The effectiveness of wilderness therapy as mental health treatment for adolescents in Norway: a mixed methods evaluation

Experiences with physical activity, health and well-being among young adults with serious mental illness

PURPOSE

To explore how young adults with serious mental illness (SMI) experience physical activity and how these experiences influence their perceived health and well-being.

METHODS

Nine young adults with SMI who had participated in an aerobic high-intensity interval training program were interviewed in depth. The interviews were transcribed and subjected to reflexive thematic analysis.

RESULTS

The results indicated that people with SMI mainly experience physical activity as a meaningful activity that contributes to an increased sense of well-being and better health. However, to overcome various barriers, it is crucial to experience social support and encouragement. The following three main themes were identified through reflexive thematic analysis: (1) positive changes in focus and an increase in well-being occur through physical activity; (2) increased mental strength results from physical activity; and (3) a lack of support and feelings of safety prevent physical activity.

CONCLUSIONS

This study shows that adapted physical activity is an important resistance resource that can promote stronger self-identity, increased mental well-being and social engagement and thus contribute to an improved ability to manage stressors. Furthermore, the findings reveal that to engage in physical activity and promote sustainable life changes, it is important for individuals to choose a physical activity based on personal interest and meaning.

Program evaluation of a wilderness experience for adolescents facing cancer: A time in nature to heal, connect and find strength

OBJECTIVE

Despite advances in cancer treatment and increased survival, adolescents in treatment for cancer often suffer from psychosocial distress, negative mood, and chronic health problems. Wilderness therapy is considered a promising program to address psychosocial issues among adolescents with mental or behavioral health issues. There is little research on whether it may benefit adolescents in cancer treatment.

METHODS

This program evaluation in the form of a pilot study uses qualitative and quantitative measures to describe the feasibility, acceptability, safety, and to explore the impact of a nine-day wilderness program among adolescents aged 13-17 in treatment or who recently finished treatment for a cancer. Quantitative tracking documented recruitment, retention, safety, and participant satisfaction. PROMIS measures assessed mental and social health, positive affect, fatigue, pain interference and intensity over three time-points: pre, post, and three-months after the nine-day wilderness experience. Mean differences were compared over time. Qualitative data collection involved participant observation and open-ended interviews.

RESULTS

Study enrollment goals were met, enrolling eight adolescent participants with 100% participant retention. No serious adverse events were reported and participants described high satisfaction (9.25/10) with the wilderness experience on the final day and at three-months follow-up (9.5/10). Exploratory data analysis showed scores in a favorable direction indicating improved psychosocial outcomes in physical functioning, anxiety, depression, fatigue, and peer relations. From qualitative analysis it is suggested that program participation supported: increased self-confidence and peer connection. The program was evaluated as increasing personal accomplishment, supporting social interaction, having strong staff support, and capitalizing on the natural surroundings.

CONCLUSION

Use of a wilderness program is feasible, acceptable, and safe among this highly vulnerable adolescent cancer population. Participants described greater self-confidence and peer connection which developed as participants experienced physical competency, group leadership, and personal strength. Larger randomized controlled studies are needed to learn whether these programs can improve psychosocial outcomes.

A randomized controlled pilot study assessing feasibility and safety of a wilderness program for childhood, adolescent, and young adult cancer survivors: the WAYA study

BACKGROUND

The majority of childhood, Adolescent and Young Adult (AYA) cancer survivors suffers from long-lasting health issues following cancer treatment. It is therefore critical to explore effective health promotion strategies to address their needs. Exposure to nature is a promising approach to support the needs of young cancer survivors. This study investigated whether it is feasible to conduct a randomized controlled trial (RCT) of a wilderness program for childhood and AYA cancer survivors.

METHODS

Eligible participants were aged 16-39 years, had a cancer diagnosis, and met minimal criteria. Seventy-one individuals expressed interest and 59 were randomized to either a wilderness or a holiday program. The wilderness program involved an 8-day expedition including backpacking, sea kayaking, gorge climbing, camping, bush-craft skills, and mindfulness-practices. It was followed by a 4-day basecamp after 3 months. The comparison was an 8-day holiday program at a Spa-hotel followed by a 4-day holiday program at the same hotel after 3 months. Primary outcome was study feasibility and safety.

