Mind report 1.

0, Feb 2007

Got the Blues, then find some Greenspace
The Mental Health Benefits of Green Exercise Activities and Green Care Mind week report, February 2007
Jo Peacock, Rachel Hine and Jules Pretty Centre for Environment and Society, Department of Biological Sciences, University of Essex Wivenhoe Park, Colchester CO4 3SQ

Photographs courtesy of Cyrillia Francis and Steph Berns of Mind

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Mind report 1.0, Feb 2007

Background
Mind commissioned Professor Jules Pretty, Jo Peacock and Rachel Hine, lead researchers of the green exercise programme at the University of Essex, to investigate the mental health benefits Mind members derive from participating in a range of green exercise activities. One hundred and eight Mind members took part in our research looking at the effects of existing green exercise activities which they are already engaging in locally. In addition, a further 20 members participated in a smaller study which compared the mental health benefits experienced from participating in a green walk outdoors, with an equivalent walk indoors. Both the statistical findings from this process together with the qualitative narrative are included in the report. Mind and the University of Essex would like to thank all Mind members for their assistance with the research published in this report. We are very grateful to all the people who completed the questionnaires and those who took part in the walking study and agreed to share details about their experiences.

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Contents
1. Key findings 2. Introduction 3. Review of existing literature 3.1 The value of greenspaces and contact with nature 3.2 The value of exercise 3.3 The emergence of green exercise 3.4 What do we know so far? 3.5 What are we yet to fully understand? 3.5.1 Application of green exercise in the mental health population 3.5.2 Green exercise as a treatment for mild to moderate depression 3.5.3 Green care for marginalised populations 3.5.4 Limitations of research to date 4. Assessment of existing Mind green exercise activities 4.1 Findings - green exercise activities 4.2 Findings - people involved in the activities 5. A Mind study to compare a green outdoor walk and an indoor walk 5.1 Backgound and methodology 5.2 Results 6. Conclusions and recommendations 6.1 Issues affecting progress of research 6.1.1 Ethical issues 6.1.2 Evaluation issues 6.2 Key issues for policy 6.2.1 Amount of greenspace 6.2.2 Accessibility issues 6.2.3 Barriers to participation 6.2.4 Acceptance from service providers 6.2.5 Working in partnership 6.2.6 The need for further research 7. References 4 8 10 10 11 12 14 16

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1. Key findings
 The current health status of the UK population is becoming problematic due to our increasingly sedentary lifestyles, our poor diets and the prevalence of mental illness. Mental ill health severely compromises quality of life and sadly, sufferers of anxiety and depression are all too commonplace today. The total costs of mental illness in England have been reported to be has high as £77.4 billion. This includes the human costs of mental illness due to reduced quality of life, suffering, pain, disability and distress; and the costs of output losses in the economy due to peoples’ inability to work and costs of health and social care. Therefore, mental illness is a burgeoning concern and public spending on mental health services is continually rising. Perhaps it is about time we started to question the costeffectiveness of existing treatment options, such as therapy and drug prescriptions? Should we be thinking about preventative treatments and if so, what should we be prescribing? Is it inconceivable to think that we might already have a solution on our doorstep, which is available to everyone at minimal cost? The simple answer might exist in encouraging people to interact with nature and greenspace and to get active outdoors? A myriad of persuasive evidence demonstrates the positive relationship between exposure to nature and an individual’s health and well-being. Nature and greenspaces are often perceived as places to relax, escape and unwind from the daily stresses of modern life. This opportunity for relaxation and recreation has a positive influence on our emotional and physical well-being. Equally, participating in physical activity is known to result in positive physical and mental health outcomes. Therefore, engaging in physical activities whilst simultaneously being directly exposed to nature (“green exercise”) could offer an alternative preventative and curative option to address the worrying problem of mental illness. There is an emerging and compelling argument for green exercise therapy to be advocated as preventative medicine or the primary treatment option for some mental illnesses, as exercise has less negative side effects than many traditional drug therapies and it can positively treat patients experiencing a combination of physical and mental health problems. However, at present, there is limited evidence concerning the application of green exercise in the mental health population. With incidences of mental illness and especially depression on the increase how much do we know about green exercise as a potential treatment? There has been little research conducted which compares green exercise with more traditional treatment options, such as antidepressants or cognitive behavioural therapy but from initial findings we can confidently anticipate that green exercise is likely to be equally as effective. Some may argue that the option of green exercise therapy or green care may prove to be an even more effective treatment response than exercise alone as it encourages people to reconnect with nature and experience the additional positive health benefits that are associated with this. Contact with nature and greenspace is often uplifting and restorative, helps to reduce stress and improve mood and combining this with physical activity will offer a very efficacious treatment option. Green exercise also promotes social inclusion and enables people to make healthier choices and adopt a sustainable healthier lifestyle.

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However, the robust scientific evidence to support this hypothesis is still lacking. For the idea to gain credibility and influence government policy and the health sector, more detailed research needs to be undertaken. Some of these research limitations were addressed in this study.  108 Mind members took part in our research and completed a specifically designed questionnaire, which assessed the positive physical and mental health benefits people derived from engaging in a range of green exercise activities. It was found that the combination of exercising outside in the presence of nature (i.e. green exercise) was the most influential factor, with 89.6% of respondents stating that this was very important or important in determining how they felt. This supports the idea that it is the synergistic amalgamation of the exercise in a green environment that produces added health benefits, rather than either one alone. Many key themes emerged when assessing how taking part in these activities made participants feel. They enjoyed becoming part of a group and socialising with likeminded people. They took pleasure in the conversation and company and the activities left them feeling refreshed. They felt less stressed, more alert and alive, happier and more relaxed. Many people stated that they felt mentally healthier and a lot more motivated and positive. They felt that the activities helped to lift their depression levels and instil a feeling of calm and peacefulness. Their overall mood improved as did their confidence levels and selfesteem. Many spoke of the benefits to their fitness levels and how they felt stronger, less lethargic and more energetic. Others commented on the changes to their body profile through losing weight, easing stiffness in their joints and becoming more agile, so there were a range of physical health benefits reported. The findings from this assessment clearly showed that participating in a range of green exercise activities provided substantial social, health and well-being benefits. The contact with nature and greenspace is a necessity in enriching the experience and creates a restorative environment which people can seek pleasure in escaping to. A lot of enjoyment was derived from getting out into the fresh air, admiring the scenery and taking pleasure in the wildlife, plants and trees. Participating in these activities was often perceived as therapeutic and engendered feelings of relaxation and peacefulness. The whole process was very calming; it reduced stress levels and encouraged people to feel good about themselves by improving their self-worth, confidence and self-esteem. It inspired people to embrace their problems and start to deal with them and learn how to cope. There was a great sense of achievement when an activity was completed, as participants felt they had achieved something worthwhile and therefore felt useful. In addition, 20 local Mind group members participated in a separate small study which addressed the research question: “Will exercising outdoors in a green environment significantly improve participant’s mental health and well-being (using standardised and well-recognised mood and self-esteem measures) compared to the equivalent exercise indoors?” They took part in two
Figure 1: The change in self-esteem following participation in the walks
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Green outdoor walk 19
Index of self-esteem

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Type of walk 22 Indoor walk

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separate walks, a green outdoor walk and an indoor walk at a local shopping centre. Figure 1 clearly shows the significant improvement in self-esteem following the green outdoor walk and the detrimental effect after the indoor walk.  Participating in a green outdoor walk also significantly reduced feelings of anger (Figure 2), depression (Figure 3) and tension (Figure 4) in comparison to the indoor walk. In fact, after the indoor walk participants were left feeling tenser than when they had started. Feelings of fatigue also reduced even though they had been walking for an hour. Participants also felt more active and energetic, so it offers an ideal way of getting rid of those blues. The findings undoubtedly showed that exercising outdoors in a green environment is a lot more effective in enhancing your mood and improving your self-esteem compared to the equivalent amount of exercise indoors. Participating in the green outdoor walk was a lot more effective in reducing feelings of anger, depression, tension and confusion, in comparison to the indoor walk. It also increased feelings of vigour and left participants feeling more active and energetic. The enjoyment of engaging in green exercise activities in groups was a valuable part of the experience, as well as the opportunity to breathe in fresh air, admire the scenery and enjoy the wildlife. The findings add significant value to the ever expanding green exercise research programme as it focuses on individuals experiencing mental health issues and separates the elements that constitute the green exercise experience.
Index of tension

Figure 2: The change in feelings of anger following participation in the walks
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Index of anger

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39 Green outdoor walk 38 Type of walk

Figure 3: The change in feelings of depression following participation in the walks
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Index of depression

Indoor walk

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Type of walk

Figure 4: The change in feelings of tension following participation in the walks
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Type of walk

Green outdoor walk

In today’s world, where sufferers of mental ill health are more commonplace, nature can act as a vital health resource. With significant costs incurred due to lost outputs, increased expenditure in the provision of care and the inestimable cost to the individual, the importance of access to nature and greenspaces is paramount.

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Green exercise and green care therefore have implications for many sectors, suggesting the need for cross-disciplinary and sectoral strategies and action. Increasing support for and access to, a wide range of green exercise activities for all sectors of society should produce substantial economic and public health benefits. Such support could include the provision and promotion of healthy walks projects, green exercise on prescription, healthy school environments, green views in hospitals, care farms, city farms and community gardens, urban green space, and outdoor leisure activities in the countryside.

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2. Introduction
The current health status of the UK population is becoming problematic due to our increasingly sedentary lifestyles, our poor diets and the prevalence of mental illness. It is believed that at least one in six individuals' suffer from a “significant” mental health problem at any one time and some reports quote this figure as high as one in four. Mental ill health can severely compromise an individual’s quality of life and it is a leading cause of disability. Sufferers of anxiety and depression are commonplace and by 2020 it is predicted that depression will be the second most common cause of disability in the developed world. Mental ill health is therefore a major issue and sadly problems surrounding social exclusion, vilification and discrimination of the mentally ill are still real challenges to overcome. Mental illness is not solely a challenge for the health sector to address as it inflicts additional economic and social costs. It is estimated that the total costs of mental illness in England in 2002-03 were approximately £77.4 billion (The Sainsbury Centre for Mental Health, 2003). To put this in perspective, the cost of crime for our society in the same period was substantially less, so mental illness is costing us more than crime. The costs of mental illness can be segregated into three key areas, impacting upon human costs, health and social care and output losses (Box 1).
Box 1: The burden of mental illness in the UK
    At least 1 in 6 individuals are affected at any one time 10% of children aged 5-15 yrs suffer from a mental disorder Instances of depression and mixed anxiety rose from 7.8% in 1993 to 9.2% in 2000 £41.8 billion represents the human cost of mental illness due to reduced quality of life, suffering, pain, disability and distress   £23.1 billion is the cost of output losses in the economy due to peoples inability to work £12.5 billion is the cost of health and social care provided by the NHS and Local Authorities and informal care given by family and friends      £4.9 billion is spent on NHS hospital and community health services £1.4 billion is spent on Local Authority social services £898 million is spent on GP consultations £754 million is spent on drug prescriptions £3.1 billion per year represents the net saving across the government as a whole if better mental health care is introduced (Wanless, 2002). This conservative estimate does not include the additional savings gained from promoting mental health and preventing problems in the first instance.

