Fine-tuning the practical relevance of a quality framework for integrated nature-based interventions in healthcare facilities. A qualitative interview study.

Introduction: Integrated nature-based interventions in healthcare facilities are gaining importance as promising health and biodiversity promotion strategies. This type of interventions combines the restoration of biodiversity in the vicinity of the healthcare facility with guiding patients in that natural environment for health outcomes. However, quality appraisal of these interventions is still poorly developed. Based on a recent scoping review, the authors developed a preliminary quality framework in support of healthcare facilities designing, implementing and evaluating integrated nature-based interventions. This present study aims to fine-tune the practical relevance of the quality framework within the emerging practice. Methods: A qualitative interview study was conducted in seven healthcare facilities in Belgium. Using a combination of snowball and purposive sampling, 22 professionals, involved in the integrated nature-based intervention in their facility, participated in the study. The semi-structured interviews were transcribed and imported into NVivo. A deductive and inductive thematic analysis was used to explore the practical relevance of the quality framework. A stakeholders' assembly review and a member checking of the findings were also part of the study. Findings: Twenty-two interviews with nature management coordinators, healthcare professionals, and healthcare managers were conducted by three principal investigators in seven healthcare facilities implementing integrated nature-based interventions. The contextualization and complexity of integrated nature-based interventions in the participating healthcare facilities demonstrated the need for an evidence-based quality framework describing nature-based interventions. The study led to nine quality criteria, confirming the eight quality criteria derived from a previous scoping review, and the identification of a new quality criterion 'Capacity building, leverage and continuity'. These quality criteria have been refined. Finally, a proposal for a quality framework was developed and operationalized in a checklist. Deployment of the quality framework should be embedded in a continuous cyclical, adaptive process of monitoring and adjusting based on evaluations at each phase of an integrated nature-based intervention. Discussion: Bridging the domains of healthcare and nature management in the context of an integrated nature-based intervention in a healthcare facility requires a transdisciplinary approach. Scientific frameworks such as "complex interventions," Planetary Health and One Health can support the co-design, implementation and evaluation of integrated nature-based interventions within a cyclical, adaptive process. In addition, the importance of the quality of the interactions with nature could gain from more sophisticated attention. Finally, the implications for healthcare facilities, policymakers and education are discussed, as well as the strengths and limitations of the study.

Effect of Therapeutic Gardening Program in Urban Gardens on the Mental Health of Children and Their Caregivers with Atopic Dermatitis.

This study was conducted to identify the physical and psychological difficulties of children with atopic dermatitis and their caregivers, and to investigate the effects of participation in a novel therapeutic gardening program based on psychological intervention on their physical and mental health. The program, consisting of 15 sessions, was conducted for approximately 4 months in urban gardens in Seoul and involved 30 children with atopic dermatitis and their caregivers. Additionally, a control group of 30 non-participating caregivers was recruited for comparative analysis. The psychological and emotional changes in caregivers were assessed using six self-report scales (depression, anxiety, stress, vitality, life satisfaction, parenting efficacy) before and after participation in the program. Additionally, the depression index (CDI) and atopic dermatitis index (SCORAD, TEWL) were measured for the children with atopic dermatitis. The research results indicate that the therapeutic gardening program utilizing psychological intervention had a positive impact on the physiological and psychological health of participants. These results are significant as they demonstrate the clinical application of the professionally developed therapeutic gardening program through active intervention and operation. This study suggests that this program can serve as an effective intervention in improving the mental health of both children with atopic dermatitis and their caregivers.

Smart Anklet Use to Measure Vascular Health Benefits of Preventive Intervention in a Nature-Based Environment-A Pilot Study.

