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Nature based solution for improving mental health and well-being in urban
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Article  in  Environmental Research · October 2017

DOI: 10.1016/j.envres.2017.06.030

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 Environmental Research 158 (2017) 385–392

Contents lists available at ScienceDirect

Environmental Research
journal homepage: www.elsevier.com/locate/envres

Nature based solution for improving mental health and well-being in urban MARK
areas
⁎ ⁎
Maja Vujcica, , Jelena Tomicevic-Dubljevica, , Mihailo Grbica, Dusica Lecic-Tosevskib,
Olivera Vukovicc, Oliver Toskovicd
a
Department of Landscape Architecture and Horticulture, Faculty of Forestry, University of Belgrade, Serbia
b
Department of Psychiatry, Belgrade University School of Medicine, Serbian Academy of Sciences and Arts, Belgrade, Serbia
c
Department of Psychiatry, Belgrade University School of Medicine, Head of Day Hospital for Adults at the Institute of Mental Health in Belgrade, Serbia
d
Laboratory for Experimental Psychology, Faculty of Philosophy, University of Belgrade, Serbia

A R T I C L E I N F O A B S T R A C T

Keywords: The general disproportion of urban development and the socio-economical crisis in Serbia, followed by a number
Nature based therapy of acute and chronic stressors, as well as years of accumulated trauma, prevented the parallel physical, mental
Mental health and well-being and social adaptation of society as a whole. These trends certainly affected the quality of mental health and well-
Psychiatric patients being, particularly on the vulnerable urban population, increasing the absolute number of people with de-
Botanical garden
pression, stress and psychosomatic disorders. This study was pioneering in Serbia and was conducted in colla-
City of Belgrade
Serbia
boration with the Faculty of Forestry, the Institute of Mental Health and the Botanical Garden in Belgrade, in
order to understand how spending time and performing horticulture therapy in specially designed urban green
environments can improve mental health. The participants were psychiatric patients (n=30), users of the day
hospital of the Institute who were randomly selected for the study, and the control group, assessed for de-
pression, anxiety and stress before and after the intervention, using a DASS21 scale. During the intervention
period the study group stayed in the Botanical garden and participated in a special programme of horticulture
therapy. In order to exclude any possible "special treatment'' or ''placebo effect", the control group was included
in occupational art therapy while it continued to receive conventional therapy. The test results indicated that
nature based therapy had a positive influence on the mental health and well-being of the participants.
Furthermore, the difference in the test results of the subscale stress before and after the intervention for the study
group was F1.28 = 5.442 and p < ;.05. According to socio demographic and clinical variables, the interesting
trend was recorded on the subscale of anxiety showing that the male participants in the study group were more
anxious, with the most pronounced inflection noted on this scale after treatment. The results of this study have
shown that recuperation from stress, depression and anxiety was possible and much more complete when
participants were involved in horticulture therapy as a nature-based solution for improving mental health.

1. Introduction
Modern society has isolated people from regular contact with the
natural environment and this has led to a general disproportion of so-
cial development, which has prevented the parallel physical, psycho-
logical and social adaptation of individuals and society as a whole
(Dovijanić, 1978). The socio-economical crisis in Serbia and its urban
centres, with a number of acute and chronic stressors, as well as years of
accumulated trauma have certainly affected the mental health of the
population, causing significant psychological consequences. These ef-
fects are reflected particularly in the vulnerable population, increasing
the absolute number of people with depression, stress and psychoso-
matic disorders (Lecic Tosevski et al., 2007).
Stress related mental disorders including depressive disorders are
considered one of the biggest health problems of public concern and a
leading cause of disability in the developed world and are associated
with much personal suffering, significant economic cost and social
problems, including their high prevalence (depression is the most
common mental disorder in the general population), the weighted re-
sult, where in most cases (67%) were recurrent or chronic depression
and the significant distortion of the quality of life and well-being. Also,
depression relatively commonly (10% to 15% of depressed people) ends