RESULTS

Ultimately, 19 AYAs participated in the wilderness and 23 in the holiday program. All completed the study at one-year follow-up. Participants were mostly female (70%) and represented diverse cancers. Clinical characteristics were similar between study arms excepting greater age at cancer diagnosis in the wilderness program (age 19.1 vs. 12.5; p = 0.024). Program adherence and data completeness was high (> 90%) in both arms. Adverse Effects (AEs) in the wilderness vs. the holiday program were similar (Relative Risk: 1.0, 95% Confidence Interval 0.8-1.3). The most frequent AE was tiredness, all were mild to moderate in severity, and serious AEs were not reported. Nature connectedness significantly increased over time in the wilderness program participants, but not in the holiday program (p < 0.001). No differences were found between the two study arms regarding quality of life, self-esteem, or self-efficacy.

CONCLUSION

It is feasible to conduct a RCT and a supervised wilderness adventure is equally safe for childhood and AYA cancer survivors as a holiday program. This pilot study lays the foundation for a larger RCT to investigate the effectiveness of wilderness programs on the health of young cancer survivors.

TRIAL REGISTRATION DATE AND NUMBER

18/02/2021, NCT04761042 (clinicaltrials.gov).

Nature-based interventions for vulnerable youth: a scoping review

Nature-based interventions hold promise for vulnerable youth experiencing mental, emotional, developmental, behavioral, or social difficulties. This scoping review examined wilderness therapy, animal assisted therapy, care farming, and gardening and horticultural therapy programs to raise awareness and guide future development of research and treatment options. Studies included in this review were identified through a systematic search of the literature informed by a scoping review framework. Studies were examined by design, sample, intervention, and key findings. The majority of studies were quantitative using repeated measures designs and were conducted primarily in the United States. Sample sizes were generally small. Interventions were residential and community based with varying degrees of duration. Outcomes were largely positive across a wide range of psychosocial and behavioral measures and often maintained post-treatment. We emphasize the importance of robust empirical designs, comprehensive description of the interventions and surrounding therapies, and identification of target groups.

Mixed methods intervention studies in children and adolescents with emotional and behavioral disorders: A methodological review

BACKGROUND

Mixed methods intervention studies can improve the accuracy of interventional evaluations in the field of emotional and behavioral disorders by helping researchers gain a more nuanced understanding of how a particular intervention works. However, no studies to date have systematically examined the ways in which this type of studies have been carried out and reported.

AIM

To examine the methodological features and reporting practices found in mixed methods intervention studies in children and adolescents with emotional and behavioral disorders.

METHOD

Methodological review based on a systematic search from inception to July 2021 in Embase, Medline, PsycINFO, and SCOPUS, and a hand search in seven journals.

RESULTS

We found 30 studies, most of them published since 2019. These studies reported several patterns of mixed methods use which illustrated the unique insights that researchers can gain by using this approach. We identified several ways that authors could more clearly report the justification for using a mixed methods approach, the description of the design used, and the evidence of integration of the quantitative and qualitative components.

CONCLUSION

We make recommendations for improving the reporting quality of mixed methods intervention studies in the field of emotional and behavioral disorders.

The relationship between greenspace exposure and psychopathology symptoms: A systematic review

Greenspace exposure is associated with psychological benefits. In this systematic review, we summarized and critically evaluated the literature on the relationship between greenspace exposure (i.e., objective and subjective assessments of interactions with nature) and psychopathology incidence and symptom severity in those with and without a clinical diagnosis. A secondary aim of our review was to examine potential interactions between greenspace exposure and urban environmental features (e.g., pollution, population density) associated with poorer mental health. We identified 40 studies published between January 1, 1981, and July 31, 2020, from PubMed and PsycINFO electronic database search. Although heterogeneous in assessments of greenspace exposure and psychopathology symptom domain, the majority of cross-sectional and longitudinal evidence found that objectively assessed greenspace exposure (e.g., satellite measures of greenery) was related to less severe symptoms and lower incidence of psychopathology in children (e.g., attention-deficit/hyperactivity disorder symptoms) and adults (e.g., depression symptoms). In addition, five studies that assessed urban environmental features suggest that greenspace exposure may show a net positive relationship with psychopathology over and above the absence of urban features. We discuss limitations of the literature and future directions, including more mechanistic work to delineate the potential cognitive, affective, and behavioral factors that may contribute to the beneficial relationship between greenspace exposure and psychological health.

