Ecominds-effects-on-mental-wellbeing-evaluation-report

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Ecominds-effects-on-mental-wellbeing-evaluation-report

ong>Ecomindsong> ong>effectsong>on mental wellbeing:An evaluation for MindRachel Bragg, Carly Wood & Jo BartonEssex Sustainablitiy institute and Schoolof Biological Sciences - University of Essex


An evaluation for Mind 1ong>Ecomindsong> ong>effectsong>on mental wellbeingAn evaluation for MindRachel Bragg, Carly Wood and Jo BartonSchool of Biological Sciences and Essex Sustainability Institute, University of EssexContentsAcknowledgements....................................................... 3Glossary........................................................................ 3Executive summary....................................................... 41. Nature and mental wellbeing................................. 91.1 Introduction1.2 Mental ill-health in the UK1.3 Mental wellbeing and contact with nature1.3.1 Health and mental wellbeing1.3.2 Nature and wellbeing – The evidence1.4 Ecotherapy and green care1.4.1 Ecotherapy interventions1.5 Using ecotherapy for wellbeing1.5.1 Ecotherapy and the Five Ways to Wellbeing1.5.2 Ecotherapy and healthy life pathways1.6 Ecotherapy and resilience1.7 Ecotherapy as a treatment for depression1.8 Ecotherapy in the UK1.9 Limitations of evidence1.9.1 Limitation of current evidence base1.9.2 Evaluation of ecotherapy interventions2. ong>Ecomindsong> evaluation ............................................ 252.1 Background2.2 ong>Ecomindsong> wellbeing evaluation2.3 Green Exercise Research Team at theUniversity of Essex2.3.1 Aims2.3.2 Key objectives2.4 The Green Exercise Research Team at theUniversity of Essex3. Methodology......................................................... 273.1 Overview of research process3.2 Evaluation design and sampling strategy3.2.1 The ‘All projects’ evaluation3.2.2 The ‘In-depth’ evaluation3.3 Evaluation support for projects3.4 Ethics, consent and data protection3.5 Questionnaires3.6 Outcome measures3.6.1 Mental wellbeing3.6.2 Social inclusion3.6.3 Connection to nature3.6.4 Healthy lifestyles3.6.5 Environmental behaviour3.6.6 Other aspects of the questionnaire3.7 Statistical analyses3.8 Organisations of results in this report4. Results: ‘All projects’ evaluation........................... 374.1 ‘All projects’ evaluation: Key Findings4.2 About the ‘All projects’ evaluation4.3 About the participants4.4 About the projects4.5 Mental wellbeing findings4.5.1 Perceived positivity4.6 Social inclusion findings4.6.1 Neighbourhood belonging4.6.2 Importance of being with other people4.7 Connection to nature findings4.7.1 Perceived connection to nature4.7.2 Importance of being outside in nature4.8 Healthy lifestyles findings4.8.1 Perceived health4.8.2 Importance of exercise4.8.3 Importance of healthy food4.9 Comparative importance of aspects of theong>Ecomindsong> programme4.10 Other findings


2 ong>Ecomindsong> ong>effectsong> on mental wellbeing5. Results: ‘In-depth’ evaluation................................ 465.1 ‘In-depth’ evaluation: Key findings5.2 About the ‘In-depth’ evaluation5.3 About the projects, participants and activities5.3.1 The projects in the evaluation5.3.2 The participants5.3.3 Activities, sessions and time spent atthe project5.4 Mental wellbeing5.4.1 Wellbeing – WEMWBS5.4.2 Self-esteem – RSES5.4.3 Mood – POMS5.4.4 Effect of project type, participant genderand age on wellbeing5.4.5 Other wellbeing findings5.4.6 Comments from participants –Mental wellbeing5.5 Social Inclusion findings5.5.1 Social engagement and support5.5.2 Neighbourhood belonging5.5.3 Neighbourhood satisfaction5.5.4 Community involvement5.5.5 Effect of project type, participant genderand age on social inclusion5.5.6 Comments from participants –Social inclusion5.6 Connection to nature findings5.6.1 Connection to nature –CNS (adapted short form)5.6.2 Effect of project type, participant genderand age on connection to nature5.6.3 Comments from participants - Nature5.7 Healthy lifestyles findings5.7.1 Perceived health5.7.2 Effect of project type, participant genderand age on health5.7.3 Healthy eating5.7.4 Comments from participants - Health5.8 Environmentally behaviour findings5.8.1 Environmentally friendly behaviours5.8.2 Effect of project type, participantgender and age on environmentallyfriendly behaviour5.8.3 Comments from participants - Environment.5.9 Comparative importance of aspects of theong>Ecomindsong> programme5.10 Other findings5.11 What the participants enjoyed most about theong>Ecomindsong> sessions6. General discussion............................................... 676.1 Discussion and key successes6.2 Limitations and future research6.2.1 Limits of research6.2.2 Future research6.3 Key issues and implications for policy6.3.1 Clinical provision of mental health services6.3.2 Public health6.3.3 Social inclusion6.3.4 Employment6.3.5 Management of greenspaces6.4 Concluding comment7. The projects in the ‘In-depth’ evaluation.............. 777.1 Grow It!7.2 Grow2Grow7.3 Growing Clearer Minds7.4 Growing Well7.5 Seed to Succeed7.6 Spring to Life7.7 The Outdoor Club7.8 Wellbeing Comes Naturally (WCN)7.9 The Wildwoods ong>Ecomindsong> Project8. References............................................................ 82Appendices..................................................................90Appendix A – ‘All projects’ QuestionnaireAppendix B – Questionnaires used in ‘In-depth’evaluation – Start/EndAppendix C – Questionnaires used in ‘In-depth’evaluation – Pre/postAppendix D – Participant information sheet andconsent formAppendix E – Pre/post questionnaire coversheet


An evaluation for Mind 3AcknowledgementsThe authors would especially like to thank all of the participants and project staff for generously giving up timeand energy for the study. We are very grateful for all the help and support generously given by Mind staffand the ong>Ecomindsong> team (Grants officers and Portfolio managers). Mind would also like to thank the Big LotteryFund for funding this research.All photos are courtesy of various ong>Ecomindsong> projects and Michael Lishman unless otherwise stated.Correspondence contact:Rachel Bragg, Deputy Director, Essex Sustainability Institute and Senior Researcher, Green Exercise ResearchTeam, School of Biological Sciences, University of Essex, Wivenhoe Park, Colchester CO4 3SQ.Email: rebragg@essex.ac.uk Website: http://www.greenexercise.orgGlossaryAAIANOVAARTCBTCLESCNSDefraDoHGPnefNHSNICEPETPOMSRCTRSESRSPBSTHTCVTMDWEMWBSWHOAnimal assisted interventionsAnalysis of VarianceAttention Restoration TheoryCognitive Behavioural TherapyCentre for Local Economic StrategiesConnection to Nature ScaleDepartment of Environment Food and Rural AffairsDepartment of HealthGeneral Practitionernew economics foundationNational Health ServiceNational Institute for Health and Care ExcellencePsycho-Evolutionary TheoryProfile of Mood StatesRandomised Control TrialRosenberg Self Esteem ScaleRoyal Society for the Protection of BirdsSocial and Therapeutic HorticultureThe Conservation VolunteersTotal Mood DisturbanceWarwick Edinburgh Mental Well Being ScaleWorld Health Organisation


4 ong>Ecomindsong> ong>effectsong> on mental wellbeingExecutive summaryong>Ecomindsong>In 2007, Mind called for a new green agenda formental health highlighting the growing evidencein support of an accessible, cost-effective andnatural addition to existing treatment options, usingecotherapy interventions. Through the management ofong>Ecomindsong> (a £7.5 million Big Lottery Fund supportedopen grant scheme) Mind subsequently funded 130ecotherapy projects ranging from horticultural andagricultural schemes, through to walking groupsand regeneration initiatives in local parks. ong>Ecomindsong>has helped 12,071 people living with mental healthproblems to get involved in green activities to improveconfidence, self-esteem, and their physical andmental health.BackgroundOne in four people in England will experience amental health problem in any one year. Mental healthproblems also inflict additional economic and socialcosts and treatment is becoming increasingly moreexpensive. Public spending on mental health servicesis continually rising and in England alone during2009/10 it is estimated that £21.3 billion was spenton mental health services in total, with £1.2 billionon drug prescriptions. The cost of antidepressantshas grown dramatically and between 2010 and 2011,antidepressant drug prescriptions and their costssaw the largest increase of any drug category.Despite these increases, mental health servicesrepresent only 13 per cent of NHS spending, whenmental health problems account for 23 per cent of theburden of disease.There is now more need than ever to exploredifferent preventative and curative therapies to add tothe ‘toolbox’ of treatment options; interventions whichwhile comparable in their success rates, are oftenmore accessible and less costly to employ. The healthof the individual (and family members involved in careprovision) clearly supersedes any financial cost, butif there is a potential solution that could address bothissues simultaneously, then this could significantlyreduce both human costs and public spending.Ecotherapy‘Ecotherapy’ (sometimes called green care),comprises nature-based interventions in a variety ofnatural settings. Ecotherapy initiatives usually consistof a facilitated, specific intervention, for a particularparticipant, rather than simply ‘an experience innature’ for the general public. Ecotherapy approachesare ‘therapeutic’ in nature although some ecotherapyinitiatives also include formal therapy (e.g. counsellingsessions, CBT, psychotherapy etc) as an integral partof the programme.Although the area of ecotherapy is very diverse, thecommon linking ethos is the contact with nature ina facilitated, structured and safe way, where manyvulnerable groups gain therapeutic benefits. Byincreasing participation and awareness, ecotherapyinitiatives have the potential to improve healthand wellbeing for individuals and to significantlyreduce public health costs by encouraging healthiercommunities. Ecotherapy also has the potentialto enable resilience and can help build up anindividual’s capacity to cope with life stresses andhave a preventative effect against future mentalhealth problems.However the majority of GPs do not even considerthe use of ecotherapy as a treatment option formild to moderate depression; and many patientsare not aware that a prescription for an ecotherapyintervention could be an effective treatment for theirillness. In times of burgeoning mental health costs,economic hardship, shrinking budgets (across allsectors) and amidst worries that we are becoming asociety of sedentary and obese people, increasinglydisconnected from nature, can we really afford not topromote ecotherapy as one of the solutions?ong>Ecomindsong> wellbeing evaluation -University of EssexMind commissioned the Green Exercise ResearchTeam at the University of Essex to carry out anindependent, academic evaluation of the ong>Ecomindsong>scheme to examine the ong>effectsong> on psychologicalhealth and wellbeing of beneficiaries. This evaluationfocused on three main themes: i) Wellbeing, ii)


An evaluation for Mind 5Social inclusion and iii) Connection to nature andtwo secondary themes: iv) Healthy lifestyles and v)Environmentally friendly behaviour. The University ofEssex evaluation of ong>Ecomindsong> involved an evaluationof the ong>Ecomindsong> scheme as a whole and an in-depthevaluation of a sub-sample of nine ong>Ecomindsong> projects.The evaluation was questionnaire based and arange of composite questionnaires were developed,composed of a mixture of internationally recognised,standardised questionnaires (WEMWBS, RSES,POMS, CNS) bespoke questions and questions usedin the Big Lottery Fund Changing Spaces evaluation.Key findings• A total of 803 participants took part in the evaluationwith 515 taking part in the ‘All projects’ and 287 inthe ‘In-depth’ studies. In both studies participantswere mainly male (66-69 per cent), predominantly‘White British’ and with an average age of around40 (ages ranged from 14 to 85). Both studiesinvolved a range of different ecotherapy projects,taking a range of different approaches, of differingsizes and in different locations all over England.• Mental wellbeing: In the In-depth study, threestandardised, internationally recognised instrumentswere used to measure different elements of mentalwellbeing. For the majority of participants both theirwellbeing and self esteem scores showed a statisticallysignificant increase from the beginning to the endof their involvement with ong>Ecomindsong>, indicating animprovement in participant wellbeing over the durationof the ong>Ecomindsong> scheme. On average a participantexperienced increases in wellbeing of 17 per cent andof self esteem of 11 per cent (see Figure A).Figure A. Change in mean participant wellbeing scores fromthe beginning to the end of the ong>Ecomindsong> programmeWellbeing score706050403020Represents an increase in wellbeing of 5.3 testedwith a 2-tailed T test (p


6 ong>Ecomindsong> ong>effectsong> on mental wellbeing81 per cent of beneficiaries showed an increasein the frequency of getting involved in communityactivities after having being involved with ong>Ecomindsong>.At the start of the programme, many participantssaid that they did not feel they belonged to theircommunity but by the end of the ong>Ecomindsong> scheme,the opposite was true, with the majority sayingthat they did feel they belonged to their immediatecommunity – representing an improvement of socialinclusion for many participants.• Connection to nature: Statistically significantincreases in participant connection to nature werefound from the start to the end of the programme(for 61 per cent of people) implying that theseparticipants had become more connected to natureover the duration of the ong>Ecomindsong> scheme.• Healthy lifestyles: Statistically significant increasesin participant self-perceived ‘health’ status wereobserved both over the duration of the ong>Ecomindsong>scheme (where 59 per cent of participants sawimprovements in health of on average 31 per cent)and after taking part in one session.• Environmentally friendly behaviours: In the ‘Indepth’evaluation, in order to assess any changesin participant behaviour as a result of taking partin the ong>Ecomindsong> scheme, six questions relating toenvironmentally friendly practices were included.Starting responses indicated that the majority ofparticipants were a reasonably environmentallypro-active group at the beginning of the programmeanyway but nevertheless a statistically significantincrease in overall environmentally friendlybehaviour scores was found from the start tothe end of the ong>Ecomindsong> scheme for 60 percent of beneficiaries, showing an increase inenvironmentally friendly practices.• The importance of the three key aspects of theong>Ecomindsong> scheme: i) being with other people, ii)being outside in nature and iii) taking part in exerciseor activities; were assessed and the importance ofall three aspects were shown to be of roughly equalimportance to participants, both at the end of theong>Ecomindsong> scheme as a whole and after taking partin a single session, which suggests that participantsvalue the combination of the three aspects of theong>Ecomindsong> projects, rather than one particular feature.• Participants also told us in their own words aboutwhat they enjoyed the most about the ong>Ecomindsong>project that they were involved with. Out of the 113comments received, three major themes emerged i)the social contact – being with other people as partof a group; ii) being outside in nature – the freshair, the scenery and the beauty; and iii) the activities– learning new skills, enjoying the activities. Manyother comments expressed how people felt calmand safe outside, had fun, liked being active and felta sense of achievement.The results of the study found thatecotherapy can:• be effective in raising mental wellbeing to‘average’ levels• enhance social inclusion, vital to the recoveryof those living with mental health problems• be successful in both increasing contact withand connection to nature, enabling participantsto benefit further from the associated healthand wellbeing benefits• can improve wellbeing and social inclusionand equip participants with useful coping skills• can also help the development of healthierlifestyles and environmentally friendly living.What is particularly revealing in the evaluation ofong>Ecomindsong> is that in both studies, these improvementsto wellbeing, social inclusion and connection tonature happen right across the range of ecotherapyinterventions involved in the ong>Ecomindsong> schemeregardless of: i) type of ecotherapy intervention; ii)participant age and gender; or iii) whether or not theproject included formal therapy or not. This suggestssimilar benefits to participant wellbeing, social inclusion,nature connection, healthy lifestyles and environmentalbehaviour can result from all types of ecotherapy.Analysis of the data and comments from participantsthemselves, have shown that through ecotherapy,the recommended Five Ways to Wellbeing can beaddressed. Participants involved in ong>Ecomindsong> have:• been more Active by taking part in exerciseand activities in natural environments – gainingphysical and mental health benefits;• Connected both with other people, the widercommunity and with nature, thus increasing socialinclusion;


An evaluation for Mind 7• started to Take Notice of nature and thegreen environment around them – gaining theassociated mental health benefits and increasingconnectedness to nature;• managed to Keep Learning – both developing newskills and learning about themselves; and• been able to Give – through sharing andsupporting each other and working as a team andalso by giving back to nature through shaping andrestoring natural environments.This study adds to the growing evidence base thathighlights the effectiveness of ecotherapy interventions.Recommendations for policy:Ecotherapy has important policy implications for awide range of sectors. The health and social caresector particularly needs to consider the contributionthat ecotherapy makes to both individual mentalhealth and public wellbeing, as a more resilientpopulation has the potential to save money forthe NHS and wider public purse. The impacts ofecotherapy on social inclusion also have implicationsfor social care and employment policy and resultingknock-on ong>effectsong> can potentially lead to cost savingsto society, an important consideration in times ofdiminishing public budgets.• Ecotherapy initiatives have been proved not only tobe successful at increasing mental wellbeing andbuilding resilience but also to simultaneously produceother positive life outcomes; but there remains a lackof knowledge and acceptance among GPs (and othercare providers) of the benefits to patients gainedfrom using ecotherapy as an additional treatmentfor mental health problems such as depression.Commissioners of health and social care servicesshould take the idea of ecotherapy more seriouslyand more GPs should be supported to consider andrecognise the value of ecotherapy.• Ecotherapy represents another treatment choice forGPs and service users. The addition of another toolin the toolbox to tackle mental health problems isespecially pertinent given the long waiting lists forCBT and the increasing costs of antidepressants.With this in mind, NICE should also be called uponto consider the evidence in order to recommendthe use of ecotherapy interventions alongside othercurrent treatment options for depression, such asantidepressants and CBT.• Good health and wellbeing is multifaceted, butthis has not been converted into either measuresof success or funding streams. Ecotherapy canimprove multiple factors simultaneously, but‘traditional’ measures of success within healthcaredo not adequately recognise this. Establishment ofthe effectiveness of a treatment option should alsoconsider: i) multiple outcomes of treatment (widerthan the clinical health context); ii) the holistic effectof multifaceted interventions; iii) benefits to publichealth; and iii) benefits and cost savings to thewider society.• There is a need for ecotherapy initiatives to beincorporated into health and social care referralsystems, particularly in light of the recent changeswith clinical commissioning groups and healthand wellbeing boards. Implications for personalbudgets should also be recognised and those inreceipt of direct payments supported to accessecotherapy treatments.• Commissioners should be encouraged to considerthat ecotherapy represents an enjoyable, sociallyacceptable treatment option for mental healthconditions such as depression, and the observedpositive effect on adherence levels could prove tobe effective in encouraging uptake of mental healthtreatment and especially successful in re-engagingmen with mental health services.• There is also a need to raise awareness amongsthealth professionals and patients that ecotherapyis a valid and effective treatment option fordepression. A major concern is to overcome thepatient’s perception of whether or not ecotherapyis as an effective treatment response. Educationis therefore needed for GPs and patients alike, tohighlight the additional social and wellbeing benefitsthat an ecotherapy intervention can provide thatantidepressants, for example, do not.


8 ong>Ecomindsong> ong>effectsong> on mental wellbeing• Encouraging people to incorporate more greenexercise activities into daily routines and supportingmore ecotherapy opportunities has the potentialto increase wellbeing, not only for those alreadyliving with a mental health problem, but also interms of health promotion and illness preventionat the population level. Increasing support for awide range of ecotherapy options for all sectors ofsociety is also likely to produce substantial publichealth benefits and economic savings, and thereforeshould be promoted.• Agencies responsible for providing social careservices and promoting social inclusion would alsobenefit from recognising the potential of ecotherapyactivities to reduce social exclusion, increase socialcapital and to help people to re-integrate intosociety after a period of ill-health, something that isparticularly relevant today.• If we are all to have this access to nature, there isneed i) for more quality green spaces, (especiallyin urbanised areas); and ii) to actively protect andconserve our existing green spaces in both ruraland urban locations.Concluding commentThrough the funding of 130 ecotherapy projects andthe 12,071 people that directly benefitted from theprogramme, ong>Ecomindsong> can be considered to have hada major impact, both in terms of supporting peoplesuffering from mental ill-health and in sustaining theprovision of ecotherapy services across England.The majority of ong>Ecomindsong> participants will leave theprogramme with better wellbeing and self-esteem;feel more socially included; will have gained new skillsand developed healthier lifestyles; have enhancedpsychological health and wellbeing; and an increasedconnection to nature.These significant improvements as a result of theong>Ecomindsong> scheme all have implications for not onlythe mental wellbeing and resilience of individuals butalso for public health and the management of naturalenvironments.


An evaluation for Mind 91. Nature and mental wellbeing1.1 IntroductionIncreasingly sedentary lifestyles, poor diets and theprevalence of mental health problems are seriouslyhindering the health of the world’s population. Itis believed that at any one time, at least one in sixindividuals is suffering from a ‘significant’ mentalhealth problem 1 , and in the UK one in four peoplewill experience mental illness at some time in theirlives 2 . Mental ill health compromises an individual’squality of life, is a leading cause of disability andaffects not only the individual but families aswell. Mental health problems also inflict additionaleconomic and social costs both directly (health andsocial care; human cost) and indirectly (throughoutput losses). Unhappily, problems surroundingsocial exclusion and discrimination of those livingwith a mental health problem are still significantchallenges to overcome.There are many different interventions for tacklingmental ill health but one approach increasinglybeing used by professionals is that of ‘ecotherapy’(or Green care), which comprises nature-basedinterventions in a variety of natural settings. Thereis a mounting body of evidence that highlights thebenefits of contact with nature, such as improvedhealth and wellbeing, enhanced connection both withother people and with nature, adoption of healthierlifestyles and an increase in the desire to protectnature. The natural environment is available to mostof us on our doorsteps and at minimal cost. Couldone answer to improving our population’s mentalhealth be to encourage people to interact with natureand green space and to get active outdoors 3 ? Couldecotherapy interventions help more people livingwith a mental health problem recover and to becomeless isolated from society? Is there another optionavailable to enable mental health professionals to helpservice users?Through Mind’s lottery-funded ong>Ecomindsong> scheme, 130such ecotherapy projects, specifically for people withmental health problems, have been supported. Thisstudy puts this scheme into context and evaluates thewellbeing ong>effectsong> to participants from these naturebasedinterventions.1.2 Mental ill-health in the UKIn England it is believed that in any one year, at leastone in four people will experience a ‘significant’ mentalhealth problem 4 . Sufferers of anxiety and depressionare commonplace and by 2020 it is predicted thatdepression will be the second most common cause ofdisability in the developed world 5 . It is estimated thatthe total cost of mental health problems in England in2009-10 was approximately £105.2 billion 6 . The majorityof these costs fall mainly on those who experiencemental health problems and their families, but italso generates sizeable costs for taxpayers and forbusiness. With poor mental health often carrying moreof a cost to society than crime 7 it is also therefore amajor public health issue (See Box 1).Public spending on mental health services iscontinually rising and the cost of antidepressantshas grown dramatically. In England alone, during2009/2010 it is estimated that £21.3 billion wasspent on mental health services in total, with £1.2billion on drug prescriptions 8 . In 2010 the number ofantidepressant prescriptions dispensed in Englandwas 42.8 million and by 2011 this number had risen to46.7 million. This represents a cost of £270.2 millionand implies an increase in cost of 22.6 per cent injust one year 9 . Between 2010 and 2011 antidepressantdrug prescriptions and their costs saw the largestincrease of any drug category. Despite thesespending increases, the NHS share of budget formental health care is far lower proportionally whenthe significant mental health burden of disease isconsidered: poor mental health accounts for 23 percent of the burden of disease whilst only accountingfor 13 per cent of the NHS budget in England 10 .1 WHO 2001;2 WHO 2004, Mental Health Foundation 20133 Bermann et al 20084 Mental Health Foundation 2013; ONS 20095 World Bank 19936 The Centre for Mental Health 20107 Sainsbury Centre for Mental Health 20038 Centre for Mental Health 20109 NHS 201210 Centre for Economic Performance’s Mental Health Policy Group 2012


10 ong>Ecomindsong> ong>effectsong> on mental wellbeingBox 1: The burden of mental illness in the UK• At least 1 in 4 individuals are affected in anyone year• 1 in 10 children and young people aged 5-15years suffer from a mental health problem• Instances of common mental disorders such asdepression and anxiety in people aged 6-64years rose from 15.5% in 1993 to 17.6% in 2007• £53.6 billion represents the human cost ofmental illness due to reduced quality of life,suffering, pain, disability and distress• £30.3 billion is the cost of output losses in theeconomy due to peoples inability to work• £21.3 billion is the annual cost of health andsocial care provided by the NHS and LocalAuthorities and informal care given by familyand friends• £1.9 billion is spent on GP consultations yearly• £1.2 billion per year is spent on drugprescriptionsSources: Mental Health Foundation 2013 (bullets 1 - 2);NHS 2009 (3); Centre for Mental Health 2010 (4-6);The Centre for Economic Performance 2012 (7-8);The government is also currently spending moremoney on training therapists to co-ordinatepsychological therapies such as cognitive behaviouraltherapy (CBT). Alongside antidepressant drugs,CBT is recommended as one of the first options forthe treatment for many mental health problems 11 .However, only 1 in 3 people receive CBT within sixmonths of being referred; 1 in 5 wait over one yearand 1 in 10 wait over two years; with increased waitingtimes resulting in reduced treatment effectiveness 12 .The recommended number of sessions required forpsychological therapies are also failing to be met.For mild to moderate mental illness, six low intensitysessions of CBT are recommended, whilst for severemental illness up to 20 high intensity sessions arerecommended. Currently, some people with severemental illness are receiving as few as three sessionsof CBT and only 40 per cent of patients feel that theyreceive enough sessions to be beneficial.There is now more need than ever to explorealternative preventative and curative therapies to addto the ‘toolbox’ of treatment options; interventionswhich while comparable in their success rates, areoften more accessible and less costly to employ. Thehealth of the individual (and family members involved incare provision) clearly supersedes any financial cost,but if there is a potential solution which could addressboth issues simultaneously, then this could significantlyreduce both human costs and public spending.1.3 Mental wellbeing and contactwith nature1.3.1 Health and mental wellbeingThe ‘health’ of an individual is widely consideredto be multifaceted. The World Health Organization(WHO) defines health as being “a state of completephysical, mental and social (individual) wellbeing,and not merely the absence of disease or infirmity” 13 .Similarly the term ‘wellbeing’ (despite the lack of auniversal definition) is also considered in a widercontext, described by Defra (2007) as “a positivephysical, social and mental state; it is not just theabsence of pain, discomfort and incapacity. Itrequires that basic needs are met, that individualshave a sense of purpose, and that they feel ableto achieve important personal goals and participatein society. It is enhanced by conditions that includesupportive personal relationships, strong and inclusivecommunities, good health, financial and personalsecurity, rewarding employment, and a healthy andattractive environment.” 14Five Ways to WellbeingFollowing on from this more holistic definition ofwellbeing, in 2008, the new economics foundation(nef) – commissioned by the UK Government’sForesight Project on Mental Capital and Well-being– identified five evidence-based actions to improvewellbeing: i) Connect; ii) Be active; iii) Take notice; iv)Keep learning and v) Give 15 . It was suggested that ifeach of these five ways were built into daily routines,health and wellbeing would be enhanced.11 NICE 200912 We need to talk coalition 201013 WHO 194814 Defra 200715 Nef 2008, 2013


