The impact of gardening on mental resilience in times of stress: A case study during the COVID-19 pandemic in Singapore.

To curb the spread of Covid-19, Singapore, like other cities, had to impose movement restriction and social distancing measures that may affect the well-being of its residents. In this paper, we assessed the potential benefits of gardening on the mental well-being of Singapore residents, based on the concept of mental resilience. We hypothesized that gardening activities promote mental resilience. A survey was administered on 8,786 participants of a "Gardening with Edibles" programme, measuring their mental resilience status, engagement in gardening activities and socio-demographic information. The mental resilience scores of participants who engaged in weekly gardening were compared with the scores derived from another survey conducted during the pandemic on an online community comprising demographically representative respondents with an interest on Covid-19 related community care. The results showed that the mental resilience of those who gardened was statistically significantly higher than the online community. Within the gardening group, those with less than one hour of weekly gardening time had significantly lower scores in their total mental resilience, and five out of seven resilience factors, "emotional regulation", "relationship", "confidence", "positive thinking" and "spirituality", compared to those with more weekly gardening time, showing that the efficacy of the mediating effects may peak at a weekly gardening time of between one to four hours. Home gardening may be an effective way for people living in densely populated cities to interact with nature and build mental resilience during the pandemic.

Associations of park access, park use and physical activity in parks with wellbeing in an Asian urban environment: a cross-sectional study.

BACKGROUND: Relationships between park access, park use, and wellbeing remain poorly understood. The objectives of this study were to investigate: (1) perceived and objective park access in relation to park use and physical activity in parks; and; (2) perceived and objective park access, park use and physical activity in parks and their associations with wellbeing. METHODS: An interviewer-assisted survey collected data on perceived time to walk to parks, park use time, park physical activity time and wellbeing (using a scale containing nine domains) amongst adult participants of the Singapore Multi-Ethnic Cohort. Geospatial maps of parks and the "walkable" street networks were created for the city-state of Singapore to objectively determine distances to accessible points on park boundaries. Multiple linear regression models estimated the importance of park access to park use and associations of park access and park use with wellbeing, adjusting for potential confounders. RESULTS: Participants' (n = 3435) average age was 48.8 years (SD, 12.8), 44.8% were male and 72.6% were of Chinese ethnicity. Better perceived but not true park access was significantly associated with greater park use. Park access (perceived or true) was not associated with physical activity time in parks. Greater participant park time and physical activity time in parks were associated with higher wellbeing scores (p < 0.001). The differences in wellbeing scores between the reference groups, who spent negligible time in parks, and the highest quartiles of time in parks (10.8 h/month) and physical activity in parks (8.3 h/month) were 3.2 (95% CI 2.1-4.4) and 4.2 (95% CI 4.1-6.3) points out of 100 respectively. These associations were similar for most domains of wellbeing, with clear dose-response relationships. CONCLUSIONS: While perceived park access was strongly associated with park use and well-being, true park access was not, and neither park access measure was associated with park physical activity. Future studies could investigate the influence of park attributes on park use, physical activity in parks and wellbeing. The consistent associations of park use and particularly physical activity in parks with wellbeing suggest that promoting park use, and especially physical activity in parks, is a promising strategy for improving wellbeing in urban settings.

Activity in nature mediates a park prescription intervention's effects on physical activity, park use and quality of life: a mixed-methods process evaluation.

