e-Natureza: Affective Validation of Nature Images as a Complementary Resource for Promoting Well-being in Hospital Environment
Phase: NA
Conditions: Cancer
Sponsor: Hospital Israelita Albert Einstein

 
 
e-Natureza: Affective Validation of Nature Images as a 
Complementary Resource for Promoting Well-being in Hospital 
Environment 
 
 
 
 
 
 
 
PROTOCOL  
 
 
 
 
 
 
Sao Paulo, Brazil  
 
 Approved in the first version in 01/31/2017 
 
Human subjects protection review board number: 
Hospital Israelita Albert Einstein Research Ethics Committee 
                      
 

  
 
1. Summary 
Of all the animals that inhabit the earth, man is the only one that has a 
differentiated relationship with nature. Besides belonging to it, like other 
species, it has established, throughout its trajectory, other relations in search of 
understanding it, dominating it, exploiting it, whether for the purpose of survival, 
recreation, financial enrichment or even conservation 
The establishment of power relations in relation to the surrounding nature 
without the necessary awareness of the inevitable consequences has led to the 
critical thresholds that have been widely discussed, today, on the aegis of 
environmental sustainability. Sustainability is understood here as the 
maintenance of the functions and components of the ecosystem, in a 
sustainable manner and can also be referred to as the ability of the natural 
environment to maintain living conditions for people and other species and the 
quality of life for humans, taking into account habitability, the beauty of the 
environment and its role as a source of renewable energy. This dynamic 
environment has as main objective to stimulate the best in individuals and in the 
environment for the present and an unknown future. Although an evolving 
concept, it seeks to ensure that future generations have access to natural 
resources (Our Common Future, 1998), many of which are currently under 
threat. 
This is a relevant aspect and the most addressed in the literature, but there 
is another one of fundamental importance that is characterized by the 
interrelationship between nature and human health conditions. 
From the very beginnings of existence the idea that contact with nature 
provides harmony and balance to human beings is quite common. It is also 
clear that this relationship can also cause suffering, for example in situations 
involving animal accidents or natural disasters. 
It is a fact that, over time, man by adopting new lifestyles (not always so 
healthy) has been moving away from the contemplative moments with nature 
and, consequently, of its possible benefits on physical, mental, emotional and 
spiritual. The contemporary lifestyle has generated stressful living conditions, 

  
 
which is reflected in physical and psychic illness, which includes cardiovascular 
disease, obesity or burnout. Such an impact on health has led to the need to 
understand and prevent the deleterious effects associated with modern life in 
societies (Joye, Pals, et al, 20  ). 
On the other hand, especially in large metropolises, there is little room for 
discussion on this theme, since this distance tends to suppress the need for a 
more accurate look at the human-nature dyad in the perspective of health. 
A review of the literature that included 57 studies revealed that this topic has 
been little investigated by the health sciences, with social and environmental 
sciences being the subjects responsible for the greatest scientific production in 
this area. It is also worth noting that North America and Europe have the 
highest number of surveys (79%), and no studies are found from South America 
or Africa (Keniger, Gaston, et al.       , Although both have a rich biodiversity. 
The hypothesis that humans have an inherent inclination to contact with 
nature has been termed biophilia. The relationship between man and nature is 
represented in some way in all cultures. In the first European hospitals, gardens 
were considered an essential part of the environment to aid in the therapeutic 
processes (Grinde, Patil; 2009). 
Interactions with nature can occur in three ways: a) Indirect interaction, 
which does not require the person to be physically present in nature and may 
include activities such as observing nature in a photograph or picture or seeing 
nature through a window; 2) incidental interaction, in which the individual is 
physically present, but comes in contact with some element of nature in an 
unintentional way, it is the result of another activity (example: contacting a plant 
pot in a working environment); and 3) intentional interaction in which the 
individual intentionally seeks contact with nature, such as observing wildlife, 
gardening, or visiting a park (Keniger, Gaston, et al; 2013). 
Many people seek nature when they feel stressed. Nature-based coping 
strategies appear to be effective and there are an increasing number of studies 
demonstrating that contact with nature may have health benefits (Berg, Mass, et 
al., 2010). These benefits include positive effects on mental processes 

  
 