The present study aimed to investigate the associations between nature-based intervention and peripheral pulse characteristics of patients with PAOD using new smart technology specifically designed for this purpose. A longitudinal panel study performed between 1 January 2022 and 31 December 2022 included 32 patients diagnosed with peripheral arterial occlusive disease (PAOD) who were treated in the vascular surgeons' hospital "Dobb" in Valjevo. These patients were exposed for six months to moderate-intensity physical activity (MPA) in a nature-based environment. They practiced 150 to 300 min of walking 6 km/h and cycling activities (16-20 km/h) weekly as recommended for patients with chronic conditions and those living with disability. Univariate logistic regression analysis was used to identify factors associated with major improvements in peripheral pulse characteristics of patients with PAOD. After six months of MPA, half of the patients (50%, 16/32) achieved minor, and half of them major improvements in peripheral pulse characteristics. The major improvements were associated with current smoking (OR = 9.53; 95%CI = 1.85-49.20), diabetes (OR = 4.84; 95%CI = 1.09-21.58) and cardiac failure, and concurrent pulmonary disease and diabetes (OR = 2.03; 95%CI = 1.01-4.11). Our pilot study showed that patients with PAOD along with other chronic conditions and risk factors benefited more from continuous physical activity in a nature-based environment.

Stakeholders' perceptions of value of nature-based interventions in promoting health in people with stress-related illness: a qualitative study.

Stress-related illness is a common and increasing cause for sick leave in Sweden. Spending time in nature reduces stress and promotes health and well-being. Accordingly, nature-based interventions (NBI) for people with stress-related illness have been developed and implemented in southern Scandinavia; however, such interventions are uncommon in the Circumpolar North. Previous studies have examined the effects and experiences of participating in NBI, but research about different stakeholders' perspectives on NBI is lacking. The aim of this study was to explore different key stakeholders' perceptions of the value of NBI in promoting health in people with stress-related illness. Data were collected through semi-structured interviews with 11 persons with stress-related illness experience, 14 healthcare professionals, and 11 entrepreneurs offering NBI. Qualitative content analysis resulted in four categories: Providing opportunity for recovery, Offering new perspectives and opportunity for reflection, Empowering balance and control in life, and Enabling one to overcome barriers. Although the study was conducted in a region where NBI is not widely implemented, the different stakeholders expressed similar perceptions of the value of NBI, indicating that NBI may be a valuable complement to health care which reaches people with stress-related illness needs and promotes their health.

A qualitative study of the barriers to commissioning social and therapeutic horticulture in mental health care.

BACKGROUND: Social and Therapeutic Horticulture (STH) is a process where trained practitioners work with plants and people to improve an individual's physical and psychological health, communication and thinking skills. Evidence suggests that STH can support individuals with mental ill-health, however, current commissioning of STH within mental health care is limited. This study aimed to understand the barriers to commissioning STH in mental health care and to identify potential solutions to barriers, to support more widespread availability of services.  METHODS: Individuals with a role in mental health care commissioning from across the UK were invited to take part in semi-structured interviews via zoom. Interviews explored factors influencing the mental health services they commission or refer to, their perception of the role of STH in mental health care and the barriers to commissioning STH, together with potential solutions to any barriers identified. RESULTS: Commissioners identified a lack of knowledge of STH and evidence of its effectiveness, and a culture which prioritises traditional medical models, as barriers to commissioning. Challenges for STH providers in responding to large-scale commissioning requirements were also highlighted as a barrier. CONCLUSIONS: To upscale commissioning of STH in mental health care, STH interventions need to be embedded within NHS priorities and information on STH services and their effectiveness needs to be easily accessible to practitioners. The sector should also be supported in working collaboratively to enable commissioning of services at scale.

Nature-Based Group Exercises for People With Arthritis: A Qualitative Along-Side Interview Study of Lived Experiences.

Arthritis affects many individuals and can cause pain and limit physical functioning. Exercise is an important treatment option for individuals with arthritis; however, adherence to exercise programs can be challenging. A new initiative in Denmark has introduced nature-based exercises for patients with arthritis. This qualitative study aimed to explore the experiences of the individuals who participated in those exercises. The study used a hermeneutic-phenomenological approach and conducted along-side interviews with 12 women and three men who participated in nature-based exercise programs for arthritis. Analysis of the data revealed two main themes. The first theme highlighted the positive effects of being in nature, such as increased vitality, reduced pain, and a sense of well-being. The second theme emphasized the social benefits of participating in these exercises, including a sense of connection and community with others. Overall, this study suggests that incorporating nature-based exercises in treatment programs for arthritis could have significant benefits for individuals with this condition.

