Nature-based Therapeutic Media In Occupational Therapy
David F. Garner
Tennessee State University
A Graduate Research Project
Author’s Note
David F. Garner, Department of Health Science, Tennessee State University. Correspondence concerning this article should be addressed to David Garner, Department of Occupational Therapy, Tennessee State University, 3500 John A Merritt Blvd, Nashville, TN 37209.
Contact: dgarnerotr@gmail.com
Abstract
This paper explores how a therapeutic task involving nature-based media will affect mood and compliance compared to a traditional occupational therapy treatment. Three separate groups of subjects completed a similar task that involved a therapeutic exercise. Subjects were adults of any sex, aged 50 or over. The first group completed a task that involved interacting with live nature-based medium in the form of plants. The second interacted with pictures of nature. The third interacted with a traditional therapeutic medium. The plant medium increased mood, whereas the picture medium did decrease mood for some participants. The initial hypothesis did not hold true that a therapeutic activity involving any nature-based media would improve mood leading to higher perceived self-efficacy and better compliance over some traditional therapeutic media. However, the findings demonstrate that nature-based media decreased mood less than some traditional media. When live plants were involved, mood was increased and did lead to a higher perceived compliance to a home exercise program. The study presented in this paper shows that integrating real, tangible, nature-based media into a treatment plan or home exercise program can potentially improve client compliance.
Keywords: nature-based media, therapy with plants, garden therapy, garden-based intervention, occupational therapy, occupational intervention, mood, and self-efficacy
Nature-based Therapeutic Media In Occupational Therapy
Numerous studies have been conducted on the various facets of therapeutic media in occupational therapy. Few have investigated nature-based media or interventions among any population specifically related to the field of occupational therapy. Gardening and plant tending are popular activities especially among the geriatric population. The out-doors is a common play environment among the pediatric population. In order to understand if nature-based therapeutic media could improve client compliance especially with home exercise programs this relationship needs further study. This paper examines current research related to factors affecting compliance and the use of nature-based media in occupational therapy and reports a study comparing two types of nature-based media to a traditional occupational therapy intervention.
Literature Review
An original study by Kavanagh and Bower (1985) investigated whether humans feel more competent when they are happy or sad. Kavanagh and Bower (1985) found that by inducing a happy or sad mood through recalling a romantic success or failure a subjects' perceived efficacy towards a variety of activities were greatly affected. Activities included specific romantic activities as well as a range of specific interpersonal skills and physical-athletic competencies. They concluded that a specific mood had a strong global impact towards perceived self-efficacy despite the specific origin of the mood. Kavanagh and Bower's study aligned with previous studies that confirmed the impact of mood state on perceived self-efficacy. It presented specific evidence showing that mood can influence competence judgments equally for any activity.
Chen, Neufeld, Feely, and Skinner (1999) investigated factors that contribute to or hinder home exercise program compliance in upper extremity rehabilitation clients. The factors measured included from the Model of Human Occupation; volition, habituation, and performance, from the Health Belief Model: perceived barriers, benefits, self-efficacy, and severity, and Health Locus of Control (HLOC). Results identified two factors as strong predictors of compliance: perceived self-efficacy and internal HLOC. It was concluded that the Model of Human Occupation subsystem of volition made the greatest contribution to compliance, perhaps because beliefs and perceptions strongly motivate humans. Chen et. al. (1999) concluded that greater compliance could be fostered by involving clients in treatment planning and goal setting. This may improve clients sense of control thus decreasing barriers to compliance such as fear from lack of knowledge or understanding of interventions. While Chan et. al. identified self-efficacy as a strong predictor of compliance to home exercise programs, they failed to determine the effect mood had on the level of compliance or if specific therapeutic medium types had any effect on compliance.
A systematic review by Jack, McLean, Moffett, and Gardiner (2010) looked for major barriers to compliance so that clinicians can better identify clients who are at risk of non-compliance to treatment. They found several major barriers in populations undergoing musculoskeletal outpatient treatment including depression, low physical activity engagement in weeks prior to treatment commencement, anxiety, and low self-motivation among others. They concluded that identification of these or other barriers during client assessment will help clinicians preemptively address them. They further concluded that clinicians should be concerned with the attitudes, beliefs, and other barriers clients may have and work celebratedly with the client and caregivers to address these as early as possible in the treatment process. Jack et. al. agreed with Chan et. al. that mood contributes to client compliance as well as the significance of clinical collaboration between clinician and clients as a means to overcome barriers.
