PLANT FOR LIFE Briefing Report 11: January 2006 Ross Cameron and Sarah Swan University of Reading

The Green Health Agenda The psychological and physical health benefits associated with the natural environment appears to be gaining political momentum. In their recent report Ecosystems and human well-being, The World Health Organisation acknowledges that natural ecosystems not only provide humans with physical and nutritional requirements, but they impact on our psychological health as well (Corvalan, et al. 2005). People and communities obtain many non-material benefits from ecosystems. Ecosystems provide sites and opportunities for tourism, recreation, aesthetic appreciation, inspiration and education. Such services can improve mental health, enhance a subjective sense of culture or place; and also enrich objective knowledge of natural and social sciences. Health benefits of these services may be materially less tangible than those captured by conventional health indicators or standard economic evaluation measures, but they are highly valued by people in all societies nevertheless. On the domestic agenda too, Green Space has entered the health of the nation debate. The Forestry Commission has just released their scoping study on the economic benefits to be associated with access to green space in terms of improved health for UK citizens (Crabtree et al., 2005). This report highlights the growing concern in government with the health status of the population and its increasing sedentary lifestyle. 23% of males and 26% of females in the UK are classified as

sedentary. The cost of physical inactivity in England is estimated at 8.2bn per year with an additional 2.5bn as the contribution of inactivity to obesity. The Public Health White Paper from the Department of Health has, as three of its six overarching priorities, reducing obesity, increasing exercise and improving mental health. The report states that Green Space can contribute to the delivery of all of these objectives. Green Space is seen as a major resource for physical activity, especially walking, running and cycling (the extent to which urban and rural Green Space contribute is not made clear). Regular physical activity is highly efficacious in the prevention of illness and as a therapeutic intervention for existing illness. Physical activity is beneficial (preventative and therapeutic) for cardiovascular disease, musculo-skeletal diseases, stroke and cancer. The report outlines that access to, and use of,Green Space has benefits for psychological health but these are more difficult to quantify with the evidence available. Crabtree et al. (2005) identified there were still a number of gap areas for determining the benefits of access to green space. These were: 1. The value of psychological benefits from Green Space (from physical activity and less active use). 2. Relative risk information for different age groups and the time profile of risks when exercise is continued or discontinued. 3. Information on the benefits from increased physical activity to people who are intermediate in activity between the totally sedentary and those taking frequent physical activity 4. Improved evaluation of activity programmes with measures of health outcomes, drop out rates, added benefits and programme costs. The reports main findings are summarised 1. A permanent reduction of 1% unit in the UK sedentary population (from 23% to 22%) is estimated to deliver a social benefit of up to 1.44bn per year. This

does not include psychological benefits from Green Space. The evidence on this aspect is limited but benefits may be substantial. 2. Accessible, attractive Green Space is associated with autonomous physical activity. There is evidence that people are more likely to engage in frequent physical activity (with a lower rate of obesity) in locations that have high quality Green Space and a well cared-for environment. 3. Green Space is most valuable as a physical activity resource where it is used regularly by high volumes of people (mainly in an urban context). It needs to be accessible, attractive, and of sufficient size to facilitate activity (or connect to other areas). Sports fields generally deter undedicated use. Remote Green Space is generally less valuable as a health resource, when assessed in terms of its ability to facilitate high volume and frequent physically active use. 4. Passive use of Green Space (e.g. visual), low-level physical use (e.g. picnicking and social activities) and intermittent or irregular use i.e. not on a weekly or daily basis, is unlikely to give significant physical benefits. However, this use is associated with psychological and quality of life benefits. There is a lack of evidence as to the size of the benefits using validated health and quality of life scales. 5. There is a general lack of information on the long-term benefits of programmes that encourage Green Space-based physical activity. Data collection in organised programmes is weak and needs to concentrate on additional benefits, long-term behavioural change (drop out rates) and programme costs including costs to participants. There is a need to incorporate a standardised assessment of physical activity and brief health and quality of life information on people entering them. This would provide ongoing baseline data for more extensive follow up studies, and for community studies assessing awareness and willingness to use programmes.

6. The evidence available on activity programmes that use existing Green Space indicates the potential for cost-effective health benefits at low cost if running costs are low. Capital expenditure for woodland or other Green Space-based physical exercise projects is minimal by comparison with gyms and leisure complexes. Much depends on generating added interest by attracting relatively sedentary people into the programmes. 7. The key attribute for classifying Green Space in relation to health is its functionality in relation to physical activity. A dichotomous classification would split Green Space into: That which facilitates physical activity (through scale, attraction and accessibility or through connectedness, including networks of paths); and That which does not.