An evaluation for Mind 11ConnectSocial interaction, cohesion and connecting withothers can provide many important benefits forhealth and wellbeing. Social relationships, supportand interaction are critical for promoting wellbeingand can be protective against ill-health, whereassocial isolation and exclusion are associated withgreater incidence of ill health 16 . Social isolation oftenresults in a reduced quality of life, depression andlow self-esteem and can also predict mortality andmorbidity (see Section 1.5.2). Many adults and youngpeople are becoming disconnected from other people,experiencing loneliness and isolation 17 . Therefore thedevelopment of strategies and initiatives to promotesocial inclusion and interaction within communities areessential to health and wellbeing.Be activePhysical activity has long been proved to be animportant determinant of both physical health andpsychological wellbeing 18 . Moderate regular exercisereduces morbidity rates by 30-50 per cent, has aparticularly protective effect against several healthconditions 19 and lowers blood pressure, improvesblood lipid and glucose profiles and boosts theimmune system 20 . Physical activity also enhancesmental health by improving mood and self-esteem,reducing stress, enriching an individual’s quality of lifeand diminishing the chance of depression.Between 24-40 per cent of children, young peopleand adults fail to meet recommended physical activityguidelines in the UK 21 and the annual costs of physicalinactivity in England are reported to be approximately£8.3 billion 22 , excluding individuals who are obesedue to inactivity, which contribute a further cost of£2.5 billion per year to the economy. These figuresincorporate both costs to the NHS and associatedcosts to the economy (e.g. work absenteeism).People who are physically active reduce their risk ofdeveloping major chronic diseases by 50 per cent andthe risk of premature death by 20-30 per cent 23 . Thus,initiatives that promote physically active behavioursand their inclusion into daily routines are of greatimportance to wellbeing.Take noticeMany people these days have hectic lifestyles andoften fail to take notice of their surroundings andthings that are going on around them. Studies haveshown that being aware of what is taking place inthe present directly enhances your wellbeing and‘savouring the moment’ can help to reaffirm your lifepriorities 24 . Heightened awareness also enhancesself-understanding and allows positive choices tobe made based on an individual’s own values andmotivations 25 . Again initiatives which encourageindividuals to take notice of their environment, tobe mindful and aware of themselves will enhanceparticipant health and wellbeing.Keep learningWhether it is trying something new, learning newskills or enrolling on a course, learning has beenshown to play an important role in health andwellbeing. For children, learning contributes to socialand cognitive development, increases self-esteem andsocial interaction whilst also encourages participationin physical activities 26 . In adults, learning is positivelycorrelated with wellbeing, life satisfaction, optimismand self-efficacy, self-esteem and resilience 27 and itcan also give people a sense of purpose and hope,encouraging social interaction and making people feelcompetent 28 . By learning, problem solving skills arealso developed; this can in turn lead to better copingskills and the adoption of healthier practices. Learningis also protective against depression 29 , with olderpeople in particular, work and education opportunitiescan lift them out of a depressive state. Projects andinitiatives which encourage people to learn andwhich provide opportunities for education and skillsdevelopment can directly benefit health and wellbeing.GiveGiving to other people, through volunteering, byjoining a community group or doing something goodfor someone else, can provide substantial benefits formental wellbeing. Mutual cooperation and workingwith others can increase neuronal responses inthe reward areas of the brain, indicating that social16 Tones and Green 201017 Wood et al 2012; Hall-Lande et al 200718 CDC 1996; Laumann et al. 2003; DoH 2004; Foresight 2007;Sandercock et al. 201019 E.g. maturity onset Type II diabetes, coronary heart disease,musculo-skeletal diseases and cancer20 DoH 2009, 201121 DoH 2011; NHS 201122 DoH 2004, NICE 200923 DoH 200924 Brown and Ryan 2003; Ryan and Deci 200025 Nef 200826 Hall-Lande et al 200727 Feinstein and Hammond 2004; Hammond 200428 Tanako et al 200229 Feinsten et al 200830 Nef 2008; Rilling et al 2007


12 ong>Ecomindsong> ong>effectsong> on mental wellbeingcooperation is intrinsically rewarding 30 . In the earlyyears, the rewards gained through helping and givingto others, contribute to improved cognitive and socialfunctioning, critical to mental wellbeing 31 . Furthermore,feelings of life satisfaction and happiness are stronglyassociated with taking part in community activities andfor older people, volunteering is associated with a morepositive life meaning. Offering support to others is alsobeneficial to health and is associated with reducedrates of mortality 32 . Mental wellbeing is enhanced whenan individual is able to achieve a sense of purpose insociety and contribute to their community; so initiativeswhere helping and sharing go hand in hand with givingand teamwork are likely to be associated with increasedself-worth and positive feelings.1.3.2 Nature and wellbeing - The evidence baseThere is convincing evidence to show that exposureto the natural environment positively affects healthand wellbeing 33 . Research from a variety of outdoorsettings, from the open countryside, fields andforests, remote wilderness, parks and open spaces,to street trees, allotments and gardens has shownthat engaging with nature on a number of differentlevels (from simply viewing nature, to incidentalexposure, through to active involvement in naturebasedactivities) can produce mental (and physical)health benefits. Natural, green environments are oftenperceived as places to relax, escape and unwindfrom the daily stresses of modern life, thus having apositive effect on our emotional wellbeing.Three key theories offer explanations relating to therelationship of man with nature, and all focus on therestorative ong>effectsong> of the natural environment 34 :i) the Biophilia hypothesis 35 ; ii) the Attention RestorationTheory (ART) 36 ; and iii) the Psycho-evolutionary stressreduction theory (PET) 37 . The ‘Biophilia hypothesis’suggests there is an innate evolutionary basis to therelationship of humans with nature and recognisesman’s fundamental dependence on, and desire toconnect with, nature 38 . Attention Restoration focuses onthe cognitive changes associated with restoration, whilePET argues that restorative ong>effectsong> are derived fromthe reduction of stress, and acknowledges emotionalchanges. There is however consensus in all threetheories that nature contributes to enhanced wellbeing,mental development and personal fulfilment 39 .Evidence has shown that exposure to nature bringssubstantial mental health benefits, however if thisexposure to nature also includes participating inphysical activities (long known for their positivephysiological and psychological health outcomes) thenit is even more beneficial 40 . Over the last 10 yearsat the University of Essex, these ideas have beencombined into a programme of research investigatingthe synergistic benefits of engaging in physicalactivities whilst simultaneously being exposed tonature and this is referred to as ‘green exercise’ 41 .From this wide variety of research, we have discernedthree broad health outcomes: i) improvement ofpsychological wellbeing (by enhancing mood and selfesteem,whilst reducing feelings of anger, confusion,depression and tension) 42 ; ii) generation of physicalhealth benefits (by reducing blood pressure andburning calories) and iii) facilitation of social networkingand connectivity (by enhancing social capital). Inaddition, a recent green exercise dose-response studyindicated that these benefits can accrue even fromshort engagements in green exercise, as little as 5minutes and then diminishing but still positive returns 43 .Scientific evidence of the positive relationshipbetween exposure to nature and an individual’s healthand wellbeing is continually increasing. Given thechallenges facing our society, nature can act as anessential health resource and given the significantcosts incurred to the individual and increasedexpenditure in the provision of care, the importance ofaccess to nature and green space is vital. As a resultof this mounting evidence base, together with mentalhealth charity campaigns and much positive mediaattention, public bodies, government departmentsand voluntary organisations alike, are promoting theimportance of contact with nature for us all 44 .31 Nef 200832 Greenfield and Marks 200433 Maas et al. 2006, Pretty et al. 2006, Van den Berg et al. 2007, Bird 2007,Weinstein et al 2009, Hansen-Ketchum et al. 2009, Barton and Pretty2010, NEA 2011; O Brien and Morris 201334 Barton et al 200935 Wilson 198436 Kaplan and Kaplan 198937 Ulrich 198138 Wilson 1984; Kellert and Wilson 1993; White and Heerwagen 199839 Barton et al 200940 Barton et al 2009, NEA 201141 Pretty et al, 2003, 2004, 2005, 2006, 2007; Pretty, 2004, 2007; Peacock2007; Mind, 2007; Hine et al. 2007a,b; Hine et al. 2008a,b, c; Hine 2008;Hine et al, 2009; Barton et al. 2009; Pretty et al. 2009, Hine 2010; Bartonand Pretty 2010; Hine et al, 2011; Bragg et al, 2012; Wood et al 2012 a,b42 Research into the benefits of activities in nature for those living with dementiahas also found that green exercise can enable individuals to feel well andexperience a ‘dampening down’ or temporary absence of their dementia relatedsymptoms. Contact with nature was also found to contribute to the emotional,psychological and spiritual aspects of wellbeing for people with dementia.43 Barton and Pretty 201044 See Defra 2011, Natural Environment White Paper


An evaluation for Mind 13Figure 1. The Green Care UmbrellaGreen CareSocial andtherapeutichorticultureWildernesstherapy;Nature therapyAnimal assistedintreventionsEcotherapyEnvironmentalconservationCarefarmingNaturearts and craftsGreenexercise therapySource: Adapted fromHine Pretty et al., 2008Range of different contexts, activities,health benefits, clients, motivation and needs.1.4 Ecotherapy and green careEvidence also suggests that green exercise can havetherapeutic applications for a range of vulnerablepeople when delivered as facilitated interventions.These nature-based applications are collectivelytermed ‘green care’ 45 , although more recently theterm ‘ecotherapy’ has been widely used by projects,participants and the media alike to describe theseapproaches. The word ecotherapy has subsequentlybecome largely a “general term for nature-basedinterventions rather than a specific example of anature-based intervention” 46 . In this report the term‘Ecotherapy’ will be used in the general sense, that is,synonymously with green care.Ecotherapy initiatives usually consist of a facilitated,specific intervention, for a particular participant (orgroup of service users), rather than simply a ‘natural’experience for the general public. Ecotherapyapproaches are ‘therapeutic’ in nature although someecotherapy initiatives also include formal therapy (e.g.counselling sessions, CBT, psychotherapy etc) as anintegral part of the programme. There is a growingmovement towards ecotherapy in many contexts,ranging from green exercise therapy, social andtherapeutic horticulture, animal assisted interventions;to wilderness therapy, environmental conservationand care farming (see Section 1.4.1 and Figure 1).45 Pretty 2006; Hine et al 2008, Sempik et al 201046 Sempik and Bragg 2013


14 ong>Ecomindsong> ong>effectsong> on mental wellbeing1.4.1 Ecotherapy interventionsSocial and therapeutic horticulture (STH)Essentially, social and therapeutic horticulture (STH) isusing gardening and plants to help individuals developwellbeing and this can be done through spendingtime in gardens, participating in gardening activitiesor doing something more active such as growingfood 47 . Horticulture in a variety of contexts has proveditself to be a useful activity in promoting health andwellbeing, rehabilitation; and in enabling vulnerable anddisadvantaged individuals to reach their true potential.Because of the diversity of activities associated withhorticulture and the settings in which it can be carriedout, horticulture can be adapted to suit a wide rangeof clients and it has been used to achieve physical,social and psychological benefits for people withmental health problems, learning difficulties, physicaldisabilities, survivors of stroke, drug and alcoholproblems, social problems and others 48 .Animal assisted interventions (AAI)Animal assisted interventions (AAI) is the generalterm used for a variety of ways of utilising animalsin the rehabilitation or social care of humans 49 . AAIincludes both i) activities in which animals are presentand are considered to have a therapeutic effect (e.g.feeding livestock, petting animals, collecting eggsetc.) and ii) the more formal animal assisted therapy(AAT) which is a specific goal-directed interventionwhere an animal is an integral part of the treatmentprocess which is directed, documented and evaluatedby professionals (e.g. equine assisted therapy, pettherapy, and dolphin therapy) 50 .Care farmingCare farming is defined as the therapeutic use ofagricultural landscapes and farming practices 51 andits use is increasing within the UK 52 . On care farms,components of either the whole or part of the farmare used to provide care through a supervised,structured programme of farming-related activitiesfor a wide range of people. All care farms offer someelements of farming (involving crops, horticulture,livestock husbandry, use of machinery or woodlandmanagement etc); however, there is much varietyacross care farms in terms of the context, the clientgroup and the type of farm 53 . Mental health benefitsfrom attending care farms within the UK includesignificant improvements in both self esteem andmood 54 and research from European care farm studieswith different client groups imply that care farms havespecific qualities that many participants benefit from 55 .These include the relationship between the farmerand the client, being part of a social community andengaging in meaningful activities in a green environment.The fact that the farm provides an informal, non-carecontext, closer to ‘real life’, is also valued.Nature arts and craftsNature arts and crafts, are as the name would suggest,typically art based activities that take place whilstin the natural environment, and/or that use naturalmaterials such as grass, clay, leaves and sticks 56 . Manyecotherapy approaches or contexts include elements ofnature art and craft within their programmes.Green exercise therapyGreen exercise has previously been defined asengaging in physical activities whilst simultaneouslybeing exposed to nature. Green exercise therapy asa treatment option typically involves participating ingreen exercise activities which are facilitated and ledby an instructor (e.g. walking groups). Therapeuticapplications of green exercise (particularly walking)as green exercise therapy may prove to be an evenmore effective treatment response than exercisealone in mild to moderate depression as it encouragespeople to re-connect with nature and experience theadditional positive health benefits that are associatedwith this 57 .EcotherapyEcotherapy (in its specific rather than generalisedmeaning) is a psychological approach that is rootedin the experience of nature, which acknowledges theinterdependence of human health with the health of theenvironment. Ecotherapy initiatives use activities andexercises that emphasise the notion of “mutual healingand growth” 58 where the reciprocity between humanand nature enhances an individual’s wellbeing, whichthen promotes positive action towards the environmentwhich in turn improves community wellbeing 59 .47 Mind 2013a48 Sempik et al, 2005;Sempik and Bragg 201349 Kruger and Serpell, 200650 Sempik and Bragg 201351 Hassink, 2003, Haubenhofer et al 2010, Care Farming UK 201252 Hine et al., 2008a53 Sempik et al 2010, Hine et al 2008a54 Pretty, 2006, Peacock et al., 2007, Hine et al., 2008a55 Elings 201256 Mind 2013a57 Barton et al, 2011; Peacock et al, 2007; Mind, 2007; Sempik and Bragg 201358 Chalquist 200959 Pedretti-Burls 2008


An evaluation for Mind 15Environmental conservationFacilitated environmental conservation work isincreasingly being used as a form of ecotherapy fora variety of marginalised groups where structured,facilitated activities take place, specifically designedwith the conservation or management of the naturalplaces in mind. Environmental conservation activitiesinclude land clearing, maintaining woodland areasand other managed areas and restoring habitats forwildlife. Environmental conservation approaches areoften very similar to ecotherapy or green exercisetherapy for the mutual benefit of both natureand health. Several therapeutic applications ofenvironmental conservation activities are organised inpartnership with organisations such as the ForestryCommission (with offenders) 60 and The ConservationVolunteers (Green Gyms) 61 .a systematic approach to work with a varietyof groups but also most commonly with adolescentswith behavioural problems and adults with mentalill health 64.Although the area of ecotherapy is very diverse,the common linking ethos is the contact with nature -using a coherent and deliberate strategy to generatehealth, social or educational benefits using nature.Linking the exposure to nature with various facilitatedand structured activities, in a safe way, can offertherapeutic benefits for many different vulnerablegroups. By increasing participation and awareness,ecotherapy initiatives have the potential to improvehealth and wellbeing for individuals and to significantlyreduce public health costs by encouraging healthiercommunities.Wilderness therapyWilderness therapy can be defined as an “experientialprogramme that takes place in wilderness ora remote outdoor setting” 62 , where a range ofpersonal development and wellbeing opportunitiesare provided, through immersion in natural, wild,and wilderness settings. Wilderness therapyprogrammes are often composed oftwo elements, i) using nature as‘co-therapist’ and ii) using therapeuticactivities (including formal therapy)whilst in a wilderness location.Wilderness therapy programmestypically provide healthyexercise and diets, group andindividual therapy sessionsand separate participants fromdaily negative influences,placing them in a safe outdoorenvironment 63 . Wildernesstherapy programmes havebeen in existence in theUS for many years, largelyworking with adolescents withbehavioural problems, howeverin Europe, it is an emergingtreatment intervention which uses60 Carter and Hanna 2007 and seewww.targetwellbeing.org.uk/profile/greener_outside61 BTCV 200862 Conner 200763 Sempik and Bragg 2013; Sempik et al 201064 Hine et al, 2011


16 ong>Ecomindsong> ong>effectsong> on mental wellbeing1.5 Using ecotherapy for wellbeing1.5.1 Ecotherapy and the Five Ways to WellbeingEcotherapy approaches can potentially enhancewellbeing through all of the Five Ways to Wellbeing,thus providing multiple health outcomes. Ecotherapycan encourage individuals to connect to others andto nature. Participation in green exercise activitiesoften directly and indirectly promotes socialinteraction 65 . This connection may be facilitatedthrough participation in environmental conservationactivities, attending an allotment or a STH project.Many ecotherapy participants say that being withother like minded people or with those with mentalhealth problems can be very supportive. Ecotherapy(and green exercise in general) has been foundto build stronger communities and connect peoplethrough groups and networks. In addition, ecotherapyinterventions have been proven to increase participantconnection to nature, which in itself is an importantpredictor of subjective wellbeing and ecologicalbehaviour 66 . The evidence base has highlighted thehealth and wellbeing benefits of both contact andconnection with nature, and when combined withthe concerns that we are becoming more and moredisconnected from the natural world, ecotherapycan therefore help with the resultant drive toreconnect us with the outdoors 67 .Undertaking physical activities in outdoor greenenvironments could also offer a more viable andappealing option in maintaining long-term activitylevels in adults and children alike, as often it is theinteraction with nature and the social contact thatare the main incentives rather than the ‘exercise’per se (even though they often provide greaterimprovements in self-esteem and mood than physicalactivity alone 68 ). In this situation, the health benefitsgained from the physical activity are not the mainfocus and so become a secondary outcome. Withthe current concerns over an increasingly inactivepopulation, many of whom fearful of attending a gymor exercise class, exploring the use of ecotherapyto encourage physical activity could prove to be abenefit for all 69 .65 NEA 201166 Mayer and Frantz 2004, Hine et al, 2008b67 See for example NE 2009, RSPB 2010, Moss 201268 Pretty et al, 2005, 2007; Barton and Pretty 201069 Mind 2007


An evaluation for Mind 17Taking notice of the environment around us,particularly if it is a natural environment can haveimportant benefits for health and wellbeing 70 .Nature and green spaces are perceived as placesto relax, escape and unwind from the daily stressesof modern life and can have positive influences onwellbeing. Furthermore, the more frequent the visitsto natural spaces the lower the incidence of stress 71 .Noticing the natural environment is also likely toincrease connection to nature, for example feelingsof connectedness to nature reported after wildernessexperiences range from the aesthetic appreciation ofbeautiful scenery and landscapes to a deep sense ofbelonging to the natural world. In this context natureconnection has also been taken to include feelings ofpeacefulness and harmony; a sense of timelessness;creation of a sense of vulnerability which is humbling;learning a respect for nature and developing a senseof place 72 . People should therefore be encouraged toaccess and take notice of nature as far as possible,as this is likely to have substantial consequences fortheir health and wellbeing.Many ecotherapy approaches encourage and enableparticipants to learn something new, develop newskills and increase healthy and environmentallyfriendly behaviours, thus contributing to increasedwellbeing. Whether this new knowledge is growingfruit and vegetables, learning bushcraft skills orsimply taking part in a new activity, it all has thepotential to enhance wellbeing through learning.Similarly, many green exercise activities also enableindividuals to give to others. This may be throughgrowing food on an allotment for the community;building a community natural area or helping othersachieve goals through a shared green exercise group.In addition some ecotherapy interventions (particularlyenvironmental conservation and ecotherapy) alsoencourage individuals to give something back tonature either directly through direct tasks or indirectlythrough environmentally friendly behaviours.Ecotherapy can contribute both directly and indirectlyto wellbeing and therefore can facilitate each of theFive Ways to Wellbeing. Incorporating more greenexercise activities into daily routines and lifestyles andsupporting more ecotherapy opportunities has thepotential to increase wellbeing for both individuals andcommunities alike.1.5.2 Wellbeing and the environment - linkingenvironmental enhancement and conservation activitiesLeading on from the Five Ways to Wellbeing, therehas been a growing recognition of the multiplehealth and wellbeing impacts of contact with naturein a range of different settings and contexts. Arecent piece of research by the European Centrefor Environment and Human Health, University ofExeter Medical School and the Peninsula TechnologyAssessment Group (which included a systematicreview 73 ) examined a wide variety of differentquantitative and qualitative studies of people takingpart in environmental activities. From this research,a model has been developed which illustratesthe pathways through which multiple health andwellbeing impacts may occur for those participatingin environmental enhancement and conservationactivities. Although specifically developed forenvironmental enhancement and conservationactivities the model could also be adapted for andapplied to other nature based interventions and mayprovide a useful framework for several ecotherapyapproaches (see Box 2).1.5.3 Ecotherapy and healthy life pathwaysContact with nature does not only affect immediatehealth and wellbeing but also can also affect healththroughout a lifetime. There is growing evidence toshow that contact with nature and consequent levels ofphysical activity in childhood affects not only wellbeingat the time but also in later life 74 . Many of the socialand environmental conditions of childhood can predictor track adult health status and childhood physical andmental ill-health is carried forward in later life 75 . Lateremotional wellbeing and cognitive capacity is alsoprofoundly influenced by early social development 76 .In the same way childhood experiences innature appear to fix environmental sensitivity (apredisposition to be interested in learning about caringfor and conserving nature 77 ) in adults, suggesting aneed to establish good behaviours early 78 .70 Mitchell and Popham 2008; Hine et al 201171 Cooper-Marcus and Barnes 1995; Whitehouse et al 2001; Ulrich 2002-72 Russell et al. 1998; Russell 1999, 2001; Russell et al, 2000; Caulkins et al.2006; Hine et al 200973 Husk et al 201374 Wells and Lekies 2006, Frenn et al 2005, Pretty et al 201075 Danner et al 2001, Foresight 200876 Ainsworth and Bell 1970, Ainsworth et al. 197477 Chalwa 199878 Chawla and Cushing 2007, Cheng and Monroe 2010, Ernst and Theimer 2011


18 ong>Ecomindsong> ong>effectsong> on mental wellbeingBox 2. Wellbeing and the environment: Linking conservation activities and health (Source: Husk et al 2013)


An evaluation for Mind 19The ‘Wellbeing and the Environment’ model illustrates thepathways through which health and wellbeing impactsmay come about following participation in environmentalenhancement and conservation activities. Health-relatedoutcomes (mental health, social functioning and physical health)are affected by ‘mechanisms of change and process outcomes’which are broad themes derived from the research evidenceand either link the activity to the health-related outcomes orare considered as desirable outcomes in their own right.Moderators are the factors which might influence the outcomesand have been categorised into three sources – mechanismsof action, environment in which an activity is undertaken andthose related to the types of activity itself (i.e. the programme).Personal mediators are included to demonstrate that theevidence suggests that factors such as personal expectationsand social identity are important and that these may influencethe outcomes. Motivation is considered separately because itemerged as a key factor as to how individuals approach andpotentially benefit from the programme.Finally, the circular arrows are used to demonstrate thatparticipation is a dynamic process whose outcomes canchange and affect one another. These outcomes then cannottherefore be considered in isolation or as strictly independent(e.g. increased social contact may improve a participant’sconfidence which may result in further opportunities for socialcontact, ability to take on leadership roles and so on).For more information see http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010351/abstractFurther University of Essex research 79has developed a funnel of pathwayswithin which all our lives are shaped(Figure 2). At the top, people live longerwith a better quality of life; at the bottomthey die earlier and often live years witha lower quality of life. On the healthypathway, people tend to be active, beconnected to people and society, engagewith natural places, and eat healthyfoods. As a result, they tend to havehigher self-esteem and better mood,be members of groups and volunteermore, keep learning, engage regularlywith nature and be more resilient tostress, thus fulfilling many of the FiveWays to Wellbeing.Conversely, on the unhealthy pathway,people tend to be inactive and sedentary,be disconnected from society and socialgroups, not engage with natural places,and eat energy-dense and unhealthyfoods. They also tend to have lowersocio-economic status, be in morestressful jobs, live where active travelto work or school is difficult, haveincreased likelihood of being mentally ill,and be overweight or obese.79 Pretty et al 2010Figure 2. Life pathwaysPathway A - people tend to• Be active• Be connected to people and society• Engage with natural places• Eat healthy foodsLive longerBetterqualityof lifeThree ages of childhoodIn uteroAttachmentSecureNurturedExpolorationEngagementMemory-makingIndependenceInclusionRisk-takingAdulthoodElderly-9 mths0 yrs5-6 yrs11-12 yrs18 yrs+60-65 yrsPathway B - people tend to• Be inactive/sedentary• Be disconnected from society• Not engage with natural places• Eat energy-dense and unhealthy foodsDie earlierLive yearswith lowerqualityof lifeSource:Source:PrettyPretty et et al.,al.,20092009