The same year, McLean, Burton, Bradley, Littlewood (2010) published a similar review that identified strategies to improve compliance with musculoskeletal outpatient treatment. This review found that simple intervention adjustments alone, such as video rather than print instructions for home exercise programs, do not increase compliance with treatment overall. It found evidence does give moderate support for the use of more complex interventions addressing attitudes, beliefs, and behaviors towards physical activity, which can improve attendance at clinic sessions. This review also acknowledged research indicating the following personal factors as major barriers to compliance: low self-efficacy, depression, anxiety. However, this review only included six articles for its analysis and failed to include any studies that investigated nature-based interventions.
Beinart, Goodchild, Weinman, Ayis, Godfrey (2013) investigated which factors influence clients’ compliance to prescribed home exercises in populations with chronic low back pain. A meta-analysis review of 11 randomized controlled trials, including 1,088 participants found a high health locus of control to be key for greater compliance. It also found three intervention-related subfactors to influence compliance, but they are not related to the present study. These findings coincide with Chen et. al. (1999) that HLOC is a consequential factor in compliance. The significance of Beinart et. al. (2013) is limited because their review only featured chronic low back pain populations rather than mixed populations. However, the study is relevant because many clients with a home exercise program suffer from chronic low back pain in addition to other reasons for seeking occupational therapy services.
In a pivotal study by Orr, Mattson, Chambers, Wichrowski (2004) set out to find the major reasons clients choose to utilize horticultural therapy (HT). The study sought to find whether attitudes towards plants, a horticultural therapy program, health beliefs, or former gardening experience, affected a client’s choice to participate in HT. Several factors were found that contribute to a client’s choice to participate in HT. These included attitude toward HT, birthplace setting, age of first experience with plants, and understanding of the benefits of HT. Attitude was found to be the most consistent predictor of participation. It was also found that most clients in the study were willing to try HT. Occupational and physical therapy were required for all clients in this study, but HT was optional, so some chose not to participate. It was concluded that steps should be taken to increase client’s participation in HT. Orr et. al. (2004) did not consider how a collaboration between occupational therapy and HT might improve client’s use of HT or a client’s overall rehabilitation.
Soderback, Soderstrom, Schalander (2004) reviewed the literature on HT to identify past and present trends in its development. The results of the review found four primary intervention categories: 1) “‘Virtual’ elements from nature in the form of pictures, reading or discussion,” 2) “viewing nature through films or windows,” 3) “interacting, i.e. visiting a hospital healing garden and receiving impressions and experience,” and 4) “action through doing gardening jobs.” Populations in the literature reviewed included those with either mental or physical illness or both. The review suggested that nature viewing-based interventions (category 2) positively affect mood and provide mental restoration. Few studies were found that investigated interaction-based interventions, but those that did found a positive response and an increase in physical activity. The literature reviewed strongly supported nature interaction-based interventions (categories 3 and 4) as being effective at improving mood. This review offered an overarching view of the historical use of horticulture therapy but neglected to further investigate or quantify the effectiveness of the various forms of interventions beyond what was suggested in each study reviewed. This review suggests that viewing and interacting with nature results in positive mood improvement and some level of mental restoration.
York and Wiseman (2012) conducted a meta-ethnographic review looking for any benefits to using gardening as a therapeutic activity. This review found that gardening in the natural environment offers meaningful, satisfying opportunities to increase wellbeing and recovery. More specifically it was found that individuals related more easily to self-nurturing concepts and behavior when caring for the natural environment. Gardening was found to also aid learning and offered a high level of satisfaction to completed tasks. This review only considered the impact of garden-based therapy in a completely natural outdoor setting. It neglected to consider the use of gardening activities in a clinical setting for therapeutic purposes. However, its results do suggest that garden-based therapeutic activities may have positive implications for improving self-efficacy and internal HLOC.
Kamioka, Tsutani, Yamada, Park, Okuizumi, Honda, Okada, Park, Kitayuguchi, Abe, Handa, and Mutoh (2014) investigated the overall effectiveness of HT through a systematic review of randomized control trials. It was found that the available studies on HT are inconsistent in methodology and reporting making it difficult to identify horticultural therapy’s true effectiveness. Kamiokaa et. al. (2014) found that there is some evidence that horticulture may be effective for mental and behavioral illnesses such as dementia, depression, schizophrenia, and terminal cancer care. This study suggests that HT may be useful when working on physical goals for clients with additional mental and behavioral illnesses such as those stated above. It also indicates that more research on the effectiveness of HT is warranted.