Forest Therapy as a Nature-Based Intervention: An Option for Neurological Rehabilitation?

BACKGROUND: Forest therapy demonstrates positive effects on mood, immune system, stress levels, and general well-being. Studies on depression, stress-related illnesses, sleep disorders, and arterial hypertension have provided evidence-based proof of this. SUMMARY: The aim of this review was to examine the possible effects of forest therapy with regard to its evidence in the treatment of chronic neurological diseases such as stroke in the rehabilitation phase, Parkinson's disease, dementia, and multiple sclerosis. Therefore, the electronic databases Medline, Scopus, and Cochrane were searched for such clinical trials for the years 1970 to mid-2023 without language restriction. The literature search revealed only few studies with positive indications but too few cases to be able to make generalizable evidence-based statements. In terms of improvement in the Hamilton Depression Scale analysis of two studies in stroke patients showed slight benefits in the forest therapy group (standard mean difference -0.43; 95% CI: -0.76 to -0.10; p < 0.01). One observational study revealed a higher rate of stroke survival in patients living in marked greenness. Few nature-based interventions in dementia patients showed certain benefits in particular details. KEY MESSAGES: There are no evidence-based results on the benefit of forest therapy for chronic neurological diseases. However, there are hints that forest therapy could have a positive benefit. Therefore, a proposal for forest therapy as a component of multimodal neurological rehabilitation is presented.Die Waldtherapie zeigt positive Auswirkungen auf die Stimmung, das Immunsystem, das Stressniveau und das allgemeine Wohlbefinden. Studien zu Depressionen, stressbedingten Erkrankungen, Schlafstörungen und arteriellem Bluthochdruck haben dies evidenzbasiert belegt.Ziel dieser Übersichtsarbeit war es, die möglichen Wirkungen der Waldtherapie im Hinblick auf ihre Evidenz bei der Behandlung chronischer neurologischer Erkrankungen wie Schlaganfall in der Rehabilitationsphase, Morbus Parkinson, Demenz und Multiple Sklerose zu untersuchen. Dazu wurden die elektronischen Datenbanken Medline, Scopus und Cochrane für die Jahre 1970 bis Mitte 2023 ohne sprachliche Einschränkung nach solchen klinischen Studien durchsucht. Die Literaturrecherche ergab nur wenige Studien mit positiven Indikationen, aber zu wenigen Fällen, um verallgemeinerbare evidenzbasierte Aussagen machen zu können. Im Hinblick auf Verbesserung in der Hamilton Depressionsskala zeigte die Analyse von 2 Studien bei Schlaganfallpatienten leichte Vorteile der Waldtherapiegruppen (Standard Mean Difference −0.43; 95% CI: -0.76- -0,10; p < 0.01). Eine Beobachtungsstudie ergab eine höhere Schlaganfall-Überlebensrate bei Patienten, die in ausgeprägtem Grün leben. Einige naturbasierte Interventionen bei Demenzpatienten zeigten in einzelnen Parametern gewisse Vorteile.Es gibt bis dato keine verallgemeinerbaren evidenzbasierten Ergebnisse zum Nutzen der Waldtherapie bei chronischen neurologischen Erkrankungen. Es gibt jedoch Hinweise, dass die Waldtherapie einen positiven Nutzen haben könnte. Es wird daher ein Vorschlag für eine Waldtherapie als Bestandteil einer multimodalen neurologischen Rehabilitation vorgestellt.

The effects of nature-based interventions on individuals' environmental behaviors: protocol for a systematic review of controlled trials.

