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Influence of an outdoor garden on mood and stress in older adults


Abstract and Figures

Despite recent interest in healing gardens and therapeutic landscapes at residential care facilities, few empirical studies have measured health outcomes in elderly populations. This study explored methods for assessing psychological and physiological outcomes associated with natural environments. Seventeen residents ranging from 71 to 98 years of age (mean 84.7) engaged in the same activities at an outdoor horticultural garden or indoor classroom. Before and after the experience, subjects were assessed for positive and negative mood, anxiety, and salivary cortisol. No significant change was found in mood or anxiety level. Cortisol was significantly lower in the garden environment compared with the indoor settings, indicating greater reduction in stress level. This pilot study supports previous research finding health-related outcomes associated with brief exposure to natural environments.
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Rodiek, S (2002). Influence of an
Outdoor Garden on Mood and Stress in
Older Persons. Journal of Therapeutic
Horticulture, Volume XIII, 13-21
Influence of an Outdoor Garden on Mood and Stress in Older Persons
Susan Rodiek
Despite recent interest in healing gardens and therapeutic landscapes at residential
care facilities, few empirical studies have measured health outcomes in elderly
populations. This study explored methods for assessing psychological and
physiological outcomes associated with natural environments. Seventeen residents
ranging from 71 to 98 years of age (mean 84.7) engaged in the same activities at an
outdoor horticultural garden or indoor classroom. Before and after the experience,
subjects were assessed for positive and negative mood, anxiety, and salivary cortisol.
No significant change was found in mood or anxiety level. Cortisol was significantly
lower in the garden environment compared with the indoor settings, indicating
greater reduction in stress level. This pilot study supports previous research finding
health-related outcomes associated with brief exposure to natural environments.
Throughout the centuries nature has been considered to have healing potential. Plants, sunlight
and other nature elements have often been incorporated in healthcare settings as a therapeutic
adjunct and to improve the atmosphere for patients, staff and visitors (Lewis, 1996; Gerlach-
Spriggs, Kaufman & Warner, 1998; Cooper Marcus & Barnes, 1999). A growing body of
research is offering evidence that contact with natural environments may result in improved
health outcomes. Studies in general and healthcare populations have measured muscle tension,
blood pressure, heart rate and immune response, as well as emotional status, attentional capacity
and other indicators of psychological condition (Hartig, Mang & Evans, 1991; Ulrich et al.,
1991; Ulrich & Parsons 1992; Ulrich, 1999). However, few outcome-based studies have been
conducted with aging populations. Although landscape and horticulture professionals may
observe therapeutic outcomes in elderly subjects, unquantified reports may be difficult to
translate into justification for reimbursement policies. Controlled empirical studies with plants
and garden environments may help increase the credibility of horticulture-related treatments and
advance the understanding of specific outcomes in different populations.
Preference-Based Studies
The available preference-based research generally indicates that older adults highly value contact
with plants and natural environments. For example, Perkins (1998) found that elderly residents
of congregate facilities considered plants, especially flowers, to be extremely important, along
with sunlight, fresh air, and views of water, wildlife and other nature elements. Talbot and
Kaplan (1991) also found nature important to the elderly, especially flower gardens and outdoor
sitting areas, and that having nature nearby substantially contributed to residential satisfaction.
Lewis and Mattson (1988) found that the preferences of nursing home residents for horticultural
activities far exceeded their actual frequency of participation, suggesting that appropriate
opportunities might not have been available. A study by Stoneham and Jones (1997) found that
many aspects of gardening were of interest to residents of sheltered housing, even though the
environment was not always conducive to the realization of these desires. In private urban
gardens located within the community, Dunnett and Qasim (2000) found that the time spent
gardening was greatest in respondents over 65 years, suggesting that interest in nature may
increase with aging.
Outcome-Based Studies
In spite of these indications of the value of nature and gardening to the elderly, studies measuring
health-related outcomes associated with plants and nature elements are scarce, although some
exist. A large study with low-income urban elderly found that trees, plants and green lawns were
correlated with stronger social integration of residents, which in turn is associated with positive
health benefits (Kweon, Sullivan & Wiley, 1998). Langer and Rodin (1976) found beneficial
effects in elderly nursing home residents who cared for a plant as part of a program to enhance
sense of control. Residents given more control showed greater alertness and participation in
activities, and were found to have improved health and mortality rates measured eighteen months
later (Rodin & Langer, 1977). Mooney and Nicell (1992) found dementia-related agitation was
less in facilities with purposively designed outdoor areas than in ordinary facilities, but other
differences between the facilities may have contributed to the differences. In studying a
horticultural therapy program, Mooney and Milstein (1994) found specific benefits to elderly
residents, but the effect of plants was not separated from the effects of therapy. Whall et al.