It is evident that mental illness is a burgeoning concern and public spending on mental health services is continually rising. It is estimated that £7.9 billion was spent in England in 2002-03 on mental health services including £754 million on drug prescriptions. The cost of antidepressants has risen dramatically. In 1992, the number of antidepressant prescriptions dispensed was 9.9

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million but by 2003 this figure had increased to 27.7 million. This represents a cost of £395.2 million and implies an increase in cost of 2,083% in only 11 years. The government is also currently spending more money on training therapists to co-ordinate cognitive behavioural therapy (CBT) sessions, so mental ill health is emerging as a costly predicament. Perhaps it is about time we started to explore alternative preventative and curative therapies which, while comparable in their success rates, are cheaper to employ. The importance of the health of the individual and affected family members involved in care provision supersedes any financial cost, but if there is a potential solution which addresses both issues, this could significantly reduce public spending and human costs. Is it inconceivable to think that we might already have a solution on our doorstep, which is available to everyone at minimal cost? The simple answer might exist in encouraging people to interact with nature and greenspace and get active outdoors? The positive relationship between exposure to nature and greenspace and an individual’s health is continually being evidenced. The quality and quantity of nature and greenspace in the surrounding environment transforms a person’s mental health, both at home, at work and at the places they visit. This concept is not revolutionary but it has yet to significantly influence the planning of urban and rural environments or public health and social care priorities. However, nature and greenspaces are often perceived as places to relax, escape and unwind from the daily stresses of modern life. This opportunity for relaxation and recreation has a positive influence on our emotional and physical well-being. Therefore, in today’s world, where sufferers of mental ill health are more commonplace, nature can act as a vital health resource. With significant costs incurred due to lost outputs, increased expenditure in the provision of care and the inestimable cost to the individual, the importance of access to nature and greenspaces is paramount.

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3. Review of existing literature
3.1 The value of greenspaces and contact with nature
There is a myriad of persuasive evidence which connects regular contact with the natural environment and greenspace to enhanced physical health and mental well-being. This incorporates a variety of outdoor settings, from the open countryside, fields and forests, remote wildlands, parks and open spaces, to street trees, allotments and gardens. The key message emerging is that contact with these greenspaces improves psychological health by reducing stress levels, enhancing mood and offering a restorative environment which enables you to relax, unwind and recharge your batteries. Greenspaces also provide an ideal opportunity and incentive for exercise and can be especially valuable in urban areas for facilitating social contact and helping to bring people together. A significant relationship between the proximity of urban open green spaces, visiting frequency, duration of stay and the level of self-reported stress experienced has been reported (Grahn and Stigsdotter, 2003). The quantity of available greenspace has also been correlated with longevity and a reduced risk of mental ill health (Takano et al., 2002; De Vries et al., 2003). Open space is also vitally important for children and studies have shown that children with Attention Deficit Disorder worked better and their concentration improved after participating in activities in green surroundings (Taylor et al., 2001). So, if research strongly indicates that exposure to nature and greenspace positively affects our physical health and mental well-being, do we fully understand why? What are peoples motivations for engaging with nature? With a multitude of choices available, why do so many people still seek out green places (both rural and urban) on a regular basis? As hominids were hunter-gatherers for over 300,000 generations, having daily contact with nature and the land, are the reasons co-evolutionary? In comparison, the increasingly urbanised and industrialised environment we currently live in has only emerged in the past six to ten generations. Many of us already recognise and appreciate the health benefits we derive from spending time engaging with nature. In the UK we make 1.2 billion day visits to the countryside each year, with a further 5 billion visits to urban parks. 5 million people are regular anglers, and some 15 million garden regularly; 6 of every 10 households have a pet; and many millions of others are bird watchers, wild-fowlers, pigeon-racers, dog-walkers, ramblers, runners, horse-riders, cyclists and game shooters. Why do we do all these things? What motivates us to take the trouble to be in the presence of green nature and living things, when we can now easily stay at home and watch it on the television? Why do we say that we feel great after green activities? And if we feel so good doing it, why do we not spend more time visiting greenspaces and put time aside to enjoy it? Equally, we may question what consitutes a green experience? Do artificial plastic trees and plants have the same effect as rainforest trees or hay meadows in the spring? In what way does nature affect us emotionally as opposed to intellectually – is the experience different if you are aware the nature is simulated? What difference does spending five minutes a day in contact with nature make to two weeks in the wild? Does an individuals personal history affect their experience? Is there a contrast between urban and rural dwellers, or someone visiting their own local environment compared to someone coming from another culture? Does the culture of origin affect the experience, or is the desire to connect with nature the same irrespective of

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cultural context? These thought-provoking questions need to be explored so that we can begin to shape our reasons for engaging with nature and greenspace.

3.2 The value of exercise
Participating in regular physical activity is generally accepted as a highly effective method for preventing illness and offers a therapeutic intervention for tacking existing illness. Physical activity has been evidenced to be an important determinant of both physical health and psychological well-being. Moderate regular exercise reduces morbidity rates by 30-50% and has a particularly protective effect against maturity onset Type II diabetes, coronary heart disease, musculo-skeletal diseases and cancer. It lowers blood pressure, improves blood lipid and glucose profiles and boosts the immune system. It also enhances mental health by improving mood and self-esteem, reducing stress, enriching an individual’s quality of life and diminishing the chance of depression. We are now gaining a better understanding of the intimate interrelationship between mental and physical health, as the status of one considerably affects the other. Therefore, exercise can be used as a successful tool to ensure preferable health states are experienced. Throughout the last fifty years, the UK has witnessed a dramatic fall in the levels of daily physical activities, despite the robust evidence for staying active. On average, adults expend 500 kcal less energy per day in comparison to their ancestors fifty years ago. This is comparable to undertaking a marathon a week on top of current activity levels, just to restore this reduction in energy expenditure. This is primarily because people have become increasingly sedentary in all aspects of daily life, including during leisure time, in travelling to and from work and during work itself. Home life has also become more sedentary and although gym and fitness club membership has risen (although many have a low adherence rate) in the past twenty years, there are indications that people are becoming less likely to engage in organised sports and leisure activities. The level of weekly physical activity required to achieve general health benefits has led to the development of a universal recommendation. It advises that individuals should participate in “at least 30 minutes a day of at least a moderate intensity on 5 or more days of the week” (Department of Health, 2004). However, it is estimated that only 35% of men and 24% of women actually meet this recommendation. The major problem is the misconception that current physical activity levels are sufficient to avoid ill-health. 80% of individuals are aware that regular exercise is beneficial for their health, but most inaccurately believe that they participate in enough exercise to reap these rewards. For these targets to be met a dramatic modification is necessary and perceptions need to be revolutionised. Due to this activity transition, populations have suffered very significant public health consequences. The annual costs of physical inactivity in England are reported to be approximately £8.2 billion (Department of Health, 2004). This figure excludes individuals who are obese due to inactivity, which contributes an extra £2.5 billion annual cost to the economy. These figures incorporate both costs to the NHS and costs associated to the economy (e.g. work absenteeism). This rise in inactivity levels and the associated problems with obesity are a priority on the government’s agenda and although there is a general acknowledgement that greenspaces rich in biodiversity encourage physical activity, the relationship needs further investigation to develop a deeper understanding. Undertaking physical activities in outdoor green environments seems to be a more sustainable option in maintaining long-term activity levels, as it is the interaction with the environment and the social contact that are the main 11

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incentives. In this situation, the health benefits derived from the exercise are not the sole focus and become a secondary outcome. With the current inactivity predicament, exploring the use of rural and urban greenspaces as ideal locations to encourage physical activity could prove to be a benefit for all.

3.3 Emergence of green exercise
There is a growing body of empirical evidence which proclaims that exposure to nature induces substantial mental health benefits. Equally, participating in physical activity is known to result in positive physical and mental health outcomes. Therefore, at the University of Essex we have combined these ideas into a programme of research which investigates the synergistic benefits of engaging in physical activities whilst simultaneously being directly exposed to nature. We refer to this as “green exercise” (Figure 5). This programme addresses current concerns about the adverse health effects of modern diets and sedentary lifestyles, along with growing evidence that stress and mental ill-health have become substantial health problems for many people in industrialised societies.
Figure 5: The concept of green exercise and the health benefits it engenders Engaging in physical activity Exposure to nature and greenspaces

Green Exercise

1. Improves psychological wellbeing

2. Generates physical health benefits

3. Facilitates social networking and connectivity

Healthier communities and avoided public health costs

From a wide variety of University of Essex research involving more than three thousand people, we have discerned three key outcomes from participating in green exercise activities: 1) improvement of psychological well-being (by enhancing mood and self-esteem, whilst reducing feelings of anger, confusion, depression and tension); 2) generation of physical health benefits (by reducing blood pressure and burning calories) and 3) facilitation of social networking and

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connectivity (by enhancing social capital). Box 2 shows a selection of qualitative comments that have been collected during the research which supports this idea.
Box 2: A selection of comments collated during our research programme supporting the key health outcomes identified
1: Improves psychological well-being “It is relaxing mentally where I can get away from responsibilities of a managerial job and being a parent. I find it refreshes me for everyday life and its problems. A great day” “I feel it helps my well being and I feel more healthy” “In good spirits and very relaxed” “Good to be out and meet people. Boosts your ego and makes you feel good” 2: Generates physical health benefits “Exercise, being outdoors, enjoying the environment” “Relaxing, exercises the body, clears the head” “Fun to do, great exercise and in a beautiful location which helps keep me fit and happier” “To try to keep fit and lose weight, good company” 3: Facilitates social networking and connectivity “Enjoyment especially the social interaction and meeting and talking to people we wouldn’t ordinarily meet!” “Feel refreshed – better for taking part, enjoy social aspect” “I feel much more alive and my spirits have lifted by the walk and the company of other walkers” “As a retired person it is valuable for me to meet other people for recreation and conversation”

Our research has also enabled us to gain an insight into some of the underlying reasons for engaging in green exercise activities. Table 1 illustrates these ideas by identifying four key principles and separating these into ten sub categories, which describe some of the pleasures we commonly refer to. Green exercise seems to be effective in generating a variety of health benefits which lead to healthier communities and avoided public health costs. With the understanding of the close inter-relationship between mental and physical health gaining acknowledgement, engaging in green exercise activities presents an ideal way of advancing collective health states. Three of the government’s six key priorities in their recent Public Health White Paper were to “reduce obesity”, “increase exercise” and “improve mental health”. Therefore, encouraging more people to adopt green exercise behaviour may contribute to the compliance of these objectives whilst also enhancing the health of the nation.