20 ong>Ecomindsong> ong>effectsong> on mental wellbeingThere are clearly numerous pathways that liebetween healthy path A and unhealthy path B - thefigure has been simplified for illustration purposesonly. There are many other factors that affect ourlong-term life and health pathways but the researchdescribes the key mediators, such as social status,mental health, social inclusion, physical activity, urbandesign and contact with nature.It is proposed that it is possible to shift across theselife pathways – from B towards A as a result ofadopting healthy behaviours, or from A to B as aresult of shocks or an accumulation of stresses.Resilient individuals remain able to absorb and copewith shocks and stresses and remain on pathwayA. It follows therefore that contact with naturethrough green exercise or involvement in ecotherapyinterventions can help an individual shift across thelife pathways for a healthier, happier life throughimproving wellbeing, increasing physical activity andfostering a connection to nature, often at the sametime as enabling healthy lifestyle behaviours andcreating healthier communities.1.6 Ecotherapy and resilienceAt some point in our lives, we will all unfortunatelyexperience difficult periods. How we cope with thesetimes of stress, loss, failure or trauma will undoubtedlyinfluence our wellbeing. Although there is a lack ofa standardised definition, ‘resilience’ is consideredto be both the ability of an individual to bounce backafter times of stress; and their capacity to adapt inthe face of challenging circumstances and adversity,whilst maintaining a stable mental wellbeing 80 . Aperson’s resilience has been found to be dynamic, wemay respond to the same circumstances differentlyat different stages in our lives and what affects oneperson may not affect someone else in the sameway 81 . Our level of resilience will also affect how welive our lives, how open we are to new opportunitiesand learning new skills, and how we let ourselvesgrow and develop 82 .Resilience can be seen as a kind of ‘defencemechanism’ 83 in the battle against adversity andbuilding up an individual’s resilience can be seenas a preventative approach to future stresses. Thedevelopment of psychological ‘coping strategies’ istherefore important to build up our resilience andmaintain good mental health. Initiatives and treatmentsthat help to develop different coping strategies and buildup our resilience should therefore be encouraged.Our resilience is said to be influenced by three mainfactors: i) how we develop as children and youngpeople; ii) external factors (such as our relationshipswith other people, social inclusion, having a faith etc);and iii) internal factors (such as how we choose tointerpret events, manage our emotions and regulateour behaviour) 84 . Initiatives which positively shapethese factors will help to grow resilience.The resilience approach to increasing wellbeing isin line with the WHO concept of mental health as ‘apositive state of psychological wellbeing, going beyondthe absence of disease’ 85 . However the lack of eithera single definition or a unified approach to resilienceresearch and practice 86 has meant that inevitablyhealthcare professionals and third sector organisationsare developing a wide variety of approaches toincreasing resilience for the benefit of mental health.For Mind, their model of resilience building 87 takesthe approach that resilience should be developed bycommunities as well as individuals and recognises theimportance and interrelatedness of three key elementsin reducing the likelihood of mental health problems:• Promoting wellbeing through nef’s Five Ways toWellbeing.• Building social networks and social capital – humanrelationships are key to our capacity to respondto adversity and challenge so a strong focus onreducing isolation is needed.• Developing psychological coping strategies – tobuild resilience we need to develop increasedlevels of understanding around what affects ourmental health. Mind wants to promote insight intopsychological coping strategies; driven by principlesof positive psychology, and psychological therapiesincluding Cognitive Behavioural Therapy (CBT),Interpersonal Psychology (IPT) and also mindfulness.Whilst there has been much promotion of wellbeingand social capital by local authorities and thevoluntary sector 88 according to Mind, the contribution80 Mind 2013b81 Maston and Wright 2010 and see Action for Happinesswww.actionforhappiness.org/10-keys-to-happier-living/find-ways-tobounce-back/details82 Reivich and Shatte 2003; Tedeschi and Calhoun 2004; Masten et al,2009; Styles 201183 Davydov et al, 201084 Reivich and Shatte 2003; Maston and Wright 2010 and Action for Happiness85 WHO 200586 Davydov et al, 201087 For more information see ‘Resilience in Mind’ Mind 2013b88 See www.neweconomics.org/publications/the-role-of-local governmentin-promoting-well-being


An evaluation for Mind 21of interventions that develop psychological copingstrategies has been under examined 89 . Evidenceis growing concerning the use of psychologicaltreatments (including but not limited to CBT) for thepurposes of prevention and resilience and a recentmeta-analysis suggests that up to 38 per cent ofmajor depressive episodes could be prevented withcurrently available methods 90 . However the evidencebase has not so far been translated into practice andthere is quite a limited protocol for delivering theseinterventions in either statutory or voluntary sectorsettings: “Full use of evidence-based depressionprevention strategies has yet to be realized. Thisgap between what is known and implementation ofthese strategies requires attention, action, and thestrengthening of research and dissemination efforts” 91 .Ecotherapy has the potential to enable resiliencedevelopment through the promotion of wellbeing, theincrease of social inclusion and of mindfulness andalso by providing a natural, calm setting for moreformal therapy. All of which can help build up anindividual’s capacity to cope with life stresses andhave a prophylactic effect against poor mental healthin the future.1.7 Ecotherapy as a treatmentfor depressionWith mental health problems and especiallydepression on the increase, what is known aboutecotherapy and green exercise therapy as a potentialtreatment option? Visiting the GP is frequently thefirst step that people take when they feel depressedand it is usually the GP who is primarily responsiblefor organising their treatment.Currently UK NICE guidance recommends talkingtherapies (such as CBT) and/or antidepressantsas the first two treatment options for depression.They also promote a stepped-care model using amultifaceted treatment approach (e.g. combinationof both medication and psychological support) 92 .However, in an article reviewing four meta-analysesof efficacy trials for antidepressant drugs and CBTin 2010, it revealed that both often fail to result insustained positive ong>effectsong> for the majority of peoplewho receive them. Only 51 per cent of studies havefound positive ong>effectsong> of antidepressants whencompared to placebos 93.Whilst antidepressants and CBT are the first twotreatment options for depression, the Department ofHealth’s evolving ‘Improving Access to PsychologicalTherapies (IAPT)’ initiative continues to promotealternative treatment options 94 . Epidemiologicalevidence shows that physical activity is associatedwith a decreased risk of developing clinically defineddepression and that the antidepressant effect ofexercise is interestingly, of a similar magnitudeto antidepressant drugs and psychotherapeutictechniques 95 . In a report by the Chief Medical Officerit was stated that “physical activity is effective inthe treatment of clinical depression and can beas successful as psychotherapy or medication,particularly in the longer term”. Therefore, acompelling argument for exercise therapy to beadvocated as a treatment option can be formulated.Exercise has less negative side ong>effectsong> and canpositively treat patients experiencing a combination ofphysical and mental health problems.However, a common concern is that peopleexperiencing a period of depression do not havethe desire or motivation to exercise; but compliancerates are often much better than for medication,especially if they are receiving adequate supportand encouragement. That said, only four per cent ofGPs offer exercise as their first treatment option fordepression and only 21 per cent put exercise withintheir top three treatment options 96 .The option of ecotherapy (and green exercise therapyin particular) may prove to be an even more effectivetreatment than exercise alone as it encourages peopleto re-connect with nature and experience the additionalpositive health benefits that are associated with this.Contact with nature and green space is often upliftingand restorative, helps to reduce stress and improvemood and combining this with physical activity willoffer a very efficacious treatment option. In addition asthe nature and the activities are usually the primaryfocus, the ‘exercise’ component seems secondary, andso often seems much less daunting for participantsthan gyms or fitness clubs. Ecotherapy also promotessocial inclusion and enables people to make healthierchoices and adopt a more sustainable healthierlifestyle. However, even though the evidence is89 Mind 2013b90 Muñoz et al, 201291 Pim Cujpers et al 201292 NICE 200993 Piggott et al, 201094 DoH 201295 Mead et al, 201096 Mental Health Foundation 2009


22 ong>Ecomindsong> ong>effectsong> on mental wellbeingcontinually growing, to date there is still relativelylittle evidence on the ong>effectsong> of ecotherapy in thetreatment of depression.1.8 Ecotherapy in the UKThe last few years has seen an increase inthe number of ecotherapy projects across theUK, ranging from walking initiatives and GreenGyms through to STH projects and care farms(see Box 3).Government departments (Defra, DoH),organisations such as Natural England andlarge national charities such as the NationalTrust, RSPB, TCV and Mind all have campaignsto encourage us to have more contact withnature, to take up green exercise for our healthand wellbeing and to re-connect to naturalspaces, both as adults and children. The term‘green exercise’ has been taken up by manylocal authorities and public health professionalsfor use in promoting healthier lifestyles andecotherapy initiatives have been workingeffectively with many different vulnerablegroups and communities. The Big Lottery Fundhas supported ecotherapy projects not onlydirectly through the ong>Ecomindsong> scheme, but alsoindirectly through other funding streams such as‘Access to Nature’ and ‘Local Food’.It is apparent that there is an emerging bodyof evidence supporting green exercise andecotherapy and it is becoming increasinglyrecognised as an idea which can be linkedto current government health and social carepolicies. However there is still a way to gobefore ecotherapy is considered ‘mainstream’ asa way to increase wellbeing or as a treatmentoption in mental healthcare. The majority of GPsdo not even consider the use of ecotherapy asa treatment intervention for mild to moderatedepression; and many patients do not considera prescription for an ecotherapy intervention aseither an adequate response to their illness bytheir doctor or as an effective treatment.Box 3: Some examples of ecotherapyinitiatives currently in the UK• Approximately 200 care farms operating in theUK – using farming to improve health, wellbeingand social inclusion for many vulnerable groups. Seewww.carefarminguk.org• Well over 1000 Social and Therapeutic Horticultureprojects in the UK – using gardening andhorticulture to deliver health and wellbeing benefits.See www.thrive.org.uk and www.asthp.org.uk• Nationwide programme of over 95 TCV GreenGyms – endorsed by local health practitioners,encouraging participation in local natureconservation activities to improve health and wellbeingsince 1997. See www.tcv.org.uk/greengym• Wilderness therapy programmes for people withmental ill-health and for disaffected young peopleand youth at risk. See for examplewww.discoveryquest.org/www.wildernessfoundation.org.uk andwww.wildernessfoundation.org.uk/category/turnaround/• Natural England Green Exercise campaign andeight demonstration projects around the UK. Seewww.naturalengland.org.uk/ourwork/enjoying/linkingpeople/health/greenexercise/default.aspx• Walking for Health over 600 walking schemes runby the Ramblers and Macmillan Cancer SupportSee www.walkingforhealth.org.uk• ong>Ecomindsong> – 130 projects across England usingecotherapy for people suffering with mentaldistress. See: www.mind.org.uk/ecominds• Various groups offering ecotherapy interventions.See for example: www.ecotherapy.org.uk/www.andymcgeeney.com and www.eco-therapyuk.com/• Animal assisted interventions over UK. See forexample: www.scas.org.uk/animal-assistedinterventions/and www.equine-animal-assistedtherapy.org.uk/• Social forestry initiatives – See ForestryCommission website and http://dx.doi.org/10.1080/13549839.2013.790354


An evaluation for Mind 23So why is this the case? Is there a lack of evidenceto support the use of ecotherapy approaches? Is itsimply a lack of knowledge on the behalf of GPs andpatients that alternatives exist? Are there not enoughecotherapy initiatives out there to cater for demand? Isit that there is currently no coherent funding for suchinitiatives? Is there a lack of political will? Is it becauseecotherapy is not yet supported by NICE guidelines?Elements of all of these factors are probablyresponsible and all of these statements may be truein part, but in times of burgeoning mental health costs,economic hardship, shrinking budgets (across allsectors) and amidst worries that we are becoming asociety of sedentary and obese people, increasinglydisconnected from nature, can we really afford not topromote ecotherapy as one of the solutions?1.9 Limitations of evidence1.9.1 Limitations of current evidence baseThe evidence base for the benefits of ecotherapy iscontinually growing and can be considered convincingbut not yet complete. There is also a large amount ofanecdotal data showing a strong link between variousecotherapy or green care approaches and improvedhealth and wellbeing for a variety of cohorts. Thereis still a need for further quantitative data to supportthe qualitative narrative as many evaluations of suchinitiatives are purely qualitative or descriptive withmuch emphasis on narrative evidence.Many studies unfortunately suffer frommethodological limitations that cast somedoubt over their effectiveness as a therapeuticintervention. The lack of standardised, reliable andvalidated measures assessing changes in health andwellbeing parameters; absence of a control group;together with small sample sizes are often majorlimitations of the research findings 97 . Methodologiesare often not replicable and not all details arereported, so there is a general lack of comparablefindings 98 . There is also a lack of longitudinal studydesigns as many studies do not administer followupmeasures to evaluate the long-term ong>effectsong> ofparticipation 99 . Therefore, there is a real need for amixed approach adopting both robust standardisedinstruments to quantify outcomes and qualitativemethodologies which capture rich quotes to supportthe quantitative analyses. There is therefore a needfor further research to address these limitations.In addition, there is limited evidence concerningthe application of ecotherapy initiatives in the mentalhealth population. Steps are being taken to engagemore individuals experiencing mental illness inecotherapy (particularly Green Gym, ong>Ecomindsong>,care farming, wilderness therapy etc – see Box2). Green Gym groups often attract individualsexperiencing mental illness and evaluation findingshave reported significant increases in mental healthstate scores, a reduction in depression and a trendtowards weight loss 100 .97 Davis-Berman & Berman, 1994; Sempik 2005; Willisand Liesl 2005; Peacock et al 2007; Hine et al 2008c98 Winterdyk & Griffiths, 1984; Gillis, 1992; Cason & Gillis, 1994;Hattie et al., 199799 Russell, 1999; Epstein, 2004; Sempik 2007100 Reynolds 1999, 2002, BTCV 2008


24 ong>Ecomindsong> ong>effectsong> on mental wellbeingThe research has also not yet fully addressed theissues of exposure time and sustainability. Researchhas demonstrated that in the short term and afterrelatively short exposures to nature, of as little as fiveminutes, ecotherapy is beneficial in improving mentalhealth and wellbeing, but it is not known whether thisautomatically leads to longer-term improvements.Another important unanswered question forsustainability is to what extent do the benefits ofsuch ecotherapy interventions continue off-site?How long do the psychological benefits last onceyou return to a more stressful environment? Do thebenefits last for the day, the next day or for the nextweek? Does contact with nature provoke long-termchanges in thinking, leading to social (and political)transformations and improved public health?Finally, to date, there has been little researchconducted which directly compares ecotherapy withmore traditional treatment options, such as antidepressantsor CBT. We anticipate that ecotherapywill be effective, but the robust scientific evidenceto support this hypothesis is still incomplete.Comparative economic or ‘cost-benefit’ research forecotherapy is also currently very limited. For theidea of ecotherapy to gain credibility and influencegovernment policy and the health sector, moredetailed research needs to be undertaken.1.9.2 Evaluation of ecotherapy interventionsIn the field of healthcare evaluation, the robustnessand effectiveness of evidence has been historicallyassessed using an idea of a ‘hierarchy of evidence’.In the traditional hierarchy, particular elements ofevaluation 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 theconstruction of samples• the use of ‘blinding’ (where research participantsonly (single blind) or participants and researchers(double blind) are uncertain of which individualshave received an intervention and which a placebo)• the use of replicable methodology and standardised,validated instruments for the measurement of healthgain and other outcomes.Because the randomised control trial (RCT)contains three of the elements above (comparison,randomisation and blinding) it is seen as the ‘goldstandard’ in effectiveness methodology. The RCT isconsidered a ‘fair test’, involving the comparison oftwo treatments or interventions under conditions thatremove any bias either in the selection of participantsor the measurement of outcomes 101 . However,evaluation of nature-based interventions may find itdifficult to live up to this standard, as they, by theirvery nature, preclude the use of one (or several)desirable methodological elements. The main reasonsfor this are that ecotherapy interventions:• do not necessarily involve the application of adiscrete or defined ‘treatment’ such as a medicine• are often not amenable to placebo (e.g. it is verydifficult to design an activity that is just like being innature, but isn’t in nature at all)• cannot easily be blinded as it would not be possiblefor a patient to be honestly unsure whether theyhad been outside or not 102• outcomes are not necessarily discrete or easilymeasurable (e.g. feelings of improved generalwellbeing, increased social inclusion, feeling useful,empowered and more confident etc).In addition, it could be construed as unethical todeny participants access to ecotherapy interventions(i.e. withholding treatment) when they themselvesconsider that it might be beneficial to their healthand wellbeing. Given that ecotherapy interventionscan be characterised by these elements, the ‘goldstandard’ of a blinded and randomised control trial,has up until now, not necessarily been consideredan appropriate (or even possible) choice. Dismissingthe RCT as ‘inappropriate’ for the evaluation ofnature-based interventions though, may be limitingthe perception of the effectiveness of such initiatives.Unfortunately conducting a RCT is a costly processand to date, there seems to have also been a lack ofwill by funders of healthcare research to support anecotherapy RCT. However regardless of how viableRCTs are considered for nature-based ecotherapyinterventions, enhanced monitoring and evaluation ofthese programmes is undoubtedly needed to assesschanges in health, social and economic outcomes.101 Sempik 2007102 i.e. an individual is bound to realise that they have had the ‘nature’treatment rather than an alternative


An evaluation for Mind 252. ong>Ecomindsong> evaluation2.1 Background 103Mind provides advice and support to empoweranyone experiencing a mental health problem andcampaigns to improve services, raise awareness andpromote understanding of mental health problems.In 2007, following the commissioning of two researchstudies into green exercise initiatives 104 , Mind calledfor a new green agenda for mental health throughtheir ecotherapy campaign for Mind week. Thecampaign highlighted the growing evidence insupport of an accessible, cost-effective andnatural addition to existing treatment options,using ecotherapy interventions. The campaign wasinstrumental in raising awareness of nature-basedinitiatives for those with mental health problems.Leading on from this work, Mind was chosen as anaward partner for the Big Lottery Fund ChangingSpaces programme 105 to manage ong>Ecomindsong>; a £7.5million open grant scheme. Over the five years sincethe launch of the scheme in 2008, ong>Ecomindsong> hasfunded 130 environmental projects in England thathelp people living with mental health problems getinvolved in green activities to improve confidence,self-esteem, and their physical and mental health.ong>Ecomindsong> projects range from horticultural andagricultural schemes, through to walking groupsand regeneration initiatives in local parks. Allprojects encourage participants to enjoy andbenefit from nature and green spaces in urbanand rural environments.2.2 ong>Ecomindsong> wellbeing evaluationMind commissioned the Green Exercise ResearchTeam at the University of Essex to carry out anindependent, academic evaluation of the ong>Ecomindsong>scheme to provide robust, scientific data on theong>effectsong> on psychological health and wellbeing ofbeneficiaries derived from taking part in ong>Ecomindsong>projects. This evaluation focused on three mainthemes: i) Wellbeing, ii) Social inclusion and iii)Connection to nature and two secondary themes:iv) Healthy lifestyles and v) Environmentallyfriendly behaviour.There are two levelsto the University of Essexevaluation of ong>Ecomindsong>a) Evaluation of the ong>Ecomindsong> scheme as a whole(a meta-analysis)b) More in-depth evaluation of a sub-sample of nineindividual ong>Ecomindsong> projectsThe evaluation was not about measuring the‘performance’ of individual projects but rather measuringoutcomes for beneficiaries, projects and the ong>Ecomindsong>scheme as a whole. The process was designed to beas flexible and inclusive as possible with evaluation toolsspecifically formulated not to be a burden on projects ortoo onerous for beneficiaries. Details of the evaluationapproach can be found in Chapter 3.103 This section is taken from www.mind.org.uk andwww.mind.org.uk/ecominds/what_is_ecominds104 See Mind 2007 and Peacock 2007105 See www.biglotteryfund.org.uk/ for more information


26 ong>Ecomindsong> ong>effectsong> on mental wellbeing2.3 Green Exercise Research Teamat the University of EssexThe Green Exercise Research Team involved in thisstudy forms part of the Essex Sustainability Institute(ESI) at the University of Essex. There is growingempirical evidence to show that exposure to naturebrings substantial mental health benefits 106 and atthe same time, physical activity is known to result inpositive physical and mental health outcomes. Overthe last 10 years at the University of Essex, we havecombined these ideas into a programme of researchon ‘green exercise’ (activity in the presence of nature)and ‘green care’ (therapeutic applications of greenexercise and other nature based interventions).These address current concerns about the adversehealth ong>effectsong> of modern diets, sedentary lifestylesand a disconnection with nature, along with growingevidence that stress and mental ill-health havebecome substantial health problems for many peoplein industrialised societies.This cross-disciplinary University of Essex projectteam is engaged in primary research on i) thehealth benefits of green exercise – investigatingthe mental and physical health benefits of physicalactivities under exposure to different rural and urbanenvironments; iii) measuring connection to nature;and iii) evaluating a wide variety of green careoptions in varying contexts (including care farming,facilitated green exercise, ecotherapy and wildernesstherapy); and; and is currently leading research inthis field 107 . The Green Exercise Research Team werealso involved in conducting the original research thatsupported Mind’s Ecotherapy campaign in 2007.The Essex sustainability Institute is also a leadingauthority on the use of Participatory Appraisal andAction Research to assess the needs and opinionsof communities. With over 25 years’ experience ofparticipatory assessment, we have worked witha wide variety of organisations and target groupsboth within the UK and internationally. The ESIhas developed innovative participatory techniquesthat engage communities as active participants andthis approach encourages community ownershipof outcomes so that they are self-sustaining in thelonger term.106 Pretty et al, 2003, 2004, 2005, 2006, 2007; Pretty, 2007; Peacock 2007;Mind, 2007; Hine et al. 2007a,b; Hine et al. 2008a,b, c; Hine 2008; Hineet al, 2009; Barton et al. 2009; ; Pretty et al. 2009; Hine 2010; Bartonand Pretty 2010. Hine et al, 2011; Bragg et al, 2012; Wood et al 2012 a,b107 See www.greenexercise.org/ for more details of this research


An evaluation for Mind 273. MethodologyThis section provides an overview of the researchprocess and sampling strategy; details of supportgiven, ethical procedure and data protection; andinformation on the questionnaire development;before outlining the outcome measures used in thecomposite questionnaires and the methods employedto analyse them.3.1 Overview of research processThe University of Essex provided an independentmonitoring and evaluation process to assess keyoutcomes of the ong>Ecomindsong> scheme. The Universityof Essex evaluation of ong>Ecomindsong> was based on theexperiences of participants rather than ‘performance’of projects and focused on three main themes:i) Wellbeing, ii) Social inclusion and iii) Connectionto nature, and two secondary themes: iv) Healthylifestyles and v) Environmentally friendly behaviour.The aims of the University of Essex ong>Ecomindsong>evaluation were:• To examine changes in beneficiary wellbeing asa result of participation in ong>Ecomindsong>• To determine any changes in feelings of connectionto nature and to other people as a result ofparticipation in ong>Ecomindsong>• To determine likely perceived or actual changesin lifestyle behaviour for beneficiaries as a resultof participation in ong>Ecomindsong> in terms of healthierlifestyles and environmental behaviour indicators3.2 Evaluation design and samplingstrategyThe most appropriate approach to the ong>Ecomindsong>evaluation, in terms of financial and ease ofadministration considerations, was deemed to bethe use of a predominantly questionnaire-basedmethodology. The composite questionnaires weretherefore specifically designed to provide comparativedata, over time, on the personal outcomes ofparticipating in ong>Ecomindsong> (e.g. improved psychologicalwellbeing, social inclusion etc).There are two levels to the University of Essexevaluation of ong>Ecomindsong>: firstly an evaluation of theong>Ecomindsong> scheme as a whole (a meta-analysis typeapproach) - which we have called the ‘All projects’study; and secondly a more in-depth evaluation ofa sub-sample of nine individual ong>Ecomindsong> projects– which we have termed the ‘In-depth’ study.Furthermore, within each of these two levels, there aredifferent elements of the research (see Figure 3). Thedetails of the study design and the sampling strategyof the two levels of the evaluation will be addressedseparately in the following sections (3.2.1 and 3.2.2).Figure 3. Overview of the University of Essex ong>Ecomindsong> evaluationong>Ecomindsong> evaluation3 key themes: i) wellbeing, ii) social inclusion, iii) connection to natureAll projects studyIn-depth studyWithingroup studyBetweengroups studyChanges over theong>Ecomindsong> programmeChanges after anong>Ecomindsong> session


28 ong>Ecomindsong> ong>effectsong> on mental wellbeingto involve more than five people in the evaluation ifthey wished to do so. More details of the ‘All projects’questionnaire are covered in Section 3.5 and a copyof the questionnaire can be found in Appendix A.Each ong>Ecomindsong> project involved a slightly differentcontext, with varying numbers of participants,differing activities and timescales. Timings for thequestionnaire completion could therefore not bespecified exactly and had to be flexible, so were leftto the discretion of the project staff (with guidancegiven – see Section 3.3).The ‘All projects’ study comprised two separateelements which were dependent on whether theprojects had been able to ask the same people tofill out questionnaires both at the beginning andat the end of the programme or whether differentparticipants had been involved in completingquestionnaires at the two time points.3.2.1 The ‘All projects’ evaluationThe ‘All projects’ evaluation was open to all projectsexcept: i) the projects involved in the ‘In-depth’evaluation, ii) those projects being evaluated by CLESand NEF as part of the Big Lottery Fund NationalWellbeing Evaluation and iii) projects which wereparticipating in their own external evaluations; inorder to avoid project participants suffering from‘questionnaire fatigue’. In addition, projects where itwas not considered ethically appropriate to use theUniversity of Essex questionnaires were also omitted(for example where participants were deemed byproject staff to be particularly vulnerable, too youngor too traumatised and therefore not able to completethe composite questionnaires, even with assistance).Every ong>Ecomindsong> project was sent 10 printed copiesof the short two-page participant questionnaire bypost (and electronically by email when requested)and project staff then asked five participants atrandom in their project to complete the questionnairesat the start of their involvement with ong>Ecomindsong>.Completed questionnaires were then sent backto the University of Essex by Freepost. Towardsthe end of the programme project staff asked thesame five participants (if possible or five differentparticipants if not) to complete the remaining fivequestionnaires and once again the completedquestionnaires were returned to the University ofEssex for analysis. Projects were also encouragedFirstly, for projects who had managed to askbeneficiaries to complete both a start of programmequestionnaire and then another questionnaire atthe end of the programme a direct comparison ofparameters and any changes that have occurred overtime could be made on an individual basis. We havecalled this a ‘within group’ study.Secondly, for projects whose participants had eithercompleted one questionnaire at the start of theirtime at the project or one questionnaire at the end ofthe project, a comparison of the outcome measuresbetween two different groups of participants (thosewho have just started at a project and those whohave just finished) could be made and any resultingdifferences reported. We have called this a ‘betweengroups’ study.3.2.2 The ‘In-depth’ evaluationA subset of ong>Ecomindsong> projects were chosen togive more in-depth information on the ong>effectsong> onparticipant wellbeing, social inclusion and connectionto nature. The aim was to provide a representativesample of ong>Ecomindsong> projects to include: i) all typesof project, i.e. a mix of care farming, social andtherapeutic horticulture, environmental conservation,facilitated green exercise and nature art andcrafts projects; ii) projects both with and without aformal therapy element, iii) projects from all of thegeographic regions; iv) a range of project sizes (interms of number of beneficiaries;)and v) a variety ofdifferent grant sizes.