BACKGROUND: This process evaluation explored the implementation and mechanisms of impact of a Park Prescription Intervention trial (PPI), including the effects of hypothesised mediators (motivation, social support, recreational physical activity [PA], park use and park PA) on trial outcomes. METHODS: Participants from the community were randomly allocated to intervention (n = 80) or control (n = 80) group. The intervention included baseline counselling, a prescription of exercise in parks, materials, three-month follow-up counselling and 26 weekly group exercise sessions in parks. Process evaluation indicators were assessed at three- and six-months. Implementation indicators included participation rates in intervention components and survey questions plus focus group discussions (FGDs) to understand which components participants valued. FGDs further assessed barriers and facilitators to intervention participation. To explore mechanisms of impact, linear regression was used to compare objectively measured PA between quantiles of group exercise participation. Structural equation modelling (SEM) explored hypothesised mediation of the significant intervention effects. Framework analysis was conducted for FGDs. RESULTS: Participants were middle-aged (mean 51, SD ± 6.3 years), predominantly female (79%) and of Chinese ethnicity (81%). All intervention participants received baseline counselling, the park prescription and materials, whilst 94% received the follow-up counselling. Mean minutes of moderate-to-vigorous PA/week (95% CI) differed by group exercise participation (p = 0.018): 0% participation (n = 18) 128.3 (69.3, 187.2) minutes, > 0-35.9% participation (n = 18) 100.3 (36.9, 163.6) minutes, > 35.9-67.9% participation (n = 17) 50.5 (- 4.9, 105.9) minutes and > 67.9% participation (n = 18) 177.4 (122.0, 232.8) minutes. Park PA at three-months had significant mediating effects (95% CI) on recreational PA 26.50 (6.65, 49.37) minutes/week, park use 185.38 (45.40, 353.74) minutes/month, park PA/month 165.48 (33.14, 334.16) minutes and psychological quality of life score 1.25 (0.19, 2.69) at six-months. Prioritising time with family and preferences for unstructured activities were barriers to intervention participation. Human interaction via follow-up or group exercise were facilitators. CONCLUSION: This process evaluation showed park PA consistently mediated effects of the PPI, suggesting activity in parks was a mechanism of its effects. To optimise effectiveness, participants' preference for prioritising time with family through family involvement and tailoring the intervention to participants' preferences for structured or unstructured PA could be considered in future studies. TRIAL REGISTRATION: ClinicalTrials.gov NCT02615392 , 26 November 2015.

Effectiveness of prescribing physical activity in parks to improve health and wellbeing - the park prescription randomized controlled trial.

BACKGROUND: Programs promoting population health through physical activity (PA) and exposure to nature are popular, but few have been evaluated in randomized-controlled trials (RCTs). OBJECTIVE: To investigate the effectiveness of a park prescription intervention (PPI) for improving total moderate-to-vigorous PA (MVPA), other PA related behaviors, quality of life (QoL) and cardio-metabolic health among adults. METHODS: Healthy individuals aged 40 to 65 years were recruited through community health screenings and randomly assigned to 1) PPI: face-to-face Park Prescription + invitation to weekly exercise sessions in parks, or 2) control: standard PA materials. After the six-month intervention, participants completed accelerometer assessments, questionnaires on health behaviors and QoL, and health screenings. Independent sample t-tests were used to compare outcomes between groups, with secondary analysis adjusted for co-variates via multiple linear regression. A p-value <0.05 was considered statistically significant. RESULTS: Eighty participants were allocated to each group. Participants with mean age of 51.1 (Standard Deviation: 6.3) years were predominantly female (79%) and of Chinese ethnicity (81%). Participation in the group exercise started at 48% and declined to 24% by week 26. At six-months, 145 (91%) participants attended health screenings for outcome measure collection, and 126 (79%) provided valid accelerometer data. Time spent in MVPA favored the PPI group but this difference was not statistically significant (4.4 (- 43.8, 52.7) minutes/week; when removing 2 extreme outliers 26.8 (- 9.7, 63.4) minutes/week). Time spent in parks (147.5 (2.1, 292.9) minutes/month), PA in parks (192.5 (59.5, 325.5) minutes/month), and recreational PA (48.7 (1.4, 96.0) minutes/week) were significantly greater in the PPI group. PPI also significantly improved psychological QoL (4.0 (0.0, 8.0). DISCUSSION: PPI improved park use, PA in parks, recreational PA, and psychological QoL but not total MVPA. Future RCTs' are warranted to investigate PPI in different target populations and to provide further evidence for improvements in health outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT02615392, 26 November 2015.

Effects of horticultural therapy on elderly' health: protocol of a randomized controlled trial.