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Table 1: Four key principles describing why people enjoy engaging in green exercise activities SubPrinciples Descriptors categories Being with friends and family, companionship and social interaction, a. Social creation of collective identity, making new friends, conviviality Direct bonding with companion animals (e.g. dogs, horses) and wild b. Animals animals (both observing and hunting), feeding birds, recognising, counting and wildlife 1. Natural and collecting (greater value of rarities) and social c. Memories Visiting special places where memories and stories are provoked and connections and recalled (childhood associations), story-telling, personal identity, links to knowledge myths, stimulation of imagination, ecological literacy Large scale and longevity of nature in contrast to humans, transformative d. Spiritual capacity of green nature, oneness with nature and animals Diverse colours of nature and landscapes, views of landscape, beauty of a. Colours scenery, bird-song and sounds of other animals, light (especially sunrise / and sounds sunset), visual and aesthetic appreciation of landscapes 2. Sensory Smell and other senses, being outdoors, exposed to all types of weather, stimulation b. Fresh air changing of seasons, a contrast to indoor and city life, escape from urban pollution c. Adrenalin rush, exhilaration, fun, arising from a physical activity or Excitement experience of risk (e.g. rock climbing, mountain biking), sense of adventure Learning a skill and completing a manual task (e.g. conservation activity), a. Manual challenging, fulfilling and rewarding, sense of achievement, leading to a tasks sense of worth and value 3. Activity b. Physical Enjoyment of the activity itself and the physical and mental health benefits activity associated with it, makes people feel good, more energetic, less lethargic Getting away from modern life, relaxing (as a contrast), time alone or with a. Escape family, a time to think and clear the head, peace and quiet, tranquillity and 4. Escape from freedom, privacy, escape from pressure, stress and “rat-race”, recharging modern life batteries

3.4 What do we know so far?
Even just viewing nature through a window or in a painting can positively influence people’s well-being. Research has shown this in hospitals, prisons, the workplace and whilst travelling to work1. Green views from the window help to buffer stresses, reduce frustration and enhance concentration. Viewing green landscape paintings aids recovery from illness, improves mood, reduces stress and improves mental well-being. At the University of Essex we have demonstrated that engaging in physical activities whilst viewing a series of green rural or urban pictures reduces blood pressure and enhances mood and self-esteem (Pretty et al., 2005). Incidental exposure to nearby nature whilst engaging in some other activity also assists in reducing stress, enhancing mood status and promoting relaxation. This nearby nature incorporates countryside and neighbourhood greenspaces, parks, grounds of hospitals and care homes, along with healing gardens2. Healing gardens are designed to aid recovery from stress and are often present in hospitals and care homes, whereby stressful experiences are encountered by patients, visitors and staff. Therefore, outdoor natural settings are often

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(Verderber and Reuman, 1987; Tennessen and Cimprich, 1995; Leather et al., 1998; Parsons et al., 1998; Kaplan, 2001; Laumann et al., 2003) 2 (Cooper-Marcus and Barnes, 1995, 1999; Wells, 2000; Whitehouse et al., 2001; Ulrich, 2002; Wells and Evans, 2003)

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perceived as therapeutic “healing places” and a wide range of research has demonstrated this effect (Pretty, 2007). Direct participation in some green exercise activity, such as gardening, walking, running, cycling or fishing also yields a series of unequivocal physical and psychological health benefits. Studies have looked at the benefits of wilderness experiences, adventure therapy, forest schools, social and therapeutic horticulture (which is based on the value of gardening for mental and physical health), care farming and private and community gardens. The University of Essex has undertaken research involving 263 participants which measured the effects of ten green exercise activities (including walking, cycling, horse riding, fishing, canal boating and conservation activities) in four countries of the UK (Pretty et al., 2006; Pretty et al., 2007). We found that participants felt significantly less angry, depressed, confused and tense after engaging in the activities and their self-esteem levels all significantly improved. These improvements were not affected by the type, intensity, or duration of the green exercise activity, indicating the potential for a wider health and well-being dividend from green exercise. It is often argued that the underlying reasons for nature’s ability to help people recover from stress and mental fatigue is due to its restorative powers. Terry Hartig has pioneered the notion that nature can restore deficits in attention arising from overwork or over-concentration, making people both feel and think better. He has found that sitting in a room with tree views promotes more rapid blood pressure decline than sitting in a windowless room, and also that walking in a nature reserve reduces blood pressure more than a walk along an urban and non-green street. In both contexts, the green room and green walk, people recover more rapidly from attentiondemanding tasks and the long-term effects may be important. Another five-year study of older people found that access to green space in which they could walk was an accurate predictor for longevity, as those who walked in green places lived longer (Takano et al., 2002). It has been suggested that spending time in ecologically restored areas and having a heightened knowledge of nature can encourage more frequent visits outdoors for longer periods of time. Young people are currently becoming more and more disconnected with nature and, therefore, are currently making fewer visits to the countryside than ever before, and engaging children with nature from a young age can encourage them to participate in more outdoor exercise and make more frequent countryside visits throughout adulthood leading to the associated health benefits. It is apparent that there is an emerging body of evidence supporting green exercise and green care and it is becoming increasingly recognised as an idea which can be linked to current government health and social care policies. The research holds implications for human health, environmental protection and national policies alike. Engaging in green exercise activities conveys substantial mental, physical and social health benefits, even from relatively short exposures. These health benefits will lead to avoided public health costs, which will ultimately save the NHS money. Although there are many opportunities already available, they are accessed predominantly by reasonably healthy individuals. The cohorts of people studied to date are those already choosing to engage in green exercise activities and therefore can be considered healthy. We are yet to engage and research the harder to reach sedentary population or those experiencing mental ill-health. If we can develop a methodology for engaging these populations, the potential financial savings are immeasurable.

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3.5 What are we yet to fully understand?
3.5.1 Application of green exercise in the mental health population There is limited evidence concerning the application of green exercise in the mental health population. Initial steps are being taken to try and engage individuals experiencing mental illness in green exercise activities. For example, greater participation by the public in green exercise has led to the introduction of new initiatives, such as the “Green Gym’s” set up by the British Trust of Conservation Volunteers (BTCV). These outdoor gyms encourage participation in local nature conservation activities to improve health and well-being and establish social networks. The projects vary, including creating community gardens, managing local woodlands, tree-planting and maintenance of public footpaths. These Green Gym groups often attract individuals experiencing mental illness and initial evaluation findings have reported significant increases in mental health state scores, a reduction in depression and a trend towards weight loss (Reynolds 1999, 2002). A further national evaluation of the health benefits of participating in Green Gyms was conducted by the School of Health and Social Care at Oxford Brookes University during 2006 and is expected to be published shortly. Another example of a green exercise initiative for people suffering from mental health problems is the Stepping Out project. This is funded by Natural England (formerly the Countryside Agency) and supports and enables both informal carers of people suffering from mental ill health, and those that they care for, to explore and discover green spaces and the countryside in and around Coventry. The project is managed by Warwickshire Wildlife Trust in close partnership with Coventry Carers and the Asian Mental Health Action Project and through a series of confidence building and awareness activities forming a ‘stepping stones’ journey, Stepping Out supports and encourages participants to access the local environment3. Findings of research suggest that therapeutic applications of green exercise could therefore be effective and this is termed “green care”. There is a growing movement towards green care in many contexts, ranging from green exercise activities, social and therapeutic horticulture, animal assisted therapy, eco-therapy and care farming. Green care in agriculture or “care farming” is defined as the use of farms and agricultural landscapes as a base for promoting mental and physical health (Hassink, 2003; Braastad, 2005). Farming is used to provide mental and physical health benefits for a wide range of people. These may include those with defined medical or social needs (e.g. psychiatric patients, those suffering from mild to moderate depression, people with learning disabilities, people with a drug history, disaffected youth or elderly people) as well as those suffering from the effects of work-related stress or ill-health arising from obesity. Care farming is a partnership between farmers, health care providers and participants, and so combines the care of people with the care of the land. Care farming is part of a growing recognition that the land is multifunctional, providing a range of environmental and social goods and services. Green care on farms is thus part of a movement to reconnect people to the land, and to the food produced by domestic farming. There are now several hundred green care farms in Norway, the Netherlands, Italy, Germany, Austria, Belgium and Slovenia4. Such green care farms are formally tied to local social services and hospitals, and provide a new component of care in the community. Farmers are paid for providing a kind of “health service” whilst continuing with agriculture. This can help to maintain
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http://www.warwickshire-wildlife-trust.org.uk/SteppingOut/index.htm See Farming for Health (Europe) www.farmingforhealth.org

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the economic viability of farms, farmers benefit from the extra labour and they can still sell their produce. There are many different terms for green care in agriculture across Europe including Farming for Health, Care Farming and Social Farming but all essentially refer to the same concept. Much of the research into Green Care had until recently been largely qualitative and anecdotal, but research initiatives are currently underway examining the physical, mental and social health benefits of green care for various populations and groups. Research which is particularly relevant for people with mental health issues includes a Dutch study for example. Researchers at Wageningen University in the Netherlands are looking at the effect of green care farms on quality of life of demented elderly and for people with a psychiatric and/ or drug addiction background5. Studies in Norway (Norwegian University of Life Sciences) are looking at the health benefits of animal assisted therapy on farms for people with mental health disorders and similar studies with animals assisted interventions are being conducted in the Netherlands (Wageningen)6. While the term “care farming” is well-recognised in Europe, here in the UK, the concept is relatively new. There is an increasing amount of interest from many sectors including farmers, health care professionals and social care providers, the prison and probation services and there are a number of care farms already operating throughout the UK. However the numbers of care farms are thought to be small and the movement is very embryonic at present, with no national framework. The National Care Farming Initiative (UK)7 aims to promote and support the expansion of care farming throughout the UK and is currently undertaking research to establish the scale of care farming in the UK. Like the UK, Denmark, Finland, Italy, Austria and Germany have also initiated research into the health benefits of care farming and this is expected to combine with the research underway in the Netherlands and Norway to produce evidence to support the use of care farming for health benefits. The European Farming for Health Community of Practice(CoP) 8 , a network of those involved with care farming in Europe and beyond recognised the need for a sound body of evidence to support the health and “therapeutic” benefits of care farming in order to influence health and social care professionals and policy-makers alike (Hassink and van Dijk, 2006). The Farming for Health CoP has been instrumental in developing a COST Action on green Care in Agriculture9 which is an EU funded action to increase the scientific knowledge on the best practices for implementing green care in agriculture with the aim of improving human mental and physical health and the quality of life. In particular one of the areas of priority for the action is to coordinate research in this field by the comparison and discussion of ongoing projects related to health effects on people and the establishment of a set of good research methodologies. There has been most research into another form of green care, social and therapeutic horticulture (STH). Social and therapeutic horticulture has been used as a therapy or as an addon to therapy for many years and in the UK there has been a steady rise since the 1980s in the numbers of garden projects that offer horticultural therapy to many different groups of people. The associated health benefits to those who participate in STH are well documented and also
5 6

Simone de Bruin, Marjolein Elings, Nicole van Erp, Jan Hassink, Eric Baars Bjarne Braastad and Bente Berget (Norway) and Reina Ferwerda and Jorine Rommers (Netherlands) 7 See National Care farming Initiative (UK) website www.ncfi.org.uk 8 see www.farmingforhealth.org for more information 9 www.umb.nor/greencare

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include studies which focus on those who are suffering from mental health problems in particular. A recent collaboration between the Centre for Child and Family Research at Loughborough University and Thrive called “Growing Together” has concluded a major piece of research examining the physical, mental and social health benefits of STH (Sempik et al., 2003, 2005). In this study Sempik et al., (2003) carried out a comprehensive survey of literature of STH and discovered a wealth of descriptive literature on horticulture, health and well-being. STH projects are widely used for patients suffering from Alzheimer’s disease and a study of over 2000 older people living in the Gironde area of France conducted by Fabrigoule et al., (1995) found that it is also possible that regular participation in gardening may offer some protection against the development of dementia. In a prospective study showed that those who took part in gardening (or who travelled, carried out odd jobs or knit) were significantly less likely to develop dementia than those who did not. Later studies have shown that the exercise provided by gardening activities may also be significant in delaying the onset of dementia and Alzheimer’s disease (Rovio et al., 2005 and Larson et al., 2006). However, as is the case with green care and Green exercise projects in general although there is much descriptive and qualitative data available there is a relative scarcity of quantitative research. Sempik et al., (2003, 2005) concluded that there was also a need for more “hard” evidence to support the findings. Green care, care farming, SHT, green gyms and other green exercise projects are worthy examples of how engaging in green exercise and care activities can help people with mental health problems. Therefore, the initial successes of green care in Europe combined with innovative green exercise initiatives poses the question – should people experiencing mental illness be prescribed “green care” such as green exercise therapy, social and therapeutic horticulture or time at a care farm instead of, or in addition to, traditional medicine? 3.5.2 Green exercise as a treatment option for mild to moderate depression With incidences of mental illness and especially depression on the increase how much do we know about green exercise as a potential treatment? It is estimated that 25% of women and 10% of men in the UK will experience a period of depression requiring treatment, at some point in their lives (Halliwell, 2005). Often, visiting their GP is the first step they take in addressing the situation and it is usually the GP who is primarily responsible for organising their treatment. A recent report conducted by the Mental Health Foundation reported that in cases of mild to moderate depression, 55% of GP’s prescribe antidepressants as their first choice of treatment response (Halliwell, 2005). However, only 35% actually believe that antidepressant medication is the most effective intervention in these situations. It was reported that although GP’s deemed alternative treatments to be more suitable, 78% of them had still prescribed antidepressants as the treatment option in the last three years. In comparison, only a minority of patients experiencing mild or moderate depression are offered the choice of exercise therapy as a primary treatment response. A mere 5% of GP’s offer exercise therapy as one of their three most common treatment responses, in comparison to 92% of GP’s who commonly prescribe antidepressants as a treatment response. Yet, research has demonstrated that a supervised programme of exercise can be equally as effective as antidepressants in treating mild to moderate depression (Halliwell, 2005;

