Natural movement
The 2024 Mental Health Awareness Week theme is movement - and nature can help with being active.
“I took a walk in the woods and came out taller than trees."
Henry David Thoreau’s famous quote suggests that a physical activity like walking in a natural environment, can bring a positive benefit to our mental wellbeing and sense of self. Being outdoors, whether gardening in a back garden, walking along a river or hiking in a national park, provides many opportunities to be active.
Mental Health Awareness Week is an annual event created in 2001 by the Mental Health Foundation (MHF) and the 2024 campaign is based all around movement, to promote the benefit that physical activity has upon physical and mental health. To tie in with the campaign the MHF published a report on the links between activity and health, based on analysis of data obtained from focus groups and an online survey of 6000 adults. The analysis showed that 82% of those respondents believe that regular physical activity is good for their mental health. However the report highlights a large disconnect between that and actual behaviours, with only just over a third (36%) of UK adults meeting the recommended level of regular physical activity.
There are a number of reasons listed in the report to suggest why this disconnect is occurring. The respondents to the MHF survey were asked what would help make them more active, with the top response relating to the weather (42%) which we cannot do a lot about other than be prepared with the right clothing. However the majority of the other responses relate to things individuals can be helped with - more local, low cost activities, activities aimed at supporting beginners, and more ideas on how to incorporate physical activity into daily life. I also thought it was interesting that over a third (37%) of the respondents stated being unable to make time for physical activity as a key barrier.
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The report acknowledges the positive benefit of undertaking physical activity in a natural environment. There are multiple public health initiatives to support activities in natural environments, from informal local walking or running groups led by volunteers, to more focused social prescribing programmes. The availability and accessibility to local green-spaces is also a key factor on activity levels. What evidence base is there around some of these considerations and how do we measure the relationship between natural environments and activity levels?
Nature based activities
A large study published in 2024 was undertaken by James Grellier and an international team of researchers to consider the health benefits from physical activity undertaken in natural environments. The study used data from 2019 obtained via the Monitor of Engagement with the Natural Environment (MENE) database, covering adults aged 16 or over in England. This provided a study sample of 47,580, with the results extrapolated to a population of England of just over 44 million adults. The authors considered 6 non-communicable diseases, including major depressive disorder and physical illnesses such as stroke and heart diseases, which make a contribution of 74% to global mortality rates.
Similar to the MHF report, the authors highlight that while there is a large awareness of the importance of physical activity to health, the majority of people do not meet recommended levels. They highlight that over half of the visits to natural environments in 2019 were reported as relating to health or exercise and there is evidence that outdoor activities are more beneficial to mental health than indoor physical activities.
The analysis showed that nearly half of the 47,580 respondents visited a natural environment at least once a week. The authors used the data to calculate that nature-based physical activity could help prevent 12,763 cases of non-communicable diseases per annum, with the majority of these (10,561) relating to major depressive disorder. Their modelling also showed that for modest increases in frequency of nature based activity or number of visits to natural environments the overall potential could rise to over 15,000 preventable cases per annum. The authors estimate the financial cost saving to health care may be around £108 million. There are limitations to the analysis, including the potential bias in the sample used to extrapolate a population-level benefit, and the respondents may also undertake indoor physical activities which the MENE data does not capture. The authors also highlight that their analysis does not capture the longitudinal links between physical activity and chronic illness which can be influenced by other factors. These limitations aside, the results support other analysis and research which highlight the benefits of physical activity to health and the authors noted that “the promotion of nature-based PA may have a particularly strong role in preventing mental ill health”.
Nature prescriptions
An Australian research team of Phi-Yen Nguyen and colleagues published a systematic review and meta-analysis in 2023 of the evidence around nature prescriptions, a form of social prescribing within health care, to determine the social, mental and physical health benefits. They also considered the characteristics of such interventions and the evidence base for them.
The review used studies from 1999 to 2021 where a control group had been used to compare a nature-based activity, selecting 92 studies. The majority of the studies (66) had a Randomised Control Trial (RCT) design and mainly covered adults, with 11 studies relating to children and young people under 18 years old. Nearly all the studies related to green-space environments, principally forest and parks, with only 2 including blue-space. The studies often focused on activities which could be done individually, such as gardening or walking.
A mixture of benefits were found from the analysis, with 62 studies highlighting benefits to mental health, 39 included physical benefits and 23 noted behavioural benefits. The meta-analysis included data from 28 of the studies, with the results suggesting a moderate positive effect on depression from nature-based activities in comparison to a control group. There was also a moderate to large effect noted on anxiety. Physiological benefits included improved blood pressure and increased activity levels. The review also found several limitations in the studies, including unclear or unreported demographic data which reduces generalisability of findings and a moderate to high risk of bias, mainly due to the lack of blinding within allocation of individuals to intervention or control groups. It is also worth noting that it can be very hard when collating studies together within such reviews to find common control groups - for example a control group can be a wait list (that is do nothing), or a treatment-as-usual intervention, such as medication or therapy.
Overall the review and analysis found that nature-based prescription programmes offered benefits to physical and mental health, as well as supporting increased activity levels, with natural environments offering both variety in terms of setting and the activities they support.