⁎
Corresponding authors.
E-mail addresses: maja.vujcic@yahoo.com (M. Vujcic), jelena.tomicevic@sfb.bg.ac.rs (J. Tomicevic-Dubljevic), mihailo.grbic@sfb.bg.ac.rs (M. Grbic),
dusica.lecictosevski@gmail.com (D. Lecic-Tosevski), olivukovic@gmail.com (O. Vukovic), otoskovi@f.bg.ac.rs (O. Toskovic).

http://dx.doi.org/10.1016/j.envres.2017.06.030
Received 2 September 2016; Received in revised form 22 June 2017; Accepted 24 June 2017
0013-9351/ © 2017 Elsevier Inc. All rights reserved.
M. Vujcic et al.
Fig. 1. Locations of Botanical Garden and the Institute of Mental Health in Belgrade (1). [Source:Google Map]; View of the main entrance in Jevremovac (2) [Source: Tourist Organisation
of Belgrade]; Japanese garden (3) [author: Vujcic, M].
with suicide and often occurs associated with other mental disorders,
physical illnesses and increased overall morbidity and mortality
(Andreasen and Black, 2001; Kennedy et al., 2004; Mental Health
Foundation, 2013; Ministry of Health Republic of Serbia, 2011; Marcus
et al., 2012). According to the report of the WHO, by the year 2020,
unipolar depression will become the second leading cause of burden in
the world and the first in developing countries, after ischemic heart
disease (WHO, 2012). Factors associated with the prevalence, appear-
ance and during mental disruptions, including behavioural problems,
are poverty, gender, age, wars and catastrophes as well as family and
the social environment (WHO, 2001). After 2000, unipolar depression
was noted as a mental disorder, which significantly affected the quality
of life in Serbia (Zotović, 2005; Lecic Tosevski et al., 2007).
Relying on historical facts, Hippocrates believed disturbing factors
that lead to diseases originate from more natural than unnatural
sources, while later the Romans emphasised the healing power of
nature (Vis medicatrix naturаe) (Kaličanin and Lečić-Toševski, 1994).
There is considerable evidence of the restorative effects of natural
scenery associated with a reduced risk of psychological distress, de-
pressive symptoms, clinical anxiety and the fact that persons who are
exposed to settings with plants or have any interaction with natural,
rather than built environments, have lower levels of negative emotions
and report higher levels of positive feelings (Ulrich, 1991; Grahn and
Stigsdotter, 2010; Konijnendijk et al., 2013; Pálsdóttir, 2014; Arnberger
and Eder, 2015; James et al., 2015; Van den Berg et al., 2015; Lovell,
2016). The contemporary socioeconomic trends in Belgrade emphasise
the link between the lowest percentage of green areas and highest
percentage of residents suffering from respiratory and nervous diseases
(Vujčić et al., 2015; Vujcic et al., 2016). Highlighting the concept of a
healthy body and mind coherence, it was pointed out that a direct
connection between physical activity and education provides spiritual
and physical health and that this understanding of the purpose of the
space defined the first public parks. Such a principle represents the base
for today's horticultural therapy programmes (Grbić, 2014). An impact
analysis of horticultural therapy for overcoming stress, evaluating work
performance and the quality of life of people with mental disorders such
as schizophrenia and psychosis, accentuated that the supportive ap-
proach of horticulture on patients with severe mental illness contributes
386
Environmental Research 158 (2017) 385–392
to reducing the level of anxiety, depression and stress (Son et al., 2006;
Kam and Siu, 2010; Im et al., 2012; Kamioka et al., 2014; Pálsdóttir,
et al., 2014b).
Over the last ten years, environmental conservation interventions
(ECI) have increasingly been used as a specifically designed programme
both for the conservation and management of natural places and for the
health and wellbeing of participants and the social benefits for a variety
of marginalised groups (Bragg et al., 2013). Botanic Gardens Con-
servation International (BGCI) is the largest organisation, consisting of
800 botanical gardens in different countries. Its members emphasise the
need for a better connection between conservation and human needs
(Wyse Jackson and Sutherland, 2000). Botanical gardens have a role in
the conservation of botanical diversity, but only a few of them har-
monise this primary role with the role of improving human well-being.
The ecological implications of urban parks, as well as botanical gar-
dens, have demonstrated urban green spaces to be of particular im-