An evaluation for Mind 29The ‘In depth’ ong>Ecomindsong> evaluation is also composedof different research elements. Firstly, participantshave completed questionnaires at the beginningand at the end of their involvement with ong>Ecomindsong>,enabling an analysis of any changes in outcomemeasures on a longitudinal basis over the ong>Ecomindsong>programme (longer term changes, commonly knownas changes in ‘trait’). In addition, participants alsocompleted a series of slightly different questionnairesimmediately before (pre) and after (post) taking partin an ong>Ecomindsong> session to enable analysis of anychanges in outcome measure over a much shorterperiod of time (commonly known as changes in‘state’). Finally, several of the outcome measureswere repeated not only in the beginning and endquestionnaires but also in the pre and post activityquestionnaires, enabling an analysis of outcomemeasures at regular intervals throughout theprogramme. The aim was to encourage at least 30participants from each project to take part in theevaluation, however again, each of the nine projectswere slightly different, with varying numbers ofparticipants, activities and timescales, so this numberhad to be flexible.The evaluation process followed the steps laid out inthe ‘Flowchart for project staff’ (Figure 4). After readingthe guidelines document, project staff administeredthe consent forms and participant information sheetsto project beneficiaries. Once participants agreed totake part in the evaluation they were asked to fill ina questionnaire at the start of their involvement withong>Ecomindsong>. Further (slightly different) questionnaireswere administered by project staff before and afteran activity session together with a questionnairecoversheet. Depending on the set up of the project, thebefore/after activity element happened again at regularintervals throughout the duration of the project. Finallythe ‘end of programme’ questionnaire was administeredwhen the participant was nearing the end of theirFigure 4. University of Essex ong>Ecomindsong> Evaluation Process - Flow chart for project staffStage 1 – Entry/StartStage 2 – DuringStage 3 – Exit/EndStartconsent form givenout by projectofficer (PO)At least once during theproject a ‘before and after’ activitystudy will be conductedBeneficiary willingto participate30+participantsQuestionnaire A(Start programme)handed out by POQuestionnaire C(Before) handed outby P O immediatelyBEFORE outdooractivity session andcollected in againQuestionnaire B(End programme)handed out byproject officerNoYesQuestionnaire isanonymous andconfidentialActivity sessiontakes place as usualQuestionnaire isanonymous andconfidentialKeep consentforms safe andsend back toU of E at the sametime as QA sQuestionnaire Acompleted byparticipant andhanded backto POQuestionnaire Dcompletedimmediately AFTERoutdoor activity andhanded back to POQuestionnaire Bcompleted byparticipant andhanded backto POQuestionnaires collected back from participants (without examining or reading them - to ensure privacy)by PO who sends them back to the University of Essex in the Freepost envelopes providedFinish


30 ong>Ecomindsong> ong>effectsong> on mental wellbeingtime with the project or at a set period of time afterthe project has begun. All completed questionnaires,consent forms and coversheets were returned to theUniversity of Essex for analysis. More details of the ‘Indepth’questionnaires are covered in Section 3.5 and acopy of the questionnaires can be found in AppendicesB and C.3.3 Evaluation support for projectsVarious documents and other resources for supportwere provided for projects involved in the ong>Ecomindsong>evaluation. For both the ‘All projects’ and the ‘In depth’studies, full guidelines documents were preparedwhich gave details of all aspects of the evaluation fromwhat to do and when, through to how to administerquestionnaires in an ethically sound way and somehandy tips and hints. Telephone and email supportfrom the University of Essex and from ong>Ecomindsong> grantsofficers relating to the evaluation was available forproject staff throughout the evaluation process.In addition, the lead researcher also gave apresentation to ong>Ecomindsong> project staff in 2009detailing both the University of Essex ong>Ecomindsong>evaluation and the BIG Wellbeing and ChangingSpaces evaluation, as well as highlighting possiblefurther evaluation options for projects not selected tobe part of the In-depth study.In May 2012 the lead researcher also ran aninteractive workshop on evaluation tools and tips forong>Ecomindsong> project staff at the ‘Making Connections’networking event in order to help projects to:• show how their project works• highlight successes and further needs• convince existing or potential funders• become sustainable• add to the evidence base.3.4 Ethics, consent and data protectionEthical approval for the research was given by theScience and Engineering Faculty Ethics Committee 108 atthe University of Essex, which reviewed and approvedthe research. In line with University of Essex ethicsprocedure, participant consent was gained priorto their taking part in the ong>Ecomindsong> evaluation. Allpotential participants were told that their participationwas on a purely voluntary basis and that they couldwithdraw from the research at any time withoutprejudice and without providing a reason.In the ‘All projects’ evaluation, all participants wereasked if they consented to take part and if they wouldcomplete a short questionnaire either once or at twointervals during their involvement with ong>Ecomindsong>, bycompleting the first section of the questionnaire whichoutlined the research process, what would happen totheir data, how to withdraw from the study and thenif they consented to take part (see Appendix D).For the ‘In-depth’ evaluation, potential participantswere given an information sheet (Appendix D) to read(or project/ care staff member read one out aloudto them), before being asked to sign the consentform if they agreed to becoming involved in theevaluation. The participant information sheet provided:i) details of the research process; ii) details on how towithdraw from the evaluation or how to contact theresearch team; and iii) information on the storage ofparticipant data (in line with the Data Protection Act).Only beneficiaries, who consented to take part in theresearch, were accepted onto the evaluation and givenquestionnaires. All questionnaires were designed tobe anonymous with the only personal data collectedbeing participant postcode and initials, purely to enablecollation of questionnaires from the same participant atdifferent time points. All data collected will be held bythe University of Essex in hard copy for the durationof the ong>Ecomindsong> scheme (until 2013) and electronicallyfor up to two years after this. The data will only beaccessible to the three researchers at the University ofEssex, and will not be passed on to any third party.3.5 QuestionnairesA range of composite questionnaires were developedfor the ong>Ecomindsong> evaluation, composed of amixture of internationally recognised, standardisedquestionnaires, bespoke questions and questionsused in the BIG Changing Spaces evaluation. Allquestionnaires included questions on ethnicity,gender and age as is required by the Big LotteryFund and participants were also asked whether theywere filling out the questionnaire for themselves,helping someone with it or completing it on someoneelse’s behalf (to enable those who were not ableto complete the questionnaires themselves to beincluded in the evaluation). Participants were askedto complete the questionnaires individually and not tocompare or discuss their answers with other people.The ‘All projects’ evaluation used the same short twopagequestionnaire at both time points and the ‘In-


An evaluation for Mind 31depth’ evaluation used a series of four slightly longerquestionnaires (four pages): one for the start of theprogramme, one for the end of the programme, one forthe pre activity and another for the post activity. Projectstaff also completed a questionnaire coversheet whichrecorded various aspects of the day that the pre/postquestionnaires were administered giving informationthat could have an overly negative or positive effect onthe visit such as the weather, duration of visit and typeof activities etc (see Appendix E). All questionnairesand coversheets were then collated and sent to theUniversity of Essex for independent analysis.The types of questions and outcome measures usedare covered in more detail in Section 3.6 and completequestionnaires are included in Appendices A-D3.6 Outcome measuresThe University of Essex evaluation of ong>Ecomindsong>focused on three main themes: i) Wellbeing, ii)Social inclusion and iii) Connection to nature, andtwo secondary themes: iv) Healthy lifestyles andv) Environmentally friendly behaviour. Outcomemeasures used to measure these parameters aretherefore organised by theme.3.6.1 Mental wellbeingMental wellbeing is one of the main themes for theong>Ecomindsong> evaluation. One simple scale on ‘positivity’and three standardised, internationally recognisedinstruments (measuring wellbeing, self esteem andmood) and were therefore used in this evaluation toassess the different elements of mental wellbeing.a) Warwick-Edinburgh Mental Well-being Scale (WEMWBS)Wellbeing was measured using the Warwick-Edinburgh Mental Well-being Scale (WEMWBS). TheWEMWBS is a relatively new measure developedby the University of Warwick and the University ofEdinburgh, to enable the measurement of mentalwellbeing of adults in the UK 109 . The scale examines awide idea of wellbeing, including affective-emotionalaspects, cognitive evaluative dimensions andpsychological functioning, and is short enough to bepractical for use in both population-level surveys 110and at the individual level 111 .The long-form of WEMWBS is a 14-item scale ofmental wellbeing covering subjective wellbeing, inwhich all items are worded positively and address109 funded by the Scottish Government’s National Programme for ImprovingMental Health and Wellbeing and commissioned by NHS Health Scotland110 Tennant et al 2007111 Maheswaran et al 2012


32 ong>Ecomindsong> ong>effectsong> on mental wellbeingaspects of positive mental health 112 . The positivelyfocussed design of the WEMWBS enables its use bymental health promotion initiatives 113 . There is also ashort-form 7-item version of WEMWBS validated foruse (known as the SWEMWBS).The scale is scored by summing responses to eachitem answered on a 5-point Likert scale where 1 is‘none of the time’ and 5 is ‘all of the time’. For thelong form WEMWBS, the minimum scale score is 14and the maximum is 70 and for the SWEMWBS theminimum score is 7 and the maximum is 35, withhigher scores representing higher levels of wellbeing.Both forms of the WEMWBS have been validatedfor use in the UK with those aged 13 and above 114 .WEMWBS shows good content validity; Cronbach’salpha scores range from 0.89 to 0.91 and WEMWBSshows high correlations with other mental health andwell-being scales. Test-retest reliability at one weekwas high (0.83) and social desirability bias was loweror similar to that of other comparable scales 115 .The WEMWBS is not designed to identify individualswith exceptionally high or low levels of positive mentalhealth, so cut off points have not been developed 116 .However, a three-fold classification for WEMWBSscores has been used in research, where ‘poor’,‘average’ and ‘good’ mental wellbeing scores aredetermined by the mean and standard deviation (SD)of the data 117 . A ‘poor mental wellbeing’ is classedas more than one SD below the mean, ‘average’as within one SD of the mean and ‘good mentalwellbeing’ as one SD or more above the mean. Themean and SD used in this study were the nationalaverages taken from the most recent Scottish HealthSurvey in 2011 (M=49.9, SD 8.36) 118 .b) Rosenberg Self Esteem Scale (RSES)Self-esteem was measured using the one-page 10-item Rosenberg Self-Esteem Scale (RSES), whichprovides a one-dimensional measure of global selfesteem119 . Its validity is widely acknowledged, it iseasy to administer 120 and is considered to be the mostwidely-used and popular self-esteem measure inhealth psychology, psychotherapy and social scienceresearch and evaluation studies 121 .The instrument’s reliability (internal consistencyand test-retest) and face validity (convergent anddiscriminant) compares favourably with that ofmore elaborate measures 122 . Test-retest correlationstypically range from 0.82 to 0.88 and reportedCronbach’s alpha coefficients range from 0.77 to0.88 123 . The scale’s superior reliability and validityhas been demonstrated with many differentsample groups and its use has been validated foradolescents, adult and elderly populations. Thereare no universally recognised normative populationdatasets available for comparison purposes howeverdata from recent published research show meanscores of between 23-27 for adults with severemental illness 124 and 32.62 for US adults 125 . Thereare also no recommended discrete cut-off pointsrepresenting high and low self-esteem althoughseveral (non-peer reviewed) studies suggest thatscores between 15 and 25 are ‘normal’.RSES comprises 10 statements relating to overallfeelings of self-worth or self-acceptance and eachitem has four response choices ranging from stronglyagree (4) to strongly disagree (1). The scoring methodused in this research provided an overall singularscore ranging from 10 (poor self-esteem) to 40 (highself-esteem), thus higher scores represent higherself-esteem.c) Profile of Mood States (POMS)Mood is defined as “the subtle subjective state orfeelings of a person at any given moment” 126 . It refersto certain sets of subjective feelings (e.g. lively,grumpy, tense, relaxed, excited and weary) whichconsequentially occur in everyday life and provides areliable and valid indicator of the quality of the leisureexperience 127 .The instrument used to provide a ‘snapshot’ of moodstate and quantify any changes in mood factors wasthe Profile of Mood States (POMS) standardised30-item short-form one page version 128 . This is anadaptation of the original standard form, which was awidely applied self-report instrument, used to assesscurrent mood states and fluctuations. According to112 Parkinson 2006113 Parkinson 2006114 Stewart-Brown and Janmohamed, 2008; Stewart-Brown et al 2009;and Clarke et al 2011115 Parkinson 2006116 Health Scotland 2009117 Braunholtz et al 2007118 Rutherford et al 2012119 Rosenberg, 1965;120 Fox 2000121 Rosenberg 1989; Cusumano & Robinson 1992; Brown et al. 1995;Palmer 1995; Mactavish & Searle 1992; Torrey et al, 2000; Hughes etal, 2004; Kubany et al, 2004; and Sinclair et al, 2010.122 Pretty et al. 2003123 Blascovich & Tomaka 1993; Rosenberg 1986124 Torrey et al 2000; Hine et al 2011;125 Sinclair et al 2010126 Hull 1991127 McIntrye & Roggenbuck 1998128 McNair et al. 1971; 1992


An evaluation for Mind 33Biddle, the POMS is the dominant instrument formeasuring mood in studies examining the relationshipbetween mood states and exercise 129 and ishistorically the most frequently used tool 130 . A recentedition of the POMS bibliography 131 also reported thatmore than 2,900 articles have cited the instrument.This comprehensive inventory of POMS citationshighlights the range of settings of its application.The POMS consists of 30 adjectives which collectivelymeasure six identifiable mood factors: tensionanxiety,depression-dejection, anger-hostility, fatigueinertia,vigour-activity and confusion-bewilderment.Each adjective is rated using a 5-point Likert scalewhere a ‘0’ indicates ‘not at all’ and a ‘4’ indicates‘extremely’. Participants were instructed to completethe form according to how they felt at that moment.The six subscales yield a global estimate of affectivestate referred to as Total Mood Disturbance (TMD).The TMD score denotes an overall assessment ofemotional state and is calculated by summing the fivenegative subscales and subtracting the only positiveaffect subscale (vigour) 132 .Reliability and validity of the shortened edition of thePOMS was established by Grove and Prapavessis(1992). Internal consistency of the POMS inventoryranges from 0.84 to 0.95, and test-retest reliabilitycoefficients range from 0.65 to 0.74 133 . The validity ofthis version has been substantiated with Cronbach’salpha reliabilities for a sample of college students,ranging from 0.67 to 0.93 134 . In this study, withparticipants having been diagnosed as having severeand enduring mental health issues, mood sub-factorscores were calculated using outpatient norms.d) Perceived positivity scaleIn the shorter questionnaires used in the ‘Allprojects’ evaluation, as a proxy for measuringmental wellbeing, a one-off, simple question on‘positivity’ was included to allow participants to givetheir perceptio and asking the question both at thebeginning and at the end of participants’ involvementwith ong>Ecomindsong>, enabled comparative data to begathered and any changes in score to be calculated.3.6.2 Social inclusionSocial inclusion is another important theme of theong>Ecomindsong> evaluation and four measures were usedto assess different elements of social inclusion. All ofthe measures used were developed (or adapted) bythe Centre for Local Economic Strategies (CLES) andnef 135 as part of their ‘Wellbeing evaluation tools’ 136a) Social engagement and supportA social engagement and support measure (takenfrom the Social Wellbeing Module (SWB) of theCLES and nef wellbeing evaluation tool) was usedin the In-depth evaluation. Participants were askedhow much they agreed or disagreed with a seriesof four statements relating to different aspects ofsocial engagement and support. These statementsfrom the SWB are composed of a mix of customisedstatements and together with others adapted from theEuropean Social Survey (ESS) 137 .Responses were scored on a 5 point Likert scalewhere respondents were asked to choose from‘strongly agree’, ‘agree’, ‘neutral’, ‘disagree’ and‘strongly disagree’, for each item and an overallsocial engagement and support score was thencalculated for each respondent (the sum of score foreach question divided by 4). Social engagement andsupport scores therefore range from a minimum of 1to a maximum of 5.b) Neighbourhood belongingA simple question on ‘neighbourhood belonging’allowed participants to give their perception ofhow much they feel they belong to their localneighbourhood or community. This question is takenfrom the ‘Social Wellbeing Depth’ questionnaire fromCLES and nef and was originally adapted from ‘ThePlace Survey’ 138 .Participants were asked both at the beginning andat the end of their involvement with the ong>Ecomindsong>project “How strongly do you feel you belong toyour immediate neighbourhood or community?” andcould respond on a 4 point scale from ‘very strongly’through to ‘not at all strongly’. This measure wasincluded in both the ‘All projects’ and the ‘In-depth’evaluations.129 Biddle 2000; Grove & Prapavessis 1992130 Yeung 1996131 McNair et al. 2003132 Cashel et al. 1996; McNair et al. 1992133 Hansen et al. 2001134 McNair et al. 1992135 www.biglotteryfund.org.uk/research/health-and-well-being/evaluatingwell-being136 Available at: www.biglotteryfund.org.uk/wellbeing_evaluation_tools.pdf137 The European Social Survey is an academically-driven social survey,designed to chart and explain the interaction between Europe’schanging institutions and the attitudes, beliefs and behaviour patternsof its diverse populations. See www.europeansocialsurvey.org/ formore information.138 The Place Survey collects the views of people on a range of issuesconcerning the place they live. Results are used to measure progresson National Indicators in the Local Performance Framework. See http://data.gov.uk/dataset/place_survey


34 ong>Ecomindsong> ong>effectsong> on mental wellbeingc) Neighbourhood satisfactionSimilarly a question rating participant satisfaction withtheir local neighbourhood or community was usedin both the ‘All projects’ and ‘In-depth’ evaluations.Participants were asked “Overall, how satisfiedor dissatisfied are you with your neighbourhoodas a place to live” and could again respond on a 4point scale from ‘very strongly’ through to ‘not at allstrongly’. This question is also taken from the ‘SocialWellbeing Depth’ questionnaire and adapted from ‘ThePlace Survey’.d) Involvement in community activitiesIn order to determine the frequency that participantswere involved in community activities, a question(from the SWB and adapted from ESS) was includedin the ‘In-depth’ evaluation which asked: “How oftenin the last year have you helped with or attendedactivities organised in your local area?” Responseoptions ranged from ‘once a week’ to ‘never’ and alsoincluded an ‘I don’t know’ option.3.6.3 Connection to natureConnection to nature is also one of the main themesof the ong>Ecomindsong> evaluation and was assessed usingtwo measures. One measure is an adapted form of arecognised connectedness to nature measure and theother is a simple scale of nature connection.a) CNS adapted short formA measure for connectedness to nature was includedin the ‘In-depth’ questionnaires. This measure is basedon the standardised and validated Connectednessto Nature Scale (CNS) 139 , which is a ‘measure ofindividuals’ trait levels of feeling emotionally connectedto the natural world’. Connection to nature isconsidered to be an important predictor of ecologicalbehaviour and subjective wellbeing. Connectednessto nature has also been shown to be related toan increase in both awareness of environmentalissues and in environmentally friendly behaviour 140 .A simplified version of the CNS, adapted (but notvalidated) by the University of Essex was used in thiscontext to assess whether being exposed to natureduring involvement in an ong>Ecomindsong> project increasesan individual’s sense of feeling connected to nature.Seven questions are scored on the scale range froma minimum of 1 to a maximum of 5, with a score of 5indicating the most connected to nature. CNS score iscalculated by adding the score for each item and thendividing by 7 to give a score between the minimum of0 and a maximum of 5 (which represents the highestconnectedness to nature). Although there are nopublished norms for this measure, from University ofEssex data, mean scores from a mixed sample of 500UK adults typically vary from 3.62 (SD=.64) at time 1to 3.84 (SD=.60) at Time 2.b) Perceived connection to natureIn the shorter ‘All projects’ questionnaire, as a proxyfor measuring connection to nature, a one-off, simplequestion on ‘connection to nature’ was included toallow participants to give their perception of theirown nature connection status. This simple questionwas devised by University of Essex and has beensuccessfully used by the team in similar greencare evaluation contexts. Participants were askedto complete on a scale of 1 – 10, “how connectedto nature do you feel at the moment?” and askingthe question twice, enabled comparative data to begathered and so any changes in score as a result ofong>Ecomindsong> involvement, to be calculated.3.6.4 Healthy lifestylesHealthy lifestyles was one of the two secondarythemes of the ong>Ecomindsong> evaluation. A mix of fourquestions relating to perceptions of overall ‘health’,the importance of healthy food and healthy eatinghabits were used in this study.a) Perceived health scaleIn the same way, as a proxy for determining positivityand nature connection, a one-off, simple questionon ‘health’ was included in the ‘All projects’ and the‘In-depth’ evaluation to allow participants to give theirperception of their own health status. This simplequestion was again devised by University of Essexand has been successfully used by the team insimilar green care evaluation contexts. Participantswere asked to complete on a scale of 1 – 10, “howhealthy do you feel at the moment?” and by askingthe question both before and after involvement,comparative data was gathered to calculate anychanges in score as a result of ong>Ecomindsong>.b) Healthy eatingQuestions on priorities relating to food perceptionsand eating habits were also included in the ong>Ecomindsong>evaluation. One question used was one from CLES139 Mayer and Frantz 2004140 Hine et al 2007 and 2008a


An evaluation for Mind 35and nef (from the ‘Core tool’), a 5-pointLikert scale asking participants to statehow much they agree or disagree withthe statements: “I enjoy putting effortand care into the food that I eat” and“Healthy food often tastes nicerthan unhealthy food”.Finally, a question was alsoincluded on frequency of eatingfresh cooked meals – i.e. “Howoften do you eat a meal thathas been cooked by yourselfor someone else from basicingredients?” Responses werescored on a 5-point Likert scalewhere respondents were askedto choose from ‘always’, ‘often’,‘sometimes’, ‘rarely’ and ‘never’.3.6.5 Environmental behaviourAnother secondary theme of the ong>Ecomindsong>evaluation was environmentally friendlybehaviour. To assess levels of participantenvironmental behaviour, questions were askedrelating to environmental behaviour indicators forsustainability (from previous University of Essexresearch 141 ). The set of six questions was adaptedfrom the original 14, to account for use with ong>Ecomindsong>participants, referring to practices which are easilyachievable and require little or no cost (e.g. turningoff power at the plug when appliances are not inuse). Responses were scored on a 5 point Likertscale where respondents were asked to choose from‘always’, ‘often’, ‘sometimes’, ‘rarely’ and ‘never’ andoverall behaviour scores were obtained for eachrespondent (the sum of score for each question dividedby 6). Environmental behaviour scores therefore rangefrom a minimum of 1 to a maximum of 5.3.6.6 Other aspects of the questionnaireIn addition to the outcome measures, other questionsincluded those relating to how long participants hadbeen attending the project and their frequency ofattendance. Qualitative narrative was also collected inthe ‘In-depth’ evaluation using an open-ended questionwhere beneficiaries were asked to tell us what theyenjoyed most about the ong>Ecomindsong> project they wereinvolved with. Further anecdotal evidence was gatheredby project staff and ong>Ecomindsong> Grants Officers.A question on the comparative importance ofthe various aspects of the ong>Ecomindsong> project toparticipants composed of three simple scales,developed (and used extensively) by the Universityof Essex, was also included. Participant perceptionson how they felt about being with other people,about being outside in nature and about the exerciseor activities were assessed using the ‘importancescale’, where respondents answer by placing a crosssomewhere on an importance scale of 0-5, where 0is ‘not very important’ and 5 is ‘very important’. Thisquestion was used in both the ‘All projects’ and the‘In-depth’ evaluations.3.7 Statistical analysesQuestionnaires were collated and storedelectronically on a SPSS/PASW 18.0 database toassist in manipulating data, detecting inconsistenciesand statistically analysing the results. All datameasures were tested, where appropriate, fornormality (Kolmogorov–Smirnov test), homogeneity ofvariance (Levene’s test), sphericity (Mauchly’s Test of141 Hine et al 2008a and 2007b


36 ong>Ecomindsong> ong>effectsong> on mental wellbeingSphericity), linearity (visual) and heteroscedasticity.Descriptive statistics were obtained for each measureand mean differences between beginning andendpoint and before and after activity scores wererecorded along with the 95 per cent confidenceinterval for the estimated population mean difference.Statistical significance was set at p < 0.05.A series of one-way analysis of variances (ANOVA)were conducted on major outcome measure startingscores to see if there were any differences betweenthe data from different projects. No significantdifferences were observed so data from projectswere analysed as one group.Analyses used parametric techniquesincluding: i) Paired samples t-test; ii)one-way betweensubjectANOVA(with posthoc Tukeycomparisons where appropriate); iii) one-waywithin-subjects (or repeated measures) ANOVA(with Greenhouse Geisser corrections and posthoc Bonferroni analysis where appropriate); iv)mixed between-within subjects ANOVA (with withGreenhouse Geisser corrections and post hoc Tukey/Bonferroni comparisons where appropriate); v)one -way between subjects multivariate analysis ofvariance MANOVA (with post hoc Bonferroni analysiswhere appropriate); vi) Pearson’s Product MomentCorrelation Coefficient. Where the data were notnormally distributed or did not fulfil the sample sizeand stringent assumptions of parametric techniques,analyses used non-parametric techniques including:i) Mann-Whitney U test; and ii) Wilcoxon Signed-Rank Test (with Bonferroni correction applied whereappropriate). Percentage changes 142 of major variablesover time were calculated and where appropriate,effect size (eta-squared and partial eta-squared 143 ),strength of relationships 144 and shared variances 145were reported.3.8 Organisation of results in this reportThe results in this report have been organisedas follows:• Chapter 4 contains the findings of the ‘All projects’evaluation. Key findings are given first, followedby the participant demographics and details ofthe projects are outlined, before the resultsof both the ‘within group’ and the ‘betweengroups’ studies are organised under the fiveong>Ecomindsong> themes.• Chapter 5 contains the findings of the ‘Indepth’evaluation. Again key findings precedethe participant demographics followed by detailsof the projects included in the study and theiractivities. Finally the changes that have occurredboth over the course of the programme and over theduration of a session are arranged under the fiveong>Ecomindsong> themes.142 [(T2 – T1) / T1] x 100 = %]143 Effect size interpretations for eta squared .01 = small effect, .06moderate effect; and .14 large effect (Cohen 1988)144 Strength of relationship: r=.10 to .29 small; r=.30 to .49 medium; r=.50to 1 large145 “amount of the total variance in the dependent variable that ispredictable form the knowledge of the levels of the independentvariable” (Tabachnick and Fiddell, 2001 p52)


An evaluation for Mind 374. Results: ‘All projects’ evaluation4.1 ‘All projects’ evaluation: Key findings• The ‘All projects’ evaluation was open to all ofthe ong>Ecomindsong> funded projects and 52 projects(54%) returned data to the University of Essexfor analysis. The majority of projects in theevaluation were social and therapeutic horticulturetype projects (26), followed by environmentalconservation (12), nature arts and crafts (9),facilitated green exercise (3) and care farming (2).These numbers were representative of the totalnumbers of projects in each category.• Projects in the evaluation were located all overEngland with the most projects in London, Yorkshireand the Humber, and the South West. Projects inthe evaluation represented all grant size categoriesand size of projects in the evaluation rangedfrom 1-20 beneficiaries (two projects) to over 100beneficiaries (25 projects); those benefitting 21-40people (12 projects), 41-60 (five projects), 61-80 (fiveprojects) and 81-100 (one project).• A total of 515 participants completed questionnairesfor the ‘All projects’ evaluation, made up of 180in the ‘within group’ study and 335 participantsin the ‘between groups’ study. There were moremale participants (66%) than either female (34%)or transgender (