Background: The paper presents the rationale and methods of the planned systematic review to understand the effects of nature-based interventions on individuals' environmental behaviors. There is ample evidence that experiences in nature not only enhance human well-being but also help promote people's pro-environmentalism. Nevertheless, synthesized evidence regarding the effects of nature-based interventions on individuals' environmental behaviors is lacking. Methods: This protocol follows the Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) guidelines. The planned literature search will be conducted by using APA PsycInfo, APA PsyArticles, PubMed, ERIC, Education Source, GreenFILE, OpenDissertations, Scopus, and WEB of Science. In the protocol, we present search strategies for each specific database. Data items that we will seek to obtain from the selected publications are described in detail and cover general information about included studies, information about studies' methodology and participants, outcomes of the studies, and nature-based and comparative interventions. The outcomes will be behavioral, including aggregated and specific types of environmental behaviors, as well as reported and observed behaviors. Furthermore, the protocol provides a description of the prospective assessment of the risk of bias in both randomized and non-randomized studies. If studies appear sufficiently homogeneous, we will conduct a meta-analysis using the inverse-variance method. Details of the data synthesis are likewise provided in the paper. Results: Dissemination of the results of the planned review will be carried out via a peer-reviewed open-access journal publication. Implications: Given the great need to address current environmental issues, understanding what encourages people to act pro-environmentally is critical. It is expected that the findings of the planned review will provide valuable insights for researchers, educators, and policymakers who are involved in understanding and promoting human environmental behaviors.

Exploring the benefits of nature-based interventions in socio-economically deprived communities: a narrative review of the evidence to date.

AIM: Socio-economic deprivation encompasses the relative disadvantage experienced by individuals or communities in relation to financial, material or social resources. Nature-based interventions (NBIs) are a public health approach that promote sustainable, healthy communities through engagement with nature and show potential to address inequalities experienced by socio-economically deprived communities. This narrative review aims to identify and evaluate the benefits of NBIs in socio-economically deprived communities. METHOD: A systematic literature search of six electronic publication databases (APA PsycInfo, CENTRAL, CDSR, CINAHL, Medline and Web of Science) was conducted on 5 February 2021 and repeated on 30 August 2022. In total, 3852 records were identified and 18 experimental studies (published between 2015 and 2022) were included in this review. RESULTS: Interventions including therapeutic horticulture, care farming, green exercise and wilderness arts and craft were evaluated in the literature. Key benefits were observed for cost savings, diet diversity, food security, anthropometric outcomes, mental health outcomes, nature visits, physical activity and physical health. Age, gender, ethnicity, level of engagement and perception of environment safety influenced the effectiveness of the interventions. CONCLUSION: Results demonstrate there are clear benefits of NBIs on economic, environmental, health and social outcomes. Further research including qualitative analyses, more stringent experimental designs and use of standardised outcome measures is recommended.

Can natural environments enhance acute effects of rehabilitation exercise for older adults? A pilot randomized controlled trial.

The added value of natural environments in rehabilitation exercise is unclear. This study aimed to investigate whether there are more acute health benefits for older adults after a single rehabilitation exercise session performed in an outdoor natural environment compared with an indoor environment. Twenty-two nursing home residents were randomly assigned to the outdoor (n = 11, 79.5 ± 2.1 years) or indoor group (n = 11, 78.8 ± 5.2 years). Performance test outcomes were measured pre- and post-training session. The indoor group had a significantly higher blood pressure, greater increase in heart rate, higher perceived exercise intensity and physiological fatigue than the outdoor group. The combination of rehabilitation exercise with an outdoor natural environment may reduce exercise fatigue and improve cardiovascular health in older adults, with greater acute health benefits compared with an indoor environment. Rehabilitation exercise in the natural environments may be a highly valued environmental intervention for physiotherapy in older adults.

Experiences of a nature-based intervention program in a northern natural setting: A longitudinal case study of two women with stress-related illness.