(increase of self-esteem, improvement of mood, reduction of negative moods, 
reduction of anxiety and promotion of psychological well-being); positive effects 
on cognitive abilities (reduction of mental fatigue, restoration of attention) and 
positive effects on physical function and health (reduction of stress, blood 
pressure, cortisol levels, headaches, among others) (Keniger, Gaston, et al. al; 
       The contact with natural elements, according to some theorists, 
produces a type of fascination that is characterized by a moderate intensity and, 
generally, centered in aesthetically pleasing stimuli that allow the opportunity of 
reflection promoting in a more efficient way the restoration of the attention 
(Gressler, Gunther, 2013). 
These studies have sought to identify the influence of natural environments 
on health, but it is not always possible to be in touch with nature to enjoy its 
potential benefits. Particular situation is constituted by the processes of illness, 
in which the individual, even if he wanted, is unable (sometimes for long 
periods) to interact with natural environments. 
In nursing, since Florence Nightingale, there is a strong concern to make 
hospital environments in restorative environments. Florence already stressed 
the importance of the patient getting up or turning in bed and see through a 
window, the sky and the sunlight, at least if it cannot be shown anything else, 
claiming to be such a measure of prime importance for the recovery, or 
something very close to it (Nightingale, 1898). 
Have, in the hospitalization unit, a window overlooking a natural landscape 
has been shown to be an adjuvant potential in the recovery of surgical patients, 
by reducing the consumption of analgesics and a shorter hospital stay (Ulrich, 
       
But the hospital buildings, in the urban context, do not always provide a 
"window with a view." When we think of health institutions, especially those that 
do not have green areas, which patients could benefit from, it has directed 
researchers to other forms of contact that may bring some degree of well-being 
to patients during the hospitalization, among them the use of photographs and 
videos (accompanied or not by music), in the perspective of an indirect 
interaction. 

  
 
Therefore, audiovisual resources are beginning to be investigated, as well 
as commercial devices that create "virtual windows" are also being developed. 
However, access to these resources is very restricted in our environment, either 
due to lack of knowledge or due to economic and financial constraints. 
The randomized clinical trials conducted with patients using natural-based 
audiovisual interventions are also incipient. Eighty patients submitted to 
bronchoscopy were exposed to static scenes and sounds of nature before, 
during and after the procedure and presented significant reduction of pain 
during the procedure. The mural was purchased commercially from a specialist 
company and consisted of a quality (42; 52-inch) photograph of a mountain and 
a stream crossing the field lying next to the patient's bed during the procedure, 
accompanied by sounds of birds and of water, ears with earphones (Diette, 
Lechtzin, et al; 2003). Thirty-seven patients were also submitted to audiovisual 
stimulation 
and 
presented 
reduction 
of 
abdominal discomfort 
during 
sigmoidoscopy (Lembo, Fitzgerald, et al., 1998). Reduction of pain and anxiety 
was also observed during dressing in a small sample of patients with burns 
when submitted to video programs with nature scenes and music (Miller, 
Hickman, Lemasters, 1992). However, in addition to the small sample 
participants, methodological failures related to randomization and blinding were 
found, as well as criteria for selection of poorly established images (Drahota, 
Ward, et al., 2012).  
If on the one hand the potential of the images of nature in the production of 
well-being has already been discussed and demonstrating its therapeutic 
potential and on the production of emotions, on the other hand, there is a 
difficulty, in clinical practice, in selecting which images can assist in diverse 
clinical situations, because there is no bank of images that are validated and 
intended for this purpose. 
The studies have not clearly indicated the selection criteria of the images 
used. They are usually thematic and landscape images, such as beaches, 
mountains, forests, which represent natural environments of the countries in 
which they are developed. This leads us to some reflections on the constituent 
elements of these images. Would the contribution of each natural element be 

  
 
