title: Evaluating the Health and Wellbeing Benefits Associated with Outdoor Interventions: Informing the Development of Natural Health Services
Creators: name: Austin, C
Publisher: name: Liverpool John Moores University
Year: 2021

description: Outdoor interventions are proposed as effective health and wellbeing interventions and include activities, such as horticultural therapy, conservation volunteering and walking programmes. An array of outdoor interventions are currently being delivered in the UK to improve health and wellbeing with varying definitions, delivery and evaluation frameworks. A multitude of health and wellbeing outcomes have been associated with outdoor interventions (e.g. improved physical fitness, reduced symptoms associated with long-term conditions, improved wellbeing and social interaction). Less is known, however, about how these outcomes are gained, so that outdoor interventions can be delivered to influence these outcomes, and how these associated outcomes can be sustained long-term. This thesis extends beyond the current knowledge and understanding of outdoor interventions through a series of consecutive studies, exploring the definitions, delivery frameworks, associated health and wellbeing outcomes and evaluation protocols to capture such outcomes. Findings gained will inform the future design, delivery and evaluation of the Mersey Forest’s Natural Health Service and similar outdoor interventions to improve health and wellbeing. Study 1 interviewed 14 sector leaders (N=14) with policymaking, funding and research roles from outdoors, health, physical activity and therapy perspectives within outdoor interventions. Thematic analysis (TA) revealed unique insight into sector leaders knowledge of what is currently delivered in the UK (generically targeted, inclusive and accessible outdoor interventions with diverse psychosocial outcomes associated) as opposed to what they proposed should be delivered (specifically targeted and tailored outdoor interventions to those in greatest need, i.e. those with mental health conditions). Key delivery components within outdoor interventions, suggested to positively influence associated health and wellbeing outcomes, included the appropriate settings of outdoor interventions, the individual differences of participants, as well as the duration and difficulty of activities. Whereas mixed methods evaluation protocols were proposed to gain rigorous and robust data surrounding the effectiveness of outdoor interventions as health and wellbeing interventions, while enabling the further exploration of key delivery components, to inform future delivery. Study 2 interviewed 16 facilitators (N=16), who were currently delivering outdoor therapy interventions to examine how Study 1 findings, from sector leaders, translated into current practice. TA themes highlighted challenges faced by facilitators in defining their own outdoor therapy practice and positioning their work within the broad scope of outdoor therapy interventions delivered in the UK. Findings emphasised the impact of the lack of clarity within the literature surrounding the definitions of outdoor therapy interventions, on those delivering and participating in them, as a consequence. Insight into participant demographics (e.g. those who were ‘stuck’ and experiencing difficult life challenges) and components within the delivery of outdoor therapy interventions (e.g. the skills and competencies of the facilitators, opportunities to engage with nature and the perceived escape from stress) suggested to influence therapeutic outcomes (including improved mood, reduced stress and increased self-beliefs) were revealed. Facilitators also demonstrated innovative solutions to combine rigorous and robust evaluation protocols, while remaining flexible to outdoor therapy interventions, by adapting validated therapy measures to suit an outdoor therapy context. Finally, a mixed-methods study (Study 3) evaluated the effectiveness of outdoor interventions in improving health and wellbeing outcomes in 144 participants (N=144). Participant’s health and wellbeing was assessed across three time points, before their first session (time 0), at the end of twelve weekly sessions (time 1) and twelve weeks after completing the sessions (time 2) using validated questionnaire measures (SF36v2, WEMWBS, POMS and the RSES). Associated outcomes included improved self-reported health, wellbeing, and physical activity ratings (e.g. improved vitality, physical fitness, improved mood). Whereas TA themes from a sample of participants (n=8) and facilitators (n=3), who were interviewed after engaging in and delivering Nature4Health interventions, strengthened the quantitative health and wellbeing outcomes. Themes also identified that participants perceived autonomy, afforded though the voluntary nature of the Nature4Health interventions, the choices of activities (e.g. choice of tasks or routes walked) and levels of engagement (e.g. solitary tasks to engaging in group tasks) further promoted engagement and positively associated health and wellbeing outcomes, having important implications for future delivery. These PhD findings will therefore inform and encourage the successful delivery of a Natural Health Service and similar outdoor interventions, by effectively engaging those who would benefit most (e.g. those experiencing loss, challenging circumstances), utilising key delivery components linked to engagement (e.g. enabling choice, positive relationships with facilitators, with outdoor interventions conducted in appropriate settings) and improving health and wellbeing (e.g. improved physical fitness, decreased anxiety, increased self-esteem). The mapping of key delivery components onto relevant behaviour change models (e.g. the COM-B, BCW and TDF) and corresponding behaviour change techniques (e.g. restructuring the physical environment, overcoming barriers and implementation interventions), extends beyond the theoretical literature to date, with implications to apply these findings to the delivery of a Natural Health Service and similar outdoor interventions delivered within a wider context. Future evaluation protocols should seek to further specify key delivery components, which influence the desired health and wellbeing outcomes, to continue to inform and develop the Natural Health Service and similar outdoor intervention’s successful delivery.