PURPOSE: This study explored the experiences of people with stress-related illness participating in a nature-based intervention programme in a northern natural setting. METHODS: A longitudinal case study was conducted with two women participating in a nature-based intervention programme on a farm. Data were collected by semi-structured interviews, diaries, rating scales, and self-assessment. Qualitative data were analysed by qualitative content analysis and quantitative data are presented descriptively. RESULTS: The theme of finding a source for recovery and well-being permeates all categories. The participants perceived the farm and nature to be a calming refuge; they learned to be in the present and could manage the tasks. In togetherness with each other and the facilitator on the farm they felt understood and confident, experienced joy, and found opportunities for change. They gained knowledge and positive memories and found new approaches in life. Self-assessment questionnaires indicated improvements of functioning in everyday life and reduced stress-related exhaustion at the end of the NBI programme. CONCLUSIONS: Nature-based interventions lasting for a relatively short period seem to promote health and may be a complement to other treatments of stress-related illness. Further research is needed with a larger number of participants and in various natural settings.

Quality criteria of nature-based interventions in healthcare facilities: a scoping review.

Introduction: Implementing integrated nature-based interventions that simultaneously serve human health and the restoration of biodiversity in healthcare facilities is considered a promising strategy. As an emerging field of research and practice in healthcare, identification of quality criteria is necessary to support desired outcomes related to biodiversity, human health and intervention processes. This study is part of a larger research project in collaboration with the Flemish Agency of Nature and Forest in Belgium. Methods: A scoping review was conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews, in PubMed, Medline, Web of Science and Scopus. A step-by-step tabular screening process was conducted to identify relevant studies and reviews of nature-based interventions, published in English between January 2005 and April 2023. A qualitative content analysis was conducted and the results were then presented to the project steering group and a panel of stakeholders for refinement. Results: After filtering on the eligibility criteria, and with focus on healthcare facilities, 14 articles were included in this study. A preliminary nature-based interventions quality framework with a set of quality indicators has been developed. Discussion: When designing integrated nature-based interventions, a needs analysis of users and the outdoor environment should be conducted. Next, the integration of a One Health and biodiversity perspective and the application of a complex intervention framework, could support the quality of the design and implementation of nature-based interventions in healthcare facilities and facilitate their assessment. In future work, more rigorous research into the design and implementation of integrated nature-based interventions is needed to test and refine the quality criteria in practice.

Is altitude a determinant of the health benefits of nature exposure? A systematic review and meta-analysis.

Introduction: Nature exposure is a widely accepted option for promoting public health owing to the recent surge of scientific evidence. However, the actual settings to facilitate this initiative is yet to be extensively reviewed. In this systematic review, we have aimed to provide an up-to-date summary of interventional studies investigating the psycho-physiological effects of forests and urban forests, including details on their physical settings, and investigate an effect-modifying role of altitude and summarize data on the magnitude and shape of the association. Methods: A keyword search using five electronic academic databases (PubMed, Embase, PsycINFO, Web of Science, and Scopus) was conducted to identify relevant articles published in English from the inception year to the end of February 2022. The methodological quality was evaluated using the ROBINS-I or ROB2 tool, depending on the study design. Meta-regression and random effects model were jointly used to examine the relationship between altitude and health outcomes. Results: We included 27 eligible studies and 31 cases extracted from 19 studies were used for the meta-analysis. In the meta-regression, we observed a non-linear association between altitude and psycho-physiological effects. Altitude had a positive quadratic association with anxiety (p < 0.000, adjusted R 2 = 96.79%), depression (p < 0.000, adjusted R 2 = 98.78%), and fatigue (p < 0.000, adjusted R 2 = 64.74%) alleviating effects. Conversely, altitude demonstrated a negative non-linear association with the blood pressure-lowering effect (p = 0.009, adjusted R 2 = 32.83%). Additionally, the thermal index (THI) and illuminance (lx) levels were significantly associated with effect sizes of psychological restoration. Discussion: This review provides moderate-certainty evidence for an effect-modifying role of altitude. The meta-regression results suggested the optimal and minimal altitude ranges for psychological restoration and physiological relaxation, respectively. Despite some limitations, the study findings provide a significant basis for utilizing altitude, which is easily accessible and simple, to promote the health benefits of nature-based initiatives. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022310894, identifier: CRD42022310894.