portance to cities, not just for the potential social, economic and en-
vironmental benefits, but also for the mental health of the vulnerable
population (Konijnendijk et al., 2013).
In order to explore the potential of existing environments or spe-
cially designed green areas in the city of Belgrade as nature-based so-
lutions for improving mental health, our study was conducted in col-
laboration with the Faculty of Forestry, the Institute of Mental Health
and the Belgrade Botanical Garden. This research is pioneering in
Serbia and addresses the possibility that a horticulture therapy pro-
gramme could share evidence of the effectiveness of nature-based in-
terventions in urban areas as a solution for people experiencing mental
health problems (Lovell, 2016).
2. Methodology
2.1. Location and participants
Relying on Kaplan's concept of a restorative environment and the
fact that exposure to a green space or natural areas such as parks,
forests and community or botanical gardens tends to have beneficial
effects on stress and mood in the general population, the Botanical
Garden in Belgrade was chosen as a suitable location for this research.
M. Vujcic et al.
(Kaplan, 1992; Konijnendijk et al., 2013; Rugel, 2015). The Jevremovac
Botanical Garden, besides its educational and scientific activities, as a
part of the Institute of Botany and the Faculty of Biology, represents a
unique green oasis in the core centre of the city of Belgrade and an ideal
neighbour for the Institute of Mental Health (Fig. 1). Jevremovac covers
an area of about 5 ha, with an open space containing 350 species of
trees and shrubs and domestic, European and exotic plants. The total
plant population now comprises over 1500 trees, shrubs and herbac-
eous plants. The Jevremovac Botanical Garden includes the addition of
an open space, a greenhouse, a Japanese garden, systematic plots, a
central fountain and offices of the Institute of Botany, such as the ad-
ministrative building, the herbarium, the library, a lecture hall and
laboratories (Bjelić-Mesaroš, 2005).
The participants in this study were psychiatric patients (n=30) who
are users of the Day Hospital of the Institute of Mental Health. The
inclusion criterion for participating in the horticulture therapy pro-
gramme was one of following the International Classification of Disease
(ICD-10) codes as the primary psychiatric diagnosis of an adjustment
disorder and a reaction to severe stress (ICD-F43), anxiety (ICD-F41) or
depression disorders (ICD-F32), being treated both by pharma-
cotherapy (97.1%) and psychotherapy (73.5%). All participants were
Serbian residents and their age range was 25–65 years (mean of 45.35
years, SD = 10.16), with 70% being female patients. Relying on the
characteristics of the group, 20.6% of the participants had a family
medical history of mental illness. According to the socio-demographic
variables, more than half of the participants (61.8%) had secondary
education. About 20.7% were employed in the service sector, 13.8% in
traffic and 10.3% worked as mechanics or administrators. The exclusion
factors, besides allergies, were major physical or medical problems that
could interfere with participation in a horticulture therapy programme.
For this research, the ethics approval was obtained from the Ethics
Committee of the Institute of Mental Health in Belgrade. All partici-
pants signed an informed consent before participating in the study. The
participants were randomly selected into a study and a control group.
The study group included 16 participants and the control group in-
cluded 14 participants, with both groups having an equal gender and
diagnosis distribution.
2.2. Method
In order to measure the outcomes before and after the intervention
related to the nature based therapy programme for stress relief, fo-
cusing on a study group, a standardised instrument was used, including
data collection regarding baseline and follow-up 1 (Fig. 2) (Palsdottir
et al., 2013). The study was based on the principle of post-evaluation
(POE, post-occupancy evaluation), using the DASS21 scale, which was
initially a part of the multimodal method focusing on the role of hor-
ticultural activities and contemplation in a nature based rehabilitation
(NBR) context (Zeisel, 1984). The Depression Anxiety Stress Scale
(DASS21) is a self-report instrument measuring current (“over the past
week”) symptoms of depression, anxiety and stress (Lovibond and