The report also concluded that with the current evidence base it is not possible to provide a more detailed classification based on the characteristics of Green Space that encourage autonomous use for physical activity. Similarly, it is not possible to classify Green Space according to the psychological benefits it delivers. As the evidence base is extended it should be possible to create a more detailed classification of Green Space in relation to health benefits. Although there is scientific evidence to suggest that well-managed Green Space can encourage physical activity and may improve mental well-being, it is rarely prescribed by medical professionals. A recent paper by Pretty et al. (2003), states that Intuition, experience and some evidence support the notion that nature contact should be seen as a positive health intervention, yet health professionals have not widely adopted horticulture, wilderness, nature or animal therapy. The Pretty et al. (2003) report also goes on to re-emphasise the possible problems associated without providing access to Green Space.

If nature is important to humans, then deprivation is likely to create problems. Kellert (1993) suggests that a degraded relationship to nature increases the likelihood of diminished material, social and psychological existence. Thus increasing disconnections between people and nature will have an impact on individuals, on their communities and cultures, and ultimately on how they treat and care for nature. These disconnections are now a common part of many lifestyles in modern industrialised societies with increasing numbers of people living in urban areas, and fewer people having daily or routine contact with nature. Wilson (1993) asks what will happen to the human psyche when such a defining part of the human evolutionary experience is diminished or erased? There is a well-established literature that shows that the physical and social features of the environment affect behaviour, interpersonal relationships and actual mental states (Newman, 1980; Freeman, 1984, 1998), as well as shape relations with nature (Pretty and Ward, 2001). The design of the built and natural environment thus matters for mental health (Kaplan et al., 1998; Freeman, 1984; Halpern, 1995). People seem to prefer natural environments to other settings, and the benefits go beyond just enjoyment. Kaplan et al. (1998) indicate that such natural settings need not be remote wildlands, and emphasise the value of the everyday, often unspectacular natural environment that is, or ideally would be, nearby parks and open spaces, street trees, vacant lots and backyard gardens, as well as fields and forests. Equally, a dysfunctional built environment can often be a source of stress, and a malign influence over social networks and support mechanisms. Despite this, we seem not to care. Halpern (1995) asserts almost no reference is made by planners to the psychological literature. What does gardening mean to people ? A number of recent reports focus on gardening specifically, as a green activity and highlight the advantages (and some drawbacks) of this activity for different user groups. Unruh (2004) provides a paper which compares the meaning of gardens and gardening in daily life for people with serious health problems. Twenty-seven women and 15 men were interviewed about the meaning of gardens and gardening in their daily life. Eighteen participants were diagnosed with cancer. The majority of the

participants were aged 45 to 65 years. Approximately 2/3 of the gardens were located in small towns or rural areas of Nova Scotia, Canada. The interview questions were semi-structured and used as conversational prompts to explore interest in gardening; relationships between gardening, health and well-being; and frustrations with gardening. Comparisons were drawn between the meaning of gardening for people with cancer and people without cancer. The study revealed important benefits of gardening on physical, emotional, social, and spiritual well-being, and highlighted a key role of gardening as a coping strategy for living with stressful life experiences. Milligan et al, (2004) also explored the role gardening played in peoples lives in terms of emotional well-being. In particular, they examined how communal gardening activity on allotments contributed to the maintenance of health and well being amongst older people. Drawing on research in northern England, they examined firstly the importance of the wider landscape and the domestic garden in the lives of older people, then focused on gardening activity on allotments. Milligan et al, (2004) concluded that older people can gain a sense of achievement, satisfaction and aesthetic pleasure from their gardening activity. However, while older people continue to enjoy the pursuit of gardening, the physical shortcomings attached to the aging process means they may increasingly require support to do so. Communal gardening on allotment sites, they maintain, creates inclusive spaces in which older people benefit from gardening activity in a mutually supportive environment that combats social isolation and contributes to the development of their social networks. Similar studies evaluating the role of community gardens in the USA produced similar conclusions. Approximately one-third of the participants developed new friendships through community gardens (Patel, 1991). Patel concluded that gardening promotes a community atmosphere and gives people an opportunity to meet others, share concerns, and solve a few problems together. In his study, almost a third helped others and 14% shared their produce. What stood out in his responses was that through gardening, participants felt good about themselves and their ability to cope with the world around them. Behaviour as a social group was modified by the

presence of plants and participation in gardening activities; and gardening served as a way to break down some of the social barriers existing between neighbours. Community garden activities have also been shown to help empower individuals in the UK. The taste of a better future project aimed to empower ethnic minority women to grow their own organic food in land close to their homes (Rycroft, 2000). The author reports that All of the women said their lives had changed for the better; the project had made them happier and helped them to fight boredom. Many of the participants claimed they saw the vegetable garden as a place of natural beauty and helped provide a connection to their country of origin. Milligan et al., (2004) suggest communal gardening sites offer a practical and cost-effective way to help develop a ' therapeutic landscape'Another study (Brown et . al. 2004) examined the effects of indoor gardening on socialization, activities of daily living (ADLs), and perceptions of loneliness in elderly nursing home residents. A total of 66 residents from two nursing homes participated in this two-phase study. In the first phase, one experimental group participated once a week for 5 weeks in gardening activities while a control group received a 20-minute visit. While no significant differences were found between groups in socialization or perceptions of loneliness, there were significant pre-test and post-test differences within groups on loneliness and guidance, reassurance of worth, social integration, and reliable alliance. The results also demonstrated gardening interventions had a significant effect on three ADLs (transfer, eating, and toileting). The second phase examined differences in the effects of a 5-week versus a 2-week intervention program. Although no significant within-group differences were noted in socialization, loneliness, or ADLs, the 5-week program was more effective in increasing socialization and physical functioning. Continuing with the theme of older people, another study by Infantino (2005) discusses gardening as a strategy for health promotion in older women. According to this paper preliminary research has identified gardening as an activity that may be cognitively protective (helps keep the brain functioning in terms of learning and reasoning skills). Clarification of gardening as a concept is a first step toward the