BACKGROUND: Due to a rapidly ageing population in the world, it is increasingly pertinent to promote successful ageing strategies which are cost-effective, easily accessible, and more likely to be acceptable to the elderly. Past research associates exposure to natural environments and horticultural therapy (HT) with positive psychological, social and physical health benefits. This Randomized Controlled Trial (RCT) is designed to evaluate the efficacy of HT in promoting Asian elderly' mental health, cognitive functioning and physical health. METHODS/DESIGN: 70 elderly participants aged 60 to 85 years old will be randomized to participate in either the active horticultural therapy group or be in the waitlist control. Sessions will be weekly for 12 weeks, and monthly for 3 months. Mental health will be assessed through self-reports of depressive and anxiety symptomatology, life satisfaction, social connectedness and psychological well-being, collaborated with immunological markers. Outcome measures of cognitive functioning and physical health include neuropsychological tests of cognitive function and basic health screening. Outcomes will be assessed at baseline, 3 months and 6 months post-intervention. DISCUSSION: This RCT comprehensively investigates the efficacy of a non-invasive intervention, HT, in enhancing mental health, cognitive functioning and physical health. The results have tremendous potential for supporting future successful ageing programs and applicability to larger populations. TRIAL REGISTRATION: ClinicalTrials.gov NCT02495194 . Trial registration date: July 13, 2015. Retrospectively registered.

Features of urban green spaces associated with positive emotions, mindfulness and relaxation.

There is an established consensus among researchers that contact with nature improves mental health, wellbeing, and quality of life in urbanised environments. Studies tend to examine the health impacts of nature without identifying specific physical and spatial landscape features that could guide health-promoting design of urban green spaces. A growing body of evidence suggests that landscape features described in the Contemplative Landscape Model (CLM) can be used to measure therapeutic value of urban landscapes. CLM assesses urban landscapes across seven sub-scales: Layers of the Landscape, Landform, Vegetation, Color and Light, Compatibility, Archetypal Elements and Character of Peace and Silence. We exposed 74 healthy adults to six urban landscapes in laboratory (video representations) and naturalistic outdoor settings. We explored the associations between the visual quality of urban landscapes annotated with CLM, with self-reported positive emotions and brain activity consistent with mindfulness (Theta waves), relaxation (Alpha waves) and attention restoration (Beta waves), and differences between laboratory and naturalistic setting. CLM scores predicted self-reported Valence and Arousal, and low frequency power bands: Alpha and Theta in the naturalistic setting. Landscape features showing the strongest associations were Character of Peace and Silence, Layers of the Landscape and Archetypal Elements. Alpha, Theta brain reactivity and Arousal scores, were significantly different between laboratory and naturalistic settings (p < 0.05), while Valence scores between those settings were statistically identical (p = 0.22). Self-reported Valence and Arousal, but not brain activity, were significantly associated with the majority of landscape features in the laboratory setting. The results of the study provide guidelines on the urban landscape features most beneficial for human health, to inform urban green space design.

Therapeutic Garden With Contemplative Features Induces Desirable Changes in Mood and Brain Activity in Depressed Adults.

The therapeutic values of contact with nature have been increasingly recognized. A growing body of evidence suggests that a unique subcategory of "contemplative landscapes" is particularly therapeutic. Previous studies predominantly focused on observational designs in non-clinical populations. It is not known if these effects can be extrapolated to populations suffering from depression, and experimental designs need to be utilized to establish causality. We examined the effects of in-situ passive exposure to three urban spaces on brain activity, namely a Therapeutic Garden with high Contemplative Landscape scores (TG), Residential Green (RG) and Busy Downtown (BD), and self-reported momentary mood in adults aged 21-74 (n = 92), including 24 clinically depressed and 68 healthy participants. Portable, multimodal electroencephalography (EEG) and functional near-infrared spectroscopy (fNIRS) systems were used to record brain activity, and a Profile of Mood States (POMS) questionnaire was used to record mood before and after exposure. We tested the interactions between the site, time and group for the mood, and between site and group for the neuroelectric oscillations and brain hemodynamics. Self-reported pre- post-mood was significant only at the TG (p = 0.032) in both groups. The lowest Total Mood Disturbance (TMD) was reported at TG and the highest in BD (p = 0.026). Results from fNIRS indicated marginally significant lower oxy-Hb in the frontal region at TG as compared to BD (p = 0.054) across both groups. The marginally significant effect of site and group was also observed (p = 0.062), with the Clinical group showing much lower oxy-Hb at TG than Healthy. The opposite pattern was observed at BD. EEG results showed differences between Healthy and Clinical groups in the Frontal Alpha Asymmetry (FAA) pattern across the sites (p = 0.04), with more frontal alpha right in the Clinical sample and more left lateralization in the Healthy sample at TG. Temporal Beta Asymmetry (TBA) analyses suggested that patients displayed lower bottom-up attention than Healthy participants across all sites (p = 0.039). The results suggest that both healthy and depressed adults benefitted from exposure to TG, with possibly different pathways of mood improvement. Visiting therapeutic nature with contemplative features may provide valuable support for the treatment of depression in clinical populations and a self-care intervention in non-clinical populations.

