Introduction
Several literature reviews and intervention studies have examined and reported on the psychological, physiological and social health benefits of human exposure to nature (Ulrich et al., Reference Ulrich, Simons, Losito, Fiorito, Miles and Zelson1991; Kaplan, Reference Kaplan1995; Barton and Pretty, Reference Barton and Pretty2010; Hartig et al., Reference Hartig, Mitchell, de Vries and Frumkin2014; Seymour, Reference Seymour2016; Martin et al., Reference Martin, White, Hunt, Richardson, Pahl and Burt2020; Jones et al., Reference Jones, Tarter and Ross2021). Given this growing body of evidence, healthcare institutions are interested in leveraging the potential for integrating nature into their healthcare practice as a complementary health-promoting approach.
Recently, a number of reviews discussed nature-based interventions (NBI) implemented in an organizational or institutional health care setting (Moeller et al., Reference Moeller, King, Burr, Gibbs and Gomersall2018; Shanahan et al., Reference Shanahan, Astell-Burt, Barber, Brymer, Cox, Dean and Gaston2019; Gritzka et al., Reference Gritzka, MacIntyre, Dörfel, Baker-Blanc and Calogiuri2020), considering evidence on NBI-mediated health benefits for their target population. NBI can be defined as follows: “Nature-based interventions are planned, intentional activities to promote individuals’ optimal functioning, health and well-being or to enable restoration and recovery through exposure to or interaction with authentic nature or technological nature.” (Gritzka et al., Reference Gritzka, MacIntyre, Dörfel, Baker-Blanc and Calogiuri2020). Typical of this emerging field, is that there is a variety of NBI (e.g., ecotherapy, horticulture, outdoor therapy) used in different contexts for different purposes, making comparisons between NBI challenging (Shanahan et al., Reference Shanahan, Astell-Burt, Barber, Brymer, Cox, Dean and Gaston2019; Gritzka et al., Reference Gritzka, MacIntyre, Dörfel, Baker-Blanc and Calogiuri2020). Furthermore, many questions crucial for efficient NBI implementation remain unanswered. For example, it is often not specified which evidence-based or theoretical frameworks underlie the NBI. Moreover, it is not always clear at which type of nature interaction a particular NBI aims (Frumkin et al., Reference Frumkin, Bratman, Breslow, Cochran, Kahn, Lawler, Levin, Tandon, Varanasi, Wolf and Wood2017) and the specific role of healthcare professionals in NBI is not defined (Lauwers et al., Reference Lauwers, Bastiaens, Remmen and Keune2020). Next, given the urge for climate change mitigation and biodiversity restoration, and the emerging link with human health (Lindley et al., Reference Lindley, Cook, Dennis, Gilchrist, Marselle, Stadler, Korn, Irvine and Bonn2019; Marselle et al., Reference Marselle, Hartig, Cox, de Bell, Knapp, Lindley and Bonn2021), healthcare institutions are examining how surrounding natural environments can be designed to restore biodiversity. As such, integrated NBI could be designed and implemented that simultaneously benefits human health and environmental sustainability, as found in a One Health- approach (Rüegg et al., Reference Rüegg, Häsler and Zinsstag2018). However, the implementation of this human-nature-health interdependence in healthcare practice appears to be challenging due to its complexity (Lauwers et al., Reference Lauwers, Bastiaens, Remmen and Keune2020). Another significant aspect is that NBI in healthcare institutions can be considered complex health interventions (Skivington et al., Reference Skivington, Matthews, Simpson, Craig, Baird, Blazeby and Moore2021). Despite the recommendations for the evaluation of complex health interventions (Skivington et al., Reference Skivington, Matthews, Simpson, Craig, Baird, Blazeby and Moore2021) and the process of intervention mapping (Bartholomew Eldredge, Reference Bartholomew Eldredge, Markham, Ruiter, Fernández, Kok and Parcel2016), it is not always obvious which quality criteria are or should be monitored during the design, implementation and evaluation of NBI to guarantee its quality, predefined outcomes, sustainability and integrated character. Having more insight in these quality criteria would advance evidence-based research and effective implementation of NBI. In addition, a well-developed NBI quality assessment framework will help policymakers and healthcare professionals to design, implement and evaluate NBI.
Therefore, this scoping review aims to identify quality criteria that are relevant in the different phases of the NBI (be it in the design, implementation and/or evaluation phase). We ask the question “What is known in the literature about the quality criteria of nature-based interventions in healthcare institutions?.” The final aim of this study is to develop an NBI quality assessment framework, to be tested and refined in a subsequent qualitative study including seven NBI cases in healthcare institutions in Flanders, Belgium.