Measuring activity
One challenge within the studies covered in these reviews is how to best measure activity levels and the association to access or exposure to natural environments. A 2024 paper by Tong Liu and colleagues from Clemson University in the US undertook a scoping review to consider how to measure access to green-spaces and activity levels, which they termed mobility behaviour. They reviewed studies from 2010 onwards that were based in urban settings covering individuals of any age and which used various study designs. This provided a sample of 20 observational studies, of which the majority (18) were cross-sectional. They found three key methods were used to measure activity and green-space exposure - ecological momentary assessments (EMA), measures of affect, and spatial measurements. While the paper is primarily focused on using the studies to develop a proposed measurement model of daily exposure to green-space which am not going to cover in detail, the review highlights that the evidence from the selected studies indicates that green exercise helped to increase and maintain activity levels, while also appearing to provide greater health benefits than physical activity undertaken in more urban outdoor settings.
Children and activity
A 2012 study included in that scoping review reported a finding which suggested children who had at least 20 minutes of daily exposure to green-spaces had five times greater daily rates of physical activity than children with almost no daily green-space exposure. A more recent paper from 2023 from Giulia Squillacioti and colleagues also considered the relationship of green-spaces within urban settings upon the sedentary levels of children.
The research was undertaken in 2017 and involved 5 primary schools in the Italian city of Asti, involving 306 children aged between 9 to 11 years old (average age 9), of whom 52% were boys. Parents were asked to record their children’s activity levels, including breaking down sedentary activities into screen based ones and non-screen based (e.g reading).
The results showed that the boys in the sample were more sedentary than girls by an average of around 37 minutes each day. Around a third of the children, 105, spent more than 2 hours per day on screen based activities, of which the majority (68) were boys. The team also analysed the level of urbanisation and green-space local to the children. This analysis suggested that children in areas of greater green-space were less sedentary and spent less time on screen-based activities than those in more urbanised areas. Overall the results indicated that children in less urbanised areas had 15 minutes less sedentary time per day and daily screen-based activities were lower by 14%.
There are limitations to bear in mind, as the causal link between the local area and the children’s sedentary is difficult to confirm, while other factors in the area (e.g. weather, crime levels, pollution) may also contribute to activity behaviours during the study period. The children’s activity levels and screen usage were self-reported by parents, so may be subject to under reporting bias and it is a relatively small simple of one city which limits generalisability. However the study does support other research that suggests more access to local green-space encourages children to be more physically active, with the accompanying health benefits that brings. This appears especially relevant given the concern around increasing levels of mental ill health being reported within children and young people.
As daily life seems to be increasingly dominated by technology and with increasing urbanisation, levels of physical activity at a population level appear to be below recommended amounts or possibly decreasing, even though there is perhaps greater awareness of the importance of staying active to our health and wellbeing. Increasing levels of diseases linked to low levels of activity are a public health concern, including mental health issues. The 2024 mental health awareness week theme of movement highlights that building activity into daily life is a key factor in supporting health, both physical fitness and mental wellbeing. There is a strong evidence base that undertaking physical activity outdoors, especially in a natural environment, whether a green-space or blue-space, provides extra health benefits and can help with mental health issues such as depression and anxiety. However what is also clear is that not everyone has the access to such natural spaces locally, may not feel able to take up activity outdoors or faces barriers due to existing health conditions.
Increasing exposure and access to natural environments, creating safe and inclusive spaces especially within urban settings, is a key part of helping people to be more active and to keep moving.
Future articles of Compassionate Nature will look at studies of specific nature-based activities, supporting those with health conditions or disabilities to access nature, and encouraging those who feel disconnected to nature.
It is time for me to stop typing and looking at the screen, the outside is calling and my walking boots are waiting - although the dog is soundly asleep.
Thanks ever so much for reading this article. All the research reviewed are open access studies, so are freely available to read in detail via the links in the article or from the references below. If you think the article would be helpful to someone else please do share on, it is a freely available public post.
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References
Grellier, J., White, M. P., De Bell, S., Brousse, O., Elliott, L. R., Fleming, L. E., Heaviside, C., Simpson, C, Taylor, T, Wheeler, B.W. & Lovell, R. (2024). Valuing the health benefits of nature-based recreational physical activity in England. Environment International, 108667. https://doi.org/10.1016/j.envint.2024.108667
Liu, T., Newman, W. E., & Browning, M. H. (2024). Daily Green Exposure, Mobility, and Health: A Scoping Review. Sustainability, 16(8), 3412.
https://doi.org/10.3390/su16083412
Nguyen, P. Y., Astell-Burt, T., Rahimi-Ardabili, H., & Feng, X. (2023). Effect of nature prescriptions on cardiometabolic and mental health, and physical activity: A systematic review. The Lancet Planetary Health, 7(4), e313-e328.
https://doi.org/10.1016/S2542-5196(23)00025-6
Squillacioti, G., De Petris, S., Bellisario, V., Mondino, E. C. B., & Bono, R. (2023). Urban environment and green spaces as factors influencing sedentary behaviour in school-aged children. Urban Forestry & Urban Greening, 88, 128081. https://doi.org/10.1016/j.ufug.2023.128081
Shinrin you is my go to ❤️