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Richardson et al., 2005). In a report by the Chief Medical Officer it was stated that “physical activity is effective in the treatment of clinical depression and can be as successful as psychotherapy or medication, particularly in the longer term” (Department of Health, 2004). Therefore, a compelling argument for exercise therapy to be advocated as the primary treatment option can be formulated. Exercise has less negative side effects and can positively treat patients experiencing a combination of physical and mental health problems. A common concern is that people experiencing a period of depression will not have the desire or motivation to exercise, but compliance rates are often much better than for medication, especially if they are receiving adequate support and encouragement. The option of green exercise therapy or green care may prove to be an even more effective treatment response than exercise alone as it encourages people to re-connect with nature and experience the additional positive health benefits that are associated with this. Contact with nature and greenspace is often uplifting and restorative, helps to reduce stress and improve mood and combining this with physical activity will offer a very efficacious treatment option. Green exercise is very cost effective and participation is often free or at a minimal cost. Unlike fitness centres and gymnasiums it does not require an initial joining fee or a monthly subscription, as you can walk around your local park or woodlands at no cost. Exercising in traditional gyms often incurs an extremely low adherence rate due in part to lycraphobia (a fear of undertaking physical activity in a commercial fitness industry setting). Outdoor exercise provides the opportunity to escape this setting and the additional confinements of indoor activities. Green exercise also promotes social inclusion and enables people to make healthier choices and adopt a sustainable healthier lifestyle. However, to date, there has been little research conducted which compares green exercise with more traditional treatment options, such as antidepressants or cognitive behaviour therapy. We anticipate that green exercise will be equally as effective, but the robust scientific evidence to support this hypothesis is still lacking. For the idea to gain credibility and influence government policy and the health sector, more detailed research needs to be undertaken. Therefore, at the University of Essex we have collaborated with South Essex Partnership NHS Foundation Trust to design a feasibility study which compares a green exercise programme with a series of CBT sessions as treatment options for patients suffering from mild to moderate depression. A total of sixteen participants will be recruited to the study and eight will be randomly allocated to the green exercise group and the remaining eight to the CBT group. Each group programme will consist of a two hour session, once a week for a period of six weeks and we will evaluate and compare the effectiveness of the two different programmes. The green exercise programme will involve one hour of moderate walking in the local countryside and woodlands. This will be a led walk and a certain level of social interaction will be encouraged but monitored. The CBT programme will follow the traditional pattern and involve small group discussions and a minilecture. A series of standardised psychological instruments will be used to measure levels of depression, mood, self-esteem, social adaptation and general mental health. These will be administered at regular intervals over the six week period to monitor any changes. The initial findings from the feasibility study will be used to obtain further funding to conduct the study on a larger scale and generate a wider interest. Colleagues in Australia have also initiated some research into the participation in forest and woodland management as a treatment for depression (Townsend, 2006). Their pilot project engages people experiencing depression in nature-based activities in a woodland environment. The project is on-going but initial findings suggest encouraging improvements to physical and mental health, along with a reduction in social isolation.

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3.5.3 Green care for marginalised populations There is also limited evidence concerning the use of green exercise therapy for populations most marginalised in mental health, for example, those residing in hospitals, prisons and institutions whereby mental ill health is problematic. Two classic studies from the 1980’s (Moore, 1981; Ulrich, 1984) initiated research into the health benefits for both prisoners and hospital patients of windows overlooking greenspace compared to those facing brick walls. The first found that prisoners in Michigan whose cells overlooked farmland and trees reported 24% less sick cell visits compared to those in cells facing the prison yard. The second was a ten year comparative study of post-operative patients in Pennsylvania whose rooms either overlooked trees or a brick wall. The hospital stay for those patients with tree views was significantly less, they also required fewer painkillers and used less strong or moderate medication and nursing staff reported fewer negative evaluation comments in the medical records. An initial study in a Swedish psychiatric hospital reported the amount of damage to paintings on walls over a 15 year period. Damage was only ever inflicted on abstract paintings and there were no recorded attacks on paintings depicting nature and landscapes. In a more recent study of hospital patients, (Diette et al., 2003) demonstrated the clear value of a landscape picture accompanied by the sounds of nature. Prior to their operation, a group of bronchoscopy patients overlooked a large landscape picture present at their bedside whilst listening to sounds of birdsong and a babbling brook. This group’s level of good or excellent pain control was 50% higher in comparison to those without access to the picture or sounds. This simple intervention has financial implications if it suggests that less money can be spent on pain killing drugs for patients. These studies imply that greenspaces and nearby nature should be seen as a fundamental health resource. One of the nine major reasons that cause ex-offenders to re-offend has been identified as poor mental and physical health (SEU, 2002) and a significant number of prisoners in the UK suffer from a variety of mental health issues. “Offender and Nature” (O&N) schemes can address several of the underlying factors contributing to re-offending and are another example of an initiative to improve mental and physical health and well-being by using green exercise activities. O&N initiatives involve partnerships between offender-management organisations10 and natural-environment organisations11. Offenders and Nature schemes involve offenders working as volunteers on nature conservation and woodland sites, carrying out tasks such as creating and maintaining footpaths, opening up dense vegetation to create more diverse habitats, establishing ponds and building boardwalks. O&N schemes are seen as reparative work that benefits the public, while providing experience of teamwork, life and skills training to offenders and also boosting their confidence and selfesteem (Carter and Hanna, 2007). Many offenders and supervisors have observed a ‘calming’ and ‘focusing’ effect in volunteers. Some O&N schemes explicitly apply ‘ecotherapy’, which uses working in natural environments to support people with mental health issues and addiction problems, specifically drawing on the capacity of nature to calm, heal and inspire (Hall, 2004; Burls, 2005; Burls and Caan, 2005). As is the situation for many other green exercise and green care initiatives, although there is much qualitative and anecdotal evidence supporting these projects, there is a lack of “hard” or quantitative data and there is a need for further evaluation of these schemes.

10 11

Such as National Offender Management Service, Her Majesty’s Prison Service and National Probation Service For example Natural England, Forestry Commission, BTCV and National Trust

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Traditionally hospitals have been renowned for their surrounding beautiful gardens and array of plants (Nightingale, 1860, 1996). Similarly, monasteries often designed intricate gardens to offer a pleasant relaxing environment for the ill to visit for a respite (Gerlach-Spriggs et al., 1998). Sadly, over time, hospital funding has become more concerned with reducing the risk of infection and focusing on efficiency and this has been reflected in design and lack of greenery. Consequently, they have evolved into stressful establishments which do not fulfil the emotional needs of patients, their families and staff (Lindheim and Syme, 1983; Ulrich et al., 1991; Horsburgh, 1995). This problematic transformation needs to be addressed as research implies that gardens and nature in hospitals enhance mood, reduce stress and improve the overall appreciation of the health care provider and quality of care. Healing gardens are designed to aid recovery from stress and are often present in hospitals and care homes, where stressful experiences are often encountered by patients, visitors and staff. Sempik et al. (2002) comprehensively reviews studies that analyse positive effects of these types of gardens. In addition, Cooper Marcus and Barnes (1999) extensively review research into the positive impact of healing gardens on the patient’s health and well-being. Whitehouse et al. (2001) found that a healing garden in a children’s hospital in California had numerous positive effects on users. 54% stated that they felt more relaxed and less stressed, 24% refreshed and rejuvenated, 18% more positive and able to cope and only 10% had experienced no difference in mood. Nearly half of all observed visitors spent less than 5 minutes per visit in the garden, so even vary short visits were beneficial. Visitors to the garden want to “escape the stresses of the hospital and enjoy the relaxing and restorative elements of nature”. A lot more research needs to be conducted within the area of marginalised populations, especially targeting those with mental health problems in addition to those populations in hospitals and prisons in general. However, the findings do suggest that perhaps those involved in hospital design and planning should consider the value to patients and visitors of pleasant views from windows, of landscape artwork in wards and of hospital gardens. The majority of the research has been conducted in the USA and Scandinavia, so we need to learn from this and initiate our own research here in the UK.

3.5.4 Limitations of research to date i) Type of evidence In the fields of Social and Therapeutic Horticulture, Green care, Care Farming and Green Exercise there are several similarities to the limitations of research to date. Although there is much valuable qualitative evidence describing the physical, mental and social health benefits of exposure to exercise and nature there remains a shortage of scientifically robust, quantitative evidence. This “hard” data is necessary to convince healthcare professionals, social care providers and sceptics of the merit of green exercise and green care. ii) Exposure time to green exercise The research has also not yet fully addressed the issues of exposure time and sustainability. Research has demonstrated that short or occasional exposures to nature and physical activity are potentially highly beneficial in improving mental health and physical well-being. However, we are yet to establish whether cumulative short exposures, such as viewing nature out of a window or taking a short walk equate to longer, less frequent exposures to nature, such as a weekend trekking in the hills (Hartig et al., 2003). We do not know if short exposures alone will lead to long-term improvements, but there is some evidence to suggest that behavioural and lifestyle changes can be provoked by such activities, leading to continuing re-exposure which

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would result in a healthier population. Secondly, the findings do not explore enhanced or different effects of exposure to specific places for certain people because they hold memories and stories which are associated with them. It could be hypothesised that some environments may me green and beneficial, but anonymous, whereas others may evoke pleasant memories which affect the experience (Tuan, 1977; Gallagher, 1994). An important unanswered question for those concerned for sustainability is to what extent do the benefits of such green experiences continue off-site? How long do the physical and psychological benefits last once you return to your urbanised more stressful environment? Do the benefits last for the day, the next day or for the next week? Does contact with nature provoke long-term changes in thinking, which could lead to deep social and political transformations? iii) Economic considerations The full economic benefits of promoting nature and greenspaces as a health resource are not yet fully understood. We still lack the health economic data to accurately estimate the total savings that a public mental health strategy could yield. A recent report written by Willis and Liesl (2005) highlighted four major gaps in the current evidence base which prevents a full economic assessment of the health benefits of greenspace being evaluated. These include: 1) quantifying the value of the psychological benefits from greenspace; 2) improved evaluation of green exercise activity programmes; 3) the time profile of risks when exercise is continued or discontinued for different age groups and 4) assessing benefits from increased physical activity between the sedentary populations and those participating in intermediate or frequent activity. Therefore, large scale surveys are required which relate greenspace accessibility and use to improved health outcome measures, to enable a full economic costing to be undertaken. The Department of Health (2004) has estimated that a 10% increase in adult physical activity would benefit the UK by £500 million per year, saving 6000 lives. The potential economic impact of emotional benefits and improved mental well-being has not yet been quantified but would be additional to these physical health benefits, and might indeed outweigh them. If these activities are achieved through “green activities” that might also provoke long-term changes in attitudes to nature and the environment in both rural and urban contexts, then wider support for prosustainability policies is more likely to arise. Can green exercise and green care, therefore, be considered a good buy for pubic health, providing physical, social and mental health benefits? Can green exercise and green care be used in a preventative way before we become ill to safeguard our mental well-being? Can care farming provide another option for treating mental ill-health? Could some of the annual £10 billion of costs of obesity, coronary heart disease and physical inactivity be avoided? Could the £77 billion annual cost incurred in 2002-03 for mental illness be significantly reduced in the future? One of the central needs now is to ensure that the assessment of the value of greenspace and the countryside includes the potential mental and physical health benefits to those both working and visiting those areas. The NHS budget is several hundred times more than current spending on conservation and access to greenspaces, yet spending on these will help to prevent illness and to save the UK money.