similar in the same landscape? Observe, for example, photographs of birds, 
would be different to observe flowers? Which of these, among other visual 
reasons of nature, would have greater potential to trigger benefits? What kind of 
emotions do they trigger in the observer? It is necessary, therefore, to have 
some indicator to mark the selection of images for studies that aim their 
application in clinical practice. 
In this sense, another motivating aspect for the development of this study is 
the fact that the largest bank of images with validated emotions can not be 
published or divulged, much less make it available for clinical use, since its 
access is restricted to researchers. The International Affective Picture System 
(IAPS) is a library of images with hundreds of color photographs that represent 
various aspects of real life (sports, fashion, landscapes, violence, etc.) with the 
aim of evoking emotional states that can be easily presented in the 
experimental context of the laboratory, thus allowing accurate control over the 
timing and duration of exposure (Bradley, Lang, 1999; Lang, Bradley and 
Cuthbert, 2005). In Brazil, IAPS normative scores were evaluated with 707 
images of Brazilian university students, with the purpose of using them in the 
investigation of cognitive processes in normal individuals and in populations 
with neurological and affective dysfunctions (Ribeiro, Pompéia, Bueno, 2004). 
Another four sets of images are described in the literature: Geneva Affective 
Picture Database (GAPED), EmoPics, Nencki Affective Picture System (NAPS) 
and Open Affective Images (OPAFI). 
It is common to all these bases: formal access required, exclusive to 
researchers, for use restricted to scientific studies, without commercial use. The 
images can not be published and all the banks are asymmetrical, formed more 
by negative than positive images. These banks, therefore, are unique to 
research and can not be used in clinical practice, the main reason for the 
realization of the present study. In the hospital context, our interest also falls on 
images that have the potential to promote states of well-being and comfort. 
Besides knowing, the emotional responses, another relevant aspect to be 
questioned is if individuals more related to nature evaluate more positively the 
images of nature. On the other hand, exposure to images of nature can 

  
 
increase the feeling of connection with nature? Knowing this relationship is of 
particular importance not only for the use of images of nature as a potential 
resource of balance for human health, but also for uncovering ways to improve 
the man-nature relationship, in order to preserve it as well, thus expanding the 
relevance of the production and dissemination of validated images. 
There are clinical situations for which we believe that interventions based on 
nature may be particularly useful, among them, when patients undergo 
chemotherapy. 
Chemotherapy can cause a crisis in the patient's life, with physical and 
psychic impacts. In clinical use it is generally well tolerated by patients and 
moderate side effects are well controlled with appropriate dosages and 
judicious use of other drugs such as antiemetic’s (Sawada, 2009).  
On the other hand, emotional aspects can be ignored and more difficult to 
control. Some emotional reactions such as anxiety, depression and emotional 
distress can be observed during chemotherapy (Baker-Glenn, et al., 2010). 
Infusion time can be very distressing, but it can also be seen and experienced 
as a period of seclusion and rest. For many patients it is distressing because it 
can mean imprisonment or incapacitation to perform the tasks. He also appeals 
to discourse of boredom, lack of what to do (Sette, Gradvohl, 2014). Some 
researchers concluded that levels of emotional distress during chemotherapy 
are high, suggesting a clinical need for interventions to provide support to 
patients during chemotherapy (Decat et al., 2010). 
Helping patients find effective strategies for dealing with chemotherapy is an 
important task for nurses. Complementary interventions to pharmacological 
treatment aim to reduce suffering at different stages of treatment. 
Based on these scenario, we seek therefore produce and study an image 
database and validate them scientifically, aiming initially the care settings, in 
order to produce well-being for patients undergoing chemotherapy, as well as 
deepen our knowledge of man-nature connection, from the perspective of care, 
self-care and preservation. 
 

  
 
2. Objectives 
Verify the therapeutic potential of the validated images in the reduction of 
negative mood states and increase of positive states of patients undergoing the 
chemotherapy session. 
Verify the therapeutic potential of the validated images in the treatment-
related symptoms during the chemotherapy session. 
Verify if the rate of connection with nature influences the impact in the 
study outcomes. 
3. Design and methods 
The previously validated e-Natureza image bank consists of licensed 
images by nature photographers who volunteered to contribute to the 
development of the project. They are photos with predominance of flowers, 
colorful birds, white birds, landscapes, photos with predominance of trees, 
predominating the element water, with predominance of sky, photos related to 
the sea, totaling 480 images. 
The final image bank consists of the validated images that reached the 
low alert and high valence scores, that is, photos that were concentrated in the 
lower right quadrant of the figure below, with a view to promoting well-being and 
tranquility. 