development of theory that will enable nurses to develop interventions related to gardening. The study aimed to describe the phenomenon of gardening. Using a phenomenological methodology, interviews with five older women were analysed. Four themes emerged: "Gardening is challenge and work," "Gardening is connection," "Gardening is continuous learning," and "Gardening is sensory and aesthetic experience." The author states the phenomenon of gardening is analogous to the relationship between a spider and its web, linking internal and external environments and providing support over a lifetime. It appears that the gardening experience, as an evolving lifelong process, sustains older women in their cognitive and spiritual development. In contrast to some of the aforementioned findings, research by Bloedel et al. (2000) did not show a relationship between gardening activities and a sense of control, when a study was conducted on an elderly individual. Sense of control is important to elderly and disable people in providing value to their lives (for example, a degree of independence and control over their activities helps maintain a positive attitude for people in residential care). The authors acknowledge though that the population sample was too small to make any hardline conclusions. A recent paper by Sderback et al. (2004) highlights the role of horticultural therapy in Sweden and patients rehabilitation following brain damage. Forty-six patients with brain damage participated in group horticultural therapy. The horticulture therapy included imagining nature, viewing nature, visiting a hospital healing garden and, most important, actual gardening. It was expected to influence healing, alleviate stress, increase well-being and promote participation in social life and re-employment for people with mental or physical illness. The results obtained suggests horticulture therapy does mediate emotional, cognitive and/or sensory motor functional improvement, increased social participation, health, well-being and life satisfaction. However, the authors felt the degree of effectiveness, especially of the interacting and acting forms, requires further investigation. Gardening based injuries

A survey carried out by Powell et al. (1998) aimed to estimate the frequency of injuries associated with five commonly performed moderately intense activities: walking for exercise, gardening and yard work, weightlifting, aerobic dance, and outdoor bicycling. National estimates were derived from weighted responses of over 5,000 individuals contacted between April 28 and September 18, 1994, via randomdigit dialling of U.S. residential telephone numbers. Self-reported participation in these five activities in the late spring and summer of 1994 was common, ranging from an estimated 14.5 of the population for aerobics (nearly 30 million people) to 73.0% for walking (about 138 million people). The estimated number of people injured in the 30 d before their interview ranged from 330,000 for outdoor bicycle riding to 2.1 million for gardening or yard work. During walking and gardening, men and women were equally likely to be injured, but younger people (18-44 yr) were more likely to be injured than older people (45+ yr). Injury rates were low, yet large numbers of people were injured because participation rates were high. Most injuries were minor, but injuries may reduce participation in these otherwise beneficial activities. The authors conclude that additional studies are needed to confirm the magnitude of the problem, to identify modifiable risk factors, and to recommend methods to reduce the frequency of such injuries. Emotional responses to flowers and evolutionary behaviour A recent study published by Haviland-Jones et al. (2005) in the Journal Evolutionary Psychology aimed at understanding human response to flowers. The authors claim that for more than 5000 years, people have cultivated flowers although there is no known reward for this costly behaviour. They carried out three different studies in an attempt to show that flowers are a powerful positive emotion inducer. In Study 1, flowers, upon presentation to women, always elicited the Duchenne or true smile. Women who received flowers reported more positive moods 3 days later. In Study 2, a flower given to men or women in an elevator elicited more positive social behaviour than other stimuli (e.g. a gift of a pen). In Study 3, flowers presented to elderly participants (55+ age) elicited positive mood reports and improved episodic memory, but did not increase social contact between recipients. The authors conclude that flowers have immediate and long-term effects on emotional reactions, mood,

social behaviours and even memory for both males and females. There is little existing theory in any discipline that explains these findings. They suggest that cultivated flowers are rewarding because they have evolved to rapidly induce positive emotion in humans, just as other plants have evolved to induce varying behavioural responses in a wide variety of species leading to the dispersal or propagation of the plants. Indirect support for Wilsons, Biophilia theory (Wilson, 1984), comes from a paper by hman et al. (2001). These authors showed that images of potential threats (in this case photographs of snakes and spiders) were selected more rapidly from a matrix of images, than more benign images such as flowers or mushrooms. The authors conclude the brain works in a different way when determining threat signals from non-threatening images. This intrinsic and early response to images of natural threats, may provide addition evidence for Wilsons theory that we retain emotional responses relating to our evolutionary past.

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