Nature-based physical activity as an early intervention for teenagers | Nursing Times

Introduction

The South Eastern Health and Social Care Trust’s (SEHSCT) Population Health Strategy (2021-2024) outlines a commitment to creating conditions that enable and support individuals to lead healthy lives, both physically and mentally (SEHSCT, 2021). The trust’s approach to population health focuses on working in collaboration with individuals, communities and partner organisations to address the key factors that affect health inequalities and wellbeing, with one of the three main priority areas being “working in partnership to provide early help to improve people’s wellbeing” (SEHSCT, 2021).

SET Outdoors is one of the ‘early help’ actions identified in this strategy. The aim of SET Outdoors is to support SEHSCT children’s services to improve the health, wellbeing and quality of life of vulnerable young people via engagement in purposeful, outdoor, nature-based and/or animal-facilitated therapeutic activities and therapy.

Idea for the initiative

The Down GP Federation multidisciplinary team, based in County Down, Northern Ireland, aims to provide patients with therapeutic tools and support that will enable them to improve and maintain good mental health and wellbeing. Senior mental health practitioners from the team identified a need among their practice population to engage adolescents who were presenting with low-level anxiety and mood-related difficulties following Covid-19 lockdown restrictions and the resulting isolation from their peers. There was a desire to engage young people in a fun, meaningful and social way to address these difficulties while adhering to Covid-19 guidance and minimising the risk of transmission of the virus. It was decided that these needs could be addressed via collaboration with SET Outdoors on a sea swimming programme, as such outdoor physical activity can have significant benefits.

Mitchell (2013) studied physical activity in natural environments and concluded that it was associated with a reduction in the risk of poor mental health to a greater extent than physical activity in other environments. Bélanger et al (2019) reported that spending time outdoors promotes positive mental health among young people through increases in physical activity, and that this benefit would most likely be greater when an interaction with nature was included in the experience.

Research has suggested that visiting a ‘blue space’ – such as a river, lake or the coast – for recreation at least once a week can improve mental health (Garrett et al, 2019). Denton and Aranda (2020) interviewed regular sea swimmers; their findings support the concept that sea swimming may contribute to healthy physical and emotional wellbeing.

Some professionals and researchers, including van Tulleken et al (2018), have claimed that swimming outdoors can be used as a treatment approach for conditions such as anxiety and depression.

“Swimming in the sea really lifted my mood. I really enjoyed the waves and have learnt new skills to keep me safe in the water. I would recommend it to my friends”

Method

After a process of meeting with various swim instructors, FLOW Swimming was identified as a partner organisation for the project. Task and finish meetings were conducted via an online platform and at the selected beach to together plan the vital elements of the project: research and justification, inclusion and exclusion criteria, risk assessment, session plans, outcome measurement, equipment and budget. Following this a programme overview document was produced.

The aim of the project was to improve the emotional wellbeing of the participants, as measured both by the World Health Organization Well-Being Index (WHO-5) and qualitative feedback. The five-item WHO-5 is among the most widely used questionnaires assessing subjective psychological wellbeing. It consists of five simple and non-invasive questions, tapping into the subjective wellbeing of the respondents. The scale has adequate validity both as a screening tool for depression and as an outcome measure in clinical trials, and has been applied across a wide range of study fields (Topp et al, 2015). Programme objectives identified to help achieve the aim of improving emotional wellbeing are detailed in Box 1.

Four young people were recruited to attend the six two-hour sessions with a parent. Some parents elected to join in the swimming activity, while others prepared the fire pit on the beach. Each session incorporated a welcome with a recap of the previous session (where relevant), a safety briefing (including weather conditions and tide, and safe methods of entering and exiting the water), breathing techniques and swimming instruction, a campfire and hot chocolate, as well as therapeutic conversations regarding the Take 5 Steps to Wellbeing approach.

Take 5 Steps to Wellbeing is a set of evidence-based public health messages aimed at improving the wellbeing of the population (Belfast Strategic Partnership, 2018). The approach contributes to improving wellbeing both physically and emotionally, so that people feel good and function well. It is based on the Five Ways to Wellbeing developed by the New Economics Foundation in response to research undertaken as part of the Foresight Mental Capital and Wellbeing Project (2008).

The mental health practitioners wove the Take 5 approach into each session with the young people. Examples of how this was achieved in practice are outlined in Table 1.

Results

The WHO-5 questionnaire was completed by the young people before session 1 and after session 6. Each participant reported an improvement in their emotional wellbeing following the group programme; results are displayed in Table 2.

When scoring the WHO-5, the total raw score (maximum 25) is multiplied by 4 to calculate a percentage. 100% on the WHO-5 indicates optimal emotional wellbeing, while 0% indicates the complete absence of wellbeing (Child Outcomes Research Consortium, 2022). Participant emotional wellbeing as measured by the WHO-5 improved by 8% for one young person and 20% for another. On average, participants reported a 15% improvement in emotional wellbeing following the sea swimming programme.

In addition to the WHO-5 results, young people and their parents provided qualitative feedback. The activities were described by participants as being “great fun”, with confidence and a sense of achievement being a common theme reported by participants.

“Swimming in the sea really lifted my mood. I really enjoyed the waves and have learnt new skills to keep me safe in the water. I would recommend it to my friends.” (Young person)

One parent and her daughter reported that they now engage in sea swimming on a weekly basis. Parents reported that attending the group improved their relationship with their child; 100% reported that they (and their child) would attend future programmes.