The influence of the COVID-19 pandemic on the demand for different shades of green.

COVID-19 has heightened the dependence of urban dwellers on cultural ecosystem services provided by urban green spaces (UGS), specifically in regard to the provision of recreational opportunities, and psychological and physical health benefits arising from their use.As different types and levels of cultural ecosystem services are provided by different types of UGS, people may seek out different UGS to satisfy personal needs over various phases of COVID-19 mobility restrictions imposed by cities. We report on a study that took advantage of the different phases of COVID-19 mobility restrictions to assess the demand for and perception of different types of UGS in Singapore.The study utilised four datasets to compare demand for and visitorship patterns of UGS before the pandemic (Pre-Circuit Breaker), the duration of the strictest mobility restrictions (Circuit Breaker), and after the measures were relaxed (Post-Circuit Breaker). We used Google Search trends as a proxy for UGS demand, Google mobility data for an overview of population visitorship trends, visitor counts for granular insights on actual visitorship trends, and qualitative data on perception of parks by park visitors after restrictions eased. Parks were categorised as manicured and less manicured UGS for analysis.Search interest for UGS overall fell by more than 50% from during Circuit Breaker but the post-Circuit Breaker levels exceeded pre-Circuit Breaker, with a 70.9% increase for less manicured UGS compared to 20.8% for manicured UGS. This corroborated with Google mobility and visitor counts, which showed a steep decrease in park use followed by a rapid increase in the same periods, and with increased visitorship in the less manicured UGS. The perception study also showed that more than 50% of respondents reported visiting parks that they have never visited before, and there was a greater appreciation and use of UGS after the pandemic and preference for less manicured and more naturalistic landscapes.The pandemic has heightened the demand for cultural ecosystem services provided by UGS. Our study showed that this demand is not uniform across different types of UGS, with an increase visitorship and preference for less manicured green spaces. Read the free Plain Language Summary for this article on the Journal blog.

Associations of park features with park use and park-based physical activity in an urban environment in Asia: A cross-sectional study.

Park use is associated with health, yet our understanding of park features related to their use is limited. Singapore's parks were audited for 30 micro-features, then geospatial analysis characterized micro-features scores for parks nearest to participants' homes. Adults (3,435) reported their park use and park-based physical activity. Using linear regression models, we found living near a park with higher micro-features scores was associated with more time in parks and park-based physical activity. Specific micro-features were associated with more park time (wildlife areas, water features, forested areas, unpaved trails (2-2.6 h/month, p < 0.05)) and with physical activity in parks (water features, forested areas, large playground, open green spaces (1.8-2.2 h/month, p < 0.05)). These findings could inform parks planning to support population-health.

Horticultural Therapy Reduces Biomarkers of Immunosenescence and Inflammaging in Community-Dwelling Older Adults: A Feasibility Pilot Randomized Controlled Trial.

BACKGROUND: With the challenges that aging populations pose to health care, interventions that facilitate alleviation of age-related morbidities are imperative. A prominent risk factor for developing age-related morbidities is immunosenescence, characterized by increased chronic low-grade inflammation, resulting in T-cell exhaustion and senescence. Contact with nature and associated physical activities have been shown to boost immunity in older adults and may be promoted in the form of horticultural therapy (HT). We aimed to examine the effects of HT on immunosenescence. METHOD: We conducted a randomized controlled trial with 59 older adults assigned to either the HT intervention or waitlist control group. Older adults in the HT intervention group underwent HT intervention program over 6 months. Venous blood was drawn at baseline and at the third and sixth month from the commencement of this study. For participants who attended all 3 blood collection time points (HT: n = 22; waitlist: n = 24), flow cytometry analysis was performed on whole blood samples to evaluate the kinetics of lymphocyte subsets over the intervention period, revealing the composition of CD4+ and CD8+ subsets expressing exhaustion markers-CD57, CTLA4, and KLRG1. Enzyme-linked immunosorbent assays were employed to measure changes in plasma IL-6 levels. RESULTS: HT is associated with increased numbers of naive CD8+ T cells and fewer CTLA4-expressing terminally differentiated effector CD4+ and CD8+ memory T cells re-expressing CD45RA (TEMRA). Furthermore, IL-6 levels were reduced during HT, and the frequencies of naive and TEMRA CD8+ T cells were found to be associated with IL-6 levels. CONCLUSION: HT is associated with a reduction in the levels of biomarkers that measure the extent of T-cell exhaustion and inflammaging in older adults. The positive effects of HT on T-cell exhaustion were associated with the reduction of IL-6 levels.