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4. Assessment of existing Mind green exercise activities
There are a wide range of very successful green exercise activities and projects already in existence amongst Local Mind Associations (LMA’s). These activities include walking, gardening activities (especially on allotments), social and therapeutic horticulture, garden design, conservation activities, bush craft (exploring local woodlands and building fires etc) and dog walking. A lot of the gardening activities encourage clients to grow and learn about the plants and flowers on local allotments in the community. Many conservation groups assist garden teams working at local formal gardens, woodlands and the open countryside. They always employ a socially inclusive approach, so the activities are open to staff, service users and volunteers alike. Many of the walks take place regularly in the open countryside, at local parks or woodlands, along the beach or canalside, in all weathers. Whilst participants are walking they are often encouraged to engage in other activities such as bird watching, photography, admiring the wildlife and enjoying the scenery. Therefore with this in mind, we designed a universal tool which could be used to evaluate this wide range of green exercise activities to illustrate what positive effects they were having on participants’ physical and mental health. A specifically designed questionnaire was sent out to all Mind members who were engaging in a selection of green exercise activities and 108 completed questionnaires were returned from 19 different Mind groups (see Box 3).
Box 3: Mind groups included in the assessment of green exercise activities
          Birmingham Brighton Dartford, Gravesham and Swanley East Berkshire Great Yarmouth Havering Hull and East Yorkshire Kensington and Chelsea Lewes District and Wealden Maidstone     Mid-Staffordshire Mid-Warwickshire Redcar and Cleveland St Helens Tameside and Glossop Taunton Thurrock Wallingford West Cornwall

    

4.1 Findings - green exercise activities
The green exercise activities were predominantly made up of gardening projects, conservation activities and walking groups. 52% of the respondents were engaging in gardening activities on allotments or specific projects. These activities included weeding, digging, planting, grass mowing, watering, pruning and composting. A further 7% of participants were involved in specific conservation activities including scrub clearances and laurel thinning. 37% of respondents were participating in regular walks around local gardens, along the river bank or “cross country”. The remaining 3% were running in greenspaces regularly and 1% had been cycling.

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The duration of a typical activity session varied considerably, ranging from a minimum of 15 minutes to a maximum of 6 hours. The average length of a session was 2 ¾ hours (163.2 ± 89.4 minutes) and the most common session duration was 2 hours. 29% of the activities lasted over 4 hours. Respondents attended sessions fairly frequently, with the majority of people engaging in these activities on a weekly basis (55%). A total of 26% of participants attended sessions at least twice a week or more frequently, whereas only 6% engaged in the activities occasionally (Figure 6). Respondents were asked how long they had been attending the green exercise activity sessions. Responses varied from a minimum of one month to a maximum of 16 years. The average time was just over 2 years (25.5 ± 35.7 months); with the most common answer also being reported as 2 years. Figure 7 categorises the answers into specific groups which highlight the percentages calculated for each time period.
Figure 6: How often respondents attend the sessions
60 50 40

(%)

30 20 10 0 Daily Three times a week Twice a week Weekly Fortnightly Monthly Occasionally

Frequency

Figure 7: How long respondents have been attending the green exercise sessions
35 30 25 20

(%)
15 10 5 0 6 months or less 6 months - 1 year 1-2 years 2-5 years Over 5 years

4.2 Findings - people involved in the activities
Out of the 108 completed questionnaires returned, 72% of respondents were male and 28% were female. Figure 8 reports the percentage of individuals within each age band. It is clear that the most common age group was the 3150 years, closely followed by the 51-70 year age group. Together this made up 82% of the sample population, with a further 15% aged between 1930 years.

Length of time

Figure 8: Age categories of the respondents
2% 1% 15% 11-18 yrs 19-30 yrs 35% 31-50 yrs 51-70 yrs 71+ yrs

47%

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Respondents were asked to Figure 9: Key qualities that respondents gain out of participating reflect on the qualities they in the activity hoped to get out of What they hoped to get before starting the activity (%) 90 participating in the activities What they actually get now they 80 before they started engaging are doing the activity (%) 70 in them and compare these 60 to the qualities they actually 50 get, now they have been 40 participating in the activities 30 on a regular basis (Figure 9). 20 The most popular answer 10 overall was to “get out in the 0 fresh air” (83%), followed by Meet new people Learn new skills Get out in the Get fitter Other fresh air “meeting new people” (76%) Qualities and “getting fitter” (69%). The percentage of respondents deriving pleasure out of the 4 aspects listed increased once they were engaging in the activities regularly in comparison to their initial expectations. 17% of respondents stated “other” hopes that they anticipated getting out of the activities, before they started participating in them. These included improving their concentration, enhancing their self-esteem, keeping them occupied, keeping them sane, building their confidence, keeping them motivated, building friendships and losing weight. 16% of respondents listed “other” qualities that they actually got out of participating in the activities, since engaging in them on a more regular basis. These included improving their confidence, helping with their depression, a sense of achievement, contributing to organic growing and biodiversity, immense enjoyment and fun, socialising, friendship and keeping them occupied. Participants were also asked the question “how does taking part in these activities normally make you feel?” 103 respondents provided comments to address this question and their answers were grouped into 9 key themes:
(%)

Key theme 1. Becoming part of a group – enjoyment of socialising with likeminded people, having company and conversation and feeling refreshed.

Examples of comments from respondents “Socialising and talking about your problems helps me a great deal” “It gives me company which I don’t have where I live” “Being part of a team, getting out on a nice bright day, feeling refreshed. Often don't feel confident to be out alone. Don't have my own garden so would otherwise stay indoors” “Refreshed and feeling more like facing things. Having been with likeminded people and had company and conversation” “Like being part of the workforce in the community, feeling good”

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Key theme 2. Sense of achievement – completing a task and achieving something worthwhile, feeling useful

Examples of comments from respondents “Pleased and a sense of achievement that I have done a task that I have been asked to do and finished it” “Better about myself, feeling a sense of achievement” “Feel good about doing an activity that has definite results” “That I have achieved something worthwhile” “It makes me feel I am doing something useful”

Key theme 3. Feeling relaxed and less stressed

Examples of comments from respondents “Before attending Mind I only went out if I had to, I now find it less stressful” “Relaxed, peace of mind” “Relaxed, more focus of mind and greater co-ordination, greater self esteem”

Key theme 4. Feeling able to deal with problems and begin to cope

Examples of comments from respondents “Improves my depression, helps me be more motivated and gives me satisfaction in doing things. Since starting the project I have been able to improve on my quality of life. Coming here has helped me overcome most of my problems” “Happier and able to cope again” “Less depressed, revitalised and more able to cope with my issues” “It takes me out of my depression for a while and gives me something to look forward to” “It takes my mind off my worries”

Key theme 5. Feeling healthier and fitter – both physically and psychologically

Examples of comments from respondents “It improves my fitness and is very beneficial for my mental and physical health” “Healthier, more active, fitter” “Positive and healthy” “Healthier psychologically and physically” “Much fitter and I feel especially good immediately after a session. I feel able to chat to other runners easily and feel generally less anxious”

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Key theme 6. Feeling good about myself – improving self-worth, confidence, selfesteem

Examples of comments from respondents “It makes me feel good about myself and it improves my confidence” “A lot happier in myself, also there is a great sense of peacefulness here and the nature is wonderful” “More positive about myself, better for being with people and out in fresh air” “After being out in the fresh air and doing gardening I feel better in my self eat well and sleep well” “It gives a feeling of self worth because you have made a difference / improvement no matter how small! Slowly builds confidence which in turn has a knock on effect and improves all aspects of life”

Key theme 7. Feeling great – more alive and confident. The word “great” was used very frequently

Examples of comments from respondents “Great - life's worth living, clears the mind” “Alive and confident” “More focused, feeling confident, much happier” “Makes me feel good, it is good, makes you get out of the house, look forward to all the activities”

Key theme 8. Feeling “happy” – this word was also used very frequently

Examples of comments from respondents “It makes me feel good and happy and lifts my mood” “I enjoy the fresh air and conversation, it makes me happy” “It makes me happy”

Key theme 9. A sense of escape – getting out of the house and having something to do

Examples of comments from respondents “Its nice to get out and go for a walk, to get out of the house” “I love to get away from the hustle and noise of the town and out into the Chase wilderness, I feel great out there” “It gives me something to do during the week which makes me happy to be out socialising. I don’t tend to go out much so it gives me something to do” “Sleeping better at night, gets me out of the house, socialising better, gaining new skills, coming to the project has given me new confidence and a belief in myself” “I enjoy being in the countryside away from the stresses of the town, traffic, crowds, noise etc and the people are nice and friendly and good company”

Other comments included feeling a sense of satisfaction, feeling refreshed, at peace with nature, having a new lease of life and being set free and that it was a preferred option to sitting staring at the walls. It is clear that engaging in a range of green exercise activities generates a myriad of positive healthy feelings.

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Respondents were then asked how important being outside with nature was in determining how they felt and 88.1% stated that this was very important or important. Similarly, 88.8% felt that participating in some form of exercise was very important or important in influencing how they felt. However, the combination of exercising outside in the presence of nature (i.e. green exercise) was even more influential, with 89.6% of respondents stating that this was very important or important in determining how they felt. This supports the idea that it is the synergistic amalgamation of the exercise in a green environment that produces added health benefits, rather than either one alone. The next question in the questionnaire asked respondents to identify the differences that participating in these green activities made to how they felt and they were asked to distinguish between the mental and physical aspects. 102 comments were received concerning the mental health benefits and once again familiar messages emerged. Many respondents talked about the positive effect on their minds and how it helped them to think more clearly, provided a focus for concentration and offered overall peace of mind. They felt less stressed, more alert and alive, happier and more relaxed. Many people stated that they felt mentally healthier and a lot more motivated and positive. They felt that the activities helped to lift their depression levels and instil a feeling of calm and peacefulness. Their overall mood improved as did their confidence levels and self-esteem and some of the key comments are listed in Box 4.
Box 4: Participants comments concerning what differences the activities made to how they felt mentally “More stable, able to think for myself more” “Less worried, co-ordination of body and mind, better sense of well being” “It stimulates the mind and gives me something to concentrate my mind on” “Memory has improved and I think clearer and more positively” “I am more alert, less stressed” “Helps me to relax and stop worrying” “More relaxed and able to sleep at night” “I always feel better - more relaxed, less tense after a good session of exercise, more able to talk to people” “Lifts depression gives me a good feeling” “They help me focus on positive things rather than negative” “Makes you want to get out of bed and I’m not as low as I have been” “It feels calm and satisfying on my allotment, I look forward to going” “Improves my mood, more self-esteem and makes me feel good about myself” “Feel more confident (alive) not looking at four walls”

97 comments were received concerning the physical health benefits of engaging in green exercise activities. Overall, respondents felt a lot healthier, more alive and refreshed. Many spoke of the benefits to their fitness levels and how they felt stronger, less lethargic and more energetic. Others commented on the changes to their body profile through losing weight, easing stiffness in their joints and becoming more agile (see Box 5 for examples of typical comments).