  
 
 
Figure 1 - Distribution of 360 images of International Affective Picture 
System (IAPS). 
The randomized clinical trial will be conducted at the same institution, 
Albert Einstein Hospital, that the nature images were validated. The date 
collection of the clinical trial will be done in a period of 12 months, together with 
a convenience sample of patients, of both sexes, who is over 18 (eighteen), 
with clinical conditions and communication systems preserved, in other words, 
lucid, that allows the participation in the study and who are undergoing the first 
session of the chemotherapy treatment (most patients in the first session, have 
an altered emotional state, be it for fear, anxiety) independently of the type of 
oncological disease. 
The patients, after understood and signed the Informed Consent Form 
will respond to a questionnaire with sociodemographic and clinics variables 
(gender, age, marital status, schooling, profession, relationship with nature, 

   
 
diagnosis, treatment time, protocol type) for characterization of the sample 
(Appendix I). 
The patients will be allocated randomly into two groups: 1) control and 2) 
intervention group through Randomizer® software. 
After thirty minutes of the start of the chemotherapy session, the patient 
you will receive a notebook (specific to the study and blocked for other 
functions) that he can watch a presentation of nature images. It will be four 
videos with fifteen minutes each one.  
At the beginning and at the end of the chemotherapy session, each 
patient will make an assessment of the positive and negative affects and the 
physical and psychological symptoms related to that chemotherapy session.  
According to Paschoal and Tamayo (2008), measures of affection reflect 
how much the person feels enthusiastic, alert and active. The negative affect 
reflects how much the person feels displeasure and distress. According to these 
authors, one of the main affective measures used in study of general well-being 
is the Positive Affect/Negative Affect Scale, which through 20 words that 
describe feelings that should be answered on a five-point scale: "very little or 
nothing”, "a little", " moderately”, " too much”, and “excessively”, allowing use as 
a measure of state or trace. In Brazil, PANAS (Annex I) was adapted for the 
adult population by Giacomoni and Hutz and for adolescents by Segabinaz et al 
(2013), already validated elderly people in a virtual environment. 
The evaluation of symptoms during the chemotherapy session also will 
be evaluated by - Edmonton Symptom Assessment Scale – ESASBr - (Annex 
II). 
The Edmonton Symptom Assessment System (ESAS) is a widely used 
multi-symptom assessment tool, developed for the first time in 1991 by Bruera 
et al. to audit the symptoms of patients receiving palliative care. The ESAS is a 
viable, valid and reliable multi-symptom assessment tool for use in Brazil 
(Paiva, et al, 2015). 

   
 
The participants will also respond pre intervention to the Nature 
Connection Scale and Nature Relatedness Scale (Annex III and IV) because it 
is a variable that can interfere in the study's outcomes of interest. 
The control group will undergo the same evaluations as the intervention 
group and at the same time interval during the chemotherapy session. 
All evaluations will be performed in only one chemotherapy session. 
4. Statistical analysis plan 
Descriptive statistics will be applied to sociodemographic and clinical data of 
the study, with calculation of means and standard deviation.  
By means of inferential statistics, a comparison will be made between the 
states subsequently presented by the patients in the clinical trial, using SPSS 
statistical software. For analysis correlation will be used the Spearman and 
Pearson tests; for averages comparison if the sample is normal, the paired t-
test will be used; for nonparametric sample the Wilcoxon test, and the Fisher 
and chi-square tests for compare proportions. The tests will be considered 
significant when p <0.05. 
 
5. History of changes 
 
 Research Project- Version 1- submitted to Research Ethics Committee of 
the Hospital Israelita Albert Einstein in December 23, 2016; 
 Informed Consent Form Patient- Version 1- submitted to Research Ethics 
Committee of the Hospital Israelita Albert Einstein in December 23, 2016;  
 Documentation approved by the Research Ethics Committee of the 
Hospital Israelita Albert Einstein in the first version at a meeting held in 
             
 Documentation disapproved by ClinicalTrials.gov in the first version in 
            
 Documentation disapproved by ClinicalTrials.gov in the second version in 
            
 Documentation disapproved by ClinicalTrials.gov in the third version in 
          . 

   
 
6. Research ethics committee original report translated to English* 
*The original one is in Portuguese 
HOSPITAL ISRAELITA ALBERT EINSTEIN- SP 
CONSUBSTANTIATED TECHNICAL ADVICE OF RESEARCH ETHICS 
COMMITTEE 
RESEARCH PROJECT DATA 
Research title: e-Natureza: Affective Validation of Nature Images as a 
Complementary Resource for Promoting Well-being in Hospital Environment 
Researcher: Eliseth Ribeiro Leão 
Thematic area:  
Version: 1 
CAAE:                       
Proponent institution: Hospital Israelita Albert Einstein- SP 
Principal Sponsor: Hospital Israelita Albert Einstein- SP 
TECHNICAL ADVICE DATA 
Technical advice number:           
Project apresentation: In recent decades there has been a growing interest of 
researchers in understanding how the adoption of natural elements of daily life, 
including in hospital institutions, can characterize restorative environments and 
reflect in better health conditions for patients. Contact with nature can be done 
through photographs. However, there is no database of validated nature for 
clinical use (only for restricted use in research). This study aims to validate 
images of nature and verify its therapeutic potential in the care of cancer 
patients undergoing chemotherapy. Therefore, the research is divided into two 
phases. First we will build a web tool that allows the validation of nature 
photographs in accordance with international validation method. This phase will 
be conducted with students and health professionals as well as individuals from 