Being and doing in the outdoors brings something extra! Evaluating the Danish Healthy in Nature Project

PURPOSE

Little is known of the potential of using nature and outdoor activities in relation to community-based health promotion programmes. This study seeks a better understanding of how people with mental or chronic physical health problems experience a local outdoor health promotion or rehabilitation programmes and a better understanding of how these programs contribute to the participant's health and well-being.

METHODS

The study is based on data from the Healthy in Nature project targeting adults with chronic physical health problems and adults with mental health problems. Data was collected using a qualitative multiple case study design involving five selected cases with both qualitative interviews and observation. Data was analysed using Braun et al.'s 6-phase guide to qualitative reflexive thematic analysis, employing Self-Determination Theory as a theoretical framework. Results: Overall, the participants in the two groups experienced increased competence, autonomy, and relatedness, and the participants expressed the importance of both being in a natural environment and doing outdoor activities (friluftsliv).

CONCLUSIONS

The study makes a valuable contribution to the field of health promotion and rehabilitation pointing to nature and friluftsliv as important elements that offer great potential to community-based health promotion.

Greenspace programmes for mental health: A survey study to test what works, for whom, and in what circumstances

The health benefits of greenspace are widely acknowledged. Greenspace programmes, defined as health programmes undertaken in outside green areas such as parks, gardens, hills, and forests, are becoming more commonplace. However, there is still limited understanding of the mechanisms by which greenspace programmes are effective. This makes future development and implementation very difficult. We recently developed and published a novel framework for greenspace programmes for mental health showing what works, for whom, and in what circumstances (Masterton et al., 2020). In this current study, the accuracy of the proposed framework was tested for the first time using primary data from greenspace organisations in Scotland. Given the link between mental health and substance use, the applicability of the framework to programmes that support people with problem substance use was also tested. A survey was designed to test the contexts, mechanisms, and outcomes identified within the previously proposed framework. The survey was completed by 64 participants to provide a general overview of the framework's applicability for programmes that support mental health, as well as for programmes that support people with problem substance use. Overall, respondents agreed with all survey statements. This suggests that the framework does effectively represent the underlying context, mechanism, outcome configurations of greenspace programmes for mental health. Furthermore, there were no differences between responses from organisations that support people with problem substance use, and organisations that do not support this client group. This shows that the framework has the potential to be applicable to both greenspace programmes for mental health and greenspace programmes for people with problem substance use. This is a novel finding as, to our knowledge, there is currently no framework looking to explain the contexts, mechanisms, and outcomes necessary for greenspace programmes to be successful for people with problem substance use.

A Systematic Review and Lived-Experience Panel Analysis of Hopefulness in Youth Depression Treatment

Hopefulness is arguably of central importance to the recovery of youth with major or complex youth depression, yet it is unclear how hopefulness can best be enhanced in treatment. A narrative synthesis of published and grey literature was combined with new insights from a youth lived-experience panel (N = 15), focusing on to what extent and how specific psychological therapies and standard mental health care scaffold hopefulness as applied to depression among 14-25-year-olds. Thirty-one studies of variable quality were included in this review; thirteen were qualitative, thirteen quantitative, and five used mixed methods. Hopefulness is an important active ingredient of psychotherapies and standard mental health care in youth depression. Evidence suggests talking and activity therapies have moderate to large effects on hopefulness and that hopefulness can be enhanced in standard mental health care. However, varying intervention effects suggest a marked degree of uncertainty. Hopefulness is best scaffolded by a positive relational environment in which there is support for identifying and pursuing personally valued goals and engaging in meaningful activity. Animated (https://www.youtube.com/watch?v=o4690PdTGec) and graphical summaries (https://doi.org/10.13140/RG.2.2.27024.84487) are available.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40894-021-00167-0.