(1997) found less agitation and aggression in bathing dementia patients when they were shown
pictures of plants and animals, but the effects were not separated from food and other stimuli. A
study comparing an Eden Alternative facility with a conventional facility found no benefit from
the extensive use of plants and other elements that are part of the Eden philosophy. However,
facilities and residents differed in other ways, and the study was conducted during the first year
of Eden implementation, while a major transition in policies and procedures was underway
(Coleman et al., 2002). Although these and other studies clearly contribute to the state of
knowledge, the literature on this topic still lacks a sufficient number of controlled, outcome-
based studies which separate the effects of plants and nature elements from other therapeutic
benefit such as increased activity and social contact. Only by isolating plants and nature-related
elements can we establish that horticulture is having an effect, in addition to therapy.
The Present Study
This pilot study tested methods for comparing environmental effects by randomly assigning
subjects to the same activities in either a garden or non-garden setting. The garden setting was
lush and flowery, the indoor settings reasonably pleasant but lacking in nature elements. Before
and afterward, subjects were assessed for mood and stress indicators. It was hypothesized that
outdoor garden subjects would have more positive changes than indoor subjects, based on: 1)
the expressed preference of older adults for plants and nature elements, and 2) nature-related
health outcomes found in other populations. Because contact time was brief, it seemed likely
that any difference found between the two groups would be modest. However, even minor
differences could have important implications for the health benefits possible from long-term
contact with plants and garden environments.
Selection and Recruitment of Subjects
Subjects were recruited from a residential complex for aging, comprised of a single-story nursing
facility (private-pay) with adjacent low-rise senior apartments (HUD-financed). Facilities shared
staff and administration, and were located on the same campus in a mid-size town in the southern
United States. Resident participation was restricted to the apartment complex and the two most
independent nursing wings, as administrators considered residents of the two remaining nursing
wings too frail or cognitively impaired to participate. Recruits from the two facility types were
randomly assigned in representative proportion to the different experimental conditions.
Recruitment was voluntary, and was solicited by announcements at mealtime when most
residents were present. Forty-four percent of the recruits came from the nursing home, and fifty-
six percent from the apartments. The nursing director reviewed the list of recruits for cognitive
and physical eligibility, and none were excluded from participation.
Subject Profile
The seventeen subjects ranged from 71 to 98 years of age (mean 84.7). Apartment subjects
averaged 80.8 years, compared with 89.8 years for nursing home subjects. Average length of
residence at the facility was 5.1 years for apartment subjects, and 3.9 years for nursing home
subjects. All subjects spoke English as their first language, and were female (the only male
recruit withdrew on the morning of the experiment). Assistive devices were used by about one
third of the subjects, and were distributed fairly evenly to the different treatment conditions:
there were three canes, two walkers, and one wheelchair.
Study Design
This study measured four variables on the subjects immediately before and after a single session
in one of three different randomly assigned conditions. The variables measured were positive
and negative mood, anxiety, and salivary cortisol. The assigned conditions were three different
environments: two indoor treatments and one outdoor treatment. Aside from elements relating to
nature or the outdoors, other aspects of the treatment environments were designed to be as much
alike as possible. For example, subjects used the same type of chair and tablecloth in each
setting, and research assistants read from a prepared script, following the same schedule. To
reduce the effect of extraneous variables, external events (such as people walking by) were
reduced to a minimum, and all sessions were conducted simultaneously. To increase the
independence of their responses, subjects were instructed not to hold conversations or discuss
their responses during the session. Subjects were observed to follow these instructions, but non-
verbal interactions might have influenced responses. The outdoor group had six subjects, and the
two indoor groups had five and six subjects each.