   
 
the general population. The validated photographs will compose a database of 
images of which low activity and positive valence images will be used in the 
randomized clinical trial with patients on chemotherapy treatment. Anchored 
with assumptions from the theory of biophilia, from Florence Nightingale's 
environmental theory, our hypothesis of study is that this intervention promotes 
subjective well-being and favors more positive moods, in addition to reducing 
symptoms. 
Research Objectives:  
Contribute to the validation of images of nature for clinical use in health 
institutions 
Specific:  
1-Develop a tool that allows the application, in a web environment, of the 
affective classification of images of nature, according to the Self-Assessment 
Manikin method (SAM). 
2-Validate the images of nature with students and health professionals and 
individuals of the general population. 
3-Compare the scores obtained with similar photos that compose the IAPS 
image bank. 
4-Verify if the factor related to nature and kinship with nature influence the 
affective validation of images. 
5-Create an audiovisual nature image resource (e-nature) for clinical use in 
patients undergoing chemotherapy treatment. 
6-Verify the therapeutic potential of the validated images in the reduction of 
negative mood states and increase of positive states of patients undergoing 
chemotherapy. 
7-Verify the therapeutic potential of validated images in the reduction of 
treatment-related symptoms during the chemotherapy session. 
8-Know the patient's perception about the intervention based on nature. 

   
 
Assessment of risks and benefits: 
According to the researcher: 
Risks: 
The participation in this research presents minimal risks, perhaps, just, some 
embarrassment (shame) that some people feel when they are providing 
information about themselves. 
Benefits: 
If the patient is drawn to the intervention group, the video may bring some 
sense of well-being to the patient during chemotherapy. If the patient is 
randomized to the control group, we do not expect immediate and direct 
benefits to him from his participation, but the results will contribute to develop a 
new form of intervention that will benefit other patients in the hospitals if it is 
effective. 
Comments and Contributions to the Research:  
- 
Consideration about the Terms of mandatory presentation: 
Informed Consent Form is written in clear and accessible language, using the 
strategies most appropriate to the culture, age group, socioeconomic condition 
and autonomy of the invited to participate in the research. 
Recommendations: 
It is the responsibility of the Research Ethics Committee to "monitor the 
development of the projects, through semi-annual reports of the researchers 
and other monitoring strategies, according to the risk inherent to the research." 
Therefore, the researcher in charge must send the Partial Reports to the 
Einstein Research Ethics Committee every six months and the Final Report of 
his project, up to 30 days after its completion. 
Conclusions or Issues and List of Inadequacies: 

   
 
Following evaluation, the following documents were approved: 
1- Research Project-  Version 1- December 23, 2016; 
2- Informed Consent Form Web-  Version 1- December 23, 2016; 
3- Informed Consent Form Patient- Version 1- December 23, 2016. 
Final Considerations at the discretion of the Research Ethics Committee: 
Documentation approved by the Research Ethics Committee of the Hospital 
Israelita Albert Einstein at a meeting held in 01/31/2017. 
This technical advice was prepared based on the documents listed below: 
Document 
Type  
File  
Posting 
Author 
Situatio
n 
Project 
Basic 
Information 
Project_Basic_Information_ 
830509.pdf 
 
         
  
         
 
Accepte
d 
Informed 
Consent Form/ 
Terms 
of 
Agreement/ 
Absence 
Justification 
Informed_Consent_Form_e_na
ture_patient_versao1.pdf 
         
  
         
Eliseth 
Ribeiro 
Leão 
Accepte
d 
Informed 
Consent Form/ 
Terms 
of 
Agreement/ 
Absence 
Justification 
Informed_Consent_Form_WE
B_version1.pdf 
         
  
         
Eliseth 
Ribeiro 
Leão 
Accepte
d 
Detailed 
Project/ 
Investigator 
Brochure 
e_Natureza_23Dez2016.pdf 
         