38 ong>Ecomindsong> ong>effectsong> on mental wellbeingpart in the ong>Ecomindsong> scheme regardless of whetherthe projects were using horticulture, farming, greenexercise, nature art or conservation activities; orwhether or not they included formal therapy.4.2 About the ‘All projects’ evaluationThe ‘All projects’ ong>Ecomindsong> evaluation was open toall projects except the nine involved in the ‘in-depth’evaluation, projects which were participating in theirown external evaluations and projects where it wasnot considered ethically appropriate (for examplewhere participants were deemed by project staff to beparticularly vulnerable, too young or too traumatisedand therefore not able to complete questionnaires).The ‘All projects’ ong>Ecomindsong> evaluation comprises twoseparate analyses. Firstly, for those people whocompleted both a start of programme (or Baseline/ Time point 1) questionnaire and then anotherquestionnaire at the end of the programme (or atEndpoint / Time point 2) a direct comparison ofparameters and any changes that have occurred overtime can be made on an individual basis. We havecalled this analysis a ‘within group’ study.Secondly, some participants either completed onequestionnaire at the start of their time at the projector one questionnaire at the end of the projectenabling a comparison of the outcome measuresbetween two different groups of participants (thosewho have just started at a project and those whohave just finished) and any resulting differences to bereported. We have called this part of the analysis a‘between groups’ study.Both of these analyses are reported together in thisresults section under the various themes highlightedbelow, as the findings were very similar. The datafor the ‘within group’ or matched questionnaire studywere normally distributed and so enabled parametricstatistical tests to be carried out on the data;however the data for the ‘between groups’ studywere not normally distributed 146 and so alternativenon-parametric statistics were used. As parametricstatistics are generally considered more robust,these have been reported first in more detail, withadditional data from the non-parametric statisticsreported afterwards.Results from the ‘All projects’ evaluation have beenorganised under the following themes:• About the participants• About the projects• Mental wellbeing• Social inclusion• Connection to nature• Healthy lifestyles4.3 About the participantsA total of 515 participants completed questionnairesfor the ‘All projects’ evaluation, made up of 180 inthe ‘within group’ study and 335 participants inthe ‘between groups’ study (where 44 per cent ofparticipants completed questionnaires at the startand 56 per cent at the end of the programme).There were more male participants (66%) that tookpart in the evaluation than either female (34%) ortransgender (


An evaluation for Mind 39Table 1. Ethnicity of respondents in the‘All projects’ ong>Ecomindsong> evaluationEthnic group Per cent %White British 84.4White Irish 1.8White other 3.3Asian Indian 1.2Asian Pakistani .4Asian Bangladeshi .2Asian other .4Chinese .4Black Caribbean 1.9Black African 1.4Black other .6Mixed White and Black Caribbean .8Mixed White and Black African .6Mixed White and Asian .4Mixed other .6Any other 1.4Rather not say .4The length of time participants had been attendingthe projects varied from 1-208 weeks (i.e. one weekto four years; some participants for even longer).The baseline or start of project questionnaire wasgenerally completed between 1-4 weeks of theparticipant’s involvement with the project and theendpoint questionnaire was filled out any time afterfive weeks, depending on the structure and timing ofthe particular project. However, for the majority ofrespondents (90%) this was after one year or less.4.4 About the projectsThe ‘All projects’ evaluation was open to all projectsnot including the nine involved in the ‘in-depth’evaluation and the two being evaluated by CLES andnef as part of the Big Lottery Fund National WellbeingEvaluation. Projects which were participating inadditional external evaluations (22) were also notexpected to take part in the University of Essexevaluation, to avoid project participants sufferingfrom ‘questionnaire fatigue’. Out of the remaining97 projects, 52 projects (54%) returned data to theUniversity of Essex for analysis.Figure 5. Number and type of ong>Ecomindsong> projects in total andinvloved in the ‘All projects’ evaluationNumber of projects80706050403020101Facilitated Care farming STHGreen exerciseProject typeThe majority of projects in the evaluation weresocial and therapeutic horticulture type projects (26),followed by environmental conservation (12), naturearts and crafts (9), facilitated green exercise (3) andcare farming (2). These numbers were representativeof the total numbers of projects in each category (seeFigure 5).Only one of the projects involved in the ‘All projects’evaluation included formal ‘therapy’ (i.e. counsellingsessions, CBT etc provided by qualified mentalhealth practitioner) as part of its programme. This isrepresentative of the ong>Ecomindsong> scheme as a whole, asalthough the majority (96%) of the projects are mentalhealth interventions and are developed, delivered andmanaged by staff who are qualified mental healthpractitioners, they provide more of a ‘therapeutic’nature-based intervention rather than formal ‘therapy’(e.g. counselling, CMT, psychotherapy sessions etc.) inan outdoor environment.Table 2. Location of projects in ‘All projects’evaluation.RegionEnvironmentalconservationIn evaluationIn totalNature artsand craftsNumber of projectsYorkshire and the Humber 10North West 2North East 2West Midlands 3East Midlands 3South West 10South East 5London 11East 5South 1


40 ong>Ecomindsong> ong>effectsong> on mental wellbeingin the evaluation were located all over England withthe most projects in London, Yorkshire and theHumber, and the South West. Numbers per regionare shown in Table 2. Projects in the evaluationrepresented all grant size categories: includingflagship projects (1), large (14), medium (9) and small(28). In terms of numbers of beneficiaries, projects inthe evaluation ranged from 1-20 beneficiaries (3) toover 100 beneficiaries (25); those benefitting 21-40people (12), 41-60 (5), 61-80 (5) and 81-100 (1).4.5 Mental wellbeing findings4.5.1 Perceived positivityThe one-off, simple question on ‘positivity’ allowedparticipants to give their perception of their ownpositivity or happiness status. Participants were askedto complete on a scale of 1 – 10, “how positive do youfeel at the moment?” both at the beginning and at theend of their involvement with the ong>Ecomindsong> project.Analyses on the data for both the within groupand the between groups study showed similarresults. For the within group study, a paired T testrevealed a statistically significant increase (p.05) 151 meaning that that gender did not affect orpredict the amount of increase in positivity scores,but there were significant main ong>effectsong> for bothtime 152 (p


An evaluation for Mind 41Figure 7. Changes in proportion of participants in eachneighbourhood belonging catergory after participation in ong>Ecomindsong>Figure 8. Change in mean importance of other peoples scoresafter participation in ong>Ecomindsong>Percentage of participants (%)50454035302520151050Beginning of programmeEnd of programmeVery strongly Fairly strongly Not very strongly Not at all stronglyDegree of neighbourhood belongingMean importance score54321Significance tested with a 2-tailed T test (p


42 ong>Ecomindsong> ong>effectsong> on mental wellbeing4.7 Connection to nature findingsMeasures of connection to nature in the ‘Allparticipants’ ong>Ecomindsong> evaluation, consisted of twoscales, one on connection to nature and one on theimportance of being outside in nature.Figure 9. Change in mean perceived connection to nature scoresafter participation in ong>Ecomindsong>Perceived connection to nature score10987654321Represents increase in positivity of 1.09 tested with a 2-tailedT test (p


An evaluation for Mind 43The between groups data shows a very slightdecrease in mean scores of those participantscompleting questionnaires at the end of theirinvolvement with ong>Ecomindsong> (M=3.50 ± 1.01) comparedto those people who filled out questionnaires atthe start of the programme (M=3.60 ± .94) but thischange was not found to be statistically significant(p=.53). There were also no statistical differencesin nature importance scores between the differentgenders and age groups.4.8 Healthy lifestyles findingsMeasures of healthy lifestyles in the ‘All participants’ong>Ecomindsong> evaluation, consisted of three scales, one onperceived health, one on the importance of exerciseand one on the importance of eating healthy food.4.8.1 Perceived healthParticipants were asked to complete on a scale of1 – 10, “how healthy do you feel at the moment?” andby asking the question both at the beginning and endof the ong>Ecomindsong> scheme, comparative data was gathered to calculate any changes in score.Figure 11. Change in mean helath perception score afterparticipation in ong>Ecomindsong>Perceived health score10987654321Represents an increase in health of .95 tested with a 2-tailedT test (p


44 ong>Ecomindsong> ong>effectsong> on mental wellbeing4.8.2 Importance of exerciseParticipants were asked to gauge “how importantis taking part in exercise to you [at the moment]?”by placing a cross somewhere on an importancescale of 0-5, where 0 is ‘not very important’ and5 represents ‘very important’. Although the meanimportance of exercise scores slightly increased fromthe beginning (M=3.30 ±1.11) to the end (M=3.74 ±3.13)of the ong>Ecomindsong> scheme, this finding was not found tobe statistically significant for either the within groupstudy 171 or for the between groups study 172 . Howevera little over half of the ong>Ecomindsong> participants (53%)did experience an increase in exercise importancescores (Figure 13). No statistical differences betweengenders and ages were found.4.8.3 Importance of healthy foodParticipants were then asked “how important is eatinghealthy food to you?” and answered by placing a crosssomewhere on an importance scale of 0-5, where 0 is‘not very important’ and 5 is ‘very important’.For both the within group 173 and the between groupsstudy 174 , the mean importance of eating healthy foodscores slightly increased from the start to the end of theong>Ecomindsong> scheme, but these findings were not found tobe statistically significant. Again, no statistical differencesbetween genders and ages were found either.However, the majority (50%) of participants in thewithin group study experienced an increase inimportance of eating healthy food scores (Figure 14).Figure 13. Proportion of participants experiencing change inimportance of exercise scores after ong>Ecomindsong>29%18%53%Increased Stayed the same DecreasedFigure 14. Proportion of participants experiencing change inimportance of eating healthy food scores after ong>Ecomindsong>29%53%18%Increased Stayed the same Decreased171 [t(179) =-1.841, P>.05]172 Data showed no real change in mean scores of those participantscompleting questionnaires at the end of their involvement withong>Ecomindsong> (M=3.37 ± 1.04) compared to those people who filled outquestionnaires at the start of the programme (M=3.45 ± 1.06; p=.45)173 [Start (M=3.31 ±1.18); End (M=3.44 ±1.08); t(179) =-1.593, P>.05]174 [Start (M=3.50 ± 1.09); End (M=3.51 ± 1.09); p=.93]


An evaluation for Mind 454.9 Comparative importance of aspectsof the ong>Ecomindsong> scheme.Increases in score were observed from the beginningto the end of the ong>Ecomindsong> scheme for three out ofthe four ‘importance’ scores: importance of being withother people, importance of being outside in natureand importance of the exercise or activities. However,the importance of eating healthy food scoresremained roughly constant, as shown in Figure 15.4.10 Other findingsFor the three scales for self-perceived i) positivity, ii)connection to nature and iii) health, similar startingscores and increases over time were found (Figure 16).To assess the impact of type of project (i.e. carefarm, STH, environmental conservation project; andwhether the project had a ‘formal therapy’ elementor not) on participant health scores between the startand the end of the ong>Ecomindsong> scheme a series ofmixed between-within subjects analysis of variance(ANOVA) were conducted on the main variables.None of these analyses were statistically significant,suggesting that project typology did not affect thefindings and all types of projects saw similar positiveoutcomes, regardless of whether they were usinghorticulture, farming, green exercise or conservationactivities or whether they incorporated a formaltherapy element into their programmes or not.Figure 15. Comparative changes of 4 importance scores overthe ong>Ecomindsong> programmeImportance scoreScale score5 Beginning of programme4.5End of programme43.532.521.5109876543211Being withother peopleBeing outsidein natureThe exerciseor activitiesImportance of...HealthyeatingFigure 16. Comparative changes between the 3 perceptionscales: Positivity, Nature connection and Health over theong>Ecomindsong> programmeBeginning of programmeEnd of programmePositivity Nature connection HealthScale


46 ong>Ecomindsong> ong>effectsong> on mental wellbeing5. Results: ‘In-depth’ evaluation5.1 ‘In-depth’ evaluation: Key findings• Nine projects took part in the ‘In-depth’ evaluationrepresenting a mixture of project types (socialand therapeutic horticulture, care farming andenvironmental conservation); projects that includedformal therapy and those that did not; projectsfrom all of the geographic regions and projectsof different sizes. In total, 287 people with mentalhealth problems took part in the ‘In- depth’evaluation conducted by the University of Essex,the majority of which were male (69%) and ‘WhiteBritish’ (93%). Ages of respondents ranged from 14to 78 years of age, with an average age of 36.• Mental wellbeing: In the In-depth study, threestandardised, internationally recognised instrumentswere used to measure different elements of mentalwellbeing. For the majority of participants boththeir wellbeing and self esteem scores showed astatistically significant increase from the beginningto the end of their involvement with ong>Ecomindsong>,indicating an improvement in participant wellbeingover the duration of the ong>Ecomindsong> scheme (onaverage a participant experienced increases inwellbeing of 17 per cent and of self esteem of11 per cent). At the start of the programme themean wellbeing scores for ong>Ecomindsong> participantswere lower than average; but by the end of theprogramme, participant scores had risen to a levelin line with the population norm.• The majority of participants also experienced selfesteem (55%) and mood (76%) improvementsafter a single ong>Ecomindsong> session, with participantsexperiencing statistically significant increases in selfesteem and decreases in total mood disturbance,anger, confusion, depression and tension aftertaking part in an ong>Ecomindsong> session. Age and projecttype did not significantly alter mood scores, butthere was a statistically significant difference inmood scores between the genders, in that womenhad significantly lower scores than men, signifyingbetter overall mood.• Social inclusion: Four different measures wereused to assess various elements of social inclusionover the course of the ong>Ecomindsong> scheme. Findingsof the ‘In-depth’ study showed a statisticallysignificant increase in most (57%) participants’social engagement and support scores from thebeginning to the end of their involvement withong>Ecomindsong>, representing an improvement in socialengagement of 10 per cent (on average), althoughsome people experienced improvements of up to89 per cent. At the start of the programme, manyparticipants said that they did not feel they belongedto their community but by the end of the ong>Ecomindsong>scheme, the opposite was true, with the majority(59%) saying that they did feel they belongedto their immediate community – representingan improvement of social inclusion for manyparticipants. Similarly, more people felt ‘satisfied’ or‘extremely satisfied’ at the end of their involvementwith the ong>Ecomindsong> scheme than they did at thebeginning. When participants were asked howmany times in the last year they had helped withor attended activities organised in their local area,81 per cent showed an increase in the frequency ofgetting involved in community activities after beinginvolved with the ong>Ecomindsong> scheme.• Connection to nature: An adapted form of theConnectedness to Nature Scale was used in the‘In-depth’ evaluation to detect changes in natureconnection over the course of the ong>Ecomindsong>scheme. Again, statistically significant increases inparticipant connection to nature were found fromthe start to the end of the programme (for 61 percent of people) implying that these participants hadbecome more connected to nature over the durationof the ong>Ecomindsong> scheme. There was also a weakpositive correlation between age and connectionto nature in this study, showing that connection tonature increased slightly with participant age.• Healthy lifestyles: Using a mix of four questionsrelating to: perceptions of overall ‘health’; theimportance of healthy food; and healthy eatinghabits, elements of healthy lifestyles wereassessed. Statistically significant increases inparticipant self-perceived ‘health’ status wereobserved both over the duration of the ong>Ecomindsong>scheme (where 59 per cent of participants sawimprovements in health of on average 31 per cent)and after taking part in one session. The majorityof participants already either ‘agreed’ or ‘stronglyagreed’ with the statements “I enjoy putting effortand care into the food that I eat” (68%) and “Healthy


An evaluation for Mind 47food often tastes nicer than unhealthy food” (66%)at the beginning of the programme so althoughvery slight increases were seen over the ong>Ecomindsong>scheme these were not statistically significant.There were however changes in agreement withthe first statement “I enjoy putting effort and careinto the food that I eat” where more people agreedand less people disagreed with the statement at theend of the programme than at the beginning.• Environmentally friendly behaviours: In the ‘Indepth’evaluation, in order to assess any changesin participant behaviour as a result of taking partin the ong>Ecomindsong> scheme, six questions relating toenvironmentally friendly practices were included.Starting responses indicated that the majority ofparticipants usually ‘often’ or ‘always’ recycle;buy energy saving light bulbs; turn off the powerat the plug; and turn off the tap when cleaningtheir teeth anyway, suggesting a reasonablyenvironmentally pro-active group at the beginningof the programme. Nevertheless, slight increaseswere seen in four out of the six individual behaviourscores (recycling, buying energy saving light bulbs,turning off the tap and feeding wildlife) as a resultof participating in the ong>Ecomindsong> scheme, whilst theremaining two (turning off power at the plug andbuying local or organic food) remained constant.However, only the change in recycling glass, paperor metal was found to be statistically significant. Interms of total environmentally friendly behaviour,a statistically significant increase in overall scoreswas found from the start to the end of the ong>Ecomindsong>scheme for 60 per cent of beneficiaries, showing anincrease in environmentally friendly practices.• The importance of the three key aspects of theong>Ecomindsong> scheme: i) being with other people,ii) being outside in nature and iii) taking part inexercise or activities; were assessed using asimple ‘importance scale’. The importance of allthree aspects were shown to be of roughly equalimportance to participants, both at the end of theong>Ecomindsong> scheme as a whole and after taking partin a single session, which suggests that participantsvalue the combination of the three aspects of theong>Ecomindsong> projects, rather than one particular feature.• Improvements in all the major variables (wellbeing,social inclusion, connection to nature, healthylifestyles and environmentally friendly behaviour)were regardless of: i) whether the participantsattended a care farm, a STH or an environmentalconservation project; ii) whether they were male,female or transgender; iii) whether they were under30 or over 30 or iv) whether or not the projectincluded formal therapy. This suggests that althoughthe 130 ong>Ecomindsong> projects differed in context andcontent and delivery, similar benefits to participantwellbeing, social inclusion, nature connection,healthy lifestyles and environmental behaviouroccur for all the nature-based projects evaluated.• Participants also told us in their own words aboutwhat they enjoyed the most about the ong>Ecomindsong>project that they were involved with. Out of the 113comments received, three major themes emerged i)the social contact - being with other people as partof a group; ii) being outside in nature - the fresh air,the scenery and the beauty; and iii) the activities– learning new skills, enjoying the activities. Manyother comments expressed how people felt calmand safe outside, had fun, liked being active and felta sense of achievement.5.2 About the ‘In-depth’ evaluationThe ‘In-depth’ ong>Ecomindsong> evaluation is composed ofdifferent research elements. Firstly, participants havecompleted questionnaires at the beginning and at theend of their involvement with ong>Ecomindsong>, enabling ananalysis of any changes in outcome measures ona longitudinal basis (commonly known as changesin ‘trait’) as a result of the ong>Ecomindsong> programme.In addition, participants also completed a series ofslightly different questionnaires immediately beforeand after taking part in an ong>Ecomindsong> session toenable analysis of any changes in the outcomemeasures over a much shorter period of time(commonly known as changes in ‘state’). Finally,several of the outcome measures were repeated notonly in the beginning and end questionnaires but alsoin the pre and post activity questionnaires, enablingan analysis of outcome measures at regular intervalsthroughout the programme.All three of these elements of the analysis arereported together in this results section, organisedunder the following themes:• About the projects, participants and activities• Mental wellbeing• Social inclusion• Connection to nature• Healthy lifestyle• Environmental behaviours


48 ong>Ecomindsong> ong>effectsong> on mental wellbeing5.3 About the projects, participants andactivitiesThis section contains details on the projects that tookpart in the In-depth evaluation, the participants whowere involved, the type of activities undertaken, thelength of sessions and time spent at the project.5.3.1 The projects in the evaluationNine projects took part in the ‘In-depth’ evaluation.The aim was to provide a representative sample ofong>Ecomindsong> projects to include:a) all types of project, i.e. a mix of care farming,social and therapeutic horticulture, environmentalconservation, facilitated green exercise and natureart and crafts projects;b) projects that both included formal therapy andthose that did not;c) projects from all of the geographic regions;d) a range of project sizes (in terms of number ofbeneficiaries); ande) a variety of different grant sizes.As with any programme of this type, where anevaluation takes place over a number of years,degrees of ‘buy-in’ to the evaluation will varybetween projects and some level of drop-out is tobe expected as changes in project staffing, skills orresources occur over the duration of the programme.As a result, although the variety in geographicalregion, project size and grant size is represented,neither a project specified as predominantly facilitatedgreen exercise nor as nature arts and crafts isincluded in the ‘In depth’ evaluation. However, dueto the flexible approach of ecotherapy, many of theprojects included do actually incorporate elementsof facilitated green exercise or nature arts andcrafts. Only one of the projects involved in the ‘Indepth’evaluation included formal ‘therapy’ as partof its programme and the other eight projects are‘therapeutic’ nature-based interventions (which isrepresentative of the ong>Ecomindsong> programme as awhole). More details of the projects included in thisevaluation can be seen in Table 3 and in Chapter 7.Table 3. Name, type, size and location of projects in the ‘In-depth’ evaluationName of projectGrow ItType of projectSocial and TherapeuticHorticultureNumber ofbeneficiariesGrant SizeRegion100+ Large East MidlandsGrow2Grow Care farming 21-40 Flagship South EastGrowing Clearer MindsSocial and TherapeuticHorticulture100+ Small EastGrowing Well Care Farming 100+ Large North WestSeed to SucceedSocial and TherapeuticHorticulture1-20 Small LondonSpring to Life Environmental Conservation 100+ Large South WestThe Outdoor Club Environmental Conservation 21-40 Small South WestWellbeing comes naturally(Sheffield and Bedford)The Wildwoodong>Ecomindsong> ProjectEnvironmental Conservation 100+ Flagship NationwideEnvironmental Conservation 100+ Large South East


An evaluation for Mind 495.3.2 ParticipantsIn total, 287 people with mental health problems tookpart in the ‘In-depth’ evaluation conducted by theUniversity of Essex. The majority of these participantswere male (69%), 31 per cent were female and


50 ong>Ecomindsong> ong>effectsong> on mental wellbeingFigure 18. Frequency of attending ong>Ecomindsong> projectFrequency of attending3 or 4 times aweek or moreTwice a weekOnce a weekOnce a fortnightOnce every6 monthsOnce a yearor less0 10 20 30 40 50 60Percentage of participants %period and others offering sessions for participants foras long as they wanted to attend. However in this studythe duration varied from eight weeks to four years withan average length of time that participants had beenattending being six months (26 weeks).Activities for beneficiariesA variety of different activities were undertaken in theong>Ecomindsong> projects evaluated in this ‘In depth’ study,ranging from gardening activities and conservationwork to fire making and canoeing. Many projectsalso included cooking activities using the produceparticipants had grown and then the group ate thefood they had prepared. Other activities mentionedby respondents have been categorised by the threetypes of projects involved in the evaluation: carefarming, Social and Therapeutic Horticulture (STH)and environmental conservation projects (Table 5).


An evaluation for Mind 51Table 5. Examples of ong>Ecomindsong> project activities, as described by participants.Examples of care farming activities undertaken (in participants’ own words):• Planted onions, did the checklist• Saw the cows• Had something to eat• Planting onion sets, watering everything• Mowing• Watering plants• Seed sowing• Digging• I lawn mowered the grass• Collected some wood• Shovelling compost• Hoeing and weeding• Picking salad leaves• Weighing, sealing and labelling salad bagsto compute order• Looked around the farm at the machineryExamples of STH activities undertaken (in participants’ own words):• Sowing onion seeds and broad beans• Made some fresh pasta and pasta salad• Looking round Harlow Carr gardens• Christmas wreath making• We spent the day on the farm. Firstly we madehome-made pasta in the kitchen with flour, egg,oil and rolled with two rolling pins. Then we madefresh salad in a metal tub for dinner. After dinnerwe were escorted around the project. I saw a roofgarden and a combine harvester worth £250K andstaff showed us different crops grown• Looked at flowers in the field• Laid a stone path and some digging• Weed collecting, raking, spreading chitter• Digging, weeding• Tried pushing a massive fallen tree• Today we are displaying the finished sculpture fordisplay in the woodland setting- Willow sculptures• Bird box making, bird watching• Stone and rubbish collecting• Laid stone, went to shop• Digging• Filling barrow with stones from the fieldExamples of environmental conservation activities undertaken (in participants’ own words):• Chopping down trees, collecting tree waste,chipping tree waste• Cleared plots• Cleared some weeds from raised bed, pickedvegetables• Cut grass along edges of plots, weeded raisedbeds, added vegetation to compost, planted seeds• De-turfing, digging, bagging and watering trees• Planting vegetable seeds• Adding grass to compost container• Dry stone wall reconstruction/rebuilding work• Finished off wooden box and done someglasswork art• Group activities and cooking• I etched and engraved glass to make a usefulsculpture. I also finished my jewellery box andcontinued my spoon• Mixing with other people, willow wearing andbog pond• Organic food growing, harvesting, weeding• Raking vegetation and clearing bracken• Sanded and painted a didgeridoo• Started a fire, prepared shelter and made a tripodfor the billy can• Canoeing• Making fire• Clearing vegetation from allotment plots, pickedvegetables, dug out weeds around wildlife area• Wheel-barrowing to skip• Digging over soil, digging in top soil• Helped design and plan for a wooden structureat the pit• Made own pizza in pizza oven outdoors andtalked to everyone. Watched how to weave hazelto make a fence• Made tea for the whole group, gathered firewoodfor the tea making job• Was given my own plot, spent time weeding andplanning for the future• Taking woodchip from main pile and filling it inaround plots. General gardening and harvestinglettuce• Painted a wooden recycled seat• We built a shelter for six people using a lean tomethod and a trap; we prepared a kitchen areaand two fires, one a kitchen fire and one a groupfire. We created a toilet area• Preparing flower beds


52 ong>Ecomindsong> ong>effectsong> on mental wellbeing5.4 Mental wellbeingMental wellbeing is the main theme for the ong>Ecomindsong>evaluation. In the In-depth study, three standardised,internationally recognised instruments were used inthe evaluation to measure different elements of mentalwellbeing. Firstly, the Warwick Edinburgh MentalWellbeing Scale (WEMWBS) and Rosenberg SelfEsteem (RSE) scales were used to measure changes inparticipant wellbeing and self-esteem over the durationof the ong>Ecomindsong> programme – i.e. by comparingoutcome measures at the beginning and at the end ofthe programme. Secondly, the Profile of Mood States(POMS) (used to measure participant mood) and theRSE were used to measure changes in mood and selfesteemover the course of a session at an ong>Ecomindsong>project – i.e. by comparing outcomes before and aftera typical session. Thirdly, where self-esteem had beenmeasured at intervals over a period of time, longitudinaltrends over the programme could also be observed.5.4.1 Wellbeing - WEMWBSChanges over the ong>Ecomindsong> schemeParticipant WEMWBS scores showed a statisticallysignificant increase from the start (M=44.14 ±10.22) tothe end (M=49.43 ±9.81) of the participant involvementwith ong>Ecomindsong>, when tested with a paired samplest-test (p


An evaluation for Mind 535.4.2 Self-esteem - RSESChanges over the ong>Ecomindsong> schemeWhen self-esteem scores were tested using a pairedsamplest test, results showed a statistically significantincrease from the start of a participant’s involvementwith ong>Ecomindsong> (M=25.48 ±4.26) to the end (M=27.71±4.54, p


54 ong>Ecomindsong> ong>effectsong> on mental wellbeing5.4.3 Mood - POMSChanges after an ong>Ecomindsong> sessionThe Profile of Mood States (POMS) was used in thepre and post session study only. When looking at theoverall measure for Total Mood Disturbance (TMD), apaired samples t test showed a statistically significantdecrease in participant TMD scores (representing animprovement in mood) from before (M=145.11, ± 22.49)to after the ong>Ecomindsong> session (M=135.35, ±18.87,p


An evaluation for Mind 55Vigour scores increased 191 after the ong>Ecomindsong> sessionindicating that although participants may well have beentired, their energy levels still increased as a result of theactivities. Changes in mean scores are shown in Figure25 and mean and median scores from all subfactorsat both time points together with mean percentagechanges can be found in Table 6. The majority ofparticipants (60-71%) experienced decreases in tensionand confusion and increases in vigour.Figure 25. Change in POMS subfactors after participatingin an ong>Ecomindsong> sessionPOMS subfactor score5045403530Significance tested with a one-way betweengroups MANOVA (*p


56 ong>Ecomindsong> ong>effectsong> on mental wellbeing5.4.5 Other mental wellbeing findingsThe three mental wellbeing measures correlatedwell, both in terms of actual scores and percentagechanges with a strong positive correlation betweenWEMWBS and RSES (51% shared variance) andmedium negative correlations for TMD with WEMWBS(15% shared variance) and with RSES (10% sharedvariance). This implies that all the wellbeing measuresshow the same improvement trends over the courseof the programme with self-esteem and wellbeingboth increasing as mood disturbance decreases.Correlation results for the three wellbeing variablesand subfactors are shown in Table 7.Table 7. Correlation matrix for mental wellbeing measures (based on percentage changefrom Time 1 to Time 2)WEMWBS 1.0WEMWBS RSES TMDRSES .714 ** 1.0TMD -.385 * -.315 ** 1.0Anger -.344 * -.444 ** .680 **Confusion -.391 * -.384 ** .723 **Depression -.409 * -.346 ** .564 **Fatigue -.394 * -.159 .641 **Tension -.464 ** -.396 ** .579 **Vigour .314 .161 - .496 **Notes: r values are reported. **. Correlation is significant at the 0.01 level (2-tailed). *. Correlation is significant at the 0.05 level (2-tailed).5.4.6 Comments from participants – Mental wellbeing 5.5 Social inclusion findingsWhat participants enjoyed most – Mental wellbeingCalming and therapeutic activity.Chilling out.Talking and learning.Working with a group and finding direction.Doing something I haven’t tried before.Getting outside, being free.Learning a new thing that I have neverdone before. I really enjoy doing it.Social inclusion is one of the key themes of theong>Ecomindsong> evaluation and in the ‘In-depth’ study, fivemeasures were used to assess different elements ofsocial inclusion:• Social engagement and support• Neighbourhood belonging• Neighbourhood satisfaction• Involvement in community activities• Importance of being with other peopleAll five of these measures were used to assesschanges in participant social inclusion over theduration of the ong>Ecomindsong> programme (i.e. bycomparing outcome measures at the beginning and atthe end of the programme).


