Nature–based interventions for mental health and wellbeing
Mental illness is a large and growing challenge in the UK, often with heart-breaking consequences for countless numbers of individuals and families, and poses a strategic economic and social challenge for 21st Century Britain.
Today in the UK, 1 in 4 people experience a ‘significant’ mental health problem in any one year, with 1 in 10 of school aged children suffering from a diagnosable mental health disorder - that is around three children in every school class. The annual total cost of mental illness is currently estimated to be £105 billion (The Centre for Mental Health, 2010).
Studies show that simply spending time in or being active in natural environments is associated with positive outcomes for attention, anger, fatigue and sadness8 1, higher levels of positive affect and lower levels of negative affect (mood/emotion)2 and physiological stress3.
Most studies that have considered relationships at a population level find that more greenspace around the home has a protective effect on self-reported mental health and is associated with reduced risk of stress, tendency to psychiatric morbidity, psychological distress, depressive symptoms, clinical anxiety, depression and mood disorders for adults4. There is some evidence which suggests that certain types of environment such as coasts, mountains and woodlands and better quality natural environments are associated with better mental health5 6.
The evidence for the impacts of nature–based interventions on mental health and wellbeing is robust and has multiple benefits including reduction in depression, stress and anxiety; increased social contact, inclusion and feeling of belonging; improved self-esteem, confidence and mood; and an increase in personal achievement through meaningful activity. There is also generally positive evidence relating to the impacts of activities in natural environments on children’s mental health and their cognitive, emotional and behavioural functioning. Research and reviews undertaken by Natural England and partners show these types of interventions to be cost effective.
Throughout the country there are a growing number of examples of nature based interventions being offered as “green prescriptions”. For example, in Cornwall there is a project underway called “A Dose of Nature,” which aims to develop “green prescriptions”, so that it is easier for doctors to make available a dose of nature. They are not “true” prescriptions, of course. Nonetheless, by forming partnerships with those who manage environmental assets in the county and who are willing and able to receive patients, by providing funding to cover the gap until such services are commissioned, and by ensuring a high quality service that allows a patient whose situation with regard to their health is considered in need of such activity, a doctor is able to direct a patient towards making some potentially important lifestyle changes.
“A Dose of Nature,” is a partnership project between academics, GP surgeries, and environmental organisations and is funded by a Knowledge Exchange Fellowship from the Natural Environmental Research Council. The aim of the project is to develop a coherent approach across the county—spanning different sectors—so that questions and issues are addressed reciprocally. The project works with NHS Kernow, the Health and Wellbeing Board, and the Local Nature Partnership, as well as the University of Exeter Medical School and its biosciences department. So far five pilot schemes are in development, and the intention is to apply the model across Cornwall and beyond in due course. Dose of naturei.
So with increasingly robust evidence, interest is steadily growing in the use of nature-based interventions for mental health care, however it’s use is still a long way from mainstream health practice. So, what is stopping this wider use of nature-based interventions for mental health care? The challenge lies in increasing awareness and overcoming the barriers to accessing these interventions. Issues which we need to address include the fragmentation of provision: with many different organisations delivering nature-based care, there are a wide range of delivery models, and differing language used to describe the activity and the benefits to both the user and the health professionals. To add complexity, some providers offer both public health programmes for the general population as well as the often more structured green care interventions which are designed as a treatment for clients with a defined health need. All of this creates a degree of confusion and uncertainty for people using these services and importantly, barriers for health professionals such as GPs and Clinical Commissioning Groups if referral to nature-based solutions is to become more common place.
To explore the challenges, barriers and steps required to enable a greater number of nature-based interventions to be commissioned in mental health care, Natural England funded a number of reports one of which 7focused primarily on understanding more about green care interventions. It recommended that the “nature based intervention” sector works together in partnership to help promote clearer messages to policymakers, health commissioners and potential service users using common language to describe activities and outcomes.
The Report highlights the need to distinguish between i) specifically designed and commissioned interventions for individuals with a defined need (green care), and ii) public health programmes for the general population (see Figure 1). This will ensure that nature-based service providers use the appropriate language (and evidence) in order to talk to the right health commissioners – i.e. green care providers should target health and social care commissioners (Clinical Commissioning Groups and Local Authorities (social services)) and more general nature-based programmes should target commissioners of Public Health (PHE and Local Authority public health departments).
The report has led to a more focused piece of research funded by Natural England and commissioned from Mind and Care Farming UK, soon to be published, which examines how social prescribing is being used to support mental health care using the natural environment through “green prescriptions”. It looks at examples of good practice which could be significantly scaled up and replicated more widely8.
