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Results from an 18 country cross-sectional study examining experiences of nature for people with common mental health disorders

Abstract

Exposure to natural environments is associated with a lower risk of common mental health disorders (CMDs), such as depression and anxiety, but we know little about nature-related motivations, practices and experiences of those already experiencing CMDs. We used data from an 18-country survey to explore these issues (n = 18,838), taking self-reported doctor-prescribed medication for depression and/or anxiety as an indicator of a CMD (n = 2698, 14%). Intrinsic motivation for visiting nature was high for all, though slightly lower for those with CMDs. Most individuals with a CMD reported visiting nature ≥ once a week. Although perceived social pressure to visit nature was associated with higher visit likelihood, it was also associated with lower intrinsic motivation, lower visit happiness and higher visit anxiety. Individuals with CMDs seem to be using nature for self-management, but ‘green prescription’ programmes need to be sensitive, and avoid undermining intrinsic motivation and nature-based experiences.

Introduction

There is considerable evidence that contact with (safe) natural environments such as parks and woodlands (green spaces), and rivers and lakes (blue spaces), can reduce the risk of onset of common mental health disorders (CMDs) such as depression and anxiety1. This may, in part, be because contact with the natural world is intrinsically motivating2,3, i.e. enjoyable for its own sake4, and can both reduce negative emotions and increase positive ones5. However, we know relatively little about the everyday nature-related motivations, practices and experiences of those who are already experiencing CMDs. Is nature contact only good for reducing the risk of onset, or can it also help management and recovery? ‘Green care’6 and ‘green prescription’7 initiatives suggest that it might, but evidence draws largely on small-scale studies using self-selected samples8. As far as we are aware, there has been no large-scale examination looking at everyday green/blue space experiences by individuals currently experiencing CMDs. The current research aimed to explore these issues.

CMDs were the leading cause of disability in 2015, with depression accounting for around 50 million person years lived with disability (YLD) and anxiety around 25 million YLDs, globally9. Although a range of treatments are available, individuals face challenges getting access to, and/or responding to treatment, including limited availability of face-to-face psychotherapy, potential side-effects of medication, and stigma10. The need for safe, complementary approaches, with a low risk of side effects is widely acknowledged11. Evidence suggests that contact with nature might be able to be part of a package of complementary treatments, at least for some individuals.

Analysis of longitudinal data suggests people experience less psychological distress in years when they are living in greener urban areas12. This is supported by cross-sectional findings revealing positive associations between greener urban areas and lower antidepressant prescription rates13. Experimental studies find that people with CMDs get more symptom relief from a walk in natural rather than urban settings14,15. ‘Green care’ initiatives, including horticultural therapy, care farming, and wilderness therapy, and ‘blue care’ initiatives such as outdoor swimming and surfing, have reported similar benefits6,16. Consequently, there is growing interest in ‘green prescriptions’, where health care practitioners refer CMD patients to accredited blue/green care protocols, or simply recommend spending more time in nature17.

These schemes remain relatively small-scale, however, due to concerns about acceptability, feasibility, and generalisability of benefits beyond self-selected individuals7. A key aspect of depression is a ‘motivation deficit’, i.e. a difficulty in engaging in everyday activities or trying new things18, and thus it may be hard to encourage individuals to start visiting nature or maintain regular contact, despite being intrinsically motivated2. Similarly, a feature of various anxiety disorders, and sometimes depression, is ‘experiential avoidance’ where individuals try to avoid potentially anxiety-inducing thoughts, feelings, and/or activities19. Since public green/blue spaces may present unpredictable environmental and/or social circumstances, people with some CMDs (e.g. agoraphobia) may wish to avoid these settings, again, despite being intrinsically motivated. Given that both motivational deficit and experiential avoidance have affected the success of programmes to promote physical activity among individuals with CMDs20, these experiences may also undermine the success of green prescription initiatives.

Further, according to self-determination theory (SDT), feeling pressured to engage in activities by others can undermine intrinsic motivation21,22. Thus, feeling pressured to visit nature by friends/family, or more formally by a ‘green prescription’ from a medical professional, may be inadvertently detrimental. In the framework of SDT, there may be a shift from visiting nature because it is intrinsically enjoyable and fun, to visiting because of an internalised desire to meet the expectations of others21. In turn, this can lead to increased feelings of anxiety, especially if individuals feel they are failing to live up to these expectations23.

The current study used data from an 18-country survey on recreational contact with green/blue spaces to explore these issues. Individuals with CMDs were identified based on self-reported medication use. Further questions asked about intrinsic motivations to spend time in nature, recreational green/blue space visit frequency, experiences of the most recent visit, and perceived social pressure to spend time in nature. The survey was part of an international project that had a particular focus on blue spaces24, so while recreational nature visit frequency spanned both green and blue spaces, the specific visit was concerned only with the most recent blue space visit.