An evaluation for Mind 575.5.1 Social engagement and supportParticipants were asked how much they agreed ordisagreed with a series of four statements relating todifferent aspects of social engagement and support.Responses were scored on a 5-point Likert scalewhere respondents were asked to choose from‘strongly agree’, ‘agree’, ‘neutral’, ‘disagree’ and‘strongly disagree’ and an overall total engagementand support score was then calculated.To determine if there were statistically significantchanges in mean scores for each statement, a seriesof Wilcoxon Signed Rank Tests were performed 194 . Astatistically significant increase in participants feelingthat they have people who care about them (p


58 ong>Ecomindsong> ong>effectsong> on mental wellbeingIn terms of overall total social engagement and supportscores, a paired samples t test showed a statisticallysignificant increase in participant social engagementand support scores from the start (M=13.64, ± 2.47) tothe end of ong>Ecomindsong> scheme (M=14.72, ±2.29, p


An evaluation for Mind 595.5.4 Community involvementWhen participants were asked how many times in thelast year they had helped with or attended activitiesorganised in your local area, the majority of them(81%) showed an increase in the frequency of gettinginvolved in other community activities 199 after beinginvolved with the ong>Ecomindsong> scheme (Figure 31).Figure 31. Changes in frequency of participant involvement incommunity activities as a result of the ong>Ecomindsong> programmePercentage of participants (%)100806040200At leastonce aweekAt leastonce amonthAt leastonce every3 monthsAt leastonce every6 monthsBeginning of programmeEnd of programmeLessoftenNever5.5.5 Effect of project type, participant gender andage on social inclusionEither a series of mixed between-within subjectsanalysis of variance – ANOVA (where the data wereparametric); or a series of Wilcoxon Signed-Rank Testson a split data file (when the data were non parametric)were conducted to assess the impact of project type,participant gender and participant age on the socialengagement and support, community belonging andneighbourhood satisfaction scores between the startand the end of the ong>Ecomindsong> scheme. There was asignificant increase in social engagement and supportscores after taking part in ong>Ecomindsong> regardless of: i)whether the participants attended a care farm, a STHor an environmental conservation project; ii) whetheror not the project had a ‘formal therapy’ element; iii)whether they were male, female or transgender; oriii) whether they were under 30 or over 30. As withwellbeing findings, there were no significant differencesin social engagement and support, community belongingof neighbourhood satisfaction scores between thedifferent project types, different genders or differentage groups and no interaction ong>effectsong> and so it can beconcluded that none of these factors affected levels ofthe social inclusion measures used or the amount ofchange in scores between the start and the end of theprogramme. This suggests that all observed changeswere due to taking part in the ong>Ecomindsong> scheme.5.5.6 Comments from participants – Social inclusion5.6 Connection to nature findingsConnection to nature is another main theme ofthe ong>Ecomindsong> evaluation and was assessed in theWhat participants enjoyed most – Social inclusionMixing with people, getting on the job,working with a group and taking direction.Being out in scenic surroundings and theteamwork aspect of the task.Sense of satisfaction upon completionof the project.The company of our group in the fine weather.Chatting with friends.Working as a team, the company and food.Sleeping under the stars.Looking what other allotments have beendoing, meeting people.Chatting to other women.Meeting new people, chatting and gettingto know the place.Made close friends…Meeting fellow students/tutors. We want it tobe a celebration day and the sun has come out.The overall meeting up of people. Helpfuland friendly staff, teamwork.‘In-depth’ evaluation with an adapted form of theConnectedness to Nature Scale. This measure wasused both to detect changes over the course of theong>Ecomindsong> scheme and also to examine changes as aresult of one ong>Ecomindsong> session.5.6.1 Connection to Nature Scale (CNS) adaptedshort formChanges over the ong>Ecomindsong> schemeA paired samples t test showed a statistically significantincrease in participant connection to nature from thestart (M=3.66, ± .49) to the end of the ong>Ecomindsong> scheme199 i.e. in addition to ong>Ecomindsong>


60 ong>Ecomindsong> ong>effectsong> on mental wellbeing(M=3.86, ±.48, p


An evaluation for Mind 61conservation project; ii) whether or not the projecthad a ‘formal therapy’ element; iii) whether theywere male, female or transgender; or iii) whetherthey were under 30 or over 30. There were nosignificant differences in connection to nature scoresbetween the different project types, different gendersor different age groups and no interaction ong>effectsong>and therefore none of these factors affected levelsof connection or the amount of change in scoresbetween the start and the end of the programme.There was however a weak positive correlationbetween age and connection to nature at both timepoints: beginning of programme (r=.231, p=.001, 5 percent shared variance); and end of programme (r=.250,p=.02, 6 per cent shared variance) when tested usinga Pearson’s Product Moment Correlation Coefficient,implying that connection to nature increased slightlywith age in this study.5.6.3 Comments from participants – Nature5.7 Healthy lifestyles findingsWhat participants enjoyed most – NatureBeing out in scenic surroundings and theteamwork aspect of the task.The scenery whilst canoeing downthe river Dart.Being close to nature and interacting socially.Sleeping out in the woods, the company,food and teamwork.Being in the sunshine.Being involved in group activities, beingat one with nature seeing signs of animalactivities i.e. deer and badger, being with newfriends and leaving without a trace.I enjoyed being round the different cropsgrown out in the fields, such as barley andoats and plants that attract bees, learningwhat the crops look like.‘Healthy lifestyles’ was one of the two secondarythemes of the ong>Ecomindsong> evaluation. A mix of fourquestions relating to perceptions of overall ‘health’,the importance of healthy food and healthy eatinghabits were used in the ‘In-depth’ study.Perceived healthParticipants were asked to complete on a scale of 1 –10, “how healthy do you feel at the moment?” and byasking the question both at the beginning and end ofthe ong>Ecomindsong> scheme and pre and post session, anychanges in score can be calculated.Changes over the ong>Ecomindsong> schemeA paired samples t test showed a statisticallysignificant increase in participant ‘health’ scores fromthe start (M=6.05, ± 2.13) to the end of the ong>Ecomindsong>scheme (M=7.02, ±1.82, p


62 ong>Ecomindsong> ong>effectsong> on mental wellbeingthe programme (M= 7.24 ±1.73, p= .003) as shown inFigure 33. This implies an improvement in participanthealth over the course of the ong>Ecomindsong> scheme.Figure 33. Changes in health at 3 times points acrossong>Ecomindsong> programmeMean health score10987654321Beginning ofprogrammeSiginificance tested with a repeated measuresAnova (p


An evaluation for Mind 63Box 4. Example of healthy eatingoutcome from an In-depth evaluationproject.Participants were also asked how often they would “Eata meal that has been cooked by yourself or someoneelse from basic ingredients” and could answer ‘always’through to ‘never’ on a 5 point Likert scale. Howeverno significant changes in this parameter were observedover the duration of the ong>Ecomindsong> scheme and meanvalues were 3.8 for both time points.5.7.4 Comments from participants – HealthWhat participants enjoyed most – Health‘Growing fruit and veg in small spaces’ and‘Growing people’ are both initiatives from oneof the projects in the ‘In-depth’ evaluation –Growing Clearer Minds. Over the summermonths, each member of the group wasallocated a metre plot of allotment to dig, plantand harvest. The produce was so abundantthat project participants and staff decided toswap recipes and extend their culinary skills,enjoying the food they had grown by cookingit creatively. As a result of this growing,cooking and sharing, a recipe book has beendeveloped for sale, with all proceeds beingused entirely to help fund the Growing forClearer Minds Programme which as wellas Growing Fruit & Veg, includes WillowSculpture, Garden Mosaics and Caring forPotted Plants.For more information see:www.mindinmidherts.org.uk/page65.htmlThe air and exercise.The open air and company.Good exercise and teamwork.The fresh air, skimming stones and singing.Weather was nice, general gardening,had scones and damson jam made by avolunteer from damsons picked from a treeat the allotment.The exercise and also the fire tendingand cooking on the fire.Being out in the fresh air.I enjoyed spending the day in the countryin the summer sun, eating fresh saladgrown from the project for dinner, suchas radish, very tasty!….5.8 Environmentally friendly behaviourfindingsAnother secondary theme of the evaluation wasenvironmentally friendly behaviour. Six questionsrelating to various environmentally friendly behaviourswere asked at the beginning and at the end of theong>Ecomindsong> scheme to discern if there had been anychanges in participant behaviour as a result of takingpart in the programme.5.8.1 Environmentally friendly behavioursWhen the frequency of environmentally friendlybehaviours was examined, the starting responsesindicate that the majority of participants usually oftenor always recycle; buy energy saving light bulbs; turnoff the power at the plug; and turn off the tap whencleaning their teeth anyway, suggesting a reasonably


64 ong>Ecomindsong> ong>effectsong> on mental wellbeingenvironmentally pro-active group in the first place.Nevertheless, slight increases were seen in 4 out of the6 individual behaviour scores (recycling, buying energysaving light bulbs, turning off the tap and feeding wildlife)as a result of participating in the ong>Ecomindsong> scheme,whilst the remaining two (turning off power at the plugand buying local or organic food) remained constant(see Figure 35). When tested with a series of WilcoxonSigned-Rank tests, only the change in recycling glass,paper or metal was found to be statistically significant(p


An evaluation for Mind 655.9 Comparative importance of aspectsof the ong>Ecomindsong> schemeA question on the comparative importance of thevarious aspects of the ong>Ecomindsong> project to participantscomposed of three simple scales was included in the ‘Indepth’evaluation. Participant perceptions on how theyfelt about being with other people, about being outsidein nature and about the exercise or activities wereassessed using the ‘importance scale’, both at the endof the programme as a whole and after participants hadtaken part in a particular ong>Ecomindsong> session.Figure 36. Change in environmentally friendly behaviourscores participating in the ong>Ecomindsong> programmeAspects of ong>Ecomindsong> programmeThe exerciseor activitiesBeing withother peopleBeing outsidein natureBeginning of programmeEnd of programmeThe importance of all the three aspects seemed tobe of roughly equal importance to participants, bothat the end of the ong>Ecomindsong> scheme as a whole andafter taking part in an ong>Ecomindsong> session (see Figure37), which suggests that participants valued thecombination of the three aspects within the ong>Ecomindsong>projects rather than one particular feature.5.10 Other findingsAll of the major variables correlated well with thewellbeing measures, both in terms of actual scoresand percentage changes. The only exception wasenvironmentally friendly behaviours, which onlycorrelated with health (medium, positive correlation,12 per cent shared variance). There were strongpositive correlations between social engagementand self-esteem (33% shared variance); andmedium positive correlations between wellbeingand connection to nature, social engagement andhealth, health and self-esteem. This implies that allthe wellbeing measures show the same improvementtrends over the course of the programme with allvariables increasing together. All correlation resultsfor the main variables are shown in Table 8.0 2 34 5Mean importance scoreTable 8. Correlation matrix for main variable measures (based on percentage changesfrom Time 1 to Time 2)WEMWBSRSESSocial engagementand supportConnectionto NatureHealthEnvironmentallyfriendly behaviourWEMWBSRSESSocial engagementandsupportConnection toNatureHealthEnvironmentallyfriendlybehaviour1.0.633** 1.0.348** .572** 1.0.312* .287* .275* 1.0.337* .323* .133 .345** 1.0.010 -.082 -.038 .061 .353** 1.0


66 ong>Ecomindsong> ong>effectsong> on mental wellbeing5.11 What participants enjoyed about theong>Ecomindsong> sessionsThere were many different aspects aboutbeing involved in an ong>Ecomindsong> projectthat participants said they enjoyed themost. Out of the 113 comments received,three major themes emerged i) the socialcontact - being with other people as partof a group; ii) being outside in nature- the fresh air, the scenery and thebeauty; and iii) the activities – learningnew skills, enjoying the activities. Manyother comments expressed how peoplefelt calm and safe outside, had fun,liked being active and felt a sense ofachievement. The majority of commentsfrom participants about the variouselements of their ong>Ecomindsong> projects theyenjoyed the most are included under thefive themes of the evaluation, howevercomments relating to the activities andthe ‘learning’ experiences together withany other miscellaneous comments areshown below.What participants enjoyed most – The activities, learning etcWorking on my plot.Planting seeds, cutting grass.Enjoyed raking the vegetation andpulling weeds out.Learning how to prepare the soil andwhat seeds to put in.Meeting people, cup of tea and cake,painting the seat, watering.Learning a new thing that I have neverdone before. I really enjoy doing it.Had some giggles. Learned a few thingsabout machinery and crops.The wreath making, it was very enjoyableand I would like to do it again.Something new that I am good at –apparently a natural!Doing something I haven’t tried before.Painting.Weaving and learning new skills.Learning to etch and engrave. Something newthat I am good at- apparently a natural.BBQ at the other end. Canoeing was fun too.I enjoyed the whole experience.Picking a packing task.I really enjoy the activities, they are stretchingme, though I can sometimes get frustrated – it’sall good practice for going back to work.Sense of satisfaction upon completion ofthis long project (we’ve been working onthis wall for many weeks).Talking and learning about farm to fork.Sense of satisfaction.


An evaluation for Mind 676. General discussion6.1 Discussion and key successesThe ong>Ecomindsong> evaluation focused on three mainthemes: i) Wellbeing, ii) Social inclusion and iii)Connection to nature and significant improvementswere observed in all three parameters, all of whichhave implications for not only the mental wellbeingand resilience of individuals but also for public healthand the management of natural environments.Mental wellbeing parameters of positivity in the ‘Allprojects’ evaluation and of self-esteem, wellbeingand mood in the ‘In-depth’ evaluation all improvedsignificantly for the majority of participants over thecourse of the ong>Ecomindsong> scheme (and very oftenafter just a single ong>Ecomindsong> session). At the startof the programme for many ong>Ecomindsong> participants,wellbeing scores were lower than average but by theend of the programme, participant scores had risento a level in line with population norms suggesting theong>Ecomindsong> scheme can be effective in raising mentalwellbeing to ‘normal’ levels .For social inclusion, again both studies showedstatistically significant improvements, with socialengagement and support levels increasing by atleast 10 per cent for most participants. Whilst theincreases in the other social parameters were notalways so profound, there were some interestingtrends with the majority of participants feeling thatthey now belonged to their immediate community (theopposite from how the majority felt at the start ofthe programme) and with 81 per cent of participantsgetting involved in community activities morefrequently, after taking part in the ong>Ecomindsong> scheme.Participants also reflect this trend in their own wordswith the preponderance of comments relating to thesocial benefits of attending the ong>Ecomindsong> projects.Overall these findings suggest that ecotherapy canenhance social inclusion, helping people to broadentheir personal networks, learn new skills and improvetheir employment chances; vital to the recovery ofthose suffering with mental health problems.Similarly in terms of connection with nature,statistically significant increases in connection tonature (of 40 per cent on average) were foundbetween the beginning and end of taking part inong>Ecomindsong>, for the majority of participants, and thiswas true in both studies. Connection to nature hasbeen proved to enhance mental wellbeing and this,together with the worry that we as a society arebecoming disconnected with nature, shows thatecotherapy can be successful in both increasingcontact with and connection to nature, enablingparticipants to benefit further from the associatedhealth and wellbeing benefits.Interestingly, the presence of a weak positivecorrelation between age and connection to nature inthis study shows that connection to nature increasedslightly with participant age. This finding could implyeither that people may become more connected tonature as they get older or that perhaps youngerpeople now are not as connected to nature asprevious generations.Other important findings concern the effect of theong>Ecomindsong> projects on participant behaviours. Resultsfrom both studies showed statistically significantincreases in participant self-perceived ‘health’status over the duration of the ong>Ecomindsong> schemeand often after taking part in one session. Smallerimprovements were also observed in healthy eatingand exercise parameters. In addition, regardingenvironmentally friendly behaviour, a statisticallysignificant increase in overall scores was found fromthe start to the end of the ong>Ecomindsong> scheme for 60per cent of beneficiaries, showing an increase inenvironmentally friendly practices (particularly inrecycling). Therefore not only does involvement in anecotherapy intervention improve wellbeing and socialinclusion and equip participants with useful copingskills, but it can also help the development of healthierlifestyles and environmentally friendly living.What is particularly revealing in the evaluation ofong>Ecomindsong> is that in both studies, these improvementsto wellbeing, social inclusion and connection tonature happen right across the range of ecotherapyinterventions involved in the ong>Ecomindsong> scheme. Withinthe programme, projects from five different ecotherapyapproaches (STH, care farming, green exercisetherapy, environmental conservation and naturearts and crafts) provided a mix of different activitiesand interventions in a variety of different contexts,for different lengths of time and in various naturalenvironments. In addition there was a mix of projects


68 ong>Ecomindsong> ong>effectsong> on mental wellbeingthat are ‘therapeutic’ interventions and those whichalso offer more formal treatment options - ‘therapy’- such as CBT, counselling or psycho-educationsessions. No statistically significant differences werefound in any of these variables suggesting similarbenefits to participant wellbeing, social inclusion,nature connection, healthy lifestyles and environmentalbehaviour can result from all types of ecotherapy.Whilst both men and women experienced asignificant increase in health scores after takingpart in ong>Ecomindsong>, women had significantly lowerhealth scores 214 than men, implying that they feltless healthy than men overall. In terms of mood,significant differences in mood scores between thegenders were also observed, where even thoughimprovements occurred for both genders, womenhad significantly better overall mood than men. Theother trend relating to participant demographics wasthat a relationship between connection to natureand age emerged 215 ; suggesting that connection tonature may increase as we get older. However, eventhough these slight differences in parameters due toparticipant gender and age were observed, in relationto the overall beneficial ong>effectsong> on participant healthand wellbeing, similar trends were found across alldemographics in this research. The implications aretherefore, that ecotherapy can generate health andwellbeing benefits regardless of participant age,gender or ethnic origin.Another interesting aspect of the ong>Ecomindsong> schemethat has emerged is that more men were involvedin the ong>Ecomindsong> projects than women. Historically ithas been notoriously difficult to encourage men inparticular, to engage with mental health interventions,possibly due in part to the reluctance to admit ahaving a ‘problem’ and from the perceived stigma ofaccessing treatment. For certain types of ecotherapy,some activities can be physically demanding and214 In the ‘All projects’ study, no differences emerged in the ‘In-depth’ study215 In both studies


An evaluation for Mind 69may possibly be viewed by some as being moretraditionally male-oriented. For men who are worriedabout how their mental health intervention may beperceived by others, activities such as environmentalconservation tasks, farming, woodland managementand gardening may be easier to talk about or admitto than a counselling session for example. In addition,both participants and staff have said that often inecotherapy, projects tend to adopt the ‘leave thediagnosis at the gate’ strategy which also contributesto reducing stigma and prejudice of attending.There are two further related aspects of ecotherapythat appear to contribute to the relatively highadherence levels experienced at nature-basedinterventions. Firstly most ecotherapy approachescater for several groups of people or individualsat the same time and will sometimes also involveparticipants who are ‘well’ and may also involvevolunteers, all carrying out activities together asa team. This makes it difficult to tell at a glancewho is unwell and who is healthy; who may befeeling ‘vulnerable’ and who is not, and because itis hard to distinguish between people in this way,it can further break down barriers and encouragesocial inclusion. Secondly, the comments receivedfrom participants in this study suggest that theyfound taking part in these ecotherapy interventionsenjoyable, even when the weather was bad; manyfound a sense of achievement and belonging andappreciated being outside in the fresh air. All of theseelements are likely to affect attendance. Therefore,although involvement in ong>Ecomindsong> has been shownto be equally beneficial for both men and women,could ecotherapy be considered as a successful wayof encouraging more men to access mental healthtreatment services?Analysis of the data and comments from participantsthemselves have shown that through ecotherapythe recommended Five Ways to Wellbeing can beaddressed. Participants involved in ong>Ecomindsong> have:• been more Active by taking part in exercise andactivities in natural environments – gaining physicaland mental health benefits;• Connected both with other people, the widercommunity and with nature, thus increasing socialinclusion;• started to Take Notice of nature and thegreen environment around them – gaining theassociated mental health benefits and increasingconnectedness to nature;• managed to Keep Learning – both developing newskills and learning about themselves; and• been able to Give – through sharing and supportingeach other and working as a team and also bygiving back to nature through shaping and restoringnatural environments.In addition, throughout this study, involvement inong>Ecomindsong> has been shown to promote wellbeing,foster social inclusion and help people to cope withpoor mental health, all of which are considered crucialfor building up an individual’s resilience. Ecotherapyuses nature and nature-based activities not only tohelp participants bounce back from adversity but alsoto adapt in the face of challenging circumstances thatthey may face in future. Ecotherapy should thereforebe encouraged not only for use as a treatment optionfor people with mental health problems but also as apreventative approach to future stresses. Ecotherapycould therefore be used for groups that have anelevated risk of developing a mental health problem(for example; older people, the unemployed, peoplewith long term physical disabilities or health conditions).Although the three main parameters of wellbeing,social inclusion and connection to nature areconsidered separately in the results sections of thisreport, and improvements to all three have been seenover the course of the ong>Ecomindsong> scheme, it is perhapsthe combined effect of the three elements togetherthat has the most powerful synergistic consequence.The significance of the ‘combination effect’ is alsoreflected in comments from participants themselves,who when asked which of the main elements of theong>Ecomindsong> project they felt had been most important tothem (being with other people, being outside in natureand taking part in exercise or activities) in both studiesthey rated them as of equal importance, implyingthat participants value the combination of the threeaspects of the ong>Ecomindsong> projects, rather than oneparticular feature. Given that ecotherapy approachesare characterised by this blend of meaningful activitieswhilst in nature and with other people, this is perhapsthe key to its success. The fact that this blend resultsin improvements to several different parameters atthe same time also suggests an efficient process.The potential of gaining multiple positive health andwellbeing outcomes from one approach - ecotherapy –must therefore be considered more beneficial and costeffective than approaches focusing on single outcomes.216 Correct at time of writing – likely to be more217 Mind 2007;


70 ong>Ecomindsong> ong>effectsong> on mental wellbeingThrough the funding of 130 ecotherapy projects andthe 12,071 216 people that have been involved withand helped by the programme, ong>Ecomindsong> can beconsidered to have had a major impact, both in termsof supporting people suffering from mental ill-healthand in sustaining the provision of ecotherapy servicesacross England.The aim of the ong>Ecomindsong> scheme was to help peopleliving with mental health problems to get involvedin nature-based initiatives in order to improve theirconfidence, self-esteem, and their physical andmental health. In this regard, given the statisticallysignificant rise for the majority of participants inmental wellbeing parameters such as wellbeing,positivity, self-esteem and mood over the courseof the programme, ong>Ecomindsong> can be seen ashaving been a success. These findings suggest thatecotherapy could be beneficial for a range of mentalhealth conditions and could be used as a treatmentoption in the same way as antidepressants andtalking therapies.In addition, the need had been recognised for morerobust, scientific evaluation to be carried out on thebenefits of ecotherapy projects for people sufferingwith mental health problems 217 , in addressing this,the ong>Ecomindsong> scheme has also been successful.The ong>Ecomindsong> wellbeing evaluation involved over800 participants from 61 different projects, and thefindings from this study (derived from outcomemeasures which are standardised, widely used andrecognised by health and social care professionals)add convincing evidence that a wide range ofdifferent ecotherapy projects can provide a range ofmental wellbeing benefits for participants.6.2 Limitations and future research6.2.1 Limitations of researchAs with any study, there are a number of limitationswhich may have affected the results of this research.• Firstly, evaluating 130 diverse projects is alwayschallenging. Although all of the projects wereworking in nature, with a view to increasingwellbeing and social inclusion for people withmental health problems, they all predictably havetheir own individual aims, objectives and structures,delivery methods, timescales and focus. In additioneach project varies in the staff skills, resources,motivation and time needed to be involved in anevaluation process. Designing an appropriateevaluation methodology suitable for the majority ofprojects is therefore not easy and without doubtsome projects and staff engage more with theprocess than others.• Secondly, due to both logistics and availableresources, all methods in the University ofEssex evaluation were questionnaire based,which unfortunately inevitably tends to excludeinvolvement of some participants. Although everystep was taken to ensure that questionnaireswere as simple as possible, not too lengthy or tooonerous to complete; and it was made clear thatthose who couldn’t access questionnaires could behelped by project staff or carers if they wished;there were still some groups or individuals forwhom the questionnaires were not appropriate andwhose voices were not heard.• As with any research of this type, the idealapproach to collection of data is by independentevaluators, able to administer questionnaires,conduct interviews and carry out participantobservation on a representative sample ofparticipants. This approach is quite costly, in termsof time, resources and money, especially given thatong>Ecomindsong> consisted of 130 projects all over England,and was therefore not possible for this evaluation.All questionnaires were therefore administeredby project staff, with guidance and supportfrom University of Essex staff, which may haveintroduced the possibility of representation bias.• Overall numbers of people taking part in theong>Ecomindsong> evaluation were good, and sufficientto enable statistical analysis. However, althoughrepresentative of the programme as a whole, somegroups had smaller numbers and so precludedany meaningful statistical analysis. For examplein this study over 89 per cent of participants wereclassified as ‘white British’ and there were notenough people in any of the other categories todetermine if the beneficial ong>effectsong> of ecotherapywere similar or different for all ethnic groups.• Although the significant improvements to wellbeing,social inclusion and nature connection areconsiderable through direct comparisons made forparticipants ‘before’ and ‘after’ their involvementwith the ong>Ecomindsong> scheme, there was no controlcondition in this study. That is, no comparisonto other options for participants, for example acomparison between attending an ecotherapy