Wagenfeld and Atchison (2014) examined how occupational therapists (OT) use gardening as a therapy intervention and attempted to identify features in the garden that affect participation through an online survey of practicing OT’s. It was found that garden-based interventions are used frequently by practicing OT’s. Watering plants was the most frequently used intervention, along with planting, weeding, pruning and others. Garden related journaling was also used but was the least frequent intervention reported. Practice settings included nearly all common settings with the top two being inpatient rehabilitation followed by skilled nursing facilities. Environments where garden-based interventions occurred included outdoor gardens (58.62%), indoors in clinic (48.28%), outdoors but not in garden (24.14%), classrooms (12.07%), and client rooms (5.17%). Garden-based interventions were reported to be used for several reasons including meaningful and purposeful for client by 93.66 percent of OT’s and motivating for client by 80 percent of OT’s. This study helps establish garden-based interventions as popular by showing they are used rather frequently, and they are purposeful, meaningful, and motivating. However, Wagenfeld and Atchison (2014) did not demonstrate the effectiveness of garden-based interventions in relation to other nature-based media or more traditional interventions.
The above literature was used as the basis for designing the study presented in this paper. Based on the literature reviewed, it was hypothesized that a therapeutic activity involving nature-based media would improve mood leading to higher perceived self-efficacy and better compliance over some traditional therapeutic media. Traditional media is here defined as items historically and frequently used by occupational therapy practitioners for home exercise programs (i.e. picking small items out of a bin of dry beans, peg boards, putty, resistance bands, puzzles, arm cycles, etc.) Mood was selected as the best variable to measure for the purposes of this study because of its high impact on self-efficacy. A comparison of three types of therapeutic media were selected to compare how each impacted mood. Two were nature-based non-traditional media and the third was a traditional therapeutic medium.
Methodology
Three activities were selected to have a similar motion of manipulating objects with the dominant hand and moving them in a horizontal plane within the personal space while seated at a table. The study included 30 subjects in a between subject’s design with three separate groups. 10 subjects were randomly assigned to each group. Subjects were recruited from two separate senior daytime community centers, one located in a large metro area and the other in a town of less than 17,000 residents. The subjects were recruited using a verbal announcement during regular business hours. The announcement was made by a staff member of the establishment considered to be familiar to most of its clientele. A description of the research project was read aloud for all to hear. This description was as follows:
The research project is investigating the effectiveness of various methods used in occupational therapy. Volunteers for research projects are an important factor to the continued improvement of the field of occupational therapy. Participation will only require approximately 15 minutes of your time. No previous experience with occupational therapy is required. All that is needed is a willing attitude and a few minutes of your time. Your participation would be beneficial and greatly appreciated. If you are willing to participate, please raise your hand.
A potential participant screening form was then passed out to all those who raise their hand. They were aided in filling it out as necessary. The screening form included these questions:
1. Have you been diagnosed with any chronic musculoskeletal conditions including but not limited to tendonitis, carpel tunnel syndrome, arthritis, fibromyalgia, or others?
2. Can you lift and hold up to three (3) pounds?
3. Do you currently have any fractures, wounds, or other conditions that may make lifting up to three (3) pounds unsafe?
4. To the best of your knowledge are you allergic to any plants?
5. Are you legally dependent or in the care of a legal guardian?
6. Are you over the age of 50 years?
Candidates could participate if they met the following criteria: legally independent, musculoskeletal conditions did not prevent them from lifting and holding three pounds while seated, no known plant allergies, and over the age of 50.
Subjects were randomly selected to be placed in one of the groups. Each subject was then taken individually to a separate well-lit room at the facility where the door could be closed to reduce noise. The subject was seated at a small table across from a single researcher. Next each subject was asked to sign a consent form. If subjects were unable to read the form, the researcher read it to them. If they consented to participate, they were given an overview of the research process by the researcher reading a scripted orientation. Then they were given the primary survey (see Figure A). Next scripted instructions were read aloud and any confusion about the task was addressed by the researcher. Then the components for the activity were placed before the subject and the timer started for five minutes. When the timer finished the subject was told to stop. Finally, they were given the secondary survey (see figure A). Afterword, the conclusion script was read aloud.
