I am an occupational therapist, and I mainly work in pediatrics. I have a lot of experience in schools, early intervention, and private practice. What I am presenting today is a snippet of a longer continuing education course that I developed as part of my capstone for my post-professional doctoral program at Nova Southeastern University. The idea today is to get all of you to start thinking about interventions along the outdoor continuum.
Olmstead, one of the developers of New York Central Park, was quoted as saying, "Viewing nature employs the mind without fatigue and yet exercises it; tranquilizes it and yet enlivens it; and thus, through the influence of the mind over the body, gives the effect of refreshing rest and reinvigoration to the whole system." Thus, it is important to get into nature as seen in Figure 1.
Figure 1. Nature pics.
I briefly wanted to discuss a few books, websites, and peer-reviewed journal articles that I have found that really support the health benefits of participation in nature and occupational therapy's role. A lot of these books have informed my work shown in the graphic in Figure 2.
Figure 2. Some resources.
We have Richard Louv's, "The Last Child in the Woods," and his second book, "Vitamin N." There is a book by Wallace Nichols called "Blue Mind," where it talks all about the ocean, and how we all have a strong desire to be near things that are blue and different bodies of water. There is "The Nature Fix," which I really enjoyed. It talks about the individual author's journey of finding evidence that nature is beneficial and creates positive experiences. She traveled all over the globe and shares great stories and studies that are being done internationally. There is also the "Therapeutic Gardens: Design for Healing Spaces," coauthored by Amy Wagenfeld. She is a good friend of mine and was my residency supervisor. She is one of the only OTs that I have found so far that discusses OT in relation to nature. She believes that OTs need to have a seat at the table in designing spaces as we can use our ability to understand the person, the environment, and the occupation to promote participation. Amy has been involved with a lot of really interesting things that I will talk about later. The final one, and it is not on this slide, is called "Eat Dirt." It is about how microbes, that are found in dirt, can positively influence stress.
This was a term coined by Richard Louv in 2008. In his book, "The Last Child in the Woods," he talked about children not spending as much time outdoors as in past generations. He stated this could be due to several factors, including over-scheduling, but he focused mainly on safety and access as the issues. He said that children are not likely able to roam their neighborhoods freely or explore nature. Due to fear of injury or abduction, they tend to stay closer to home, and often, in the home. Another issue is the rise of technology. In many playgrounds, the equipment has been eliminated to avoid any risky play. We are in a very litigious society. Richard Louv called for a return to unstructured play outdoors and on playgrounds. As occupational therapists, we have to consider perceptions of safety and liability as well.
- Increased risk of sedentary behaviors lead to obesity (Prentice-Dunn & Prentice- Dunn, 2012)
- 9.4% of children 2-17 years of age are diagnosed with ADHD (CDC, 2018)
- Children are spending 8 hours per day on technology
Here are a few trends that have informed this course about what is really happening out there in practice and in the larger world in which we practice. There is an increased risk of sedentary behaviors that leads to obesity. We have 9.4% of children, age two to 17, diagnosed with ADHD. Children are spending eight hours per day on technology, on average, and the World Health Organization, in 2002, said that there were two million deaths per year as a result of physical inactivity.
Occupational Therapists' Alignment to the Use of Nature
- Approaches to intervention such as create, establish, maintain, modify and prevent;
- Outcomes related to the enhancement of occupational performance, prevention, health and wellness, quality of life, participation, and occupational justice
As OTs, how can we consider context and participation? As we will talk about a little later, nature can ameliorate a lot of our clients' symptoms. We tend to work with clients who are stressed, depressed, apathetic, have decreased emotional regulation, children with ADHD and autism, and older adults with dementia. Even though the literature spans many different disciplines, the Occupational Therapy Practice Framework (OTPF) talks about the different types of approaches that we can use, including the most reductionistic looking at body functions and our motor and process skills that are essential for occupation and for general health promotion. We can start with personal factors, but then we can also think about our approaches to intervention. It is within our scope of practice to create opportunities for people to establish and restore, and then maintain those skills. This is that direct intervention of increasing joint integrity, mobility, social relationships, environmental modification, etc.