An evaluation for Mind 71intervention; and taking part in either alternativetreatment options or interventions in other settings(either inside or outside).• Similarly, there were changes in wellbeing, socialinclusion and connection parameters from thebeginning compared to the end of participantinvolvement with ong>Ecomindsong>, and it is likely that theseimprovements were a direct result of participatingin the programme. However what is not knownis exactly how much of this change is directlyrelated to ong>Ecomindsong>. Although all participants inthe programme were experiencing mental healthproblems, some may have been referred to othersupport and others may have been on medication atthe same time, both of which may have affected theoutcomes (either positively or negatively) and thusmakes it harder to establish a direct causal link.6.2.2 Future researchIn future research it would therefore be beneficial to:• Include a comparison study between interventionsbased in a clinical setting versus the naturalecotherapy setting (in terms of clinical outcomes,adherence levels and in reduction of the use ofmore expensive subsequent mental health servicesfor example) – this would be useful in order toinform the NHS debate on good practice in thetreatment of mental ill-health;• Implement a follow-up study in the future. The longterm monitoring of these ong>Ecomindsong> interventionshas undoubtedly provided evidence of the health,wellbeing and social benefits to participants, buta follow-up study would provide indicators andstatistics of any further or continuing treatment;further social, community and employmentachievements; as well as implications for futureresilience. When compared to a similar group notreceiving ecotherapy interventions, this will provide avalid comparison of the ong>effectsong> of these programmes.• Include a cost-benefit comparison study betweenparticipation in an ecotherapy programme andindividual therapy in a clinical setting and treatmentwith anti-depressants.• Commission further research to provide evidenceto determine the most advantageous duration ofecotherapy programmes, in terms of changes in


72 ong>Ecomindsong> ong>effectsong> on mental wellbeingmental health parameters. We know that relativelyshort exposures to nature can be beneficial but wedo not know the optimum duration of interventionand the most favourable frequency of attendancebut further research in this area would greatlyinform this debate.• Explore further the case for the inclusion of moreformal psychological therapies within ecotherapysettings as to whether this would make interventionsmore or less successful. Given that ecotherapymay be more effective precisely because it doesnot generally include a formal therapy element andusually leaves participant diagnoses at the gate, thiswould be interesting to ascertain.• There are calls for further research into this fieldby clinicians, commissioners and ecotherapypractitioners, however many organisations arereferring clients to ecotherapy services, suggestingthat they are already persuaded by its efficacy.The evidence base is continually growing and isconsidered ‘convincing but not yet complete’, so is thepriority to fill in the research gaps with cost benefitanalysis, optimum duration studies and follow-upresearch or is there a also case for collation theevidence and packaging it in an accessible way (orvariety of formats) for commissioners?6.3 Key issues and implications for policySince the call for “a green agenda for mental health”from Mind in 2007 there has undoubtedly been progressin raising awareness of the relationship betweennature and health. Land managers and environmentalconservation organisations have seized the opportunityto promote another reason to conserve our naturalplaces. The realisation that ecosystem services canalso include health and wellbeing benefits, whilstconsidered a little progressive ten years ago, is nowwidely accepted. However even though there has beenan increasing recognition that nature can be a valuablehealth resource, this has not yet fully translated intohealth and social care. Undoubtedly the term greenexercise has become more popular, with several NHSorganisations generally advocating green exercise forhealth to many different groups of people in society.The potential of ecotherapy as a mainstream mentalhealth treatment option however has still to be realised.This study adds to the growing evidence basewhich highlights the effectiveness of ecotherapyinterventions such as those involved in the ong>Ecomindsong>scheme. This evidence is now considered by manyas being convincing, if not yet complete. Ecotherapytherefore has important policy implications for a widerange of sectors.


An evaluation for Mind 73The health and social care sector needs to considerthe contribution that ecotherapy makes to bothindividual mental health and public wellbeing, as ahappier more resilient population has the potentialto save money for the National Health Service. Theimpacts of ecotherapy on social inclusion also haveimplications for social care and employment policyand resulting knock-on ong>effectsong> can potentially lead tocost savings to society, an important consideration intimes of diminishing public budgets.6.3.1 Clinical provision of mental health services• Ecotherapy initiatives have been proved not only tobe successful at increasing mental wellbeing andbuilding resilience but also to simultaneously produceother positive life outcomes. However there remainsa lack of knowledge and acceptance among GPs(and other care providers) of the benefits to patientsgained from using ecotherapy as an additional oralternative treatment for mental health issues suchas depression. Commissioners of health and socialcare services need to be encouraged to take the ideaof ecotherapy more seriously and more GPs shouldbe supported to consider and recognise the value ofsuch green care.• With this in mind, NICE should also be called uponto consider the evidence in order to recommendthe use of ecotherapy interventions alongside othercurrent treatment options for depression, such asantidepressants and CBT. A recommendation fromNICE will help to raise the perceived legitimacy of suchnature-based interventions and make it easier both forGPs to prescribe and patients to receive this treatment.• The debate for ecotherapy as a clinical treatmentoption, is not whether ecotherapy is more (orless) effective than treatment with antidepressantsor CBT, but rather that it represents anothertreatment choice for GPs and service users. Aswith any condition, certain treatments suit differentpeople and what works for one individual may notnecessarily work for another, highlighting the needfor a range of options available in order to offer achoice of treatments. Similarly patients often havebeen found to benefit most from a combination ofapproaches and ecotherapy could be combinedwith CBT or antidepressants to maximise patientrecovery. The addition of another tool in the toolboxto tackle mental health problems is especiallypertinent given the long waiting lists for CBT andthe increasing costs of antidepressants.• Good health and wellbeing is generally recognisedas being multifaceted and not merely the absenceof disease. Ecotherapy has been shown to provideparticipants with multiple wellbeing outcomes, butthe broad definition of health has not been convertedinto either the measures of success or fundingstreams. Ecotherapy can improve multiple factorssimultaneously but ‘traditional’ measures of successwithin healthcare do not adequately recognise this.Establishment of the effectiveness of a treatmentoption is still focussed on discrete treatments(medicines as tablets etc.) and do not yet consider:i) multiple outcomes of treatment (wider than theclinical health context); ii) or the holistic effect ofmultifaceted interventions; iii) benefits to public health;or iv) benefits and cost savings to the wider society.• There is a need for referral to ecotherapy initiativesto be incorporated into health and social carereferral systems, particularly in light of the recentchanges with clinical commissioning groups andhealth and wellbeing boards. Implications forpersonal budgets should also be recognised andthose in receipt of direct payments supported toaccess ecotherapy treatments.• Mental health commissioning services should beencouraged to consider that ecotherapy representsan enjoyable, socially acceptable treatment optionfor depression, and the resultant observed effecton attendance and adherence levels could proveto be effective in encouraging uptake of treatmentand especially successful in re-engaging men withmental health services.• There is also a need to raise awareness amongstpatients that ecotherapy can be a valid and aneffective treatment option for mental health problems,such as mild to moderate depression. A majorconcern in encouraging more ‘green prescriptions’for nature-based initiatives, is to overcome thepatient’s perception of whether or not ecotherapyis as an effective treatment response. Patientsoften subconsciously believe that taking a tabletwill automatically make them feel better, and someperceive that a prescription for medication is a signthat they have been taken seriously by their doctor.Leaving the doctor’s surgery with a prescription218 White et al 2013


74 ong>Ecomindsong> ong>effectsong> on mental wellbeingfor green exercise therapy, a recommendation totake part in STH or a prescription to attend a carefarm may not be deemed as effective or even asatisfactory treatment. Education is also needed forGPs and patients alike to highlight the additionalsocial and wellbeing benefits that an ecotherapyintervention can provide that anti-depressants, forexample, do not.6.3.2 Public health• Contact with and connection to nature is continuallybeing proven to improve mental wellbeing andto have a therapeutic effect even after shortexposures. Encouraging people to incorporatemore green exercise activities into daily routinesand lifestyles and supporting more ecotherapyopportunities has the potential to increase wellbeingnot only for those already living with a mentalhealth problem but for health promotion and illnessprevention at the population level, particularly forthose groups with an elevated risk of developing amental health problem.• Increasing support for and access to a wide rangeecotherapy and green exercise activities for allsectors of society is (in addition to the personalwellbeing benefits) also likely to produce substantialpublic health benefits and economic savings, andtherefore should be promoted. Healthy, active andhappy people, feeling connected to nature whilstliving in local communities rich with social capital,will ultimately lead to a better overall health for thenation and reduced costs for both the NHS and forpublic health bodies.6.3.3 Social inclusion• Agencies responsible for providing social careservices and promoting social inclusion wouldalso benefit from recognising the potential ofecotherapy activities to increase the health andmental well-being of their communities, patientsand clients. Ecotherapy has been shown to reducesocial exclusion, increase social capital and to helppeople to re-integrate into society after a periodof ill-health, something that is particularly relevantto local authorities, government departments(e.g. Department for Communities and LocalGovernment) and third sector organisations alike.• Ecotherapy programmes and green exerciseinitiatives could also be recommended formarginalised groups such as those in care andspecial education institutions, long-stay hospitalsand prisons for example. Ecotherapy initiativescould be more widely used by probation servicesand residential care providers in the UK forincreased mental health. In times with increasingprison populations, a prevalence of prisonerswith mental health problems and concerns overthe effectiveness of current probation services,there is great potential for ecotherapy to be usedas an additional option in the rehabilitation ofoffenders into society. In addition with an emphasisof devolving more social care into the communitysetting, ecotherapy could also help marginalisedpeople become more involved in society and withtheir local community.6.3.4 Employment• Ecotherapy has been shown to lead to wellbeingand social inclusion benefits as participants developnew skills and learn to re-engage with theircommunities and the wider society. Ecotherapyinterventions often lead to employment dividends,which have implications for the government’s driveto encourage people recovering from poor healthto return to work. Ecotherapy has the potentialtherefore to be used alongside existing strategiesfor helping people to get back into employment.6.3.5 Management and conservation of green spaces• The achievements of ecotherapy interventions haveimplications for those responsible for managingand promoting our natural green spaces. Althoughland managers have been successful in promotingthe health and wellbeing benefits of contact withnature through visiting their sites, the importanceof green spaces to the nation’s health is still largelyunderestimated by policy-makers and the generalpublic. Findings from this study have highlightedthe multiple outcomes from ecotherapy and recentresearch 218 has shown that lower mental distressand higher wellbeing is linked with living in urbanareas with more green space, highlighting furtherthe importance of policies to protect and promoteurban green spaces for community wellbeing. If weare all to have this access to nature, there is needboth for i) more quality green spaces, (especiallyin urbanised areas); and ii) to actively protect andconserve our existing green spaces in both ruraland urban locations.


An evaluation for Mind 75• Unfortunately there appears to be a distinctincongruity between the proven positive wellbeingoutcomes of green exercise and ecotherapy andthe existing drivers of economic development. Withcurrent worries over the shrinking economy, risingunemployment and an increase in numbers of peopleliving in poverty there has been a call to ‘kick-start’the building industry, to employ more constructionworkers and craftsmen, to build more houses andthus to revive the economy. There is a danger that inthe rush to pull us out of economic depression, that avaluable health resource for us all, accessible greenspace, is sacrificed in the process. Historically in theregeneration of urban areas, green spaces haveoften been removed either to build more houses orto keep down maintenance costs, and there is oftena perception that parks and community gardensoffer more opportunities for criminals to hide. In ruralareas, modern agricultural development and theneed for new housing continue to put pressure ongreen spaces.• This also has serious implications for health andsocial inequalities, we know that a lack of greenspaces in residential areas corresponds withmental-ill health, lower wellbeing 219 , lower physicalactivity, more obesity, graffiti and litter 220 and oftengoes hand in hand with low socio-economic status.219 White et al 2013220 Ellaway et al 2005


76 ong>Ecomindsong> ong>effectsong> on mental wellbeingTherefore providing additional green spaces inthese areas where people suffer the most may beparticularly beneficial for the poorest members ofsociety 221 .• Under the National Planning Policy Framework 222local planning authorities have a duty to takeaccount of and support local strategies to improvehealth, social and cultural wellbeing for all.Directors of Public Health should use their roles towork with departments across the local authorityto ensure health considerations are at the heartof planning decisions, particularly those regardinggreen spaces.• Local Nature Partnerships should be encouragedto recognise the health and wellbeing benefits ofcontact with nature and work to ensure that oururban and rural green spaces are preserved forthe benefit of the nation’s health, that plannersand developers enhance and not destroy greeninfrastructure and to encourage public access tocountryside and urban green spaces.6.4 Concluding commentParticipating in the 130 ecotherapy projects in theong>Ecomindsong> scheme has provided a myriad of mentalwellbeing benefits for those involved. The majority ofong>Ecomindsong> participants will leave the programme withbetter wellbeing and self-esteem; feel more sociallyincluded; will have gained new skills and developedhealthier lifestyles; have enhanced psychologicalhealth and wellbeing; and an increased connectionto nature. These significant improvements as a resultof the ong>Ecomindsong> scheme all have implications for notonly the mental wellbeing and resilience of individualsbut also for public health and the management ofnatural environments.Those responsible for the provision of health andsocial care for those suffering with mental healthproblems should therefore consider the multiplehealth, mental wellbeing and social benefits toparticipants in ecotherapy initiatives (such as thosesupported by ong>Ecomindsong>), when commissioning andfunding mental health and public health services.221 Mitchell and Popham 2008222 Department for Communities and Local Government 2012


An evaluation for Mind 777. The projects in the ‘In-depth’ evaluation7.1 Grow ItLead organisation: Amber TrustLocation: Swanwick, DerbyshireContact Details: Tracy LitchfieldEmail: tracyl@ambertrust.co.ukWebsite www.ambertrust.co.uk/index.asp?id=29The Grow It project is an allotment project thatprovides a supportive learning environment to enablevolunteers to improve both their mental and physicalwellbeing and their self-confidence. Participants getinvolved in gardening at all levels from choosing thetypes of plants to grow, through to the harvesting ofcrops. Many volunteers also take the produce fromthe allotment home for consumption. The allotmentis open to volunteers two days per week and thereare also visits to other allotments and gardens forvolunteers to take part in. Since the start of theproject approximately 150 volunteers have attendedthe allotment. The Amber Trust highlights thebenefits of working on the allotment as: i) improvedmental well-being and physical health; ii) reducedsocial isolation; iii) working, learning and educationalopportunities; iv) community cohesion; v) promotionof mental health and reducing stigma and;vi) helping the wildlife and environment.I leave the allotment witha sense of satisfactionand contentment; Ihave such a relaxingnight after being onthe allotment. I havemade friends that Ican talk to, that helpsmy worries go awayand I don’t feelso isolated7.2 Grow2GrowLead organisation: CommonworkLocation: Edenbridge, KentContact Details: Paula ConwayEmail: PaulaC@commonwork.orgWebsite: www.commonwork.org/projects/grow2growGrow2Grow provides therapeutically supportedplacements for vulnerable young people, agedbetween 16 and 25 years, who are intransition, excluded or recovering frommental health problems and in orleaving care. The project takesplace on an organic dairy farmin Kent, where young peoplegrow organic fruit andvegetables and provideproduce for Commonworkeducation centre andpublic events. Youngpeople also work with thedairy herd, learning milkingand stock work. Through the project young peopletherefore learn new skills in horticulture, agriculture,farming, catering, independent living skills, buildingmaintenance and woodwork, with some youngpeople obtaining an accreditation in horticulture andland based studies through a partnership with a localschool. Young people are referred to the project byGPs, Community Mental Health services, leavingcare services, children and young people’s servicesand Connexions. Young people receive a six weekintroduction to the programme and are thenoffered up to 3 days per week for amaximum of 2 years. Grow2Growis managed by a ConsultantClinical Psychologist with 20years’ experience workingwith people with mentalhealth problems in theNHS and in fostering andadoption services. Thereare currently 5 youngpeople who regularly attendthe farm.


78 ong>Ecomindsong> ong>effectsong> on mental wellbeing7.3 Growing Clearer MindsLead organisation: Mind in Mid HertsLocation: Stevenage and HitchinContact Details: RosieEmail: growingclearerminds@hotmail.comWebsite: www.mindinmidherts.org.uk/page65.htmlThe GrowingClearer Mindsproject is designedto encouragepeople with mentalhealth difficulties toenjoy and benefitfrom nature andgreen spaces bybeing involvedwithin their localcommunity. Thefunding received forGrowing ClearerMinds enabled them to run three 12-week projectswhere participants attend environmental andart workshops and visits, listen to talks fromguest speakers and take part in research anddemonstrations, together with opportunitiesto get involved in environmental projects andlocal societies. The experiences gained throughattending environmental and art projects helps toraise self-esteem and reduce stress, contributingto overall improvements in mental and physicalhealth. During their time on the project thereis much opportunity for learning, with someparticipants learning how to grow fruit andvegetables and care for plants; and for others howto make mosaics and sculptures. Since the startof the Growing Clearer Minds project a total of 69participants have taken part and the project hasproduced a cookbook.One participant told us what they enjoyed most:The overall meeting up of people; Helpful andfriendly staff, teamwork7.4 Growing WellLead organisation: Growing WellLocation: Low Sizergh Farm, Kendal, CumbriaEmail: info@growingwell.co.ukWebsite: www.growingwell.co.ukGrowing Well is an organic growing enterprise whichhas provided support through organic horticulture topeople recovering from mental health issues for thelast 4 years (although the Growing Well has beenrunning since 2004). The aim of Growing Well’song>Ecomindsong> project is to offer opportunities forpeople recovering from mental health problemsto build their confidence and skills. The projectoperates an organic growing company on10 acres of Dairy Farm at the edge of theLake District. All produce from the farm issold directly to local people througha successful Community SupportAgriculture scheme, as well asto local retailers. The projectaims to provide opportunities forparticipants to be involved in thebusiness at all levels, from seedsowing up to the board of directors. The projectoffers the traditional growing activities alongsidehorticulture courses and educational farm visits. Sincethe start of the project approximately 130 participantshave been involved.I would never have gone to the AGM twelve monthsago. I am seeing changes – I wouldn’t have gone tothe Open Day twelve months ago. – I am really seeinghow ill I was over the last five years. I do feel thingshave changed, Growing Well was fundamental to it.


An evaluation for Mind 797.5 Seed to SucceedLead organisation: CrisisLocation: Spitalfields, Tower Hamlets, LondonContact Details: Paula LonerganTel: 020 7426 3834Website: N/ACrisis (a national charity for single homelesspeople) runs an ong>Ecomindsong> funded food growingproject called Seed to Succeed. Seed to Succeedworks in partnership with the Attlee Youth andCommunity Centre and uses food growing as a toolto improve the mental health, physical well-being andknowledge and skills of homeless and vulnerablyhousedpeople. The project has transformedneglected plots of land into thriving green spacesfor growing (and selling) healthy organic produce.Led by the Crisis Skylight Garden Tutor, projectactivities run during four ten-week terms peryear, on Monday afternoons and have to dateinvolved 14 participants. Seed to Succeed utilisesthe help of up to three volunteers in workshopsand aims to document the lifespan of the projectphotographically. The produce is grown for use atthe Crisis Skylight Café, a social enterprise providingfree training and accredited qualifications homelessmembers pursuing catering as a career.7.6 Spring to LifeLead organisation: Sharpham Outdoor Project,The Sharpham TrustLocation: Sharpham Estate, DevonContact Details: Sharpham Outdoors Project ManagerEmail: outdoors@sharphamtrust.orgWebsite: www.sharphamtrust.org/Outdoors-Project/Mental-Health/Spring-to-LifeThe Spring to Life project is a mental healthrecovery project for young people sufferingmental health trauma. The project aims to connectvolunteers and participants whose lives have beenaffected by mental health problems, to help recoverythrough time spent outdoors. The project takes placeon the Sharpham Estate, which consists of 550acres of woodland, rivers, gardens and farmland.The estate offers opportunities for conservationactivities, woodland craft, bush craft and survivalskills, outdoor sports, horticulture, health andwell-being workshops and team-building and trustdevelopment workshops.Programmes last for approximately 10 weeks,with two groups attending on one day each week.Participants are involved in a programme of activitieswhich improves their physical and mental health, andtakes them on a journey of personal discovery withthe natural world. The Spring to Life programmeallows participants to start their personal recovery,at their own pace and in consultation with mentalhealth specialists. Mentors, who themselves havehad experience of mental distress are involved inthe delivery of the programme and are well-placedto support the young people on their journey torecovery. Since the start of the Spring to Life projectapproximately 148 participants and 11 mentors havebeen directly involved.


80 ong>Ecomindsong> ong>effectsong> on mental wellbeing7.7 The Outdoor ClubLead organisation: The Outdoor ClubLocation: Bude, North DevonContact Details: Pete AdamsEmail: pete.adams@theoutdoorclub.co.ukWebsite: www.theoutdoorclub.co.ukThe Outdoor Club provides adults with experienceof mental health problems with opportunities toparticipate in a programme of bush craft activitiesoperated from a rustic log cabin on the edge offree access woods. Through being outdoors andengaging in activities such as fire building, greencraft and flora and fauna identification participantsare supported in connecting with themselves, otherpeople and the natural environment. Nature is a corepart of the therapeutic relationship which is developedthroughout the project and often acts as a catalystto understanding. Participants are typically enrolledon the project for 11 weeks, however in addition tothis, therapy days, weekends and longer therapeuticsessions are all available. Since the start of theproject 31 people have been involved in the OutdoorClub sessions.I’ve been a lot calmer in the last few weeks.7.8 Wellbeing Comes Naturally (WCN)Lead organisation: The Conservation Volunteers (TCV)Location: Nationwide, but Bedford and SheffieldWCN involved in evaluationContact Details: Dominic Higgins (TCV NationalProgrammes Manager)Email: d.higgins@tcv.org.ukWebsite: www.tcv.org.ukThe WCN programme was launched by BTCV 223in 2009 to encourage people experiencing mentalhealth problems to become environmental volunteers,and through this volunteering improve their mentalhealth. TCV aims to help people to connect with thenatural world, through WCN, to get involved in moremeaningful volunteering activities, to develop their skillsand take on more responsibility. The programme alsoaims to reduce the social exclusion of those with poormental health.The WCN programme is a nationwide initiative,with 28 projects running throughout England.Each group welcomes new volunteers with mentalhealth problems and engages them in sessions ofnature conservation such as: food growing as partof an allotment group; preserving habitats throughbiodiversity action teams; and heritage preservationactivities. Volunteers can be referred through mentalhealth agencies or they can self-refer. Throughthe programme it is hoped that participants will reconnectwith nature, become more confident andhappy, build skills and social networks and become anintegral part of a group, helping to lead and organize.Projects aim to support individuals and help them totake on extra responsibilities where appropriate. Initiallythe programme hoped to involve 450 volunteers withexperience of mental health problems overall, howeversince it started, WCN has involved many more people at1311 volunteers involved to date.Just two of the WCN projects were involved in theUniversity of Essex ong>Ecomindsong> evaluation (Bedfordand Sheffield), as in addition TCV are carrying outan overall evaluation of all 28 projects. For moreinformation on this evaluation, contact DominicHiggins (see above).223 BTCV changed to TCV over the course of ong>Ecomindsong>


An evaluation for Mind 817.9 The Wildwoods ong>Ecomindsong> ProjectLead organisation: The Wildwood trustLocation: Herne Bay, KentContact Details: Peter CollardEmail: ecomind@wildwoodtrust.orgWebsite: www.wildwoodtrust.orThe Wildwood Trust is a wildlife charity and visitorattraction set up in 2002 to support native wildlifeagainst the natural backdrop of ancient coppicedwoodland. The Wildwood Trust’s ong>Ecomindsong> volunteerproject is providing volunteering opportunities forpeople with direct experience of mental healthproblems. Volunteers work with the ranger team,and have help with a huge range of projects aroundthe park, from improving the woodlands for thenew bison enclosure, to setting up the pumpsin the new beaver pond filtration system, andbuilding dead-hedging by the pathways aroundthe wood. Participants have support and guidancefrom the ong>Ecomindsong> Volunteer Coordinator, gainingenvironmental skills, and building confidence andexperience. Currently have six ong>Ecomindsong> volunteerscome per day from all walks of life, with differentlevels of skill, with all having some experience ofmental health problems. Since the project started,50 people have been involved in the programme.