Lovibond, 1995b). The DASS21 is designed in the form of a
Fig. 2. Overview of data collection regarding baseline and follow-up 1.
387
Environmental Research 158 (2017) 385–392
questionnaire containing 21 questions and three subscales with seven
phrases that describe how the participants felt in the past week: De-
pression (“I couldn't seem to experience any positive feeling at all”), An-
xiety (“I was worried about situations in which I might panic and make a
fool of myself”) and Stress (“I found it hard to wind down”). The eva-
luation was performed using a quarter-scale (no, sometimes, often, and
almost always). The official version of the DASS21, translated into
Serbian, was used in this study. The DASS21 represents one of the most
commonly used instruments for assessing unpleasant emotional feelings
and it is currently one of the most popular measures for estimating
symptoms of depression, anxiety and stress in clinical and non-clinical
research. Because of the suitable psychometric properties, the DASS21
is well suited for use in empirical research, given its simplicity and
accessibility in the public domain (Jovanović et al., 2014). The parti-
cipants were randomly selected for the study and the control group and
self-tested for depression, anxiety and stress before and after the in-
tervention, using the DASS21 scale.
2.3. Procedure
The Stress Recovery Theory and the Attention Restoration Theory
both speak in favour of the premise that nature has the ability to rapidly
reduce stress and evoke soft fascination that gives our brain an op-
portunity to rest and recover from mental fatigue (Ulrich et al., 1991;
Kaplan and Kaplan, 1989). Also, gardening activities have been found
to improve mood, self-esteem and physiological measures such as cor-
tisol, which is associated with acute stress (Buck, 2016). The horti-
culture therapy concept involves an intervention that is based on ac-
tivities and experiences in a natural environment with overall goals for
the patients (Corazon et al., 2010).
The intervention period started at the beginning of October 2015
and lasted for four consecutive weeks. During the intervention period,
the study group stayed in the Botanical Garden three days a week for
one hour and participated in a special nature-based therapy pro-
gramme. Horticulture therapy is relatively new from an academic
perspective, but a fast-growing area within the field of socio-horti-
culture. However, horticultural therapy is yet to be accepted as a pro-
fessional treatment in patient and medical circles alike (Lewis, 1973;
Kim, 2013). For this research, the horticulture therapy programme
presented in Table 1, was composed with the collaboration of psy-
chiatrists, doctors and therapists from the Institute of Mental Health,
and adjusted to the conditions and the environment of the Jevremovac
Botanical Garden in Belgrade, focusing on the patients’ treatment goals.
Concerning the higher amount of exposure to green settings in ac-
cordance with previous studies on content, length and frequency of
visits and the fact of the greater self-reported benefits and wellbeing, as
well as the perceived sense of the restorative effects, a therapy pro-
gramme in the Botanical Garden was organised (Lafortezza et al.,
2009). The programme included 12 sessions involving the standardised
horticultural programme, art therapy and relaxation sessions with a
specific theme and objectives, and all the main activities were related to
working with living plants. For this study, the patients gave their
consent to be photographed (Fig. 3).
In each session there was an introduction and preparation period,
followed by scheduled activities and group sharing. All the horticulture
activities took place at the Systematic plots, while the art therapy and
relaxation sessions were performed in the Japanese garden and other
parts of the Jevremovac Botanical Garden (Fig. 4). The therapy gardens,
urban parks or specially designed green areas, such as Gothenburg
Botanical Garden or The Alnarp rehabilitation garden, Sweden, as well
as the Jevremovac garden design, include an evidence-based approach
and health-promoting characteristics that can be experienced through
our sensory dimensions such as sight, smell, taste, sound and a tactile
experience (Grahn and Stigsdotter, 2010; Sahlin et al., 2014; Marcus
and Sachs, 2014).
In order to exclude the possible "special treatment'' or ''placebo
M. Vujcic et al. Environmental Research 158 (2017) 385–392

