indicated a minimal level of maintenance and recurrent use being limited to a few areas of the garden. The interviews added nuance and new issues to these results, resulting in the following themes: maintenance, accessibility, safety, therapeutic setting and free space, many ways to play, and social and private spheres. The participatory design process led to an optimization of the garden, including changes to its physical design related to making the garden safer, positively distractive, and more versatile in terms of activities. Improvements were also made regarding policy for use, maintenance, and informing users. CONCLUSION: The design guidelines were tested, and the evidence was strengthened, adding nuance and new issues to consider during further development of the guidelines. Both the POE and the participatory design process were confirmed as crucial aspects of evidence-based health design.

"That Guy, Is He Really Sick at All?" An Analysis of How Veterans with PTSD Experience Nature-Based Therapy.

Serving in the military leads to mental diseases, such as post-traumatic stress disorder (PTSD), for a percentage of soldiers globally. The number of veterans with PTSD is increasing and, although medication and psychological treatments are offered, treatment results could be improved. Historically, different forms of nature-based therapy have been used for this target group. However, in spite of anecdotally good results, studies measuring the effect of this form of therapy are still lacking. The aim of this study is to explore how veterans with PTSD manage their everyday lives during and after a ten-week nature-based intervention in a therapy garden. METHODS: Eight veterans participated in qualitative interviews, which were conducted during a one-year period and were analyzed using interpretative phenomenological analysis (IPA). RESULTS: Five themes emerged from the IPA analysis: Bodily symptoms; relationships; building new identities; the future; and lessons learned. All the participating veterans gained a greater insight into and mastering of their condition, achieved better control of their lives, and developed tools to handle life situations more appropriately and to build a new identity. This improved their ability to participate in social activities and employment. CONCLUSION: The results should be considered in the future treatment of veterans with PTSD.

Environmental Strategies of Affect Regulation and Their Associations With Subjective Well-Being.

Environmental strategies of affect regulation refer to the use of natural and urban socio-physical settings in the service of regulation. We investigated the perceived use and efficacy of environmental strategies for regulation of general affect and sadness, considering them in relation to other affect regulation strategies and to subjective well-being. Participants from Australia, Finland, Germany, Great Britain, Italy, India, the Netherlands, Portugal, and Sweden (N = 507) evaluated the frequency of use and perceived efficacy of affect regulation strategies using a modified version of the Measure of Affect Regulation Styles (MARS). The internet survey also included the Satisfaction with Life Scale (SWLS), emotional well-being items from the RAND 36-Item Health Survey, and a single-item measure of perceived general health. Environmental regulation formed a separate factor of affect regulation in the exploratory structural equation models (ESEM). Although no relations of environmental strategies with emotional well-being were found, both the perceived frequency of use and efficacy of environmental strategies were positively related to perceived health. Moreover, the perceived efficacy of environmental strategies was positively related to life satisfaction in regulating sadness. The results encourage more explicit treatment of environmental strategies in research on affect regulation.

"I look at my own forest and fields in a different way": the lived experience of nature-based therapy in a therapy garden when suffering from stress-related illness.

Evidence confirms that nature-based therapy (NBT) has a positive effect on people with mental illnesses. However, there is a lack of evidence on the meaning of NBT for specific patient groups. The Nacadia® Therapy Garden was designed according to an evidence-based design process, and an NBT programme was developed. The aim of the study was to illuminate the phenomenon of participants' lived experience of the NBT in Nacadia. Fourteen participants took part in semi-structured interviews (SSIs), and by way of reflective lifeworld research, the SSIs were analysed to identify and describe the meanings of the phenomenon. The essence of the phenomenon was found to be a process of adopting a searching approach to NBT and Nacadia to become familiar with the conditions. This familiarity stimulated the development of confidentiality and attachment to Nacadia. Feeling protected, safe, cared for, and not exposed was important, and motivated feelings of freedom, reduced demands, and increased the ability to access and try a spectrum of NBT activities. It encouraged participants to develop personal approaches and coping strategies to implement in their everyday lives for moving on.

It is not all bad for the grey city - A crossover study on physiological and psychological restoration in a forest and an urban environment.

Today, urbanization presents a challenge to urban planning with regard to creating healthy living environments. The aim of this research is to gain further knowledge of the restorativeness of a best case urban and natural environment: that is a historic down town urban environment and forest environment located in an arboretum. The study has a cross-over design where 51 (N) female university students are exposed to the two environments through both seated viewing and walking. A mixed method approach is used with both physiological measurements of blood pressure (BP) and heart rate variability (HRV) and psychological measurements of mood change and perceived restorativeness. The HRV results show no significant differences between the two environments, and both environments are found to be more physiologically restorative than being at the office or on the minibus. The results of the psychological measures indicate that the forest walk has a positive effect on mood, while the walk in the urban environment has no effect. The forest environment is also rated more highly with regard to perceived restorativeness than the urban environment. The results support the current research that shows natural environments as more restorative than urban environments. The study also adds to the ongoing debate on healthy urban planning by indicating that architectural and historical qualities may be associated with the physiological well-being of citizens.

Health-Promoting Nature Access for People with Mobility Impairments: A Systematic Review.

This study systematically evaluated the scientific evidence for health benefits of natural environments for people with mobility impairments. Literature searches based on five categories of terms-target group, nature type, health-related impacts, nature-related activities and accessibility issues-were conducted in four databases (Web of Science, Scopus, CAB ABSTRACT and Medline). Twenty-seven articles from 4196 hits were included in the systematic reviews. We concluded that people with mobility disabilities could gain different health benefits, including physical health benefits, mental health benefits and social health benefits from nature in different kinds of nature contacts ranging from passive contact, active involvement to rehabilitative interventions. Several issues related to the accessibility and use of nature for people with mobility impairments need attention from professionals such as landscape architects, rehabilitative therapists, caregivers and policy makers. The overall quality of methodology of the included studies is not high based on assessment of the Mixed Methods Appraisal Tool (MMAT). Moreover, more randomized controlled trials and longitudinal studies that focus specifically on evidence-based health design of nature for people with mobility impairments in the future are needed.

'Everything just seems much more right in nature': How veterans with post-traumatic stress disorder experience nature-based activities in a forest therapy garden.

Available evidence shows that an increasing number of soldiers are seeking help for post-traumatic stress disorder. The post-traumatic stress disorder condition has big emotional and psychological consequences for the individual, his/her family and the society. Little research has been done to explore the impact of nature-based therapy for veterans with post-traumatic stress disorder although there is a growing amount of evidence pointing towards positive outcome. This qualitative study aims to achieve a deeper understanding of this relationship from the veteran's perspective. Eight Danish veterans participated in a 10-week nature-based therapy. Qualitative interviews were conducted and analysed using the interpretative phenomenological method. The results indicated that the veterans have achieved tools to use in stressful situations and experienced an improvement in their post-traumatic stress disorder symptoms.