Can Exposure to Certain Urban Green Spaces Trigger Frontal Alpha Asymmetry in the Brain?-Preliminary Findings from a Passive Task EEG Study.

A growing body of evidence from observational and experimental studies shows the associations between exposure to urban green spaces (UGSs) and mental health outcomes. Little is known about which specific features of UGS that might be the most beneficial. In addition, there is potential in utilizing objective physiological markers of mental health, such as assessing brain activity, but the subject requires further investigation. This paper presents the preliminary findings from an on-going within-subject experiment where adult participants (n = 22; 13 females) were passively exposed to six landscape scenes within two UGSs (a park and a neighborhood green space) and three scenes of a busy urban downtown (control site). The landscape scenes were pre-selected based on their contemplative landscape score (CLS) to represent different levels of aggregation of contemplative features within each view. Participants went to each of the sites in a random order to passively view the scenes, while their electroencephalography (EEG) signal was being recorded concurrently. Frontal alpha asymmetry (FAA) values, commonly associated with the approach-related motivation and positive emotions, were extracted. The preliminary results show trends for the main effect of site on FAA, suggestive of stronger FAA in park compared to the control site, akin to more positive mood. There was also a trend for the interaction between the site and scene, which suggests that even within the individual sites, there is variability depending on the specific scene. Adjusting for environmental covariate strengthened these effects, these interim findings are promising in supporting the study hypothesis and suggest that exposure to urban green spaces may be linked to mental health outcomes.

Nature-based activities improve the well-being of older adults.

Current literature shows that interaction with urban greenery can have a wide range of positive health outcomes. Targeted nature-based programs, such as therapeutic horticulture, have been shown to result in multiple health benefits for older adults residing in temperate environments, but much less research has been carried out on populations with different phenotypes, such as older Asian adults in the tropics. The current study investigated the effects of a 24-session therapeutic horticulture program on 47 older participants in Singapore, with an experimental pretest posttest design. We found that participants maintained healthy sleep patterns and psychological health, as well as showed reduced anxiety and improved cognitive functioning (p < 0.05). In addition, they reported an increase in mean happiness score after each session. This study provides new evidence using a comprehensive set of indicators across the affective, cognitive, functional, psychosocial and physical domains, supporting current literature on the benefits of nature programs, with a novel focus on tropical environments. It provides evidence that the nature-based intervention has the potential to be translated to programs to benefit older adults in the tropics.

The Park Prescription Study: Development of a community-based physical activity intervention for a multi-ethnic Asian population.

This mixed-methods study aims to inform the development of a 'Park Prescription' intervention, including face-to-face counseling on physical activity and park use and providing weekly structured exercise sessions in the park to promote physical activity. Participants aged 40-65 years were recruited from regional health screening events in Singapore where they completed a questionnaire (N = 97) and consented to focus group (FG) participation (N = 16). The questionnaire assessed current park use, and the type, duration, and intensity of park-based activities that would be of interest. FGs explored the barriers and facilitators of physical activity (in parks). Short interviews (N = 16) with 'doers', i.e., people already engaging in park-based physical activity, identified motivational factors and ways to overcome common barriers. Participants acknowledged the health benefits of parks and valued them because of their pleasant landscapes, greenery and facilities. However, few participants engaged in physical activity at the parks, because they were too busy or too tired. Participants mostly indicated doing informal activities, such as walking, cycling or playing traditional Asian games when using the parks for exercise. A variety of low-to-moderate intensity park-based activities such as walking, cycling or aerobics were of interest to participants who expressed the willingness to engage in structured exercise sessions on weekday evenings or weekend mornings. Strategies to increase physical activity in parks included: encourage planning, create social support, identify alternatives for bad weather, improve proximity/accessibility to parks and park safety. The effectiveness of the Park Prescription intervention in promoting physical activity, park use, as well as physical and mental well-being will be tested in a one-year Randomized Controlled Trial.