Table 1
Weekly activities for the horticulture therapy programme at the Jevremovac Botanical Garden.

Day 1 (one hour) Day 2 (one hour) Day 3 (one hour)

Week 1 → Presentation of the HT programme. Tour of the
Botanical Garden (Introduction and Orientation)
Week 2 → Visit the Japanese garden (Relaxing; Stress-coping
strategies)
Week 3 → Work activity (Plot weeding; Social support in a group)
Week 4 → A therapy walk through the garden and rest by the
central fountain (Relaxing; Stress-coping strategies)
Visit the Greenhouse and relax on the grass
lawn outside (Sunbathing and Meditation)
Work activity (Collecting acorns and hazelnuts;
Social support in a group)
Art therapy in Japanese Garden (Draw a
favourite element; Awaken creative mood)
Work activity (Potting collected autumn fruits;
Social support in a group)
Work activity (Collecting chestnuts; Social support in a
group)
Organised walk through the garden and learning about
the species (Develop interest in plants)
Work activity (Potting collected autumn fruits; Social
support in a group)
Visit favourite parts of the garden and share common
experiences (Summarising group experiences)

Fig. 3. A display of the therapy sessions in the Jevremovac Botanical Garden (author: Vujcic, M).

388
M. Vujcic et al. Environmental Research 158 (2017) 385–392

Fig. 4. Map of the Jevremovac Botanical Garden in Belgrade.

effect", the control group conducted the organised activities in parallel

with the study group. The control group was included in the occupa-
tional and art therapy while continuing to receive conventional
therapy, in conditions without plants, at the Day Hospital of the
Institute of Mental Health in Belgrade.

2.4. Statistical analysis

The data was analysed using descriptive and inferential statistics. As

descriptive statistics we used means, standard deviations, percentages
and frequencies. In order to test treatment impact we used a two-fac-
torial analysis of variance, with the group (study – control) as the be-
tween subject factor and testing (pre-post) as the within subject factor.
Fig. 5. Average stress subscale scores for study and control group, on pre and post-test.
A two factorial ANOVA was also used in order to test interactions be-
tween the treatment and socio demographic variables such as gender
and education. In these analyses, as factors, we used the group (study – subscales, no effect was found. This finding is encouraging in terms that
control) and gender (male - female) or education (higher – middle), the stress represents the main factor that generates the mental disorders
while as a dependent variable we used the change on the DAS scales of modern age, including the depression and anxiety (Nieuwenhuijsen
(difference between pre and post test). et al., 2010; Stigsdotter et al., 2011; Adevi, 2012; Leiter et al., 2014).
The horticulture therapy programme at the Jevremovac Botanical
Garden had positive influence on patients, through a notable reduction
3. Results and discussion of stress. Some previous studies have shown that nature-based therapy
effects, also have some existential reflections that are important for the
We tried to assess the influence of the horticulture therapy on some study population in the process of recovery from exhaustion disorder
aspects of the participants’ mental health measured by the DASS21
and stress-related mental disorders (Palsdottir et al., 2013; Sahlin et al.,
scale, by comparing the results of the two groups, the study and the 2014).
control, tested at two time points: before the study group started hor- Additionally, the demographical distribution was included as the
ticulture treatment (pre-test) and after finishing the treatment (post- categorical variables in order to explore the nature of the correlation
test). The data was analysed using a two-factor analysis of variance. The between socio-demographic factors and mental health and well-being
significance of change in the outcome measures from the baseline to among patients (Boncinelli et al., 2015; Bragg and Atkins, 2016). We
post intervention for the study and the control groups are listed in tried to test whether some socio-demographic variables could influence
Table 2.
obtained results. We wanted to examine do pre-post test differences on
The main finding is a significant interaction between testing (pre or DASS21, especially on stress subscale, between the study and the con-
post) and group (study or control) F1.28 = 5.442; p < ; .05. This result
trol group, vary according to gender and education level of the parti-
shows that there was a larger change in the stress subscale of DAS in the cipant. Namely, we wanted to test moderation effects of gender and
study group compared to the control group (Fig. 5). On the other two
education on obtained horticulture therapy effects in previous analysis,
so we performed two-factorial analysis of variance. As a dependent
Table 2
variable we used differences between pre and post-test scores on
Comparison of variances on subscale of stress between study and control group.
DASS21 subscales, and as factors we used group (study-control) and
Source Measure Df1 Df2 F Sig. Eta Squared gender. Table 3 presents an interaction between the treatment and the
socio-demographic variable gender.
Pre int_Post int Depression 1 28 8.766 0.006 0.238
The results show only significant main effect of group (study-con-
Anxiety 1 28 10.795 0.003 0.278
Stress 1 28 21.842 0.000 0.438 trol) on stress subscale, which is in accordance with previous analysis.
Pre int_Post int Depression 1 28 1.075 0.309 0.037 No other interactions between group and gender were significant. This
Group* Anxiety 1 28 1.227 0.277 0.042 finding shows that gender did not change horticulture therapy effects
Stress* 1 28 5.442 0.027 0.163 obtained in previous analysis. Although, an interesting trend was re-
Group Depression 1 28 0.678 0.417 0.024
Anxiety 1 28 1.555 0.223 0.053
corded on anxiety subscale, showing that the male participants ex-
Stress 1 28 0.075 0.786 0.003 perienced larger pre-post test change in the study group compared to

