Nature based mindfulness interventions for long-term health conditions, a meta-analysis of the evidence and a cross-sectional study exploring psychological pathways underlying nature’s benefits on chronic pain

Abstract

This thesis aimed to explore nature for people with long-term health conditions.

The first chapter presents a systematic review and meta-analysis examining the effects of mindfulness practiced in natural environments, compared with a range of comparators on depression, anxiety and stress for people with long-term health conditions. Comparator conditions were categorised into three groups: (1) non-active controls, including treatment as usual, waitlist or no-intervention conditions; (2) active mindfulness-based controls delivered in non-natural settings, and (3) active non-mindfulness, non-nature controls comprised of structured therapeutic, education, exercise-based or recreational activities delivered without mindfulness components or nature exposure. Ten articles were included in the meta-analysis. Study quality was assessed using the Cochrane Risk Of Bias 2 (ROB2) tool, with most studies rated as high risk, partly due to the absence of pre-registered protocols and the inclusion of non-randomised study designs. Overall, findings show that nature-based mindfulness interventions were beneficial for depression and stress.

Specifically, nature-based mindfulness interventions were more beneficial than treatment as usual or waiting list comparators for depression. Nature-based mindfulness interventions were also more beneficial than active non-mindfulness, non-nature interventions for stress. Smaller, non-significant effects were found for nature-based mindfulness benefitting anxiety overall and for nature-based mindfulness interventions compared to active non-mindfulness, non-nature controls for depression. The role of the environmental context could not be clarified due to a lack of studies.

Although these findings are encouraging that the addition of nature may enhance the effectiveness of mindfulness for people with long-term health conditions, several limitations in the literature were identified. Only two health conditions were located within our sample: chronic pain and depression.

Meaning, further research is required to validate our findings trans-diagnostically. Recommendations for future research include reducing the heterogeneity of interventions and increasing the rigorousness of research to reduce the risk of bias. Further research with methodologically stronger studies is required to draw definitive conclusions.

The second chapter is an empirical study exploring noticing nature and nature connectedness benefits for people with chronic pain. This study aimed to investigate the psychological constructs connecting chronic pain and engagment with nature. Specifically, it examined whether noticing nature predicted nature connectedness, mindfulness and pain rumination more than passive nature contact or time in nature. A further aim was to clarify the pathway between nature connectedness and pain rumination, proposing mindfulness as a potential mediating factor. A cross-sectional survey was completed by 154 adults with chronic pain. Correlational analyses, multiple hierarchical regression analyses and mediation analyses were conducted, to explore associations between noticing nature, nature connectedness, mindfulness, and pain-related rumination. Noticing nature did not predict pain rumination or mindfulness more than passive nature contact or time in nature.

Mindfulness did not mediate the relationship between nature connectedness and pain rumination. However, noticing nature significantly improved the predictive model of nature connectedness, beyond passive contact or time in nature.

Noticing nature appears to strengthen nature connectedness among people with chronic pain. However, it was not associated with increased mindfulness and therefore cannot be considered an alternative mindfulness strategy. These findings suggest that individuals with chronic pain can benefit from being in nature without needing to actively notice it, though further experimental research is warranted.