When we think about the use of nature, we can think about creating programs, establishing interventions outdoors, and helping people to maintain their areas of occupation that are important to them. We can also think about outcomes as well. Occupational therapy looks at outcomes related to enhancing occupational performance at the individual, group, and population level. For participation, we look at health and wellness. Literature has emerged that states that participation in natural environments can be restorative, provide much needed physical activity, and assist with health promotion and prevention of illness. I believe that participation in natural blue and green environments is something that can and should be promoted by occupational therapy. Occupational therapy roles include advocacy for time spent outdoors, education of others about its health benefits, and then providing direct interventions outdoors. It all falls well within our scope of practice. Occupational therapy is perfectly aligned to promote health through outdoor participation, and I believe very importantly, model the use of nature and interventions. Later, I will show you programs like edible gardens that we could create. We can also education pediatricians about movement and nature prescriptions. Then, finally, we can help to remove socioeconomic and disability barriers to help people to participate in spite of barriers.
Theory Supporting Participation Outdoors
- Attention Restoration Theory
- Biophilia Hypothesis
- Psycho-evolutionary framework
As we move forward, there are several theories that we can cite when we are articulating why we are helping our clients to participate in nature and developing programs.
Attention Restoration Theory
The first one is Attention Restoration Theory, and this is cited a lot in the literature, but the person who we attribute it to is Kaplan, in 1995. He says that participation in nature offsets everyday stress and attentional fatigue. This theory states that humans are forced to attend to necessary but uninteresting aspects of daily life, and therefore, we become fatigued, directing our attention to these tasks. When we participate in natural outdoor environments, it allows us to recover from this directed action fatigue, as he calls it. This occurs through something called soft fascination, which is a property of engaging outdoors in which one does not exert attentional effort, it allows the mind to rest.
The second theory I want to discuss is the Biophilia Hypothesis, and this is cited in the literature by Wilson in 1993. He says that we are genetically programmed to positively respond to the natural environment. We are drawn to natural environments that support success and survival.
Finally, Aldrich says that modern humans have an innate preference for certain types of settings. Early humans recognized these low-risk settings that provided opportunities for rest and fostered successful survival. We want to have that same type of preference.
Health Benefits of Participating Outdoors
In the next several slides, I'll be talking about some of the different health benefits that I found in the literature. I would like you to consider all of the different interventions that we could provide and how you could articulate that in your practice, and how your population or the individual you are working with would benefit from an intervention outdoors.
Vital Signs and the Immune System
- Miyazaki and Lee (2004) leisurely forest walks compared with urban walks
- Viewing aquariums with high levels of marine life (Cracknell, 2014)
The first that I want to discuss is vital signs and the immune system. Miyazaki and Lee did a study in which they compared leisurely forest walks with urban walks. They found with these leisurely forest walks that there was a 12% decrease in cortisol levels, 7% decrease in sympathetic nerve activity, 6% decrease in heart rate, and 1.4% decrease in blood pressure. This is called forest bathing in Tokyo, and it is used to increase restoration. After three days of hiking for several hours per day, the subjects had a 40% increase in natural killer cells, or NK cells, that lasted seven days.
In addition to the Miyazaki and Lee study, Cracknell, in 2014, completed a study in which they were looking at levels of marine life and how that impacted people, and they found that viewing aquariums with higher levels of marine life, was associated with greater reductions in heart rate and greater increases in self-reported mood. I think that is very interesting as we do not always have the ability to get our clients outdoors. So, even something as simple as viewing an aquarium with high levels of marine life can be something that can contribute to changes in vital signs and the immune system.
- 50% increase in asthma from 1980-2000
- Increase in tree-lined streets=Decrease in childhood asthma
(Lovasi et al., 2008)
In terms of respiratory health, we see that there was a 50% increase in asthma, from 1980 to 2000. The CDC says that 8.3% of children, aged 18 and below, have asthma. There was a study by Lovasi et al., 2008, that looked at the density of tree-lined streets and childhood asthma in New York City. They found an increase in tree-lined streets resulted in a decrease in childhood asthma.