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M. Vujcic et al. Environmental Research 158 (2017) 385–392

Table 3 Table 4
Significance of the effects of group, gender and interaction of the two on DASS21 pre-post Comparison of variances on DAS scale between the treatment and variable education.
test differences.
Source df F Sig. Eta Squared
Source df F Sig. Eta Squared
DAS_depression change group 1; 26 0.592 0.449 0.022
DAS_depression change group 1; 26 1.271 0.27 0.047 (post-pre) education 1; 26 4.026 0.055 0.134
(post-pre) gender 1; 26 0.012 0.912 0 group * 1; 26 0.043 0.836 0.002
group* 1; 26 0.258 0.616 0.01 education
gender DAS_anxiety change group 1; 26 0.652 0.427 0.024
DAS_anxiety change (post- group 1; 26 3.866 0.06 0.129 (post-pre) education 1; 26 0.431 0.517 0.016
pre) gender 1; 26 1.98 0.171 0.071 group * 1; 26 0.153 0.699 0.006
group* 1; 26 3.602 0.069 0.122 education
gender DAS_stress change (post- group 1; 26 3.917 0.058 0.131
DAS_stress change (post- group 1; 26 7.611 0.01 0.226 pre) education 1; 26 0.731 0.4 0.027
pre) gender 1; 26 2.525 0.124 0.089 group * 1; 26 0.019 0.892 0.001
group* 1; 26 1.067 0.311 0.039 education
gender DAS_total change (post- group 1; 26 1.555 0.224 0.056
DAS_total change (post- group 1; 26 4.004 0.056 0.133 pre) education 1; 26 1.734 0.199 0.063
pre) gender 1; 26 1.01 0.324 0.037 group * 1; 26 0.009 0.924 0
group* 1; 26 1.334 0.259 0.049 education
gender

2014). The single-case studies recommended nature-based programmes

as proven solutions for work-related mental disorders, associated with
constant stress exposure, expressing reduced work performance and
frequent sick leave (Pálsdóttir et al., 2014; Bratman et al., 2015).
Horticulture, in a variety of contexts, has proved itself to benefit a wide
range of clients’ health and wellbeing, involving physical, social or
psychological health and enabling vulnerable individuals to reach their
true potential (Sempik and Bragg, 2013; Thrive, 2015).