Expanding the Mind-Body-Environment Connection to Enhance the Development of Cultural Humility.

The unique health care needs of diverse individuals and communities are complex. To meet these needs, healthcare professionals are being called upon to alter traditional ways of thinking, perceiving, and acting in order to create more inclusive environments. Research shows that using mindsight, a process that increases both insight and empathy, can enhance an individual's mind-body-environment connection, increase self-awareness, and promote the development of cultural humility. This paper will discuss the current perspectives on the mind/body/environment connection from a Western lens that may impact the enactment of cultural humility for healthcare providers. Two evidence-based approaches, yoga and forest therapy, are recommended as effective intervention tools in fostering mindsight and cultural humility. Blending traditional cognitive learning with techniques anchored in the physical body may hold promise in supporting the development of mindsight and cultural humility in healthcare education and practice.

Nature-Based Feasibility Intervention to Influence Mitigation Strategies for Perceived Stress.

Burnout, compassion fatigue, and perceived stress among undergraduate nursing students are significant factors leading to a poorer quality of life, decreased job satisfaction, and adversely impact patient outcomes. Burnout among undergraduate nursing students is a critical individual and workforce issue with contributing factors including a relentless schedule, academically challenging and rigorous programs, pressure to perform, and the completion of clinical hours caring for patients. This paper describes our feasibility study of a nature-based intervention (NBI) to reduce perceived stress and quality of life as it relates to burnout, and compassion fatigue. Quantitative data was collected through demographics, surveys, and electronic sensor data. The project's aim was to determine the feasibility of NBI monitored by NatureDoseTM to decrease perceived stress burnout and compassion fatigue among undergraduate nursing students.

Social Workers' Choice Making in Supporting Nature Activities by Parents and Children in Shelters.

Visiting a natural environment such as a garden or park helps people to recover from stressful circumstances. Women's shelters and homeless shelters have started to integrate nature in their work, especially for families who seek temporary refuge, with the aim to support parents' functioning and resilience. For professionals who want to facilitate engagement with nature among their clients, it may be helpful to learn how other professionals choose nature activities for the support of parents. The current study was aimed to uncover how social workers choose a nature activity for the support of parents, resulting in a model that can be used as a reflective tool among shelter professionals. The model is based on an analysis of actions of professionals, captured in case descriptions written by shelter professionals about parenting supportive nature activities that they facilitated for families under their care. The model shows that social workers promoted a back-and-forth between children's exploration away from the parent and being with the parent. In facilitating these interactions, social workers used nature as an environment with stress reducing and strengthening capacities for parents and as an environment with supportive qualities for children's play. A dimensional framework was extracted that described how professionals may choose activities.

The Multi-Sites Trial on the Effects of Therapeutic Gardening on Mental Health and Well-Being.

Although many people affected by COVID-19 suffer from some form of psychological distress, access to proper treatment or psychosocial interventions has been limited. This study aimed to examine the feasibility and preliminary effects of a therapeutic gardening program conducted during the COVID-19 pandemic. The program consisted of 30 sessions and was conducted at 10 nationwide sites in Korea from June to November 2021. Mental health and well-being were assessed using the Mental Health Screening Tool for Depressive Disorders, Mental Health Screening Tool for Anxiety Disorders, Engagement in Daily Activity Scale, brief version of World Health Organization Quality of Life, and Mindful Attention Awareness Scale. Cohen's d value was calculated for the effect size, and a multilevel analysis was used to determine the longitudinal effects of therapeutic gardening. The effect sizes for depression, anxiety, daily activities, quality of life, and mindfulness were 0.84, 0.72, 0.61, 0.64, and 0.40, respectively. Multilevel analyses showed that all five mental health variables improved significantly over time as the therapeutic gardening program progressed. Therapeutic gardening is promising and applicable as a nature-based intervention to improve the mental health of individuals experiencing psychological distress especially in the COVID-19 pandemic.

Nature-Based Meditation, Rumination and Mental Wellbeing.