- 90% comes from ultraviolet B radiation from the sun
- Deficiency linked to a number of diseases
(Reeves et al., 2014)
Another area that shows some of the health benefits of nature is vitamin D. Ninety percent of the vitamin D that we have and use in our body comes from ultraviolet B radiation from the sun. A small amount of these fat-soluble molecules can be obtained in a diet, but again, 90% comes from the sun. A deficiency in vitamin D has been linked to a number of diseases including metabolic disorders, autoimmune conditions, psychiatric, respiratory, and cardiovascular disorders. Lack of vitamin D can affect preeclampsia. There is a role for the educating of women of childbearing age, even though occupational therapists might not particularly work with pregnant women as a population.
There are low vitamin D levels in nursing home residents that are strongly associated with dementia. Occupational therapists can advocate for increased time spent outdoors with our nursing home residents to get some of that direct sunlight. Many times, when we do take older adults outside, we end up sitting them in the shade or covering their skin.
Physical Activity and Balance
- Balance. Hiking has positive effects on static balance; with girls displaying more improvement in balance than boys.
- Physical Activity. Casey et al. (2015) total physical activity was up to 3.3 times higher outdoors than indoors.
- Children who spent 1 hour or more outdoors had 4.4% less sedentary time than those who did not.
In terms of physical activity and balance, we found that hiking can have a positive effect on static balance, even more so in girls than in boys. In this study that I am citing, 24 male and female adolescents, aged 19 to 21, hiked every day for 20 days. This was found to have positive effects on balance. In terms of physical activity, the overall takeaway from the Casey et al. study was that total physical activity was 3.3 times higher outdoors than indoors. Thus, the children were participating more outdoors. And, when children spend one hour or more outdoors, they had a 4.4% less sedentary time, in general. One hour or more of less sedentary time tells us that being outdoors might change habits.
Vision and Sleep
- Vision- Rose et al. (2008) participation outdoors was found to be protective against myopia in children
- Natural, bright light improves attention and sleep (Harb, 2015).
- Children who get exposure to outdoor light in the morning (as compared to staying indoors) actually set their body clock for a better night’s sleep (Rensselaer, 2010).
There are also health benefits related to vision and sleep. Rose et al., in 2008, talked about participation outdoors being protective against myopia. Myopia is an eye condition, in which distant objects appear blurry and close objects appear normal. They thought it may be related to the low accommodative demand in distance vision or the light intensity indoors. Higher light intensity and increased pupil restriction activity outdoors may result in less image blur. I think this study is highly relevant. It provides justification for another health benefit of OT.
In addition, natural bright light improves attention and sleep. We know that children and adults all perform better when they are getting the right amount of sleep. To go along with that, adults who have short sleep patterns, less than seven hours per day, report more obesity, being more physically inactive, and are more likely to be smokers as compared to those getting the recommended seven hours per night. Children who get exposure to outdoor light in the morning, as compared to staying indoors, set their body clock for a better night's sleep.
Emotional Regulation and Mental Health
- Berto (2014) states that increased accessibility to forest and green spaces increase happiness and result in improved mood and concentration.
- Green spaces lower stress, anger, depression in people of all ages.
- Protective association between greenness or green space and risk of depression (Bezold et al., 2018)
There are many researchers out there looking at emotional regulation and mental health and the relation to being outdoors. Rita Berto has a lot published in this area. She has stated that green spaces can lower stress, anger, and depression in people of all ages. Increased accessibility to forest and green spaces increases happiness and results in an improvement in mood and concentration. Bezold found a protective association between greenness and green space and a risk of depression. In a systematic review, Fowler, 2010, found that participation outdoors was the most common health outcome related to emotions. He said the negative emotions of anger and sadness decrease after exposure in a natural environment.