It is hoped that this and other research will help to transform the quality and growth of nature-based interventions, thereby enabling the natural environment sector to make a serious contribution to the growing demand for health and care services for people with mental illnesses in the UK.
Natural England’s Outdoors for All Programme
Natural England’s Outdoors for Allii Programme continues to work to improve opportunities for all people in England to enjoy and benefit from the natural environment. Natural England works with and chairs the National Outdoors for All Working Group (NOfAWG), which brings together users and providers of services for the diverse population that would otherwise not have access to the countryside. The purpose of the working group is to commission research and provide evidence to show the benefits of access to the countryside; and to promote and facilitate solutions to mainstream the use of the natural environment in supporting positive health outcomes. For example Natural England has recently published a series of evidence briefing sheets that set out the evidence linking the benefits of the natural environment to a number of outcomes such as mental healthiii and dementia, physical activityiv and obesityv, physiological healthvi, learningvii and connection to natureviii.
Also the NOfAWG partnership organised a successful conference on Transforming Mental Health and Dementia Provision with the Natural Environmentix on November 10th 2016, in London. The event brought together the health and social care sectors with natural environment sector to stimulate closer working and improve the mechanisms that can enable ”natural solutions” to become a mainstream activity in supporting people with mental ill-health or dementia. It showcased best practice in commissioning and scaling up of nature-based projects and was aimed at commissioners of mental health and dementia services, GPs, social care providers, public health and other relevant departments of local authorities, as well as those working in nature-based projects. Proceedings of the conference will be available.
The Outdoor Recreation Network
The Outdoor Recreation Network (further information below) has organised two well attended conferences which included presentations and discussion on the ‘Overcoming Barriers’ theme. The first focussed on ‘Public Health in Outdoor Recreation’x in March 2015, and the second looked at ‘Outdoor Recreation and Active Lifestyles: understanding behavioural change’xi in October 2016. The presentations for both events are on the Outdoor Recreation Network website and available at the links.
This article has been written by Jane Houghton and Sarah Preston of Natural England on behalf of the Outdoor Recreation Network
For further information about Natural England’s work on overcoming barriers to access the natural environment, please contact Sarah Preston firstname.lastname@example.org and Jane Houghton email@example.com
Information about the Outdoor Recreation Network
ORN is a network which is committed to gathering, exchanging, developing and sharing information to develop good policy and practice in outdoor recreation across the UK and Ireland.
This is achieved through:
- networking between member organisations and other interested organisations
- holding seminars, workshops, conferences and organising research meetings a recent example being conference on ‘Outdoor recreation and active lifestyles – understanding behavioural change’
- distributing the information to a wider audience through e-zines, a journal, digital media and a library of publications freely available on its website.
Members of the Outdoor Recreation Network are organisations and individuals in the public, private and voluntary sectors and the network reaches thousands of interested people.
ORN is funded through membership fees by a range of government departments, agencies and other bodies who share an interest in outdoor recreation issues.
1 Thompson Coon, J., et al, Does participating in Physical Activity in Outdoor Natural Environments have a Greater Effect on Physical and Mental Wellbeing than Physical Activity Indoors? A Systematic review. Environmental Science and technology, 2011. 45 (5): p. 1761 - 1772
2 McMahan, E.A. and D. Estes, The effect of contact with natural environments on positive and negative affect: A meta-analysis. The Journal of Positive Psychology, 2015. 10(6): p. 507-519.
3 Haluza, D., R. Schonbauer, and R. Cervinka, Green Perspectives for Public Health: A Narrative Review on the Physiological Effects of Experiencing Outdoor Nature. International Journal of environmental Research & Public Health, 2014. 11(5): p. 5445-5461.
James, P., et al., A Review of the Health Benefits of Greenness.
Current Epidemiology Reports, 2015: 2(2) p. 1-12.
5 Dean, J., K. van Dooren, and P. Weinstein, Does biodiversity improve mental health in urban settings? Medical hypotheses, 2011. 76(6): p. 877-880.
6 17. Lovell, R., et al., A systematic review of the health and well-being benefits of biodiverse environments. J. Toxicol. Environ. Health Part B, 2014. 17: p. 1-20.
7 BRAGG, R., ATKINS, G. 2016. A review of nature-based interventions for mental health care. Natural England Commissioned Reports, Number 20
8 BRAGG, R. and LECK, C. Good practice in social prescribing for mental health: The role of nature-based interventions. Natural England Commissioned Reports, Number XXX.2016