Methods
An exploratory scoping review will be conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews (Peters et al., Reference Peters, Godfrey, McInerney, Khalil, Larsen, Marnie and Munn2022), including qualitative, cross-sectional and other quantitative peer-reviewed studies. Scoping reviews “map systematically the breadth of evidence available on a particular topic, field, concept, or issue, often irrespective of source (i.e., primary research, reviews, non-empirical evidence) within or across particular contexts. Scoping reviews can clarify key concepts/definitions in the literature and identify key characteristics or factors related to a concept, including those related to methodological research” (Munn et al., Reference Munn, Pollock, Khalil, Alexander, Mclnerney, Godfrey and Tricco2022). Scoping reviews are considered a legitime and rigorous methodology (Peters et al., Reference Peters, Godfrey, McInerney, Khalil, Larsen, Marnie and Munn2022) and are appropriate for poorly known, interdisciplinary, complex research topics (Peters et al., Reference Peters, Marnie, Tricco, Pollock, Munn, Alexander and Khalil2020). This methodology, in combination with the use of the Preferred Reporting Items for systemic reviews and Meta-Analysis extension for Scoping Reviews consisting of conducting and reporting standards, underpins the quality of this review (Tricco et al., Reference Tricco, Lillie, Zarin, O'Brien, Colquhoun, Levac and Weeks2018). A first screening process will be conducted independently by the two PRs based on published peer-reviewed study titles and abstracts. Disagreements will be solved by discussion, consensus and by consultation with the wider interdisciplinary research team (e.g., human health, biodiversity, bioscience engineering). Potential researchers' bias in screening will be taken into consideration and discussed as well. A second screening will take place while the full texts are being read. Finally, for the sake of rigor, feedback on the findings of the review (Arksey & O'Malley, Reference Arksey and O'Malley2005) will be solicited first from the project steering group, composed of members of a larger research project of which this study is part of, and subsequently from a multi-stakeholder assembly (e.g., healthcare or ecology practitioners, managers, policymakers).
Search strategy
Up to date, a preliminary search was conducted across four databases, PubMed, MEDLINE, Scopus and Web of Science focusing on reviews of NBI, to identify the most relevant search terms according to the topic of NBI. Titles and abstracts, keywords and index terms were screened to identify all possible search terms. Concerning the topic of biodiversity, a set of search terms was compiled by an expert researcher in ecology, and completed by the wider interdisciplinary research team.
Search terms
The scoping review protocol and its search terms were discussed with the interdisciplinary research team and the project steering group. For example, the types of NBI (e.g., care farm vs. green care farm, traditional prisons vs. prisons with a healthcare unit and surrounded by nature), the proximity of the healthcare institution to the natural environment and types of nature (e.g., indoor vs. outdoor, view on nature or physical contact with nature) were discussed regarding their relevance for the aim and the review question of the study.
Several sets of search terms were developed and tested. Each set and its combination were refined by an experienced librarian at the University of Antwerp, Belgium. Finally, two remaining sets with the use of filters in certain databases gave the best quality and practicality of search results in view of the aim and research question of this study (Table 1). The same databases mentioned above will be used in the final study on NBI for which this protocol is developed.
Eligibility criteria (population, concept and context)
Population
The target populations of these NBI studies may be healthcare professionals (as NBI users or either prescribers or practitioners), or other staff or patients.
Table 1. Sets of keywords and used filters
Concept
We will include studies in which individuals or groups participate in NBI. Studies discussing care farms will be included when they focus on the benefits of the natural environment on human health (e.g., green care farms). Purely animal-assisted therapies such as equine-assisted therapy or working with dogs or similar are also not included for the same contextual reason.
Context
NBI should be implemented in an institutional setting (e.g., hospital, residential care facility, nursing or retirement home), surrounded by green or blue space. Quality criteria will be understood as factors that mediate or support the success of the intervention processes, the health benefits for the participant and the biodiversity of the surrounding natural environment of the health institution.
Type of studies
This scoping review will consider qualitative, cross-sectional and other quantitative peer-reviewed studies. The review will be limited to studies published in English between January 2005-April 2023. Additionally, we will hand-check the references of all included articles to identify all relevant literature.
Exclusion criteria
Studies will be excluded when limited to animal-assisted care interventions, individual cases, community gardening, focus on other objectives than care (e.g., recreation), indoor and virtual nature and no institutional healthcare setting.
Selection of studies
All identified citations will be collected and uploaded into a shared group in Rayyan, a web-based platform for reviews, and duplicates will be removed. Then, a step-by-step tabular process will be undertaken. First, based on the inclusion/exclusion criteria, the two PRs will conduct a screening of title and abstract. Second, the full texts will be assessed against the inclusion criteria by the two PRs and two additional researchers. Reasons for excluded studies at this stage will be recorded and reported in the scoping review. Results, uncertainties or disagreements regarding inclusion that arise at each stage will be resolved by discussion and consensus with the research team.
The search and selection process for relevant literature will be described in a PRISMA flow diagram (Moher et al., Reference Moher, Liberati, Tetzlaff, Altman and Group2009; Tricco et al., Reference Tricco, Lillie, Zarin, O'Brien, Colquhoun, Levac and Weeks2018).