We tested the following hypotheses (H):

Intrinsic motivation Individuals will believe time in nature to be intrinsically motivating (H1a). However, given general motivational deficits among people with CMDs, their levels of intrinsic motivation will be lower than for people without CMDs (H1b).

Nature visit frequency Given potential experiential avoidance, nature visit frequency will be lower for people with, versus without, CMDs (H2).

Blue space visit wellbeing Blue space visits will be associated with high levels of positive emotions (e.g. happiness, H3a), and low levels of negative emotions (e.g. anxiety, H3b), for people both with and without CMDs. However, given motivational deficits, happiness levels will be relatively lower (H3c), and anxiety levels relatively higher (H3d) among people with, versus without, CMDs.

Perceived social pressure Perceived social pressure will moderate outcomes such that the greater the perceived pressure, the lower intrinsic motivation (H4a), the less likelihood of visiting nature regularly (H4b), and the lower happiness (H4c) and greater anxiety (H4d) on recent blue space visits.

Results

Preliminary statistics

Table 1 presents descriptive statistics. There were n = 2,698 (14%) respondents who reported having at least one CMD, slightly below the 17% annual figure25. This is likely due to the fact we focused on medication use as a proxy for CMD, and current rather than annual rates. In terms of specific conditions the frequencies were: depression (only) n = 910 (4.8%); anxiety (only) n = 1013 (5.4%); both depression and anxiety n = 775 (4.1%). Supporting Hypothesis 1a, intrinsic motivation to spend time in nature, for the sample as a whole, was significantly above the mid-point of 4 (M = 5.80, SD = 1.36), t(18,837) = 181.60, p ≤ 0.001, 95% CI = [1.78, 1.82], Cohen’s d = 1.32. This was true of all four groups (i.e., depression, anxiety, both, neither), all ts > 28.23; all ps < 0.001; all ds > 1.01. In terms of visit frequency, more than half of all participants in each of the four groups reported visiting nature ≥ once a week (differences between groups, i.e. Hypothesis 2, are tested below). Supporting Hypothesis 3a, overall sample happiness during the last visit was also significantly above the mid-point of 4 (M = 5.81, SD = 1.11), t(14,972) = 199.36, p ≤ 0.001, 95% CI = [1.79, 1.83], Cohen’s d = 1.63. Again, this was true of all four groups, all ts > 33.45; all ps < 0.001; all ds > 1.20. By contrast, and supporting Hypothesis 3b, visit anxiety for the whole sample was significantly below the mid-point of 4 (M = 2.15, SD = 1.44), t(14,970) = − 157.49, p ≤ 0.001, 95% CI = [− 1.88, − 1.83], Cohen’s d = -1.28, and for all four groups, all ts > 18.48; all ps < 001, all ds > − 0.75. Finally, Perceived Social Pressure (PSP) was also, on average, low (M = 2.41, SD = 1.79), and significantly below the mid-point of 4, in general t(17,798) = − 118.73, p ≤ 0.001, 95% CI = [− 1.62, − 1.57], Cohen’s d = − 0.89, and for all four groups independently all ts > 10.70; all ps < 0.001, all ds > − 0.38. As predicted, spending time in nature appeared intrinsically motivating for everyone, including those with CMDs, and this was supported by corresponding experiences of generally high levels of happiness and low levels of anxiety on the most recent visit.

Intrinsic motivations

Although all groups were above the mid-point (H1a), supporting H1b, those with depression (only) (B = − 0.14, 95% CI = [− 0.23, − 0.05], p = 0.002), or anxiety (only) (B = − 0.33, 95% CI = [− 0.42, − 0.25], p < 0.001), and those with both (B = − 0.24, 95% CI = [− 0.34, − 0.14], p < 0.001), reported significantly lower levels of intrinsic motivation for spending time in nature, compared to no reported condition.

Visiting nature at least once a week

Contrary to H2, those with anxiety (OR = 1.19, 95% CI = [1.02, 1.38], p = 0.026) were significantly more likely to visit nature weekly compared to no reported condition. There was no significant difference in visit likelihood for those with depression (OR = 1.03, 95% CI = [0.88, 1.19], p = 0.736) or both conditions (OR = 1.00, 95% CI = [0.85, 1.19], p < 0.001) compared to no condition.

Happiness and anxiety on the most recent blue space visit

Contrary to H3c, compared to those with no reported conditions, those with depression reported similar levels of happiness (B = − 0.04, 95% CI = [− 0.12, 0.04], p = 0.325), and those with both depression and anxiety reported higher happiness (B = 0.10, 95% CI = [0.01, 0.19], p = 0.031). Only those with anxiety experienced, as predicted, lower happiness on the most recent visit (B = − 0.17, 95% CI = [− 0.24, − 0.10], p < 0.001). Supporting H3d, however, compared to those with no reported conditions, visit anxiety was higher for all three CMD groups: depression (B = 0.17, 95% CI = [0.07, 0.28], p = 0.001); anxiety (B = 0.20, 95% CI = [0.11, 0.30], p < 0.001); both (B = 0.24, 95% CI = [0.12, 0.35], p < 0.001).