  
         
Eliseth 
Ribeiro 
Leão 
Accepte
d 
Others 
Responsability.pdf 
         
  
Eliseth 
Ribeiro 
Accepte
d 

   
 
         
Leão 
Others 
Reasercher_Term.pdf 
         
  
         
Eliseth 
Ribeiro 
Leão 
Accepte
d 
Others 
Participants_Term.pdf 
         
  
         
Eliseth 
Ribeiro 
Leão 
Accepte
d 
Others 
Managers_Term.pdf 
         
  
         
Eliseth 
Ribeiro 
Leão 
Accepte
d 
Cover Sheet 
Cover_Sheet 
         
  
         
Eliseth 
Ribeiro 
Leão 
Accepte
d 
 
Technical Advice Situation: 
Approved. 
Is the CONEP appreciation required? 
No. 
 
SAO PAULO, February 03, 2017 
Signed by: 
Fabio Pires de Souza Santos 
(Coordinator) 
 
 
Adress: Av. Albert Einstein 627-  2ss 
Neighborhood: Morumbi                                                          CEP: 05.652-    
Federative Unit: SP                                                                     County: Sao Paulo  
Phone: (55 11) 2151- 3729      Fax: (55 11) 2151-0273         E-mail: cep@einstein.br 

   
 
Appendix I 
QUESTIONNAIRES OF THE SOCIO- DEMOGRAPHIC AND CLINICAL DATA 
OF THE RESEARCH PARTICIPANTS 
  
Search title: “e-Natureza: Affective Validation of Nature Images as a 
Complementary Resource for Promoting Well-being in Hospital Environment“ 
 Researchers: Eliseth Ribeiro Leão, PhD 
  
Age: ________________ Gender: ( ) male ( ) female 
Status: ( ) single (a) ( ) married / partner (a) ( ) divorced (a) ( ) widow(er) 
Highest educational level: 
( ) fundamental incomplete / ( ) complete fundamental 
( ) incomplete high school / ( ) high school complete 
( ) incomplete superior / ( ) superior complete 
( ) post-graduation lato sensu / ( ) post-graduation stricto sensu 
Occupation: _____________________________________________________ 
Born in area: ( ) urban ( ) rural 
Lived in area: ( ) urban ( ) rural 
How often do you relate to nature? 
( ) never ( ) rarely ( ) often ( ) very often 
Diagnosis: ______________________________________________________ 
How long are you treating this cancer (in months)? _______________________ 
Protocol type: ____________________________________________________ 
 
*Original in Portuguese 
 
 

   
 
Annex I 
Positive Affect / Negative Affect Scale (PANAS) 
This scale consists in words and phrases that describe different feelings and 
emotions. Read each item and then mark the appropriate answer in the space 
next to each word. State how much you are feeling AT THIS TIME. 
  
  
  
  
  
  
  
Nothing or very 
slightly 
A little 
Moderately 
Enough 
Extremely 
Alert 
  
  
  
  
  
Attentive 
  
  
  
  
  
Determined 
  
  
  
  
  
Excited 
  
  
  
  
  
Excited 
  
  
  
  
  
Inspired 
  
  
  
  
  
Interested 
  
  
  
  
  
Strong 
  
  
  
  
  
Afraid 
  
  
  
  
  
Ashamed 
  
  
  
  
  
Afflicted 
  
  
  
  
  
Guilty 
  
  
  
  
  
Hostile 
  
  
  
  
  
Uneasy 
  
  
  
  
  
Nervous 
  
  
  
  
  
Terrified 
  
  
  
  
  
Upset 
  
  
  
  
  
Proudly 
  
  
  
  
  
  
*Translated and validated to Portuguese 
 
 

   
 
Annex II 
Edmonton Symptom Assessment Scale – ESASBr 
This is a symptom assessment scale. You will respond to 10 items with 
responses ranging from 0 (minimum intensity) to 10 (maximum intensity). 
Please circle the number that best describes your symptoms AT THIS TIME. 
*Translated and validated to Portuguese 
 
 
 
 
 
 
 
 

   
 
Annex III 
Connectedness to nature scale*- Mayer and Frantz, 2004 
 
*Translated and validated to Portuguese 
 
 
 
 
 
 
 
 
 
 

   
 
Annex IV 
Nature Relatedness Questionnaire* – NRQ - Nisbet, Zelenski & Murphy, 2009 
*Translated and validated to Portuguese