Motivation and emotion/Book/2022/Green prescription motivation

Overview
The world's chronic disease burden rate is a growing area of concern, especially in the United States (US) where 40% of people have two or more chronic diseases (See Figure 1.) such as diabetes, hypertension and mood disorders (Buttorff et al., 2017, as cited in Kondo et al., 2020). Additionally, over 16 million adults experience a depressive episode each year (Kessler et al., 2005, as cited in Kondo et al., 2020) and children spend approximately eight hours a day watching a screen (Domingues-Montanari, 2017, as cited in Kondo et al., 2020).

Many different health behaviours contribute to the development and onset of chronic diseases, for example having a sedentary lifestyle (Kondo et al., 2020). Sedentary lifestyles often involve a lack of physical exercise and can lead to higher rates of chronic diseases and mortality (Proper et al., 2011, as cited in Kondo et al., 2020). Nature has been shown to positively impact physical, psychological and social health and wellbeing (Lauwers et al., 2020, as cited in Schultz et al., 2022). The World Health Organisation defines health as “a state of complete physical, mental and social wellbeing, not merely the absence of disease or infirmity” (Callahan, 1973, as cited in Schultz et al., 2022). This definition of health has shifted from an outdated disease-centred model to an approach in which the promotion of health relies on human activity in physical and biological environments (Schultz et al., 2022).



This book chapter explores the focus questions of what green prescription is, what factors motivate people to engage in green prescription and what psychological theories surround green prescription. Within these three focus questions, key concepts such as the forms and benefits of green prescription, the difference between green prescription and green exercise, along with theories and research will be discussed.


 * What is green prescription?
 * What motivates people to engage in green prescription?
 * What theories are involved in green prescription?

What is green prescription?
In this section, the definition of green prescription will be explored, as well as it's various forms and benefits. The key differences between green prescription and green exercise will be discussed, as well as the effects of screen time in comparison to green prescription benefits. At the end of this section there is a short quiz to test your knowledge on the key concepts covered.

Definition
Green prescription, often referred to as ‘nature prescription’, is a prescription that involves nature-based activities (Ausmed, 2022). The prescription is given to a patient by a health professional, for example a general practitioner (GP) and prescribes how long a patient should spend outdoors according to their specific and defined needs (Ausmed, 2022). An effective nature-based activity for one person may not be effective for another: for example, lying down in the sun would be great for someone who is vitamin D deficient; however, for someone with a sedentary working lifestyle a walk would be more suitable (Ausmed, 2022).

Green prescription is not to be confused with green exercise (See Figure 2.), which is a more casual self-directed approach; for example a person wanting to jog outside to reduce stress and get fit (Barton et al., 2016, as cited in Van den Berg, 2017).

Forms of green prescription

 * Being outside among nature (See Figure 3.)
 * Walking
 * Gardening (See Figure 4.)
 * Playing different sports
 * Lying down in a green open space (Ausmed, 2022).



Green prescription benefits

 * Reduction in mild-to-moderate diabetes
 * Lower levels of anxiety and depression
 * Reduction in obesity (Green Adelaide, 2022).
 * Increased physical and mental wellbeing
 * Reduction in blood pressure
 * Improvement in mood
 * Better sleep patterns (Victorian Government, 2022).
 * Increase self-efficacy
 * Increase sense of positive identity (Oswald et al., 2020).

Effects of screen time

 * Lower mental health
 * Higher levels of depression (See Figure 5.)
 * Increased anxiety
 * Lower emotional functioning
 * Lower quality of life
 * Poor academic achievement (Oswald et al., 2020).
 * Higher risk of obesity
 * Poor self-esteem
 * Poor cognitive development
 * Reduced sleep (Stiglic & Viner, 2019).

Quiz
{What is the difference between green prescription and green exercise? - Green prescription involves being among nature for health benefits, whereas green exercise refers to doing physical exercise in nature - Green prescription involves doing physical exercise in nature, whereas green exercise refers to being among nature for health benefits - Green prescription involves someone choosing, whereas green exercise involves a health professional instructing someone to spend time in nature for health reasons + Green prescription involves a health professional instructing someone to spend time in nature for health reasons, whereas green exercise involves someone choosing
 * type="[]"}

Psychological theories
In this section, four main theories surrounding green prescription compliance will be explored and explained in detail, with a short quiz at the end to test your knowledge on the key information covered.

Ecological dynamics theory
Kugler and Turvey state that ecological science is a multidisciplinary approach to the study of living systems, their environments and the reciprocity between the two (Kugler et al., 1980). The environment refers to a set of surroundings within which an organism (See Figure 6.) can perceive and act, as well as change their relationship with (Gibson, 1979). James Gibson's theory of ecological psychology emphasises continuous organism-environment interactions as a way of understanding human behaviours in performance environments (Gibson, 1979).