“It was a great programme. It helped to distract the children from their worries and anxieties, and showed them that they could push their boundaries. It built resilience and let them try something new.” (Parent)

“He only went into the water for a few minutes on the first day and on the last day he stayed in the water for the full time. He was made to believe in himself.” (Parent)

Two parents who attended the group discussed the benefits to their own mental health, which included anxiety reduction and the social opportunities afforded by spending time with other parents:

“I can totally identify with the health benefits of open water swimming. After each of the sessions I felt a great sense of achievement, motivated and totally energised. I believe it has opened my eyes to a new form of exercise. I would definitely recommend this as a means of promoting mental health for any age group.” (Mother)

Discussion and limitations

This trial of a coproduced therapeutic intervention suggests that there are many reasons for health professionals working with young people experiencing early-onset mood difficulties to consider nature-based physical activity as a treatment medium. Nurses working across the Down GP Federation have used other mediums successfully in collaboration with SET Outdoors, for example, animal-facilitated intervention and horticulture, with a wealth of positive feedback from young people and their parents. Participants of this sea swimming programme reported improvements in wellbeing, which were both reflected in WHO-5 scores and feedback comments, suggesting that the programme was an appropriate treatment method within the context of early intervention and disease prevention.

We acknowledge that there may be barriers to setting up these kinds of group interventions, including geographical location, sourcing an appropriately qualified swim instructor, and lack of resources, such as time, money and staffing.

The fact that the sea swimming programme was coproduced in Northern Ireland may make it difficult to generalise the treatment across other parts of the UK and Ireland. Northern Ireland’s healthcare system differs to that of the rest of the UK; health and social care, for example, are not separate services and funding is a devolved issue. In Ireland, the healthcare system is different from the UK’s NHS in that not all citizens qualify for free public healthcare.

It was challenging to recruit young people to this activity, in part perhaps because the young people had been in lockdown for months before the intervention, because of their mood-related symptoms and because transport could not be provided to and from the sessions (Covid-19 risk assessment did not allow patients from different households to travel in a vehicle together). It is hoped that, as news spreads throughout the GP practices in the Down Federation of the success of this intervention, it will become easier to recruit future participants.

When it was apparent that the target number of eight young people could not be achieved, the scope of the activity was widened to incorporate parents. In hindsight, this added unexpected depth to the group, with parents forming social connections and reporting that completing the weekly activity with their child improved relationships. Research has consistently demonstrated the association between poor parental mental health and negative outcomes for children (Wolicki et al, 2021).

Future programmes should consider the benefits of including parents in group interventions for teenagers. Possible benefits include improved parent-child attunement and attachment, improved parental – as well as adolescent – emotional wellbeing, fewer difficulties associated with recruiting socially anxious or avoidant teenagers, and long-term systemic changes, such as families choosing to exercise together on a regular basis. Parent improvements in emotional wellbeing after the sea swimming sessions could easily have been captured using WHO-5, which would have led to a deeper understanding of how the programme helped the whole range of participants. Ingoldsby (2010) investigated randomised control trials, which examined different methods of improving family engagement in child mental health interventions, with the goal of identifying supporting evidence for frequently used interventions due to their assertion that “engaging and retaining families in mental health prevention and intervention programs is critically important to [ensure] maximum public health impact”.

Mental health practitioners working across primary care in Northern Ireland were commissioned by various GP Federations to offer early, preventative and brief interventions targeting mild to moderate mental health problems. The nurses working in the Down GP Federation are ideally situated in the community, with a remit for patients from cradle to grave, to offer this type of family-centred, motivating and preventative treatment. Within the SEHSCT, this programme has been adapted in collaboration with other services/nursing professionals, such as child and adolescent mental health services. In this case, the goal was not to prevent mental ill health but to target specific mood-related symptoms, and, once again, 100% of young people reported improvement post-programme (a reduction in anxiety symptoms as measured by the Beck Anxiety Inventory).

The concept of taking therapy outside of the clinical setting and of incorporating physical activity into mental health interventions is not unique to nursing. Indeed, this approach (using outdoor physical activity to promote health and wellbeing) has been used across the SEHSCT by occupational therapists, social workers, physiotherapists and psychologists. Nurses are critical to the delivery of health and social care; making up a quarter of the NHS workforce (National Audit Office, 2020). This means that nurses can play an important role in driving innovation across healthcare settings.

Thompson (2019) argues that the current emphasis on mental wellbeing plays an important role in widening the focus of nurses and health professionals beyond the narrowness of the medical model. He states that mental health can be better understood in holistic terms; as quality of life, which is made up of psychological, social and spiritual factors and their various interactions. Nursing this group of young people in an outdoor setting allowed for an inclusive, motivating programme, which introduced social exercise as a stress-management strategy. Young people did not simply talk about their problems on a one-to-one basis with a nurse, be informed about treatment approaches or take medication. They had a ‘lived experience’; they were taught new skills experientially, challenged themselves in real-life situations, formed peer relationships and gained confidence via trial and error in a safe and supported environment.

Conclusion

Research has highlighted the significant health benefits of engaging with outdoor blue spaces, but the authors are unaware of any clinical research that uses sea swimming in this manner with adolescents. Further research into this potentially transformative treatment medium for this patient group is needed to add weight to the feasibility of incorporating sea swimming into early intervention and prevention treatment programmes.