Environmental Conditions
The outdoor environment consisted of an umbrella table set up near a tree at a university
horticultural garden. Two indoor treatment environments were used, chosen to be as much alike
as possible: a classroom located at the horticultural garden; and an activity room at the subjects’
residential facility. Allowing one group to stay at the facility was intended to control for the
“field trip” effect; this group also did a few minutes of mild exercise to compensate for the
physical activity of the travel component. Each environment was arranged for subjects to sit
comfortably around a table, with a research assistant and facility staff member nearby. Weather
was a major environmental variable, and had to be comfortable for older adults, but not
necessarily a “perfect” day. The experiment was conducted in early spring, with a light breeze
and the sky about 40% cloudy. The temperature indoors was about 73 degrees Fahrenheit, and
outdoors about 68 degrees (considered barely warm enough by staff), but was warmed by
occasional sunshine. Ambient light levels (measured at the center of each table) were in the
same range for both indoor settings, 61 and 90 foot-candles, which is typical for fairly bright
indoor rooms (one foot-candle equals one lumen per square foot, or about 10.8 lux). The light
outdoors was much brighter (890 foot-candles), even though measured on a partly cloudy day
under a ten-foot-wide dark green umbrella. Higher light levels are characteristic of outdoor
environments, and were anticipated as an important aspect in which the treatment environments
would differ.
Environmental Contrast
To emphasize the difference between the two types of environments, nature elements were added
to the garden setting, and removed from the indoor settings. For example, the outdoor setting was
located where vegetation screened the view of nearby buildings, and flowering plants such as
potted bougainvillea were added. At the indoor settings, plants and nature paintings were
systematically removed, and the windows covered with sheer white paper which allowed natural
light but no direct views to the outdoors. The purpose of increasing or reducing the nature
content of the environmental settings was to clearly distinguish between effects due to nature and
non-nature elements, and to maximize the contrast of what was expected to be a very subtle
effect, considering the brief exposure subjects would have during this experiment.
Study settings and instruments were designed to accommodate physical and sensory limitations
common in older adults. Treatment locations were examined for safety hazards, and the outdoor
environment was located where it would be protected from the wind. Research assistants were
trained to give verbal instructions slowly and clearly. Questionnaires were presented in large
type (Arial 14 point), and formatted for maximum legibility. The measures of psychological
well-being used in the experiment were: positive mood, negative mood, and anxiety. Salivary
cortisol was measured as a stress marker, and was included for three reasons: First, as a
biological measure, cortisol does not rely on the interpretation of test questions or subjective
perception of emotional state. Second, it should be unaffected by acquiescence or fear of
retribution, which are common on psychological tests with an institutionalized population.
Third, because cortisol is closely associated with physical health and well-being, any
environmental feature which affects cortisol might have important implications for the health of
older adults (see Vogt, 1992, pp. 214-218 for an overview).
Mood (affect). Positive and negative mood were assessed with a ten-item scale
(Philadelphia Geriatric Center Positive and Negative Affect Rating Scale, Lawton, Kleban,
Dean, Rajagopal, & Parmelee, 1992; see also Kane & Kane, 2000). This scale was designed
specifically for use with older adults, is brief enough to administer repeatedly, and measures
positive and negative domains independently. The negative constructs represented are
depression (sad, depressed), anxiety (worried), and hostility (irritated, annoyed). The positive
constructs are feeling interested, energetic, happy, warmhearted, and content. For this study,
questions were phrased as “How strongly do you feel this way right now?” Responses used a
five-point scale from Not at All to Very Strong, with possible scores ranging from five to
twenty-five on each domain.
Anxiety. Participants’ level of anxiety was assessed with a ten-item subscale of the
widely used Spielberger State-Trait Anxiety Inventory (STAI), considered appropriate for
repeated measurements (Spielberger et al., 1979; Spielberger, Gorsuch, Lushene, Vagg &
Jacobs, 1983). This measure was chosen because of the uncomplicated questions and lack of
somatic items. Ten items indicate the presence or absence of anxiety, such as “I feel calm” or “I
am tense.” Respondents were asked to “circle the answer which describes your feelings right
now,” from Not At All to Very Much, using a four-point scale with possible scores ranging from
ten to forty.
