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Exercise-, nature- and socially interactive-based initiatives improve mood and self-esteem
Copyright © Royal Society for Public Health 2012 March 2012 Vol 132 No 2 l Perspectives in Public Health 89
SAGE Publications
ISSN 1757-9139 DOI: 10.1177/1757913910393862 Downloaded from rsh.sagepub.com by Pro Quest on March 26, 2012
PEER REVIEW
Exercise-, nature- and socially interactive-based initiatives improve mood and self-esteem
It is also important for maintaining five days of the week (17.5 kcal/kg/week). health46–49 and improved quality of life in
physical fitness, strengthening the The National Institute of Clinical ageing populations.49 Thus, nature can
immune system, increasing stress Excellence (NICE) recommends provide a resource for tackling illness and
tolerance and preventing some of the participating in three structured, act as an effective upstream health
diseases of affluence, such as cancer, supervised exercise sessions (45 minutes promotion intervention for clinical
heart disease, cardiovascular disease, to 1 hour) per week for 10 to 12 weeks to populations.3,50–51
type II diabetes, obesity and back treat mild depression.5 The prescriptive A number of initiatives combine nature
pain.19–20 The rates of these nature of exercise guidelines for this and exercise to promote health (e.g.
co-morbidities are as high as 60% population is fraught with challenges and social and therapeutic horticulture,
among individuals with mental illness.21–22 a recommended physical activity session wilderness therapy, adventure therapy,
The relationship between exercise that focuses on overall movement rather green gyms). The therapeutic application
and improved mood identifies a link but than structured exercise might be more of these nature-based approaches offers
not causality.14 Probable reasons achievable. However, the evidence implies treatment options for individuals
underpinning this mechanism include the that maintaining a positive mood almost experiencing mental or physical illness
distracting nature of exercise which certainly requires adherence to a longer- that do not rely solely on drug therapies.
confines negative thoughts, the term exercise or activity programme.14 Green gyms promote physical and mental
opportunity for social interaction and to The type of environment can also play health through active, supervised
master new skills23 and physiological a key role in the success of an exercise- participation in environmental
adjustments in endorphin and cortisol based therapeutic intervention. Studies conservation work within the local
levels,24 which all improve mood. comparing indoor and outdoor exercise environment.52 Significant improvements
Although cause and effect are difficult to settings34–36 showed that outdoor in Health-Related Quality of Life (HRQOL)
decipher, the evidence base reviewing experiences were rated as more scores and cardiovascular fitness were
the effectiveness of exercise as a restorative.34 Moods were affected by the reported, along with increased muscular
treatment option for depression is type of environment, with indoor walking strength, coping ability and reduced risk
continually growing.14,25–26 Meta-analytic associated with increased frustration, of functional limitations in later life.52
effect sizes for exercise as a treatment anxiety, anger and sadness.36 Walking Adherence rates were also favourable
option for depression compared to no outdoors was associated with positive when compared to those recorded in
treatment report reasonably large moods, such as feeling happy, delighted, traditional gym-based schemes. In the
effects.14,27–29 There are many joyful and pleased, and a decrease in national evaluation those with the lowest
methodological issues that might bias negative moods. Walking outdoors initial physical health scores were nine
the findings in favour of exercise, but the increased vitality, however, no change in times more likely to see the biggest
consistently large effect sizes justify this measure was experienced during improvements in their scores compared
further research. Exercise has also been indoor walks.35 The presence of nature to members with higher scores.53
compared to other established treatment was an influential factor in improving Similarly, members with the lowest mental
options, such as antidepressants and vitality outdoors.35 health scores at the outset were three
cognitive behavioural therapy (CBT) Nature is defined as ‘the environment times more likely to see the biggest
programmes. Initial findings imply that in which organisms or their biotopes improvements. The least active
exercise is equally as effective as both expressly manifest themselves. In participants were three times more likely
antidepressants and CBT, as no addition to nature reserves, this will also to increase their physical activity levels,
significant differences were reported include farmland, production forest, so these nature-based exercise
between the interventions.14,30 Studies urban green spaces and back interventions are effective in increasing
have also investigated the health benefits gardens.’37 It is well established that activity time for those who need it most.54
of introducing an exercise programme for exposure to nature leads to positive However, the evidence concerning the
outpatients with schizophrenia31–32 and mental health outcomes and cognitive, application of green exercise in the
individuals with alcohol misuse affective and behavioural changes.38 The mentally ill population is limited. Research
problems33 with positive outcomes. link between contact with nature and has demonstrated that short singular
An optimal dosage for beneficial improved mental health is understood by exposures to nature and physical activity
exercise prescription is still unclear. The those who regularly seek out green are potentially beneficial in improving
most effective type, intensity, frequency, spaces and choose to participate in mental health in the general
duration and conditions (supervised or green exercise activities (any activity in a population,39–40,55 but little research has
unsupervised, indoors or outdoors, green space in the presence of focused on clinical populations. Positive
group or individual) of the activity remains nature).39–42 Access to green space is changes in mood and self-esteem (SE)
ambiguous.14,25 Dunn et al.16 proposed a important for mental health and is have been seen after as little as 20
dose–response relationship for the associated with longevity and decreased minutes when comparing pre and post
treatment of major depression, with the risk of mental illness in Japan,43 measures.39–42 However, studies
most effective treatment being Scandinavia44 and the Netherlands,45 analysing the benefits of repetitive
30 minutes per day on three or improved perception of general exposure over a period of weeks are
Exercise-, nature- and socially interactive-based initiatives improve mood and self-esteem
Exercise-, nature- and socially interactive-based initiatives improve mood and self-esteem
Exercise-, nature- and socially interactive-based initiatives improve mood and self-esteem
Table 3
Mean (M) scores for self-esteem and overall mood pre and post one session
Green exercise 23.6 ± 6.0 21.0 ± 6.1* 53 154.3 ± 24.6 143.1 ± 24.6* 51
Social activities 20.7 ± 6.2 20.3 ± 5.9† 52 142.4 ± 26.2 134.4 ± 21.2*†† 53
Exercise-, nature- and socially interactive-based initiatives improve mood and self-esteem
underlying differences may relate to attracted mainly female participants, contribution. The findings also generate
group dynamics, demographics and whereas the GE programme recruited an further questions regarding the
length of programme. The SA club has equal number of males and females. The underlying mechanisms of differences in
been in existence for over 20 years and GE participants also represented a environmental exposure. This study did
many members have been regularly slightly younger generation, which makes not attempt to record environmental
attending for up to 12 years. In generalization more difficult. It was not characteristics such as temperature,
comparison, members of the GE group possible to collect all data humidity, light and vitamin D exposure,
did not necessarily socialize together at simultaneously, however data was but these factors could contribute to
the drop-in centre but came together to collected at similar times of the year to changes in mood. Thus, outdoor
participate in the walks (which did not account for any seasonal affects. The weather conditions for the GE group may
always involve the same individuals). The health-promoting initiatives were of have influenced the findings. Similarly,
differences in these parameters imply different durations, which might have had nature’s components (i.e. sound, smell,
that members of the established social an impact on acute effects. However, visual, etc.) have not been assessed
group are already experiencing health weekly sessions were always of the independently to recognize the
benefits from participating in regular same duration for each group contribution of each to the overall
social activities. respectively. experience and restorative properties of
The dose–response data showed that The sample size limits substantiated nature exposure.