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Box 5: Participants comments concerning what differences the activities made to how they felt physically “ I feel a lot stronger and fitter” “My fitness has improved, I feel refreshed and alive” “I feel fitter for getting out more often” “Feel lifted and less lethargic” “More energetic and less lifeless” “I feel as though I can do things without being tired. I am more active, less lethargic, I want to join in things and my body is looser and more agile” “More stamina and less physically restless” “I use my hands so it helps my hands to move better as they are painful and stiff due to arthritis” “Stops the stiffness in the joints, that I get when I just sit around doing nothing” “Lost weight, more agile, helps to keep my body moving” “Becoming involved in outdoor activities, also good therapy for body and soul” “Helped me to get more active” “Makes me feel good to get my heart pumping”

Finally, participants were asked to comment on what they felt was special about the activity and 102 responses were received. It was clear from the collated narratives that there were 5 main aspects which were special about the green activities. These were the: 1) Social benefits; 2) Benefits from contact with nature; 3) Benefits from the activity itself; 4) Psychological benefits and 5) Physical benefits. These findings clearly support the green exercise model and the following tables illustrate some of the key comments supporting each feature.

Key feature 1. Social benefits – meeting and socialising with people out in the fresh air, team work, companionship, camaraderie, being part of a group

Examples of comments from respondents “Excellent teamwork, meeting new people to make friends, we are a family and look out for each other” “I think it is because I take part with people I know well, who enjoy doing the same things and nobody judges you or criticises you” “Everyone is friendly and I feel part of something collectively positive” “I have made new friends and am able to communicate better, staff members are very helpful and listen to my problems, everybody is very friendly towards me” “It gives me the opportunity to be active and social, team work, being outside with others, making friends, enjoying their company” “The chance to meet people, plus a chance to exchange news and views”

N.B: 44% of respondents made comments concerning social benefits

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Key feature 2. Benefits of contact with nature – fresh air, wildlife, trees, plants, scenery

Examples of comments from respondents “Being with nature, out in the fresh air and the peace and quiet” “Because I was out in the open air and was also interested in the birds and wildlife” “Being outside hearing and seeing wildlife watching your own plants grow. It gives me a good feeling” “Freedom, space, no one to judge you, view the scenes, keep fit, breathe in the fresh air. I love being in nature's garden, that's how I see it” “You see lots of wildlife, get a feeling of space and tranquillity and see places I wouldn't normally see if travelling by car” “A closeness to nature is the most special feeling and it gives you acceptance of yourself”

N.B: 21% of respondents made comments concerning social benefits

Key feature 3. Benefits of the activity itself growing vegetables, learning new skills, new experiences

Examples of comments from respondents “The activity is good to look back at when completed. We have all worked very hard on our allotment, the results have been very rewarding “It gets people out into a different environment other than what they would usually do” “Learning new skills, growing vegetables from seed that you can eat” “Gardening is very therapeutic because it is stress free, outdoors, physical and you can see what you love achieved at the end” “Its fun, it costs nothing, no special equipment and the views are stunning”

N.B: 17% of respondents made comments concerning social benefits

Key feature 4. Psychological benefits – therapeutic, calming, sense of achievement

Examples of comments from respondents “Open air activity is good for my mental health. My confidence has improved. Also meeting others who have similar mental health problems helps” “Takes my mind of the depression” “Its therapeutic and calms me” “It is special because it gives you a sense of achievement in all the jobs you do on the farm”

N.B: 10% of respondents made comments concerning social benefits

Key feature 5. Physical benefits

Examples of comments from respondents “Keeps you active and mobile” “Being close to nature and doing physical activities” “Its easy physically but all counts helping towards my fitness for the future” “The exercise with nature”

N.B: 8% of respondents made comments concerning social benefits

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The findings from this assessment clearly show that participating in a range of green exercise activities provides substantial social, health and well-being benefits. The contact with nature and greenspace is a necessity in enriching the experience and creates a restorative environment which people can seek pleasure in escaping to. A lot of enjoyment is derived from getting out into the fresh air, admiring the scenery and taking pleasure in the wildlife, plants and trees (Box 6). Participating in these activities is often perceived as therapeutic and engenders feelings of relaxation and peacefulness. The whole process is very calming; it reduces stress levels and encourages people to feel good about themselves by improving their self-worth, confidence and self-esteem. It inspires people to embrace their problems and start to deal with them and learn how to cope. Participants feel healthier and fitter, more alive, refreshed and a lot happier. There is a great sense of achievement when an activity is completed, as participants feel they have achieved something worthwhile and therefore feel useful. Engaging in green activities in groups also inspires new friendships to develop and enhances social capital, which supplements the range of health benefits experienced. Participants enjoy becoming part of a group, socialising with likeminded people and having companionship, camaraderie and conversation. Therefore, meeting and socialising with people out in the fresh air is a key ingredient in the activities success.
Box 6: Comments from a participant engaging in gardening activities at a local allotment A woman aged between 51 and 70 years has been working on a local allotment regularly for the past 11 years. She attends the sessions most weeks and typically spends around 6 hours on the allotment per session. Before she started helping out at the allotment she hoped that this would provide her with an opportunity to learn some new skills and get out in the fresh air. Since she has been attending regular sessions, she finds that not only does she learn new skills and get out in the fresh air, but she’s also enhanced her fitness, met new people and contributed to organic growing and biodiversity. “I enjoy gardening, seeing things grow and then picking, cooking and eating them and I feel a sense of achievement. I'm interested in learning about gardening and about nature conservation and I love watching wildlife, birds etc. If I arrive at the allotments feeling low or preoccupied I feel my mood lift and I find a sense of well-being” “I have been interested in "green" activities all my life - gardening, walking, conservation, being close to nature, but the "extra" benefit of this is the sense of sharing and co-operating with other people. Also our allotment site is very beautiful and peaceful so I feel in harmony with the world there” “I enjoy the physical movement and effort and I appreciate the experience of all my senses sight, sound, smell, taste and touch and I like working with the earth” “It's very creative - especially so since our allotment leader is not only a great gardener but also an artist so as well as producing great fresh food through working physically in the open air we're also involved in making a beautiful place. Some would say a place of healing too, and everyone is kind and supportive of one another”

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5. A study to compare a green outdoor walk and an indoor walk
5.1 Backgound and methodology
Another major gap in the evidence base is the comparison of indoor exercise to equivalent outdoor green exercise activities. This would enable us to identify what extra health benefits are derived from the contribution of the green elements. When comparing innovative outdoor voluntary activities, such as the green gyms to indoor sports, the adherence rates are a lot more successful in the long term. Nearly half of the participants of indoor sports drop out within the first six months, whereas walking outside seems to be the most preferred form of exercise to maintain adherence (Hilldsdon and Thorogood, 1996). Research analysing joggers also reported that running in a stimulating green environment detracted the mind from the physical discomfort of exertion and fatigue. This enabled participants to continue jogging for longer periods of time (Pennebaker and Lightner, 1980). However, there is a shortage of compelling evidence in this area, especially in the UK. To date the University of Essex has been involved in a series of studies and research programmes that have analysed the physical and mental health benefits of participating in green exercise activities. However, a key question which is yet to be addressed is: how does green exercise compare to exercising indoors? If the type, intensity and duration of the exercise remains the same, but it is conducted in two very distinct environments (indoors, with no green natural elements and outdoors in a natural green space), we would be able to establish what additional benefits the “green” engenders. Therefore Mind approached the University of Essex for advice and guidance to enable them to undertake some innovative research. This research involved local Mind group members engaging in a green outdoor walk and a comparable indoor walk and results were analysed by the University of Essex. This short study addressed the research question: “Will exercising outdoors in a green environment significantly improve participant’s mental health and well-being (using standardised and well-recognised mood and self-esteem measures) compared to the equivalent exercise indoors?” The locations for the indoor and outdoor walks were initially identified and then the walks took place in early January 2007. They occurred one week apart, at a similar time of day and both lasted for an hour. Mini-buses were used to transport participants to the locations. The outdoor green exercise walk involved walking around Belhus Woods Country Park, which has a diverse landscape of woodlands, grasslands and lakes12. In contrast the indoor walk involved walking around Lakeside shopping centre. In both conditions continuous walking was preferred, although participants were allowed to stop briefly to admire the scenery or shop windows and a certain level of social interaction was also encouraged. Both of the group walks were led by the same Mind organiser and they were equivalent in duration and intensity. The same leader was present at both walks to ensure consistency of personality. The study was a repeated measures design, as the same group of subjects participated in both walks to eliminate their diverse health states as confounding variables. 20 members of various local LMA groups volunteered to take part in the research and they all attended both of the organised trips.

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Belhus Woods Country Park http://www.essexcc.gov.uk/vip8/ecc/ECCWebsite/dis/guc.jsp?channelOid=14413&guideOid=16906&guideContentOid=14412

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A mixed method design incorporating both quantitative data and qualitative narrative was utilised to collect data using a composite questionnaire. The questionnaires were administered immediately before and immediately after both of the walks to allow direct comparisons to be made and to identify any changes in health parameters as a direct result of exposure to the environment. The questionnaires included standardised tools which measured participants’ levels of self-esteem and mood and other qualitative questions were asked to allow us to capture some detailed narrative. Participants were asked to complete the questionnaires individually and not to compare or discuss their answers. Questions were answered according to how the participant felt at that particular moment in time. The standardised tools incorporated in order to determine any changes in psychological states derived from the walks, measured self-esteem and mood. Self-esteem was measured before and after the walks using the one-page Rosenberg Self–Esteem Scale (RSE) (Rosenberg, 1989), which is a widely used measure of self-esteem in health psychology. Mood change was measured before and after the walks using the (McNair et al., 1984) Profile of Mood State questionnaire (POMS). This is a short form one-page version of the POMS test which has a background of successful use for mood change post-exercise. The POMS subscales measured were anger, confusion, depression, fatigue, tension and vigour. In addition, a Total Mood Disturbance (TMD) score was calculated to denote an overall assessment of emotional state. This method is regularly used as it provides an indicator of overall mood. It involved summing the POMS subscale T-scores of anger, confusion, depression, fatigue and tension and then subtracting the T-score for vigour (McNair et al. 1992, p.6).
Photographs from the green outdoor walk at Belhus Woods Country Park

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Photographs from the indoor walk at Lakeside shopping centre

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5.2 Results
A total of 20 participants took part in both walks, of which 7 (35%) were male and 13 (65%) were female. 47% of the participants were aged between 31-50 years and the remaining 53% were aged between 51-70 years. Initially, a paired samples t-test was conducted to identify if there were any significant differences in the participants’ preliminary mood and self-esteem scores between the two walks. This did not reveal any significant findings, indicating that prior to both the walks participants’ levels of self-esteem and mood were comparable. Secondly, paired samples t-tests were conducted to identify any significant changes in starting self-esteem and mood levels and those reported after each walk. Each walk was initially analysed separately to distinguish any differences between the two walks. i) Outdoor Walk Figure 10 highlights the statistically significant improvement in self-esteem from 21.3 to 19.0 (p<0.01) (Note - the lower the value, the higher the self-esteem). Scores ranged from a high of 12 to a low of 37 prior to the walk. After the green outdoor walk, they ranged from the highest possible self-esteem score of 10 to a low of 35.
Figure 10: The change in self-esteem following participation in the green outdoor walk
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Index of self-esteem