The scripted orientation was as follows: “You are about to complete a task that will measure your mood. First you will be asked to complete a short survey. Next you will be asked to complete the task. Finally, you will be asked to complete a second survey.” The scripted instructions varied for each group and are included below. The scripted conclusion was as follows:
This study is looking at how different therapeutic tasks affect people's mood and their willingness to do the task as part of a therapeutic home exercise program. I ask that you not discuss what you have done in this session with other individuals at this facility as that may skew the results of other participants. Do you have any questions?
Group A subjects were asked to water plants for 5 minutes while remaining seated. They were given enough potted plants to continue watering the entire time. Plants included 15-20 4-5-inch (10-13 cm) tall African violets (Saintpaulias) and three 12-15-inch (30-38 cm) spider plants (Chlorophytum comosum). A bowl of water was set with in reach and a 2 tablespoon (29.6 ml) scoop was provided to transfer the water to the plants. The plants were placed in trays to catch any water that ran out the bottom of the pots. Once these items were placed in front of the subject, the researcher read aloud the following scripted instructions:
Your task will last 5 minutes. Your task will be watering plants. Please use the cup before you to transfer water to each pot from the water container. Please do not move the water container and be careful not to spill any water. It is important that the water goes directly in the dirt and does not touch the flowers as it will damage them. Please hold all question until the end unless you are not clear on what the task requires. Please refrain from talking once the timer begins unless it is urgent. Do you understand the task?
Once they confirmed they understood the task they were told to begin, and the timer was set. After completion the secondary survey was administered.
Group B subjects were asked to look through a large picture book of nature photographs while seated. Books were chosen with an abundance of large pictures and minimal text. The covers of the book were wrapped in brown paper, so the title would not affect the subject’s mood. Four books were chosen including The Complete Encyclopedia of Garden Flowers by Kate Bryant published 2003 by Thunder Bay Press, These Rare Lands: Images of America’s National Parks by Stan Jorstand and Mark Strand published 1997 by Simon & Schuster, Great Smokey Mountains by Connie Toops published 1992 by Voyager Press, Our Amazing World of Nature: Its Marvels & Mysteries by Reader’s Digest published 1969 by The Reader’s Digest Association. These books were randomly assigned to various subjects. Once the book was placed in front of the subject the researcher read aloud the following scripted instructions: “Your task will take 5 minutes. Your task will be looking through the large picture book before you. You may pause on each page to look at the pictures but do not stop for more than 10 to 15 seconds. The researcher will let you know if you pause for too long by saying, "please turn to the next page." Focus only on the pictures while avoiding reading the text. Please use one hand to turn the pages. Please hold all question until the end unless you are not clear on what the task requires. Please refrain from talking once the timer begins unless it is urgent. Do you understand the task?” Once they confirmed the task was understood, they were told to begin, and the timer was set. After completion the secondary survey was administered.
Group C subjects were asked to sort beans while seated. A large bowl filled three-fourths of the way with one and a half pounds of pinto beans, half pound of black beans, and 30 steel three-quarter inch hardware nuts were placed before them along with an empty container about 6 inches (15 cm) apart. The researcher read aloud the following scripted instructions:
Figure A
Primary Survey
Please fill out immediately prior to starting task:
How would you rate your present mood?
Bored |
|
|
| Excited |
1 | 2 | 3 | 4 | 5 |
Sad |
|
|
| Happy |
1 | 2 | 3 | 4 | 5 |
Secondary Survey
How would you rate your present mood after completing this task?
Board |
|
|
| Excited |
1 | 2 | 3 | 4 | 5 |
Sad |
|
|
| Happy |
1 | 2 | 3 | 4 | 5 |
How would you rate this activity?
Unpleasant |
|
|
| Pleasant |
1 | 2 | 3 | 4 | 5 |
How likely would you be to do this activity daily as part of a doctor prescribed home exercise program?
Very Unlikely | Unlikely | Somewhat | Likely | Very Likely |
1 | 2 | 3 | 4 | 5 |
Why?
Ethnicity: Age: Gender:
Childhood setting (please circle one): RURAL, SUBURBAN, URBAN
Do you have any previous gardening or plant tending experience?
If you answered 'yes' to the above question, how much experience do you have?
Your task will take 5 minutes. Your task will be sorting and transferring beans from one container into another container using one hand. Please sort the dark beans and the hardware nuts into the empty container leaving the light beans behind. Please do not move the containers. Please hold all question until the end unless you are not clear on what the task requires. Please refrain from talking once the timer begins unless it is urgent. Do you understand the task?