3.1. Limitations of the study

While the findings of this study showed potentially significant re-

Fig. 6. Average anxiety subscale scores for study and control group, for two genders.
the control. No such difference between the study and the control group
was seen in the female participants. This might indicate that anxiety
could also be affected by horticulture therapy but only for the male
participants. Still, this is only a trend and it should be tested on a larger
sample to verify is it a significance (Fig. 6). Drawn from the similar
studies, the activities in a specially designed green environment re-
duced stress hormones such as adrenaline and noradrenaline and
showed the relaxing effect on physiological parameters both in male
and female subjects (Li et al., 2011).
The effects of education were also tested by two-factorial analysis of
variance. As a dependent variable we used differences between pre and
post-test scores on DASS21 subscales, and as factors we used group
(study-control) and education. The results show that neither of the main
effects or interactions were significant, leading us to conclusion that
education did not change horticulture therapy effects obtained pre-
viously (Table 4).
The results of this study speak in favour of the significant effect of
horticulture therapy registered only on a stress subscale. It seems that
the study group experienced a notable reduction of stress after horti-
culture therapy. This kind of change was not recorded in the control
group, the group that was not involved in the horticulture therapy. This
effect was not moderated either by gender or education. Also, we no-
ticed an interesting trend on the anxiety subscale, indicating that there
might also be an effect of horticulture therapy, but only for the male
participants. Relying upon a mutual correlation of the socio-demo-
graphical status and some positive effects after nature-based therapy, in
this case, it is possible to anticipate encouraging outcomes for the pa-
tients’ mental state. The interesting implications from other research
found significant increases in social interaction in a study involving
people with mixed mental health diagnoses (Lewis, 1973; Sempik et al.,
sults, they have some limitations that should be mentioned. First, our
sample was relatively small and non-probabilistic, which means that it
is not representative of the wider population. Another limitation of this
study is the fact that the control group performed their activities at the
Day Hospital of the Institute of Mental Health, which leaves open the
possibility for an alternative interpretation of our findings. Namely, we
cannot say whether the reduction of stress was less notable in the
control group because the participants had not been relocated. In order
to resolve this dilemma, the control group should leave the psychiatric
institution for some time and perform their activities outside the Day
Hospital.
4. Conclusion
This study indicates that exposure to an urban green space and in-
volvement in the horticulture therapy programme in the botanical
garden have clear benefits for fundamental components of mental
health, including a process of recovery from stress-related mental dis-
orders. The self-rated levels of stress, measured from the baseline and
continued to decline to the follow-up 1, have shown that the four week
period certainly affected the individuals with mental health conditions,
particularly those with mood and stress disorders. Assessing the nature-
based tool impact along with the socio-demographic factors, it is pos-
sible to understand the link between gender and the improvement in
mental health and the profound appreciation of the nature-based
therapy programme.
The participants perceived that the green environment had a re-
cuperative effect and there was a clear indication that experiences from
the botanical garden programme provided them with stress coping
strategies (Corazon et al., 2010; Sahlin et al., 2014). Engaging in work
activities such as weeding and potting collected autumn fruit or art
therapy sessions, as an interactive part of the horticulture programme,
increases social support in a group and helps to awaken a creative mood
in patients. The results of this study specified that recuperation from

390
M. Vujcic et al.
depression, anxiety and stress was possible and much more complete
when participants have been involved in horticulture therapy as a
nature-based solution for improving mental health and well-being.
Nature-based therapy is recommended to psychiatric patients as a form
of occupational or supportive therapy. Our study might contribute to
addressing the need for interdisciplinary, integrated mental health
promotion, prevention and treatment of mental disorders.
Additionally, the interventions that make use of special green en-
vironments such as the Jevremovac Botanical Garden as settings for
mental health promotion or therapy tend to show positive outcomes
and are, additionally, found to be cost effective (Lovell, 2016). In these
initiatives, the green care sector needs to better promote and share
evidence of the effectiveness of nature-based interventions, including
ecosystem services and green infrastructure, for people experiencing
mental health problems. The botanical gardens can play a key role as a
setting or resource for promoting mental health and horticultural
therapy techniques are widely accepted as a useful prevention or
treatment of poor mental health and specific conditions in some groups,
especially in urban areas (Frazel, 1991; WHO, 2001; Konijnendijk et al.,
2013; Bragg and Atkins, 2016).
Acknowledgements
We acknowledge the psychiatrists, therapists and nurses of the Day
Hospital of the Institute of Mental Health in Belgrade for their support
and collaboration in this study. We are sincerely grateful to the man-
agement team at the Jevremovac Botanical Garden in Belgrade. We
would like to thank all the participants who generously shared their
experiences.
Also, we would like to thank the anonymous reviewers for their
thorough, insightful and affirmative comments. This paper has been
realised as a part of the project, “Studying climate change and its influence
on the environment: impacts, adaptation and mitigation” (43007), financed
by the Ministry of Education and Science of the Republic of Serbia,
within the framework of integrated and interdisciplinary research for
the period 2011–2016.
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