Psycho-evolutionary stress recovery theory
Psycho-evolutionary stress recovery theory states that exposure to nature reduces stress by distracting from daily life stressors and developing feelings of interest and calmness (Ulrich et al., 1991, as cited in Loureiro et al., 2021). Furthermore, Lahart et al. (2019) states that green exercise increases affect (pleasant emotions), energy, enthusiasm and enjoyment; while reducing anxiety and worry, depression and aggression (Loureiro et al., 2021).

Attention restoration theory
Attention restoration theory explains the relationship between nature and health through directed and involuntary attention (Kaplan & Kaplan, 1989, as cited in Loureiro et al., 2021). Directed attention involves mental effort and can lead to fatigue (Rogerson & Barton, 2015, as cited in Loureiro et al., 2021), whereas involuntary attention, especially in natural environments, requires no mental effort and can help with fatigue (Berman et al., 2008, as cited in Loureiro et al., 2021). One study by Foo (2016) found that people who spent time in forests experienced a sense of being away, which positively affected their mood and mental health (Loureiro et al., 2021).

Self-determination theory
Self-determination theory is often used within a sport and physical exercise context as a way of understanding motivation and behaviour (Deci & Ryan, 2000). The theory involves the main types of motivation that drive behaviour: Intrinsic, extrinsic and amotivation (Deci & Ryan, 2000). Intrinsic motivation involves undertaking an activity for the satisfaction of the activity itself, whereas extrinsic motivation refers to the performance of an activity to attain a separable outcome (Deci & Ryan, 2000).

Motives of green prescription
In this section, the various motives of green prescription will be discussed and explored in detail, with case study examples outlined. There will also be a short quiz at the end of this section to test your knowledge on the key concepts covered.

Enjoyment
Enjoyment (See Figure 7.) has been found to be the greatest intrinsic motivator for engaging in green exercise (Fraser et al., 2019). Research has highlighted that individuals should engage in physical activities that they enjoy to increase their motivation (U.S. Department of Health and Human Services, 2010, as cited in Fraser et al., 2019). Enjoyment has also been shown to increase exercise program adherence (Schasberger et al., 2009), with one systematic review finding that enjoyment motivates individuals to visit natural areas (Calogiuri & Chroni, 2014). Green exercise studies have also found an association between enjoyment and the future intention to exercise (Focht, 2009).

Cleo is advised by her GP to spend at least 30 minutes outside each day to reduce her anxiety. She decides to walk but finds it hard to complete the 30 minutes of exercise so she tries jogging instead. She finds this way more enjoyable and is able to complete her 30 minutes of exercise each day.
 * Case study - 1

Social environment
The environment is a key extrinsic factor motivating green prescription compliance (Fraser et al., 2019). The outdoor environment provides space for social interaction (See Figure 8.) and allows for many opportunities that are not available in controlled indoor settings (Brymer et al., 2014, as cited in Fraser et al., 2019). Social interactions have been found to encourage compliance in green prescription programs (Schasberger et al., 2009), especially interactions with friends and family (Fraser et al., 2019).

Dune is overweight and is told by his doctor to play sport at least two times a week to reduce his weight. He joins a local tennis club and quickly makes friends with people in his age group. He finds himself playing tennis more and more each week, eventually going everyday.
 * Case study - 2

Natural surroundings


Calogiuri and Elliott (2017) found competitive sport exercisers to be more driven by extrinsic factors such as natural surroundings compared to gym exercisers who focus on body-oriented motives. Similarly, a review by Pomfret and Bramwell (2016) found that the surroundings in which adventurous sport takes place (See Figure 9.) can be a key motivating factor.

Clementine recently visited her GP regarding her recent depressive episodes. Her GP told her that she can either take antidepressants or try a green prescription. Based on her needs the GP advised that the green prescription would involve participating in sport at least 3 times a week. Opting for the green prescription, Clementine decides to take up swimming at her local pool but finds herself unmotivated. Due to this, she decides to try swimming at a professional sport institute and finds that she is a lot more motivated.
 * Case study - 3

Quiz
{What motivates green prescription compliance? - Environment, enjoyment and family + Social environment, enjoyment and natural surroundings - Satisfaction, natural environment and social connections - Social connections, friends and natural surroundings
 * type="[]"}

What dose of green exercise improves mental health?