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90 ong>Ecomindsong> ong>effectsong> on mental wellbeingAppendix A - All projectsong>Ecomindsong> evaluationThe University of Essex has been commissioned by Mind to evaluate the ong>Ecomindsong> scheme. Wewill be asking participants to complete questionnaires both at the beginning and at the end of theirinvolvement with the project. We value your comments and would be most grateful if you couldspare the time to complete our short questionnaire. All the information given to us will be treated asanonymous and will not be passed on to a third party. More information about this evaluation can befound at the end of this questionnaire.You do not have to answer the questions if you do not want to. If you can’t answer a questionjust leave it and go onto the next question. When you have completed the questionnaire pleasehand it back to the person who gave it to you or post it to the freepost address at the end of thequestionnaire. Thank you!1. I agree to completing this questionnaire (please tick)..........................................................................2. Name of project 3. Date4. Are you completing this questionnaire: (please tick relevant box)At the beginning of your involvement with the project?..........................................................................During your involvement with the project?..............................................................................................At the end of your involvement with the project?....................................................................................5. Approximately how long have you been coming to the project?6. Please read the following statements and tick the one that applies to you:I am filling in the questionnaire about myself..........................................................................................I am a project worker or helper reading out the questions to the participantand filling in their responses....................................................................................................................I am a carer/ guardian completing the questionnaire on behalf of someone else.................................7. Your gender Male Female Transgender8. Your age?.............................................................................................................9. What is your ethnic group? (please tick only one box)WhiteBritishIrishOther White (please specify below)Black or Black BritishCaribbeanAfricanOther Black (please specify below)Asian or Asian British MixedIndianPakistaniBangladeshiOther Asian (please specify below)MixedWhite and Black CaribbeanWhite and Black AfricanWhite and AsianOther Mixed (please specify below)ChineseAny other (please specify below)I do not wish an ethnic background to be recorded


An evaluation for Mind 9110. So that we can match up your responses before and after the activity, please write the firstpart of your postcode and the initials of your first name and surname in the boxes below:Postcode First name initial Surname initialThe next few questions are about how you feel about your health, your happiness, other peopleand nature.11. On a scale of 1 – 10, how healthy do you feel at the moment? (please circle one number only)Not very healthy 1 2 3 4 5 6 7 8 9 10Veryhealthy12. On a scale of 1 – 10, how connected to the natural world do you feel at the moment?(please circle one number only)Not veryconnectedto nature1 2 3 4 5 6 7 8 9 10Veryconnectedto nature13. On a scale of 1 – 10, how positive do you feel at the moment? (please circle one number only)Not veryhappy1 2 3 4 5 6 7 8 9 10Veryhappy14. How strongly do you feel you belong to your immediate neighbourhood or community?Very strongly Not very strongly Fairly strongly Not at all strongly15. Below is our importance scale. Please put a cross somewhere on each line to tell us howimportant each of the following is to you at the moment:Being outside in natureBeing with other peopleTaking part in exercise or activitiesEating healthy foodNot very importantVery importantThank you very much for sparing the time to complete our questionnairePlease hand the questionnaire back to the person that gave it to you or send it freepost toRachel Hine,Centre for Environment and Society,University of Essex,Freepost NATE1541,Colchester CO4 3SBRIf you have any questions about this research please contact the key researcher Rachel Hine,either by post at the address above, by phone: 01206 872219 or by email: rehine@essex.ac.uk


92 ong>Ecomindsong> ong>effectsong> on mental wellbeingAppendix B1 - In depth startong>Ecomindsong> evaluationThe University of Essex has been commissioned by Mind to evaluate the ong>Ecomindsong> scheme. We will beasking participants in various ong>Ecomindsong> projects to complete questionnaires at the beginning, duringand at the end of their involvement in the project to see if there have been any changes over time.We value your comments and would be most grateful if you could spare the time to complete ourquestionnaire. All the information given to us will be treated as anonymous and will not be passed on to athird party. More information about this evaluation can be found in the accompanying information sheet.You do not have to answer the questions if you do not want to. If you can’t answer a questionjust leave it and go onto the next question. When you have completed the questionnaire pleasehand it back to the person who gave it to you or post it to the freepost address at the end of thequestionnaire. Thank you!1. Name of project 2. Date3. Are you completing this questionnaire: (please tick relevant box)At the beginning of your involvement with the project?..........................................................................During your involvement with the project?..............................................................................................At the end of your involvement with the project?....................................................................................4. Please read the following statements and tick the one that applies to you:I am filling in the questionnaire about myself..........................................................................................I am a project worker or helper reading out the questions to the participantand filling in their responses....................................................................................................................I am a carer/ guardian completing the questionnaire on behalf of someone else.................................5. Your gender Male Female Transgender6. Your age?.............................................................................................................7. What is your ethnic group? (please tick only one box)WhiteBritishIrishOther White (please specify below)Black or Black BritishCaribbeanAfricanOther Black (please specify below)Asian or Asian British MixedIndianPakistaniBangladeshiOther Asian (please specify below)MixedWhite and Black CaribbeanWhite and Black AfricanWhite and AsianOther Mixed (please specify below)ChineseAny other (please specify below)I do not wish an ethnic background to be recorded


An evaluation for Mind 938. So that we can match up your responses before and after the activity, please write the firstpart of your postcode and the initials of your first name and surname in the boxes below:Postcode First name initial Surname initialThe following sections of the questionnaire contain questions about how you feel about yourself,your community and nature. They are made up of standardised questions so some of the words andphrases are written in different styles. Please ask if you need any help. There are no right or wronganswers, so please just answer honestly by ticking the relevant box for each question.9. Please answer each of these questions in terms of the way you feel at the present moment,by ticking the relevant box in the following scale.StronglydisagreeDisagreeNeutralAgreeStronglyagreeI am part of nature and nature is part of meHumans are more important than plants and animalsI fully understand how my actions affect the natural worldJust like a tree is part of a forest, I feel like a part of the natural worldI recognise and value the importance of other living thingsI often feel disconnected from plants and animalsI am just a tiny part of the natural worldAdapted from Meyer and Frantz 200510. On a scale of 1 – 10, how healthy do you feel at the moment? (please circle one number only)Not very healthy 1 2 3 4 5 6 7 8 9 10Veryhealthy11. Here is a list of statements dealing with your general feelings and thoughts about yourself.(Please tick the relevant box to answer the questions)StronglydisagreeDisagreeAgreeStronglyagreeOn the whole, I am satisfied with myselfAt times I think I am no good at allI feel that I have a number of good qualitiesI am able to do things as well as most other peopleI feel I do not have much to be proud ofI certainly feel useless at timesI feel that I’m a person of worth, at least on an equal plane with othersI wish I could have more respect for myselfAll in all, I am inclined to feel that I am a failureI take a positive attitude toward myself© Rosenberg, 1965.


94 ong>Ecomindsong> ong>effectsong> on mental wellbeing12. Please tell us how much you agree with the following statements by ticking the appropriate boxStronglydisagreeDisagreeNeutralAgreeStronglyagreeThere are people in my life who really care about meI regularly meet socially with friends and relativesI find it difficult to meet with people who share my hobbies or interestsPeople in my local area help one another13. How often in the last year have you helped with or attended activities organised in your local area?At least once a weekAt least once a monthAt least once every 3 monthsAt least once every 6 monthsLess oftenNeverDon’t know14. Below are some statements about feelings and thoughts. Please tick the box that best describesyour experience of each over the last 2 weeksStatements:None ofthe timeRarelySome ofthe timeOftenAll ofthe timeI’ve been feeling optimistic about the futureI’ve been feeling usefulI’ve been feeling relaxedI’ve been feeling interested in other peopleI’ve had energy to spareI’ve been dealing with problems wellI’ve been thinking clearlyI’ve been feeling good about myselfI’ve been feeling close to other peopleI’ve been feeling confidentI’ve been able to make up my own mind about thingsI’ve been feeling lovedI’ve been interested in new thingsI’ve been feeling cheerfulWarwick-Edinburgh Mental Well-Being Scale (WEMWBS) © NHS Health Scotland, University of Warwick and University of Edinburgh,2006, all rights reserved.


An evaluation for Mind 9515. How strongly do you feel you belong to your immediate neighbourhood or community?Very strongly Not very strongly Fairly strongly Not at all strongly16. Overall, how satisfied or dissatisfied are you with your neighbourhood as a place to live?(please circle one number only)Extremely dissatisfied 1 2 3 4 5 Extremely satisfied© CLEF and NEF 200817. How often do you do the following?AlwaysOftenSometimesRarelyNeverRecycle glass, paper and metalUse energy saving light bulbsTurn off power at the plug on appliances when not in useTurn off the tap whilst brushing your teethBuy organic or local foodEat a meal that has been cooked by yourself or someone else frombasic ingredientsPut out food for birds or other wildlife18. Please tell us how much you agree with the following statements by ticking the appropriate boxStronglydisagreeDisagreeNeutralAgreeStronglyagreeI enjoy putting effort and care into the food that I eatHealthy food often tastes nicer than unhealthy food© CLEF and NEF 2008Thank you very much for sparing the time to complete our questionnairePlease hand the questionnaire back to the person that gave it to you or send it freepost toRachel Hine,Centre for Environment and Society,University of Essex,Freepost NATE1541,Colchester CO4 3SBRIf you have any questions about this research please contact the key researcher Rachel Hine,either by post at the address above, by phone: 01206 872219 or by email: rehine@essex.ac.uk


96 ong>Ecomindsong> ong>effectsong> on mental wellbeingAppendix B2 - In depth endong>Ecomindsong> evaluationThe University of Essex has been commissioned by Mind to evaluate the ong>Ecomindsong> scheme. We havebeen asking participants in various ong>Ecomindsong> projects to complete questionnaires at the beginning, duringand at the end of their involvement in the project to see if there have been any changes over time.We value your comments and would be most grateful if you could spare the time to complete ourquestionnaire. All the information given to us will be treated as anonymous and will not be passed on to athird party. More information about this evaluation can be found in the accompanying information sheet.You do not have to answer the questions if you do not want to. If you can’t answer a questionjust leave it and go onto the next question. When you have completed the questionnaire pleasehand it back to the person who gave it to you or post it to the freepost address at the end of thequestionnaire. Thank you!1. Name of project 2. Date3. Are you completing this questionnaire: (please tick relevant box)At the beginning of your involvement with the project?..........................................................................During your involvement with the project?..............................................................................................At the end of your involvement with the project?....................................................................................4. Please read the following statements and tick the one that applies to you:I am filling in the questionnaire about myself..........................................................................................I am a project worker or helper reading out the questions to the participantand filling in their responses....................................................................................................................I am a carer/ guardian completing the questionnaire on behalf of someone else.................................5. Your gender Male Female Transgender6. Your age?.............................................................................................................7. What is your ethnic group? (please tick only one box)WhiteBritishIrishOther White (please specify below)Black or Black BritishCaribbeanAfricanOther Black (please specify below)Asian or Asian British MixedIndianPakistaniBangladeshiOther Asian (please specify below)MixedWhite and Black CaribbeanWhite and Black AfricanWhite and AsianOther Mixed (please specify below)ChineseAny other (please specify below)I do not wish an ethnic background to be recorded


An evaluation for Mind 978. So that we can match up your responses before and after the activity, please write the firstpart of your postcode and the initials of your first name and surname in the boxes below:Postcode First name initial Surname initialThe following sections of the questionnaire contain questions about how you feel about yourself,your community and nature. They are made up of standardised questions so some of the words andphrases are written in different styles. Please ask if you need any help. There are no right or wronganswers, so please just answer honestly by ticking the relevant box for each question.9. Please answer each of these questions in terms of the way you feel at the present moment,by ticking the relevant box in the following scale.StronglydisagreeDisagreeNeutralAgreeStronglyagreeI am part of nature and nature is part of meHumans are more important than plants and animalsI fully understand how my actions affect the natural worldJust like a tree is part of a forest, I feel like a part of the natural worldI recognise and value the importance of other living thingsI often feel disconnected from plants and animalsI am just a tiny part of the natural worldAdapted from Meyer and Frantz 200510. On a scale of 1 – 10, how healthy do you feel at the moment? (please circle one number only)Not very healthy 1 2 3 4 5 6 7 8 9 10Veryhealthy11. Here is a list of statements dealing with your general feelings and thoughts about yourself.(Please tick the relevant box to answer the questions)StronglydisagreeDisagreeAgreeStronglyagreeOn the whole, I am satisfied with myselfAt times I think I am no good at allI feel that I have a number of good qualitiesI am able to do things as well as most other peopleI feel I do not have much to be proud ofI certainly feel useless at timesI feel that I’m a person of worth, at least on an equal plane with othersI wish I could have more respect for myselfAll in all, I am inclined to feel that I am a failureI take a positive attitude toward myself© Rosenberg, 1965.


98 ong>Ecomindsong> ong>effectsong> on mental wellbeing12. Please tell us how much you agree with the following statements by ticking the appropriate boxStronglydisagreeDisagreeNeutralAgreeStronglyagreeThere are people in my life who really care about meI regularly meet socially with friends and relativesI find it difficult to meet with people who share my hobbies or interestsPeople in my local area help one another13. How often in the last year have you helped with or attended activities organised in your local area?At least once a weekAt least once a monthAt least once every 3 monthsAt least once every 6 monthsLess oftenNeverDon’t know14. Below are some statements about feelings and thoughts. Please tick the box that best describesyour experience of each over the last 2 weeksStatements:None ofthe timeRarelySome ofthe timeOftenAll ofthe timeI’ve been feeling optimistic about the futureI’ve been feeling usefulI’ve been feeling relaxedI’ve been feeling interested in other peopleI’ve had energy to spareI’ve been dealing with problems wellI’ve been thinking clearlyI’ve been feeling good about myselfI’ve been feeling close to other peopleI’ve been feeling confidentI’ve been able to make up my own mind about thingsI’ve been feeling lovedI’ve been interested in new thingsI’ve been feeling cheerfulWarwick-Edinburgh Mental Well-Being Scale (WEMWBS) © NHS Health Scotland, University of Warwick and University of Edinburgh,2006, all rights reserved.


An evaluation for Mind 9915. How strongly do you feel you belong to your immediate neighbourhood or community?Very strongly Not very strongly Fairly strongly Not at all strongly16. Overall, how satisfied or dissatisfied are you with your neighbourhood as a place to live?(please circle one number only)Extremely dissatisfied 1 2 3 4 5 Extremely satisfied© CLEF and NEF 200817. How often do you do the following?AlwaysOftenSometimesRarelyNeverRecycle glass, paper and metalUse energy saving light bulbsTurn off power at the plug on appliances when not in useTurn off the tap whilst brushing your teethBuy organic or local foodEat a meal that has been cooked by yourself or someone else frombasic ingredientsPut out food for birds or other wildlife18. Please tell us how much you agree with the followingstatements by ticking the appropriate boxStronglydisagreeDisagreeNeutralAgreeStronglyagreeI enjoy putting effort and care into the food that I eatHealthy food often tastes nicer than unhealthy food© CLEF and NEF 200819. Below is our importance scale. Please put a cross somewhere on each line to tell us howimportant you have found each of the following during the project:Being outside in natureBeing with other peopleTaking part in exercise or activitiesEating healthy foodNot very importantVery importantThank you very much for sparing the time to complete our questionnairePlease hand the questionnaire back to the person that gave it to you or send it freepost to Rachel Hine,Centre for Environment and Society, University of Essex, Freepost NATE1541, Colchester CO4 3SBRFor more information about this research then please contact Rachel Hine rehine@essex.ac.uk


100 ong>Ecomindsong> ong>effectsong> on mental wellbeingAppendix C1 - In depth preong>Ecomindsong> evaluationThe University of Essex has been commissioned by Mind to evaluate the ong>Ecomindsong> scheme. Wewill be asking you to complete questionnaires both before and after you have taken part in anenvironmental activity.We value your comments and would be most grateful if you could spare the time to complete ourquestionnaire. All the information given to us will be treated as anonymous and will not be passed onto a third party. More information about this evaluation can be found at the end of this questionnaireYou do not have to answer the questions if you do not want to. If you can’t answer a questionjust leave it and go onto the next question. When you have completed the questionnaire pleasehand it back to the person who gave it to you or post it to the freepost address at the end of thequestionnaire.Thank you!1. Name of project2. Date3. Please read the following statements and tick the one that applies to you:I am filling in the questionnaire about myself..........................................................................................I am a project worker or helper reading out the questions to the participantand filling in their responses....................................................................................................................I am a carer/ guardian completing the questionnaire on behalf of someone else.................................4. Your gender Male Female Transgender5. Your age?.............................................................................................................6. What is your ethnic group? (please tick only one box)WhiteBritishIrishOther White (please specify below)Black or Black BritishCaribbeanAfricanOther Black (please specify below)Asian or Asian British MixedIndianPakistaniBangladeshiOther Asian (please specify below)MixedWhite and Black CaribbeanWhite and Black AfricanWhite and AsianOther Mixed (please specify below)ChineseAny other (please specify below)I do not wish an ethnic background to be recorded


An evaluation for Mind 1017. So that we can match up your responses before and after the activity, please write the firstpart of your postcode and the initials of your first name and surname in the boxes below:Postcode First name initial Surname initial8. How long have you been coming to this project or initiative?9. How often do you come here?3-4 times a week or more Twice a weekOnce a weekOnce a fortnightOnce a monthOnce every 6 monthsOnce a year or lessThe following sections of the questionnaire contain questions about how you feel about yourself andnature. They are made up of standardised questions so some of the words and phrases are writtenin different styles. Please ask if you need any help. There are no right or wrong answers, so pleasejust answer honestly by ticking the relevant box for each question.10. Please answer each of these questions in terms of the way you feel at the present moment,by ticking the relevant box in the following scale.StronglydisagreeDisagreeNeutralAgreeStronglyagreeI am part of nature and nature is part of meHumans are more important than plants and animalsI fully understand how my actions affect the natural worldJust like a tree is part of a forest, I feel like a part of the natural worldI recognise and value the importance of other living thingsI often feel disconnected from plants and animalsI am just a tiny part of the natural worldAdapted from Meyer and Frantz 200511. On a scale of 1 – 10, how healthy do you feel at the moment? (please circle one number only)Not very healthy 1 2 3 4 5 6 7 8 9 10Veryhealthy


102 ong>Ecomindsong> ong>effectsong> on mental wellbeing12. Below is a list of words that describe feelings people have. Please read each one carefully.Then tick ONE box under the answer to the right which best describes how you feel right now.Statements: Not at all A little Moderaretly Quite a bit ExtremelyTense 1 2 3 4 5Angry 1 2 3 4 5Worn out 1 2 3 4 5Lively 1 2 3 4 5Confused 1 2 3 4 5Shaky 1 2 3 4 5Sad 1 2 3 4 5Active 1 2 3 4 5Grouchy 1 2 3 4 5Energetic 1 2 3 4 5Unworthy 1 2 3 4 5Uneasy 1 2 3 4 5Fatigued 1 2 3 4 5Annoyed 1 2 3 4 5Discouraged 1 2 3 4 5Nervous 1 2 3 4 5Loney 1 2 3 4 5Muddled 1 2 3 4 5Exhausted 1 2 3 4 5Anxious 1 2 3 4 5Gloomy 1 2 3 4 5Sluggish 1 2 3 4 5Weary 1 2 3 4 5Bewildered 1 2 3 4 5Furious 1 2 3 4 5Effcient 1 2 3 4 5Full of pep (energy) 1 2 3 4 5Bad-tempered 1 2 3 4 5Forgetful 1 2 3 4 5Vigorous 1 2 3 4 5POMS COPYRIGHT © 1989 EdITS/Educational and Industrial Testing Sevice, sAN dIEGO, ca 92107.


An evaluation for Mind 10313. Here is a list of statements dealing with your general feelings and thoughts about yourself.(Please tick the relevant box to answer the questions)StronglyagreeAgreeDisagreeStronglydisagreeOn the whole, I am satisfied with myselfAt times I think I am no good at allI feel that I have a number of good qualitiesI am able to do things as well as most other peopleI feel I do not have much to be proud ofI certainly feel useless at timesI feel that I’m a person of worth, at least on an equal plane with othersI wish I could have more respect for myselfAll in all, I am inclined to feel that I am a failureI take a positive attitude toward myself© Rosenberg, 1965.That’s all for now!Thank you very much for sparing the time to complete the first part ofour questionnairePlease hand the questionnaire back to the person that gave it to you or send it freepost toRachel Hine,Centre for Environment and Society,University of Essex,Freepost NATE1541,Colchester CO4 3SBRIf you have any questions about this research please contact the key researcher Rachel Hine, eitherby post at the address above, by phone: 01206 872219 or by email: rehine@essex.ac.uk


104 ong>Ecomindsong> ong>effectsong> on mental wellbeingAppendix C2 - In depth afterong>Ecomindsong> evaluationNow that you have finished your environmental activity we would be most grateful if you could spare thetime to complete the second part of our questionnaire. Again, all the information given to us will be treatedas anonymous and will not be passed on to a third party.You do not have to answer the questions if you do not want to. If you can’t answer a question just leaveit and go onto the next question. When you have completed the questionnaire please hand it back to theperson who gave it to you or post it to the freepost address at the end of the questionnaire.Thank you!1. Please read the following statements and tick the one that applies to you:I am filling in the questionnaire about myself..........................................................................................I am a project worker or helper reading out the questions to the participantand filling in their responses....................................................................................................................I am a carer/ guardian completing the questionnaire on behalf of someone else.................................2. So that we can match up your responses before and after the activity, please write the firstpart of your postcode and the initials of your first name and surname in the boxes below:Postcode First name initial Surname initial3. Please tell us what activities you did today?4. How long did you spend at the project or initiative today?5. What did you enjoy the most about today?


An evaluation for Mind 105The following sections of the questionnaire contain questions about how you feel about yourself andnature. They are made up of standardised questions so some of the words and phrases are writtenin different styles. Please ask if you need any help. There are no right or wrong answers, so pleasejust answer honestly by ticking the relevant box for each question.6. Please answer each of these questions in terms of the way you feel at the present moment, byticking the relevant box in the following scale.StronglydisagreeDisagreeNeutralAgreeStronglyagreeI am part of nature and nature is part of meHumans are more important than plants and animalsI fully understand how my actions affect the natural worldJust like a tree is part of a forest, I feel like a part of the natural worldI recognise and value the importance of other living thingsI often feel disconnected from plants and animalsI am just a tiny part of the natural worldAdapted from Meyer and Frantz 20057. On a scale of 1 – 10, how healthy do you feel at the moment? (please circle one number only)Not very healthy 1 2 3 4 5 6 7 8 9 10 Very healthy8. Below is our importance scale. Please put a cross somewhere on each line to tell us howimportant you have found each of the following during the project:Not very importantVery importantBeing outside in natureBeing with other peopleThe exercise or activity


106 ong>Ecomindsong> ong>effectsong> on mental wellbeing12. Below is a list of words that describe feelings people have. Please read each one carefully.Then tick ONE box under the answer to the right which best describes how you feel right now.Statements: Not at all A little Moderaretly Quite a bit ExtremelyTense 1 2 3 4 5Angry 1 2 3 4 5Worn out 1 2 3 4 5Lively 1 2 3 4 5Confused 1 2 3 4 5Shaky 1 2 3 4 5Sad 1 2 3 4 5Active 1 2 3 4 5Grouchy 1 2 3 4 5Energetic 1 2 3 4 5Unworthy 1 2 3 4 5Uneasy 1 2 3 4 5Fatigued 1 2 3 4 5Annoyed 1 2 3 4 5Discouraged 1 2 3 4 5Nervous 1 2 3 4 5Loney 1 2 3 4 5Muddled 1 2 3 4 5Exhausted 1 2 3 4 5Anxious 1 2 3 4 5Gloomy 1 2 3 4 5Sluggish 1 2 3 4 5Weary 1 2 3 4 5Bewildered 1 2 3 4 5Furious 1 2 3 4 5Effcient 1 2 3 4 5Full of pep (energy) 1 2 3 4 5Bad-tempered 1 2 3 4 5Forgetful 1 2 3 4 5Vigorous 1 2 3 4 5POMS COPYRIGHT © 1989 EdITS/Educational and Industrial Testing Sevice, sAN dIEGO, ca 92107.


An evaluation for Mind 10713. Here is a list of statements dealing with your general feelings and thoughts about yourself.(Please tick the relevant box to answer the questions)StronglyagreeAgreeDisagreeStronglydisagreeOn the whole, I am satisfied with myselfAt times I think I am no good at allI feel that I have a number of good qualitiesI am able to do things as well as most other peopleI feel I do not have much to be proud ofI certainly feel useless at timesI feel that I’m a person of worth, at least on an equal plane with othersI wish I could have more respect for myselfAll in all, I am inclined to feel that I am a failureI take a positive attitude toward myself© Rosenberg, 1965.That’s all for now!Thank you very much for sparing the time to complete the first part ofour questionnairePlease hand the questionnaire back to the person that gave it to you or send it freepost toRachel Hine,Centre for Environment and Society,University of Essex,Freepost NATE1541,Colchester CO4 3SBRIf you have any questions about this research please contact the key researcher Rachel Hine, eitherby post at the address above, by phone: 01206 872219 or by email: rehine@essex.ac.uk


108 ong>Ecomindsong> ong>effectsong> on mental wellbeingAppendix D - Part info sheetEvaluation of the ong>Ecomindsong> initiative- Information for ParticipantsHere are more details about this research for you to keep and details of who to contact if you wouldlike to know more.The Big Lottery Fund’s Changing Spaces programme has granted Mind a financial award to managean open grant scheme, called ong>Ecomindsong>, which aims to fund environmentally-orientated projects. Thefunded projects will involve people with direct experience of mental distress and help integrate theminto the community using projects conducive to good mental and physical health. The University ofEssex has been commissioned by Mind to evaluate this ong>Ecomindsong> project.Taking part in the research is on a purely voluntary basis and participants are free to withdraw atany time without prejudice and without providing a reason. All data collected will be anonymous andwill be held by the University of Essex in hard copy for the duration of the ong>Ecomindsong> scheme andelectronically for up to 2 years after this. The data will only be accessible to the researchers RachelHine and Jo Barton at the University of Essex, and will not be passed on to any third party.If you have any questions or if you would like to withdraw your data from the research thenplease contact the key researcher Rachel Hine, either by post: iCES - Interdisciplinary Centre forEnvironment and Society, Department of Biological Sciences, University of Essex, Wivenhoe Park,Colchester CO4 3SQ or by phone: 01206 872219 or email: rehine@essex.ac.ukPlease fill out the consent form below, then tear or cut it off and hand it back to project staff.Consent FormIf you wish to participate please read and tick the first four boxes.If you do not wish to participate please tick only the fourth box.I have read and understood the project information above..........................................................I understand that my participation in the research is voluntary and that I amfree to withdraw from the study at any time without giving a reason.........................................I understand that all of the non-anonymous information I provide(my date of birth and initials collected for identification purposes)will be kept confidential, as described above................................................................................I agree to take part in the study. Taking part in the study may includecompleting questionnaires or taking part in interactive workshops..............................................I do not agree to take part in the study.........................................................................................Name of Participant Signature DatePlease tear off this consent form and hand back to project staff – Thank you


An evaluation for Mind 109Appendix E - Pre-post coversheetActivity Coversheet FActivity Coversheet F is to be completed by the project officer for every Before/after session evaluationand is to be included with the completed questionnaires C and D when returned to University of Essex.Please can you complete the following information...1. Approximately how long did the group spend doing activities outside during today’s session?2. What types of activities were they participating in?3. What was the weather like today?4. Any other comments relevant to the research?Thank you very much for completing the coversheet for this session.Please put this coversheet with the questionnaires and return to in the reply-paid envelopes or justsend by Freepost to:Rachel Hine,Centre for Environment and Society,University of Essex,Freepost NATE1541,Colchester CO4 3SBR.Any queries please contact Rachel Hine on 01206 872219, 07789 541175 or email: rehine@essex.ac.uk


8789_Ecomind_Project_Directory_v7.indd 1 16/10/2013 14:168198 a-w 2:Layout 1 2/10/13 11:25 Page 1Making sense ofecotherapyFeel better outside,feel better inside:Ecotherapy for mental wellbeing,resilience and recoveryong>Ecomindsong>Directory of projects 2009-2013The Economic Benefits of ong>Ecomindsong>A case study approachecotherapyJuly 2013These documents are downloadable atmind.org.uk/ecotherapyTo find your local Mind, visitmind.org.uk/mind_in_your_areaMind15-19 BroadwayLondon E15 4BQcontact@mind.org.uk@MindCharity/forbettermentalhealth

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