After completion the secondary survey was administered.
Results
Group A included 10 subjects, five were black and five white, nine were female and one male. Of the 10 subjects three reported their childhood setting as rural, four as suburban, and three as urban with a mix of each ethnicity from each setting. The subjects ranged from 59 years to 82 years old and mean age was 72.5 years. Eight of the 10 subjects reported no change in their mood after completing the activity, zero reported a decrease in mood, and two reported an increase (see Figure 01). Both of those that reported a positive change reported their childhood setting as suburban.
Seven of the subjects reported many years of previous plant tending or gardening experience while three reported some previous experience. In response to the survey question “How likely would you be to do this activity daily as part of a doctor or healthcare professional prescribed home exercise program?” four responded very likely, two responded likely, one responded somewhat likely, two responded unlikely, and one responded very unlikely. Seventy percent responded favorably to watering plants as part of a home exercise program (see Figure 03). When asked to answer why they chose a particular response, subjects gave various answers that were sorted into six categories (see Figure 04). Fifty percent reported they enjoyed nature or found the activity engaging while 20 percent reported they would do the activity because it was beneficial. Thirty percent found it not engaging or too difficult.
Group B included 10 subjects, five were black and five were white, eight were female and two males. Of the 10 subjects, six reported their childhood setting as rural, two as suburban, and two as urban with a mix of each ethnicity from each setting except suburban. Both subjects from that setting were black. The youngest subject in the group was 67 years old and the oldest was 93 with a mean age of 78.3 years. Four of the subjects reported no change in mood after the activity, four reported a decrease, and two reported an increase (see Figure 01). Both of those that reported an increase in mood reported their childhood setting as rural. Of those that reported a decrease, two reported an urban and two a rural childhood setting.
Six of the subjects in this group reported having many years of experience with plant tending or gardening, three reported some experience, one reported none. In response to the survey question “How likely would you be to do this activity daily as part of a doctor or healthcare professional prescribed home exercise program?” three responded very likely, three responded likely, one responded somewhat likely, three responded unlikely, and zero responded very unlikely (see Figure 02). Seventy percent of subjects responded favorably to the activity of looking through a large picture book of nature photographs as part of a home exercise program (see Figure 03). When asked to answer why they chose a particular response, subjects gave various answers that were sorted into six categories (see Figure 04). Seventy percent reported the activity as engaging, beneficial, or that they like plants or nature. Thirty percent said the activity was not engaging.
Group C included 10 subjects, five were black and five were white, eight were female and two males. Of the 10 subjects, three reported their childhood setting as rural, one as suburban, and six urban with a mix of each ethnicity from each setting. The subjects age ranged from 59 years 85 years old with the mean age of 74.5 years. Three of the subjects reported no change in their mood after the activity, six reported a decrease, and only one an increase in mood (see Figure 01). Of those that reported a decrease in mood, four reported a childhood setting as urban, one as suburban, and one as rural.
Three of the subjects in this group reported many years of experience tending plants or gardening, two reported some, and five reported none. In response to the survey question “How likely would you be to do this activity daily as part of a doctor or healthcare professional prescribed home exercise program?” two responded very likely, two responded likely, four responded somewhat likely, one responded unlikely, and one responded very unlikely (see Figure 02). Of the respondents, 80% responded favorably to sorting beans as part of a home exercise program (see Figure 03). When asked why they chose a particular response, subjects gave various answers that were sorted into six categories (see Figure 04). Forty percent gave the reason as the healthcare professional says the activity is beneficial while 20% thought the activity beneficial or engaging. Forty percent said the activity was not engaging or too difficult.
Figure 01: This figure shows how many points each subject’s mood changed after completing their activity. The numbers were calculated by adding the results of the two mood Likert scales of the Primary and Secondary Surveys then calculating the change between the Primary and Secondary Surveys.
Figure 02: Subjects rated the therapeutic activity they completed.
Figure 03: Subjects rated the likelihood they would do the activity daily as part of a health professional prescribed home exercise program. Group A is represented by the inner ring, Group B by the middle ring, and Group C by the outer ring.
Figure 04: Subjects provided the reason for the rating they gave in Figure 03.