20 Represents a significant increase in self-esteem of 2.31 (p< 0.01) 21

22

The change in the six subscale mood factors were also analysed following participation Figure 11: The change in the subscale mood measurements following participation in the green outdoor walk in the green outdoor walk. 44 Before Figure 11 illustrates the Significance tested with 1After 43 tailed t test (* p<0.05; ** significant reductions in feelings p<0.01; *** p<0.0005) 42 of anger (from 42.6 to 39.2, 41 p<0.05); confusion (from 39.5 40 to 36.5, p<0.01); depression 39 (from 42.1 to 39.4, p< 0.01); 38 fatigue (from 43.4 to 37.1, p< 37 0.0005) and tension (from 39.5 36 to 34.4, p<0.01), so participants 35 were feeling less angry, 34 confused, depressed and tense Anger * Confusion ** Depression ** Fatigue *** Tension ** Vigour after the outdoor walk. Feelings Mood factor of vigour increased from 40.7 to 42.1, so even though they had been walking for an hour, participants felt less fatigued and more active and energetic.
Index of mood

Before

After

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Therefore, Figure 12 shows that the total mood disturbance (TMD) significantly improved after participating in the outdoors green walk from 166.4 to 144.4 (p<0.01) (Note – the lower the score, the better the overall mood).
Index of TMD

Figure 12: The change in total mood disturbance (TMD) following participation in the green outdoor walk
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145

150 Represents a significant improvement in total mood disturbance of 21.9 (p< 0.01)

ii) Indoor walk Figure 13 highlights the non significant decrease in selfesteem from 21.0 to 21.8 (Note the lower the value, the higher the self-esteem). Scores ranged from the highest possible self-esteem score of 10 to the lowest possible score of 40, both before and after the indoor walk. The change in the six subscale mood factors were also analysed following participation in the indoor walk. Figure 14 illustrates the only mood factor to be significantly reduced, which was fatigue (from 42.3 to 39.0, p<0.05). Feelings of anger reduced slightly (from 41.6 to 41.1) and depression levels also reduced slightly (from 41.3 to 40.8, p<0.01). However, in contrast to the green outdoor walk, feelings of tension slightly increased (from 37.2 to 37.7) and confusion levels also slightly increased (from 39.2 to 39.5). Feelings of vigour decreased from 41.7 to 38.7, so after this walk, participants were feeling less active and energetic and more tense and confused. Therefore, Figure 15 shows that the total mood disturbance (TMD) hardly changed after participating in the indoor walk from 159.9 to 159.4 (p<0.01) (Note – the lower the score, the better the overall mood).

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160

165

170 Before After

Figure 13: The change in self-esteem following participation in the indoor walk
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Index of self-esteem

21

22 Before After

Figure 14: The change in the subscale mood measurements following participation in the indoor walk
43 42 41
Index of mood

Significance tested with 1-tailed t test (* p<0.05; ** p<0.01; *** p<0.0005)

Before After

40 39 38 37 36 35 34 Anger Confusion Depression Fatigue * Tension Vigour Mood factor

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Index of TMD

Finally, we used a mixed betweenwithin ANOVA test to compare the change in self-esteem and mood levels between the two walks. This would enable us to establish and confirm which walk was having the most beneficial effect on their psychological health status. Figure 16 shows the changes in self-esteem after both walks, with starting self-esteem scores averaged for both conditions. This graph illustrates the positive improvement in self-esteem following the green outdoor walk and the negative effect after the indoor walk. Therefore, there was a statistically significant difference between the 2 groups (F= 6.3; p<0.05).

Figure 15: The change in total mood disturbance (TMD) following participation in the indoor walk
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145 Represents a non significant improvement in total mood disturbance of 0.5

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170 Before After

Figure 16: The change in self-esteem following participation in the walks
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Green outdoor walk 19
Index of self-esteem

Figures 17 to 22 illustrate the changes in the six subscale mood factors after both of the walks. Once 20 again starting mood scores have been averaged for both conditions, to allow direct comparisons to be 21 made. There was a statistically significant difference between the 2 Type of walk groups for anger (F= 4.2; p<0.05); 22 Indoor walk confusion (F= 5.8; p<0.05); depression (F= 4.7; p<0.05) and tension (F= 8.0; p<0.01). There were no significant differences between the groups in feelings of fatigue or vigour.
Figure 17: The change in feelings of anger following participation in the walks
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Figure 18: The change in feelings of confusion following participation in the walks
40 Indoor walk

42 Indoor walk 41

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Index of confusion
Green outdoor walk

Index of anger

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39

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Type of walk

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Green outdoor walk

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Figure 19: The change in feelings of depression following participation in the walks
42 44 43 41
Index of depression

Figure 20: The change in feelings of fatigue following participation in the walks

Indoor walk
Index of fatigue

42 41 40 39 38 Green outdoor walk 37 Indoor walk

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39

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Type of walk

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Type of walk

Green outdoor walk

Figure 21: The change in feelings of tension following participation in the walks
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Figure 22: The change in feelings of vigour following participation in the walks
43 Green outdoor walk

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Index of vigour
Green outdoor walk

Index of tension

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Type of walk

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Indoor walk

Type of walk

Index of total mood disturbance

Therefore, when combining all of the six subscale mood factors to calculate the change in TMD (Figure 23), there was a significant difference between the 2 groups (F=8.6, p<0.01) (Note – the lower the score, the better the overall mood).

Figure 23: The change in feelings of total mood disturbance following participation in the walks
140 Green outdoor walk

145

150

155 The findings clearly show that exercising outdoors in a green 160 environment is a lot more effective Indoor walk in enhancing your mood and improving your self-esteem 165 Type of walk compared to the equivalent amount of exercise indoors. Participating in a green outdoor walk can significantly reduce feelings of anger, depression, tension and fatigue, whilst also making you feel more active and energetic, so it offers an ideal way of getting rid of those blues.

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In addition to analysing changes in Figure 24: How much enjoyment participants derived from psychological health states, we various aspects of the walks Green outdoor walk also asked participants to use an 5.0 Indoor walk enjoyment scale to rate how much 4.5 4.0 enjoyment they got out of various 3.5 aspects of the walks. The short 3.0 scale ranged from “did not enjoy at 2.5 all” (1) to “enjoyed a lot” (5) and the 2.0 mean answers are displayed in 1.5 Figure 24. It is clear that 1.0 participants enjoyed the scenery 0.5 and the exercise more in the green 0.0 outdoor walk. They also enjoyed The scenery Being with other The exercise Being outside / Doing something people shops different being in the company of other Feature people and doing something different more in the green environment. Spending time outside in the fresh air was more enjoyable than walking around the indoor shopping centre. Participants were also asked to comment on what they thought was special about both of the walks (Box 7).
Box 7: What did you feel was special about the walk? Comments from participants Green outdoor walk (12 comments received out of the 20 completed questionnaires) “It makes you feel good in the fresh air, looking at the water makes you feel relaxed. Joining in with other people. I like walking in the countryside” “Apart from meeting other Mind members, it was extremely good to take part and involve my members” “Good exercise and meeting up with other groups” “Very good exercise” “All different Mind groups getting together” “Meeting others, visiting different places, fresh air, exercise and talking to others” “Getting close to god's beautiful creation” “Scenery” “Made me forget how down I felt, whilst on the walk” “Being able to do something different” “Getting out of doors” “Meeting others in similar circumstances, fresh air, nice views, other people's company” Indoor walk (11 comments received out of the 20 completed questionnaires) “It was not as good as the open air” “It is a good exercise and walking with other people makes you feel better in yourself” “Enjoyed being with people and getting to know other people from Mind groups” “Very good exercise and meeting other people” “Meeting with other Minds” “Very worthwhile” “Did see this as exercise” “It was better than being outside” “If it helps others it's all worth it” “Great but on benefits so cannot enjoy fully the experience” “Being part of a group that seeks to counter problems engendered by mental health, the exercise”
Index of enjoyment

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The comments were very focused on the enjoyment derived from spending time with other people, especially during the indoor walk. However, narrative relating to the green outdoor walk did mention the enjoyment gained from getting out into the fresh air, the scenery and participating in the exercise itself. A selection of participants provided reflective comments of their experiences a couple of weeks after participating in both of the walks (Box 8). Many participants felt that the positive benefits gained from taking part in the green outdoor walk lasted for a few days and in some cases were especially apparent the following morning.
Box 8: Reflective comments received from participants a couple of weeks after the walks “I had my first nights sleep for a long time without sleeping tablets after the green outdoor walk. Also I made a call to a family member on return home from the woods, which I had been putting off as perhaps I was not in the right place” “Felt relaxed with nature, one to one with the creator, lifts your spirits and depression” “The outdoor walk was very nice and made me feel very uplifted and happy” “I enjoyed the walk and the scenery very much. It was nice to be with other people, it made me feel good to be out in the fresh air. It was lovely to breathe in your lungs. It was very good exercise and makes you feel good” “It was nice to browse around the shops with other people as it’s nice to do things together. I enjoyed the walk but preferred the walk outside, it made you feel great and like you had achieved something worthwhile” “It was very nice to have walked around with other people and been with other people. It was a cold day and very muddy but very good”

The results from this small study support previous green exercise research findings reported by the University of Essex, which refer to significant improvements in self-esteem, total mood disturbance and enhanced social capital. Although there was no control condition to compare the findings to (e.g. what activities members usually engage in, such as meeting for a coffee, art classes etc), the significant findings generate some thought provoking questions. Participating in the green outdoor walk was a lot more effective in reducing feelings of anger, depression, tension and confusion, in comparison to the indoor walk. It also increased feelings of vigour and left participants feeling more active and energetic. The enjoyment of engaging in green exercise activities in groups is a valuable part of the experience, as well as the opportunity to breathe in fresh air, admire the scenery and enjoy the wildlife. Therefore, exercising outdoors within a green environment has to be a preferred option to engaging in comparable exercise indoors. The findings add significant value to the ever expanding green exercise research programme as it focuses on individuals experiencing mental health issues and separates the elements that constitute the green exercise experience.