both SE and TMD levels improved over conclusions but it does inform the effect The effectiveness of exercise as a
the six-week period for all groups size upon which to calculate a future treatment option for depression has
combined, although no interaction larger study. Self-esteem and mood are already been compared to
effects were reported. The lack of very labile, especially for those antidepressants and CBT
differentiation between the programmes experiencing mental health problems programmes.14,30,72 Antidepressants often
implies that introducing GE as a when it can be even more accentuated. have many adverse side effects and
health-promotion initiative for people Therefore, a one-off measure once a there is often a time lag between
experiencing mental ill health is equally week does not account for events prescription and elevations in mood.14
as effective as the existing options. occurring throughout the week or prior to Therefore, GE could potentially be
the activity. In addition, a common side advocated as a parallel intervention to
effect of psycho-active drugs is flattening traditional drug therapy in the treatment
Limitations of affect and if participants were receiving of mental illness to enhance both acute
There are methodological limitations with drugs to control their mood, this would and chronic improvements in mood.
this type of fieldwork which are have had an impact on the findings. Research suggests that people
unavoidable. Variation in attendance and However, irrespective of starting levels, experiencing serious mental illness often
non-equivalent, self-selecting groups participation in the health-promoting accept exercise as a potential treatment
with no consistent membership restricts initiatives generally improved both SE option and frequently identify it as one of
longitudinal and between-group analyses and TMD after a single session. the most valued components of
and limits interpretation of the findings. Therefore, they had positive acute effects treatment.17
Attendance rates for both the S and SA which could lead to longer-term chronic GE programmes also promote
groups were relatively consistent and improvements. reconnection with nature and an
represented typical behaviour. In opportunity to experience the additional
contrast, a random selection process of positive health benefits that are
participants was enforced in the GE Conclusion associated with this.39–42 Contact with
group to avoid exclusion issues. This This study highlights the methodological nature and green space is often uplifting
limits the comparability of the groups as challenges involved with this type of and restorative, and helps to reduce
50% of the GE participants only attended research and the limitations identified stress and improve mood.39–42
one session compared to 14% in the suggest a need for further research. Combining this with physical activity may
other two programmes. Only 8% of the Future research studies could include offer a very efficacious treatment option.
GE participants attended five or six randomized controlled trials or waiting list GE also promotes social inclusion and
sessions compared to 21% and 47% in control groups, although attrition rates creates the circumstances and
the S and SA groups, respectively. This may still be varied. GE could be associated social networks within which
affects the reliability of the longitudinal compared to other types of exercise and healthier lifestyle choices are more likely.
analysis of SE and TMD as many GE the findings suggest a need to It is clear that social connections,
members only had the opportunity to independently analyse the social exercise and nature all have a key role to
participate in a single session. component. The social interaction was a play in addressing mental ill health.
The demographics of each group also consistent element in all initiatives, so Combining these elements may also play
differed, which might have influenced the future studies could attempt to a role in managing and supporting
findings. The two existing initiatives disaggregate this to assess its recovery from a range of mental health
Exercise-, nature- and socially interactive-based initiatives improve mood and self-esteem
problems, suggesting a potential green support could include the provision and Acknowledgements
approach to mental healthcare and promotion of healthy walks projects, The authors would like to thank all
promotion. green exercise on prescription, healthy participants for consenting to take part in
GE has implications for many sectors, school environments, green views in this research project. Appreciation is
suggesting the need for cross- hospitals, care farms, city farms and shown to both Maldon and Colchester
disciplinary and cross-sectoral community gardens, urban green Mind groups, volunteer support workers
strategies and action. Increasing space, and outdoor leisure activities in and staff for their assistance with the
support for and access to a wide range the countryside. In the current context evaluation process. The Colchester Mind
of GE activities for all sectors of society of increasing incidence of mental ill group was instrumental in facilitating the
could produce substantial economic health, the importance of a new green green exercise programme and the
and health benefits, both at the agenda for mental health that improves Maldon Mind group kindly permitted the
individual micro level and public and access to nature and green spaces authors access to their ongoing social
environmental macro level. Such is needed. intervention programmes.
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