Potentially moderating role of perceived social pressure (PSP)

Intrinsic motivations

Supporting H4a, PSP was associated with lower intrinsic motivation, even for those with no reported conditions. For each unit increase in PSP there was a 0.09 decrease in intrinsic motivation towards visiting natural spaces (B = − 0.09, 95% CI = [− 0.10, − 0.08], p < 0.001). The negative association was even stronger for people with depression (B = − 0.06 (95% CI = [− 0.10, − 0.01], p = 0.022), such that each unit increase in PSP was associated with an additional 0.06 decrease in intrinsic motivation, over and above the 0.09 decrease among those without conditions (i.e. total = − 0.09 + − 0.06 = − 0.15). The interactions between PSP and anxiety (B = 0.01 (95% CI = [− 0.03, 0.06], p = 0.603) and both depression/anxiety (B = 0.03 (95% CI = [− 0.02, 0.08], p = 0.194), were not significant. Each unit increase in PSP for those with anxiety was associated with a − 0.08 (i.e. − 0.09 + 0.01) decrease in intrinsic motivation, and for those with both conditions with a − 0.06 (i.e. − 0.09 + 0.03) decrease. In other words, there was a decrease but it was not larger than that already shown by those without conditions.

Visit frequency

Contrary to H4b, PSP was associated with a marginally greater likelihood of visiting nature ≥ once a week, for those without conditions (OR = 1.02, 95% CI = [1.00, 1.04], p = 0.050). The interactions for those with depression (OR = 1.07, 95% CI = [0.98, 1.16], p = 0.134), and both conditions (OR = 1.05, 95% CI = [0.97, 1.14], p = 0.238) were not significant, suggesting that PSP tended to increase visit likelihood for these individuals in the same was as those without conditions. Those with anxiety, however, were significantly more likely to visit ≥ once a week than those without conditions, as PSP increased (OR = 1.11, 95% CI = [1.02, 1.20], p = 0.012).

Happiness and anxiety on most recent blue space visit

Supporting H4c, even for those without conditions, each unit increase in PSP was associated with a B = − 0.04 (95% CI = [− 0.05, − 0.03], p < 0.001) decrease in visit-related happiness. That none of the interactions between PSP and CMD group were significant suggests that everyone had a similar negative association (depression: B = − 0.01, 95% CI = [− 0.05, − 0.03] p = 0.528; anxiety: B = − 0.03, 95% CI = [− 0.07, 0.01], p = 0.103; and both: B = − 0.01, 95% CI = [− 0.03, 0.05], p = 0.659).

Finally, supporting H4d, for those without conditions, each unit increase in PSP was associated with a B = 0.18 (95% CI = [0.17, 0.19]) increase in visit-related anxiety. This time, the interactions between PSP and CMD group were all significant (depression: B = 0.15 (95% CI = [0.09, 0.20], p ≤ 0.001; anxiety: B = 0.13, 95% CI = [0.08, 0.17], p ≤ 0.001; and both: B = 0.09 (95% CI = [0.04, 0.14], p = 0.001). These patterns are presented in Fig. 1. As PSP increases for those without conditions, anxiety also increases (blue points). However, the relationship is even steeper for all CMD groups (red points), a synergistic effect suggesting that those with CMDs who feel pressured are also susceptible to feeling greater anxiety during visits.

Estimated anxiety (unstandardized coefficients, 95% Confidence Intervals) during last nature visit as a function of perceived social pressure for each CMD group. Estimates are based on models controlling for: sex, age, perceived financial strain, employment status, marital status, number of children in household, having a long-term limiting illness, smoking status, alcohol use seasonal wave and country; and visit-related factors, number of companions, presence of dog, transport mode, travel time, visit duration, and anxiety ‘yesterday’.

Covariates

Due to space constraints results for covariates are presented and discussed in Supplementary Materials section 3.