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6. Conclusions and recommendations
6.1 Issues affecting progress of research
6.1.1 Ethical issues Most evaluation work is considered as a type of research and in many settings this brings up the issue of ethics. Ethical dimensions should therefore be taken into account when considering research into green care or green exercise especially if people with special needs or from vulnerable groups are involved. Interviewing or surveying both members of the public and professionals, in terms of the right to privacy and protection from physical or emotional harm must also be considered. For example, when dealing with children, the issue of parental consent should be thought of, informed consent is also necessary for adults and involvement with GP referred patients may produce confidentiality issues. In healthcare settings in the UK, research is likely to be within the remit of NHS Research Ethics Committees, and possibly NHS Trust Research and Development committees. Even if there are no formal healthcare links with the project, evaluation work may still fall under the remit of Local Authority or University ethical regulations. Although undeniably necessary, the extensive ethical application procedures in the UK, often take several months before research can begin, thus can limit the progress of the research and can make applying for ethical approval a very timeconsuming and administrative chore. 6.1.2 Evaluation Issues The evaluation of both green care and green exercise projects aimed at increasing participation in nature-based exercise in both rural and urban areas presents many interesting challenges. 1. the variety of projects and initiatives incorporated within the “green exercise” or “green care” definition 2. the complexity of relationships with different dimensions of health 3. the production of evidence of the effectiveness of health-related activities In the field of healthcare evaluation, the robustness and effectiveness of evidence is traditionally assessed using an idea of a ‘hierarchy of evidence’. In the traditional hierarchy, particular elements of evaluation design are seen as indispensable if the ‘scientific’ nature of evidence is to be preserved. Foremost among these are:    the application of a comparative method including a ‘control’ sample the use of randomness as a principle in the construction of samples the use of ‘blinding’ (research participants and researchers are uncertain of which individuals have received an intervention and which a dummy or placebo) the use of replicable methodology and standardised, validated instruments for the measurement of health gain and other outcomes

Because of the above, the ‘double-blind randomised control trial’ (RCT) is seen as the ‘gold standard’ in effectiveness methodology. However, evaluation of green care and green exercise interventions may find it difficult to live up to this standard, as they, by their very nature,

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preclude the use of one (or several) desirable methodological elements. The main reasons for this are:     Green exercise does not involve the application of a discrete or defined ‘treatment’ such as a medicine Green exercise is not applied to an identifiable population of ‘patients’ (therefore randomised samples of ‘treated’ and ‘untreated’ patients are not identifiable) Green exercise is not amenable to placebo (e.g. it is not possible to design an activity that is just like a country walk, but isn’t a country walk at all.) Green exercise activities can not be blinded as it would not be possible for a patient to be honestly unsure whether they had been on a country walk or not. The outcomes being looked for are not discrete or easily measurable (e.g. feelings of improved general wellbeing, augmented social capital, “healthy communities”)

Given that schemes promoting ‘green exercise’ are characterised by all of the above, we can see that the ‘gold standard’ of a blinded and randomised control trial is not necessarily an appropriate (or even possible) choice. Researchers at Loughborough University are currently embarking on a feasibility study of a RCT approach in Social and Therapeutic Horticulture to examine these very issues. Evaluation methodologies must therefore try to use as many elements of classic randomised trials as they can. They could also be specifically designed to include qualitative elements in addition to quantitative elements, such as asking participants and users to reflect on their experiences of involvement with schemes, in their own words. This type of work does not figure at all in traditional approaches to proving effectiveness, but, in terms of attempting to illustrate the kinds of impacts that ‘green exercise’ schemes can have on the lives of participants, the use of qualitative methods is clearly one appropriate path to follow.

6.2 Key issues for policy
Green Exercise and Green Care have important policy implications for a wide range of sectors. It is clear that a large number of people already use the countryside and urban greenspaces, from which they derive a health benefit, however, physical and mental health problems are on the increase and many people do not access greenspaces at all. Exposure both to nature and green space and to physical activity should be a central part of the policies and strategies of a large number of organisations. It seems evident then that promoting participation in both green exercise activities and green care has important implications for public and environmental health. Therefore, increasing support for and access to a wide range of green exercise and green care activities for all sectors of society should produce substantial economic and public health benefits as well as reducing individual human suffering. However, for this promotion to be successful, we firstly need to discuss and address some of the key issues that will be raised.

6.2.1 Amount of greenspace We need both more quality greenspaces, (especially in very urbanised areas), and to actively protect and conserve existing green spaces in both rural and urban locations alike. There

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seems to be a distinct incongruity between the positive conclusions of green exercise reported in this research document and the existing drivers of economic development in both rural and urban regions. In the regeneration of urban areas, green spaces are often removed to keep down maintenance costs, and there is often a perception that well-vegetated places offer more opportunities for criminals and drug-dealers to hide. In rural areas, modern agricultural development and the need for new housing continue to put pressure on greenspaces where people can enjoy green exercise opportunities. 6.2.2 Accessibility issues We need to encourage access and recreation providers to ensure that more people have easy access to green areas within a short distance from their home. The availability of accessible green space close to home is a well-known factor in levels of exercise participation, and particularly if these areas are located within a few hundred metres or a 5 minute walk from home. The extensive amount of accessible green space already available to the public constitutes a very significant health resource for the country (the Natural Health Service), but at present too few people make use of these opportunities, and those that do tend to be from only certain social groups. Groups with low participation rates in countryside recreation as a whole are young people; low-income groups; ethnic minorities and disabled people. We have also shown that people suffering from mental ill-health particularly receive physical, mental and social health benefits from participating in green exercise activities. Given that many people who suffer from depression and stress can reap great benefits from participating in green exercise activities, it would be interesting to map the areas of accessible greenspaces in the UK with the areas of highest mental health vulnerability to see if there is a positive correlation. People who are most disconnected from nature may be those who suffer the most. The availability of accessible nearby nature as greenspaces in urban areas or countryside in rural areas, has the potential to make us feel better or to make us feel disconnected and so it can be argued that contact with nature is crucial to safeguarding the mental health of the nation. Perhaps therefore, countryside agencies and greenspace managers should ensure that i) services at urban parks, country parks, recreation areas and other greenspaces are focused on encouraging socially-excluded groups and people with mental health concerns to access nature and ii) greenspaces are accessible to all in practice as well as in theory.

6.2.3 Barriers to participation If green exercise can have such a positive effect on health, why are more people not regularly taking exercise and visiting green spaces? Firstly, it is apparent from current participation rates that a large proportion of the UK population already engages in various forms of green exercise. Thus, there is already a health dividend being experienced. On the other hand, recent data indicates that another substantial proportion of the population is in danger of becoming obese and too sedentary. It is clear that there are barriers to participation, which are affecting different groups of people in different ways (Table 3). How, then, can environmental and health policy sectors overcome the challenge of finding ways to remove these barriers to participation?

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Table 3: Current potential barriers to participation in green exercise activities Potential Barriers Reasons Many people assume that in order to have any benefit to health, walks need to be Time available for at least an hour and because of this many people feel that they then cannot spare this much time to walk. Many people find it difficult to get the motivation to do any type of exercise and this Lack of motivation is accentuated even more for people suffering from mental ill health. They often state that they are too tired from a long day’s work. Public spaces are sometimes seen as ‘risky’ and associated with crime. The fear from personal attack, angry farmers, farm animals or fear of having a medical Perceptions of emergency may affect people’s willingness and ability to make the most of these personal safety natural places. The absence of safe pavements and walking and cycling paths is also a concern. Some groups of adults and children are not independently mobile and can’t get to Lack of transport these places or there may be a lack of public transport which limits travelling options options. If there are busy roads to cross this often acts as a challenging obstacle. Many people do not know where footpaths start, finish or how to get to them. Local Location of rights Authorities and land managers should place a higher emphasis on rights of way of way signage and maintenance to encourage access. A lack of knowledge about the terrain of an area can also act as a barrier to participation, if there is no information available on the type of surface, severity of Terrain hills, maintenance standards of paths and hedges and potential obstacles. This is doubly worrying for those people suffering from joint and balance problems or those with generally low levels of fitness. A lack of information about facilities, such as toilets, that may available en route Facilities may also act as a deterrent. Some people need a reason to go for a walk. These reasons include: walking with Purpose a pushchair, walking the dog, or social reasons such as meeting people or family time.

6.2.4 Acceptance from healthcare and social service providers The health sector needs to consider the contribution that green exercise makes to both individual health and public well-being. After all, a fitter, happier population has the potential to save money for the National Health Service. Any forthcoming Physical Activity Plans should emphasise the value of nature and green space for formal and informal use, and also stress the therapeutic value of the outdoors (both rural and urban) for delivering mental well-being. Health professionals at Primary Care Trust level, including GPs, should work closely with other sectors to link health and the environment more closely. Environmental, countryside, sports and planning professionals and green care practitioners can all be involved in affecting the mental health of local communities in partnership with PCTs. Exercise prescription should be increased to encourage those with sedentary lifestyles and weight problems to become aware of the personal health benefits. A recommendation to take part in existing local “walking for health” schemes or other green exercise activities is a relatively cheap and effective way for primary health care practitioners to encourage people to become more active. There is a lack of knowledge and acceptance of the benefits to be gained from using exercise referral in treating depression among GPs, and providers of health and social care need to be encouraged to take the idea of “green care” more seriously. GP’s should be encouraged to consider and recognise the value of “green prescriptions”.

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It is also important that the general public is made aware of the benefits of contact with nature. Those people who already appreciate the positive effect of a walk in the park or a stroll on the beach for example would readily agree that nature is good for you, but people who are disconnected from nature may not have had the chance ever to feel such benefits. A major problem in encouraging more “green prescriptions” is to overcome the patient’s perception of whether green exercise is as an effective treatment response. Sometimes, patients subconsciously believe that taking a pill will automatically make them feel better, whereas leaving their doctor’s surgery with a recommendation to engage in regular outdoor walks may not be deemed as effective or even a satisfactory treatment. Agencies responsible for providing social care services would also benefit from recognising the potential of green care and green exercise activities to increasing the health and mental wellbeing of patients and clients. In the same way, the prison service, once well-renowned for recognising the benefits to inmates of working on a prison farm or garden, should look into increasing this potential for a happier, calmer and more socially adjusted prison population. Probation services in some areas of the UK are already recognising the potential in Care Farming and horticultural projects to provide natural, green environments to deliver both mental health and employment dividends to ex-offenders. In times with increasing prison populations, a prevalence of prisoners with mental health problems and concerns over the effectiveness of current probation services, there is great potential for green exercise activities and green care to be used as an additional option in the rehabilitation of offenders into society.

6.2.5 Working in partnership Green exercise has implications for many sectors, suggesting the need for cross-disciplinary and sectoral strategies and action. The majority of countryside visits are informal, and so we should consider how better to market the countryside as a health resource to a wide range of social groups and encourage land managers, countryside agencies and farmers to advertise the health implications of their resources. Health agencies should advertise the mental health benefits of physical activities in rural and urban green spaces and the private sector, particularly the food manufacture and retail industry, could be engaged in partnerships for provision of both healthy food and healthy places where the food is raised and grown. All public and private agencies should consider the value to the mental health and well-being of employees and customers of a pleasant outdoor landscape, water, indoor vegetation and fresh flowers, nature posters and paintings, which all can be readily incorporated into the local physical environment with minimal expense. Often research institutions face problems in accessing people to engage in their research which is vital in developing the evidence base. Therefore encouraging academic institutions, the health sector and pubic and private companies to work in partnership will be a positive step forwards.

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6.1.6 The need for further research There is a need for funding of further robust scientific research to be conducted and in particular we need to understand more about the financial savings and economic costings of increasing participation in green exercise activities. A recent report highlighted the major gaps in the evidence base which prevents us placing a monetary value on the impact of green exercise (Willis and Liesl, 2005). Leading on from this, three proposals for further research were identified: 1) Valuing the provision of greenspace for health: The factors that would encourage sedentary and obese people to engage in physical activity in green spaces need to be assessed. 2) Estimating the health benefits from the supply of greenspace relative to where people live: Assess the possibility of using National Health Survey data to estimate the contribution of greenspace to mental health, quality of life and physical activity levels. 3) Enhanced monitoring and evaluation of green exercise and green care activity programmes: Demonstrate improved monitoring and evaluation methods for green exercise and green care programmes by assessing changes in physical activity behaviour, health outcomes and economic measures. Once again, this highlights the need for collaboration between academic research institutions and health and social care professionals. A universal, standardised tool could be developed to improve monitoring and evaluation methods for a range of green exercise activities, and allow comparisons to be made.

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