Data extraction
First, a draft of a data extraction table will be piloted on a subset of sources to be included in the review to test its feasibility for the review (Peters et al., Reference Peters, Godfrey, McInerney, Khalil, Larsen, Marnie and Munn2022). Next, a summary of all retained studies will be provided, including author, year of publication, study type (review, intervention study), type of institution, type of NBI, study population, use of evidence or theoretical frameworks and outcomes of the NBI. Modifications will be mentioned in the resulting scoping review.
Data analysis and presentation
The data will then be analyzed by the two PRs and two other researchers using a descriptive qualitative content analysis. The data of each study will be categorized according to the topics of biodiversity, human health or intervention processes, with their respective quality criteria. A second analysis will be performed according to the requirements of developing a set of NBI quality indicators, defined per level (institutional, professionals, patients), if applicable, which will be detailed in the scoping review.
Formulating conclusions, proposal prototype framework and future research directions
Based on the review findings and conclusions, we will develop a set of NBI quality indicators. Ultimately, the review findings will lead to a prototype NBI quality assessment framework that will be presented to the project steering group and a multi-stakeholder assembly of, for example, healthcare or ecology professionals, managers and policymakers, with the aim of gathering and implementing feedback. The framework will be further refined and tested in a set of Flemish NBI cases. Other research directions emerging from the scoping review will be proposed as well.
Aknowledgments
The authors express gratitude to the project steering group consisting of representatives of the Agency for Nature and Forests of the Flemish Government (Myriam De Bie, Jeroen Panis) and Sarah Feys of Vlaams Infrastructuurfonds voor Persoonsgebonden Aangelegenheden, department of the government Well-being, Public Health and Family, for their contributions to the design of the scoping review protocol. We also would like to thank Barbara Lejeune, librarian at the Library of the University of Antwerp, for her technical advice in crafting the sets of the search terms and strings.
Data availability statement
Data sharing is not applicable – no new data is generated.
Author contributions
The protocol for the scoping review was conceptualized by AS, with support of BD. IS, GDB, RR and HK gave input concerning the search terms. HK and RR supervised AS and BD on maintaining rigor in the execution of the review. Several drafts of this paper were composed by AS and reviewed by BD, HK, IS and RR. All authors have read and approved the final version of the manuscript.
Funding statement
The Agency for Nature and Forests of the Flemish Government funded this study (grant number ANB-AB-2022–210), as part of a larger funded project intending to create an NBI quality assessment framework. IS was supported by a grant from the Research Foundation – Flanders (Fonds Wetenschappelijk Onderzoek (FWO)) (postdoctoral grant 1277222N).
Competing interests
The work of AS and BD was funded by The Agency for Nature and Forests of the Flemish Government, Belgium. However, all authors declare that designing and writing this study protocol was conducted in the absence of any commercial or financial relationship that could be construed as a potential conflict of interest.
Ethical statement
Ethical approval for this protocol and planned scoping review were not required.
Open access
Comments
Dear Prof. Dr. Kock,
We wish to submit our manuscript entitled ‘Quality criteria of nature-based interventions in healthcare institutions: a scoping review protocol’ as a method paper for consideration by Research Directions: One Health.
We confirm that this work is original and has not been published elsewhere, nor is it currently under consideration for publication elsewhere.
In this scoping review, we will explore potential quality criteria for designing, implementing and evaluating nature-based interventions in healthcare institutions. The scoping review is part of a larger funded project that we conduct in collaboration with The Agency for nature and forests of the Flemish Government in Belgium. The project aims to develop a quality assessment framework for integrated nature-based interventions in healthcare institutions. Interestingly, this project has an integrated vision of health, as reflected in One Health, that promotes the interdependent link between biodiversity restoration and human health. Furthermore, the nature-based intervention implemented by the healthcare institution is perceived as ‘integrated’ when it combines 1) caring for nature through restoring biodiversity and 2) caring for human health through guidance of target groups in a natural environment. However, as far as we know, it is not always obvious which quality criteria are best to monitor during the design, implementation, and evaluation of these nature-based interventions to guarantee their quality, predefined outcomes, sustainability, and integrated character. Therefore, in this project, we would first like to conduct a scoping review with the research question: ‘What is known in the literature about the quality criteria of nature-based interventions in healthcare institutions?’.
The protocol for the scoping review relies on the Joanna Briggs Institute Scoping Review Methodology and Preferred Reporting Items for Systematic Reviews with extension for scoping reviews. Ultimately, this descriptive work will result in a set of quality indicators and a prototype nature-based intervention quality assessment framework, which will be presented to the project steering group and multi-stakeholder assembly for further refinement.
We believe this manuscript is appropriate for publication by Research Directions: One Health. First, because it relies on the same goal of achieving optimal health outcomes recognizing the interconnection between people, animals, plants, and their shared environment. Second, we believe this study adds insight to the research question ‘How can we operationalize the promotion and evaluation of nature-related ‘green’ health care within a One Health perspective’.
The manuscript has been carefully reviewed by experienced academic researchers of our team.
We have no conflicts of interest to disclose.
Please address all correspondence concerning this manuscript to me at ann.sterckx@uantwerpen.be.
Thank you for your consideration of this manuscript.
Sincerely,
Ann Sterckx and co-authors