Barton and Pretty (2010) conducted a multi-study analysis of 10 studies to explore what dose of green exercise is required to improve mental health (Figure 10.), assessing levels of self-esteem and mood. They used meta-analysis methodology to analyse 10 studies involving 1252 participants from the United Kingdom (UK). The overall effect size for increased self-esteem was d ) 0.46 (CI 0.34-0.59, p < 0.00001) and for mood d ) 0.54 (CI 0.38-0.69, p < 0.00001). Dose responses for intensity and duration showed large positive effects for brief green exercise involvement, with diminishing but positive returns. Moreover, they found that every type of green environment improved self-esteem and mood; with water generating larger effects. Both men and women had similar improvements in self-esteem; however, men had slightly lower improvements for mood. Furthermore, the greatest change in self-esteem was among young and mentally ill participants and for mood, the least change was in young and old participants.

The results suggest that acute and short-term exposure to green exercise improves self-esteem and mood irrespective of duration, intensity, gender, location, age and health status. However, future studies should include even more green exercise environments to compare results. The multi-study also only focused on studies with short-term exposures to single interventions, therefore, longitudinal multi cohort studies are needed to track results over time. For instance, it is unknown how long an increased mood lasts for once an exercise has finished and whether there are accumulative effects following multiple exposures. The studies were also analysed over six years, therefore the results may have been manipulated by extraneous variables which were not controlled for. Moreover, the studies involved in the multi-study analysis were all conducted by the same university; thus future analyses should be more cross-sectional.

Park prescription intervention trial
Petrunoff et al. (2021) explored the impact of a Park Prescription Intervention trial (PPI), as well as the mediating effects of motivation, social support, recreational physical activity (PA), park use and park PA (See Figure 11.) on trial outcomes. The PPI was a two-arm randomised-controlled trial (RCT) involving 160 Singaporeans aged 40 to 65 (M = 51, SD ± 6.3 years). Participants were randomly allocated to intervention (n = 80) or control (n = 80) groups. The intervention group involved baseline counselling, a prescription of PA in parks, materials, three-month follow-up counselling and 26 weekly group exercise sessions in parks.

Implementation indicators were assessed in regards to participation rates and survey questions, plus focus group discussions (FGDs) to identify which components were valued. FGDs also assessed the barriers and facilitators to intervention participation. To explore the impact of the intervention, linear regression was used to compare measured PA and group exercise participation.

Mean minutes of moderate-to-vigorous PA per week (95% CI) differed by group exercise participation (p = 0.018): 0% participation (n = 18) 128.3 (69.3, 187.2) minutes, > 0–35.9% participation (n = 18) 100.3 (36.9, 163.6) minutes, > 35.9–67.9% participation (n = 17) 50.5 (− 4.9, 105.9) minutes and > 67.9% participation (n = 18) 177.4 (122.0, 232.8) minutes. Park PA at three months had significant mediating effects (95% CI) on recreational PA 26.50 (6.65, 49.37) minutes per week, park use 185.38 (45.40, 353.74) minutes per month, park PA per month 165.48 (33.14, 334.16) minutes and psychological quality of life score 1.25 (0.19, 2.69) at six months.

The results show that park PA consistently mediated effects of the PPI, suggesting that PA in parks is a mechanism of its effects. The intervention successfully increased recreational PA, park use, park PA and participants’ wellbeing. This suggests that being active among nature is an important mechanism for the intervention effects on behavioural and quality of life outcomes.

However, it was found that prioritising family time and preferring unstructured activities were barriers to intervention participation, whereas human interaction during the follow-up and group exercises were facilitators. To increase the effectiveness in future interventions, key barriers to participation need to be addressed. First, tailoring the intervention to participants’ preferences for structured or unstructured PA and encouraging those who prefer unstructured to gradually increase the intensity and volume. Second, considering participants’ preference for prioritising time with family by inviting family members to provide support and encouragement during the intervention. The sample was also mostly made up of middle-aged Asians, limiting the generalisation of the findings, therefore future research should involve various age groups and cultures.

Conclusion
This book chapter explored the definition of green prescription, the various forms and benefits of green prescription and the key differences between green prescription and green exercise. It also outlined the effects of screen time and four key theories involved in green prescription. The motives of green prescription were noted as enjoyment, social environment and natural surroundings, with interventions noting that brief green exercise and being active in nature among other people motivates green prescription compliance.

Recognition should be given to the use of green exercise as a therapeutic intervention, with architects improving access to green spaces and children gaining the opportunity to learn outdoors. However, a challenge for policy makers is that exercise recommendations are easily stated but rarely adopted to a large extent. Frameworks are more likely to be effective if exercise becomes a necessary part of life rather than a personal choice. Simple prescriptions are also unlikely to be accepted by people unless there is support in urban design, social care, transport policy and parenting. Accessing natural spaces for different environmental and health services may help these transitions.