Prescribing Physical Activity in Parks to Improve Health and Wellbeing: Protocol of the Park Prescription Randomized Controlled Trial.

Previous studies in primary care settings showed that brief advice prescribing physical activity for inactive patients could be an effective way to promote physical activity. Park prescription interventions confer health benefits associated with exposure to nature and increased physical activity by recommending park use specifically to increase physical activity in parks. The purpose of this trial is to evaluate the effectiveness of a park prescription intervention for increasing time spent in moderate-to-vigorous physical activity (MVPA) assessed by accelerometry. Middle-aged Singaporeans who were insufficiently active and who met health screening criteria were recruited via existing community health screening programs and allocated to one of two groups. Intervention participants received a prescription of physical activity in parks, an information pack, access to a weekly group exercise program in parks and telephone counselling (n = 80). Control participants received physical activity materials (n = 80). The primary outcome (mean difference between both groups in time spent in MVPA minutes per week measured by accelerometer) will be assessed at six months. Secondary outcomes include self-reported health behaviors, self-reported mental wellbeing and objectively-measured physical health. This is the first randomized controlled trial investigating the effectiveness of a park prescription intervention for increasing health-enhancing MVPA.

Effects of Horticultural Therapy on Asian Older Adults: A Randomized Controlled Trial.

The effect of horticultural therapy (HT) on immune and endocrine biomarkers remains largely unknown. We designed a waitlist-control randomized controlled trial to investigate the effectiveness of HT in improving mental well-being and modulating biomarker levels. A total of 59 older adults was recruited, with 29 randomly assigned to the HT intervention and 30 to the waitlist control group. The participants attended weekly intervention sessions for the first 3 months and monthly sessions for the subsequent 3 months. Biological and psychosocial data were collected. Biomarkers included IL-1ß, IL-6, sgp-130, CXCL12/SDF-1α, CCL-5/RANTES, BDNF (brain-derived neurotrophic factor), hs-CRP, cortisol and DHEA (dehydroepiandrosterone). Psychosocial measures examined cognitive functions, depression, anxiety, psychological well-being, social connectedness and satisfaction with life. A significant reduction in plasma IL-6 level (p = 0.02) was observed in the HT intervention group. For the waitlist control group, significant reductions in plasma CXCL12 (SDF-1α) (p = 0.003), CXCL5 (RANTES) (p = 0.05) and BDNF (p = 0.003) were observed. A significant improvement in social connectedness was also observed in the HT group (p = 0.01). CONCLUSION: HT, in reducing plasma IL-6, may prevent inflammatory disorders and through maintaining plasma CXCL12 (SDF-1α), may maintain hematopoietic support to the brain. HT may be applied in communal gardening to enhance the well-being of older adults.

Prefrontal cortical activation while viewing urban and garden scenes: A pilot fNIRS study.

Recent studies have shown that pleasant and unpleasant emotions could be detected through functional Near-Infrared Spectroscopy (fNIRS). This study investigates the prefrontal cortical activation in human subjects while they were viewing urban and garden scenes. A multi-channel continuous wave fNIRS system was used to record the prefrontal cortical activations from seven subjects. During the data collection, the subjects viewed 40 trials of video clips. In each trial, the subjects viewed a video of randomized urban or garden scenes for 30s followed by 30s of idle scene which showed a dark blue progress bar on black background on the screen. NIRS-SPM is employed to work out the changes of hemoglobin response and the prefrontal cortical activations were generated using group analysis based on the contrasts of urban versus idle, garden versus idle and urban versus garden. The activation for the contrast of urban versus garden showed an increase of oxy-hemoglobin on the right area of the prefrontal cortex with p <; 0.05. This preliminary result showed that the garden scene might provide a pleasant and less stressful experience as compared to the urban scene for subjects. This suggests the possibility of using a NIRS-based Brain-Computer Interface to detect subject preferences of different scenes.