Conclusion
The plant watering activity of Group A was the only group with an overall increase in mood with a rise in four points across the sample. This activity also had the least change in mood. Yet it is the only activity that did not decrease mood at all. Seventy percent responded favorably to its inclusion as part of a home exercise program primarily because they found the activity enjoyable and beneficial. If the initial assumption holds true that mood highly influences self-efficacy, then the plant watering activity is unlikely to improve self-efficacy for most clients. Yet, it is the least likely to decrease mood and therefore the least likely to lower self-efficacy. Therefore, it is concluded that where clients have any interest in such activities as plant tending or gardening, the therapist ought to seek to include these within the home exercise program and general treatment plan where practical. The client's goals, interests, and possible allergies should always be considered when developing treatment plans involving plants.
The picture viewing activity of Group B had overall nearly no change in mood with only a one-point decrease across the sample. However, it was more likely to decrease mood or have no effect than to increase mood for the majority of subjects. It should be noted that 70 percent of subjects responded favorably to its inclusion as part of a home exercise program because they found it engaging, beneficial, or they simply held an interest in plants/nature. Viewing nature did not seem to improve mood in general and therefore would likely not improve self-efficacy. However, where turning pages of a large book could be a useful treatment activity, books with nature photographs are likely to be of interest to a wide population. Other studies have pointed out the calming effect looking at nature pictures can have on a person. Therefore, this may be a good activity to include in when educating clients on stress management and relaxation techniques especially if it is known a client has an interest in plant tending, gardening, or nature scenery.
All but one of the subjects in groups A and B had either some or many years experience with plant tending. Therefore, it cannot be determined if that previous experience influenced subject’s reactions to the nature-based therapeutic mediums in this data set. It is recommended that therapists inquire about interest in this area with their clients when creating an occupational profile. When a client expresses interest, a therapist can capitalize on the benefits of including nature-based media in treatment where practical.
70 percent of participants in Groups A and B responded favorably to including nature-based media in a home exercise program. Although these media did not change client's mood significantly, clients with experience tending plants clearly desire such activities as part of therapy. It may be impractical to include nature-based media in home exercise programs for many clients. Conventional therapy practice suggests ending each treatment session with an activity clients enjoy to foster feelings of purpose and accomplishment. Nature-based media activities would be beneficial to this end especially for clients with such interests. While the activity may not improve a client's mood, it may at least provide a reward to anticipate and improve participation.
The activity of sorting dry beans in Group C was the most likely to cause a decrease in mood and unlikely to increase mood at all. There was a seven-point decrease across the sample and only one subject reported a minor increase in mood. This activity was least likely to be perceived as beneficial or engaging. It also had the highest percent of respondents that reported they would be likely to use it as part of a home exercise program if a healthcare professional thought it beneficial. Because few saw the intrinsic value of the activity, they would only engage in it if they were told it was helpful by a professional. It is therefore concluded that explaining the reasoning behind treatment activities to clients will aid them in seeing the value and improve compliance. It is also concluded that using purposeful and functional activities (such as watering plants) where clients can immediately understand the intrinsic value to themselves is much preferred to preparatory activities whenever possible.
In summary, the nature-based media demonstrated different effects on mood. The plant watering activity increased mood, whereas the picture viewing activity did decrease mood for some participants. So, the initial hypothesis does not hold true that a therapeutic activity involving any nature-based media will improve mood and lead to higher perceived self-efficacy and better compliance over some traditional therapeutic media. However, the findings demonstrate that sorting beans decreased mood more than nature-based media. This finding can be extrapolated to suggest that other common therapeutic media, especially preparatory activities, may have a similar effect on many clients. When live plants were involved, mood was increased and did lead to a higher perceived compliance. The study presented in this paper shows that integrating real, tangible, nature-based media into a treatment plan or home exercise program can potentially improve compliance.
Limitations
The author was able to find very little research or literature on the use of nature-based media in occupational therapy. This is a gap in the literature that would benefit from further study as it holds a lot of potential based on the literature that was reviewed for this paper. Horticulture therapy is backed by extensive research and the merits of combining it with more traditional therapeutic treatments in occupational therapy should be the subject of future studies.
It should be noted that this study is small containing only 30 subjects which were then subdivided into three separate categories. The demographics of the study were not a representative sample of the population of any geographic region. So further studies are needed to determine if the trends in this study remain true on a larger scale. Additionally, this study only looked at how nature-based media impacted subjects in the geriatric age group. Other age groups need to be studied to determine the merits of nature-based media among those populations.
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