A Systematic Review and Meta-Analysis of the Effects of Outdoor Education Programs on Adolescents' Self-Efficacy

While prior research has generally found Outdoor Education Programs (OEPs) to be beneficial to adolescents' self-efficacy, we sought to conduct a meta-analytic review of prior studies in this area in order to pinpoint the key elements to OEPs' effectiveness. Following Cooper's guidelines for synthesis research and meta-analysis, we searched six electronic databases for relevant articles: PubMed, Sciencedirect, Medline, PsycArticles, and Behavioral Sciences Collection of EBSCO, and Eric. Selection criteria were: Populations, Interventions, Comparators, Outcomes, Study Design (PICOS), and Methodological Index for Non-randomized Studies (MINORS). We estimated the effect size of the selected studies with a 95% confidence interval (CI), estimated I-squared (I²) for heterogeneity analysis and analyzed publication bias by Egger's test. After excluding many studies, we reviewed 12 studies with 2,642 participants that were deemed to be eligible for final analysis. We discovered a high level of heterogeneity (I-squared value =82.474) in the findings of the selected studies. Our meta-analyses revealed that adolescents participating in OEPs enhanced their self-efficacy (medium effect size; Hedges's g = 0.597) but this enhancement was moderated by participants' mental health status, the length of the experiments, study groups, and the duration of the intervention. We found no evidence of publication bias (Egger: bias = 2.001, 95% CI = -0.736 to 4.739, p = .137). We discussed our research limitations and the theoretical and practical implications of these findings and made recommendations for future research.

A scoping review to map the concept, content, and outcome of wilderness programs for childhood cancer survivors

OBJECTIVES

Systematic mapping of the concept, content, and outcome of wilderness programs for childhood cancer survivors.

DESIGN

Scoping review.

SEARCH STRATEGY

Searches were performed in 13 databases and the grey literature. Included studies describe participation of childhood cancer survivors in wilderness programs where the role of nature had a contextual and therapeutic premise. At least two authors independently performed screening, data extraction and analysis.

RESULTS

Database searches yielded 1848 articles, of which 15 met the inclusion criteria. The majority of programs (73%) employed adventure therapy. Five activity categories were identified as components of wilderness programs: challenge/risk, free time/leisure, experiential learning, physical activity and psychotherapeutic activities. A majority of the participating childhood cancer survivors were female, white, aged 8-40 years, with a wide range of cancer diagnoses. Reported outcomes included increased social involvement, self-esteem, self-confidence, self-efficacy, social support, and physical activity. Key gaps identified included the absence of randomized controlled trials (RCTs), lack of studies on long-term effects, lack of information on the multicultural aspects of programs, and missing information on engagement in nature activities after the program ended.

CONCLUSIONS

This scoping review guides childhood cancer survivors, their families, practitioners, clinicians and researchers in the development and optimization of wilderness programs for childhood cancer survivors. In addition, it informs the utilization of these programs, and identifies gaps in the evidence base of wilderness programs. It is recommended that future study reporting on wilderness programs include more detail and explicitly address the role of nature in the program. Performing RCTs on wilderness programs is challenging, as they occur in real-life contexts in which participants cannot be blinded. Creative solutions in the design of pragmatic trials and mixed method studies are thus needed for further investigation of the effectiveness and safety of wilderness programs in childhood cancer survivors.

Mapping the concept, content and outcome of wilderness therapy for childhood cancer survivors: protocol for a scoping review

INTRODUCTION

Long-term childhood cancer survivors are at risk for frailty and have significant health-related issues in adulthood. Various health promotion interventions have been proposed to enhance quality of life including wilderness therapy, which applies the impact of nature on health in a therapeutic context. Previous studies have described positive outcomes linked with various wilderness-related therapies for cancer survivors. However, there is no clarity on the role these therapies play in childhood cancer. The current scoping review aims to systematically map the concept, content and outcome of wilderness therapy for childhood cancer survivors.

METHODS AND ANALYSIS

This review will be guided by the Joanna Briggs Institute Reviewers' manual for scoping reviews. A systematic literature search using medical subject headings (MeSH) and text words related to wilderness therapy and childhood cancer survivors will be performed in EMBASE, ERIC, Medline, Psycinfo, CINAHL, Scopus, Web of Science, SPORTDiscus and Svemed+, Sociological Abstracts, supplemented by grey literature searches. Eligible quantitative and qualitative studies will be screened, included, assessed for quality and extracted for data by two reviewers independently. Results will be described in a narrative style, reported in extraction tables and diagrams, and where appropriate in themes and text.

ETHICS AND DISSEMINATION

This study describes a protocol for a scoping review that will undertake secondary analysis of data already published in literature and is therefore exempt from medical ethical review. The scoping review will inform understanding of the benefits and risks of wilderness therapy for childhood cancer survivors, their families, practitioners, clinicians and researchers, and will help elucidate the steps necessary for building its evidence base going forward. Results will be published in a peer-reviewed scientific journal.