Discussion

To our knowledge, this is the first multi-country analysis of nature-related motives, visits, and wellbeing experiences of people suffering from common mental health disorders (CMDs) such as anxiety and depression. We found that intrinsic motivation to spend time in nature was generally high, although lower among individuals with CMDs, consistent with a general motivational deficit18. The majority of individuals with CMDs visited nature at least once a week, and contrary to experiential avoidance19, those with depression were just as likely, and those with anxiety more likely, to visit compared to those with no conditions. Consistent with research suggesting natural settings are ‘calming’, ‘stress relieving’26, and can help reduce negative, ruminative thoughts26, there was a tendency to report high levels of happiness, and low levels of anxiety, during recent blue space visits across the entire population; though experiences were slightly less positive among individuals with CMDs. Finally, consistent with self determination theory21 perceived social pressure (PSP) to visit green/blue spaces was associated with lower intrinsic motivation among all groups, with the association for those with depression particularly pronounced. Higher PSP was also associated with lower visit happiness, and higher visit anxiety, especially for those with CMDs. However, PSP was associated with greater likelihood of visits, especially among those with anxiety. That intrinsic motivation to spend time in nature was high for people with CMDs and more than half were visiting nature ≥ once a week, suggests that many may be using nature for affect-regulation purposes27. Nevertheless, those with anxiety (in particular) reported lower visit happiness than those without conditions, and all three CMD groups reported higher anxiety. Although this may reflect lower intrinsic motivation (as predicted), one issue may be our focus on blue spaces, which offer potential threats (such as drowning) which may be particularly salient for people with anxiety. Although we think this unlikely, given most visits involved walking near blue spaces, further research focusing on various natural settings for people with different types of CMD is warranted. Another possibility may be that their experiences were genuinely less positive on average due to area-based factors. CMD rates are higher in low-income neighbourhoods9, and deprived areas tend to have lower quality natural environments28. Most blue space visits are local, and visits to poorer quality areas are associated with less positive experiential wellbeing outcomes29. Thus, individuals with CMDs may be reporting less positive experiences, in part, because they occur in poorer quality natural spaces, potentially exacerbating socio-economic related mental health inequalities30.

That higher PSP was associated with a greater likelihood of visiting nature, especially for those with anxiety, but lower visit-related happiness, and greater visit-related anxiety, suggests that although some (perceived) pressure may be effective at getting people out, it may undermine intrinsic pleasure from visiting nature31. However, due to the cross-sectional nature of the survey, we are unable to determine causality. It may be that this instead reflects less motivated people, who experience less positive wellbeing outcomes, going out to please others. More detailed longitudinal work is needed in the ‘green prescription’ field to unpack this issue.

Limitations

Although our sample was collected by an international polling company and was representative by age, gender and region within each country, we are not able to claim that the sample was fully representative in the respective countries. Moreover, the within country samples were also too small to test our hypotheses for each country separately. Further studies using larger samples which are able to be fully representative, such as Natural England’s, Monitor of Engagement with the Natural Environment (MENE) survey (https://www.gov.uk/government/collections/monitor-of-engagement-with-the-natural-environment-survey-purpose-and-results) are needed across multiple countries to explore the generalisability of the current findings across different geographical and cultural contexts. We also recognise that depression/anxiety are not the only CMDs, and that CMDs are on a spectrum32, so the current findings are only meant as a first exploration and are by no means definitive. Further, all the data were self-reported, and we were unable to validate people’s medication status or nature experiences. Although our prescription item is widely used33, it was also unable to account for length of use, dosage, access to other supporting services etc. or identify individuals who (a) meet criteria for a clinical diagnosis but are not currently receiving pharmaceutical treatment, (b) have particularly severe conditions, or (c) might be taking these drugs to help manage other conditions. Clearly, objective data on clinical diagnoses and treatment stage would be an important step for future research, especially as symptom severity and stage of treatment could be a critical factor in the success of green prescription uptake and adherence34. We are also aware that the explanatory power of our models was small (intrinsic motivation, visit likelihood) to moderate (visit experiences), and thus CMD status is only playing a very small role in these outcomes; there remain many other variables, beyond even our extensive set of covariates, which it is important to consider in improving our understanding of these outcomes. We also recognise that single items for measuring e.g. intrinsic and extrinsic motivation are not as robust as multi-item scales, but there is an inherent trade-off when collecting data from large-samples. Moreover, we recognise that we are assuming linearity in the response options for our outcome variables, when technically they could be considered ordinal scales. Nevertheless, it has long been recognised that findings are robust to this assumption for these kinds of dependent variables with results using linear and ordinal analyses producing essentially the same outcomes, with the linear approaches being far easier to interpret35. Finally, more in-depth qualitative work could enrich our understanding of whether and how people with CMDs are deliberately visiting nature for symptom self-management and how engagement with green/blue prescription programmes might affect their motivations and experiences34.

Conclusions

Many individuals with CMDs are motivated to visit nature, and derive psychological benefits from such visits, though area level environmental inequalities may be undermining their potential for even better experiences. Nature based programmes such as ‘green prescriptions’ are becoming more prevalent. Our data suggest that perceived pressure to visit nature may increase visit frequency, but at the cost of undermining intrinsic motivation and the emotional benefits that might be achieved. Careful techniques to discuss accessing nature as a means of self- or supported-management (e.g. motivational interviewing36), need to be integrated into these programmes if they are to offer clients the best support.

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