Novel approaches for children and young people (CYP) in the prevention and intervention of mental illness are needed and nature-based interventions (NBI) may be clinically useful. This proof-of-principle study tested the effects of a novel brief nature-based meditation on rumination, depressive symptoms and wellbeing in young people. Sixty-eight university students were randomised to one of three conditions: active control (n = 23), indoor meditation (n = 22) or nature-based meditation (n = 23). Participants completed self-report measures on state and trait rumination post intervention and depression and wellbeing at a 2-week follow-up. Depressive rumination significantly decreased post intervention in the nature condition and depressive symptoms improved for both intervention groups. Wellbeing only significantly improved at follow-up in the nature condition. Nature condition participants demonstrated one minimal clinically important difference (MCID) for wellbeing at follow-up. Depressive symptoms for this condition were below the clinically significant threshold for depression. The number needed to treat (NNT) analysis suggested that two to five young people would need to complete the intervention. Preliminary evidence suggests NBIs, such as the one in the present study, can reduce depressive rumination and symptoms and improve wellbeing. Replication with larger clinical samples is required to substantiate findings.

Nature-based interventions to promote health for people with stress-related illness: An integrative review.

BACKGROUND: Stress-related illness is increasing and is a common cause of sick leave. Spending time in nature have a positive effect on health and well-being for instance by reducing stress. Specific programmes with nature-based interventions (NBI) with the intention to involve people in activities in a supportive natural environment have been developed for people with stress-related illness. AIM: To identify and summarise scientific studies of NBIs to promote health for people with stress-related illness. METHOD: The design used in this study is integrative literature review. Scientific studies focusing on any type of NBI for people with stress-related illness were sought in Cinahl, PubMed, PsycInfo, AMED and Scopus. In total, 25 studies using both qualitative and quantitative designs were included in the review. RESULT: The reviewed studies focused on garden or forest interventions. In the majority of the studies, NBIs were performed in groups, including individual activities, and the length of programmes varied. Interventions in natural environments have unique qualities for individualised, meaningful activities and interactions with others in a non-demanding atmosphere. NBIs offer restoration that reduces stress, improves health and well-being and strengthen self-efficacy and work ability. Connectedness with nature support existential reflections and people with stress-related illness can achieve balance in everyday life. CONCLUSION: In conclusion, NBIs may have advantages to promote health for people with stress-related illness and should therefore be considered as an alternative to those affected. Further research from different perspectives, including nursing, is needed to understand the possibilities of NBIs and how they can be integrated into practice.

Social Isolation in Older Adults: A Qualitative Study on the Social Dimensions of Group Outdoor Health Walks.

Physical distancing practices during the COVID-19 global pandemic contributed to a high degree of social isolation among older adults. To reduce loneliness and other ill effects of social isolation, public health experts recommended outdoor social gathering, with physical distancing. Adopting a case study approach, we explored how social aspects of group outdoor health walks (GOHWs) mitigate social isolation for older adults and improve individual social wellbeing. We used semi-structured interviews to understand the experiences of social isolation and social relationships in nine older (50-80 s) adults participating in a GOHW in Scotland, United Kingdom (UK). Verbatim transcripts were analysed through an iterative process of thematic analysis carried out by an interdisciplinary team of qualitative researchers from environmental psychology, medicine, and geography. Themes provide insight into the social dimensions of GOHWs, the mediating effects of social experiences, and the contribution these make to individual social wellbeing. GOHWs provide opportunities to be part of a group and attend to the needs of inexperienced or physically challenged individuals. Being part of the group walk fosters casual interpersonal interactions through spontaneous mixing during and after the walk. This programmatic structure counters loneliness, engenders pleasurable anticipation of regular contact with others, supports physical activity, and fosters group cohesion. These in turn contribute to individual social wellbeing, including expanding social networks, meaningful relationships, a sense of belonging, and acting on empathy for others. GOWHs may be beneficial for mitigation of social isolation as we emerge from the COVID-19 pandemic. Findings were used to propose a conceptual model to parse social constructs and inform selection or development of quantitative social measures for future studies of nature-based interventions such as GOHWs.