Cortisol. Participants’ level of cortisol was assessed from saliva, which provided a non-
invasive approach useful for repeated measurements. Salivary cortisol is considered a reliable
measure of serum cortisol, and the short time lag of 20-30 minutes between stimulus and salivary
cortisol response (Kirschbaum & Hellhammer, 1994; Reid, Intieri, Susman, & Beard, 1992) was
suitable for this study. As an adrenal hormone stimulated by the hypothalamic-pituitary-adrenal
axis during a difficult or hopeless situation, cortisol is commonly considered a biological
indicator of stress (Brannon & Feist, 1997; Vogt, 1992). Prolonged exposure to high cortisol
level has been associated with hypertension, osteoporosis, muscle atrophy, fatigue, lowered
immune function and coronary heart disease (Raff et al., 1999; Samuels, Furlan, Boyce, & Katz,
1997). High cortisol level is also frequently associated with depression. Cortisol-lowering
agents have been used successfully to treat depression, although the role of cortisol in depression
is not fully understood (Cowen, 2002; Morrison et al., 2000; Wolkowitz & Reus, 1999). For this
study, subjects provided saliva samples by chewing on swabs provided in individual
centrifugible salivettes (Sarstedt Inc., Newton, NC). The swab was held in the mouth for about
one minute, or until saturated. Polyester swabs were chosen instead of cotton, to allow subjects
to moisten them more easily. The samples were frozen and shipped on dry ice for enzyme
immunoassay to the Clinical Research Center Core Lab, Oregon Health Science University,
Portland, OR.
Preparation, Pre-Measurement, and Travel
A few weeks before the experiment, subject demographic questionnaires were filled in, and
cortisol collection methods were pre-tested. Recruits were told generally what to expect during
the session, and asked to bring a sweater and reading glasses if needed. The experiment was
conducted on the first pre-scheduled date with dry weather and suitably warm temperatures. On
that day, about one hour after breakfast, subjects gathered in the dining hall and pre-treatment
measurements were taken. Subjects were then divided into three groups, but were not told where
any of the groups were going. Two groups traveled in the same facility van about five minutes
to the horticulture garden and adjacent classroom, while the third group went to an activity room
at the facility, after walking around for a few minutes to compensate for the travel component.
Each group was accompanied by a non-participatory facility staff member who was on hand for
physical assistance, and by a trained research assistant who administered the measures.
Experimental Session
After arriving at the experimental locations, each group of subjects was seated comfortably
around a table, and each research assistant used a prepared script to administer the scheduled
activities. Activities were intended to occupy time in a neutral manner while allowing subjects
to maintain awareness of their surroundings. One activity asked subjects to observe the
surrounding environment, and to describe it using a semantic differential scale. In another
activity, subjects spent a few minutes looking through photo books of either built or natural
environments, to match the treatment setting. These activities were conducted at a leisurely
pace, and along with a few rest periods and filling in the second set of questionnaires, occupied
the remainder of the session. The second saliva samples were collected, and the subjects were
thanked and returned to their residential facility. The entire process took about two and a half
hours overall, with measurements taken about one and a half hours apart.
One subject who recently had a stroke produced incoherent responses that were discarded. One
subject with a sore tongue was unwilling to repeat the salivary cortisol procedure, and two others
failed to produce enough saliva for a comparison. Tests were scored so that on all instruments,
higher scores represented more favorable outcomes. As treatment conditions had been very
similar, data for the indoor groups were combined. Since this experiment was merely a pilot
study, sampling method was not of great concern. The subjects were not randomly selected from
the population of interest and it is therefore not appropriate to use these data to generalize to a
greater population. Thus, the first and most appropriate analyses compare the improvements in
moods, anxiety, and cortisol levels between the sample group of garden subjects and the sample
group of non-garden subjects. Since generalizations are not made to a greater population in these
first rounds of analyses, no p-values are given. For the interest of the reader, a second round of
analyses were performed as if the sample were indeed randomly selected from the population of
interest. In these analyses, a Wilcoxon Rank Sum test was used to test for differences in the four
dependent variables between garden and non-garden populations, and the p-values are given.
The Wilcoxon Rank Sum test was used because there is not sufficient evidence at present to say
that the distributions of the dependent variables are normal, and because the sample sizes are
very small.
Figures 1 through 4 show the mean improvement in mood, anxiety, and cortisol level for the
sample group of non-garden subjects and the sample group of garden subjects. Measures of
location and spread for the four dependent variables in both groups are given in Tables 1 through
4. As can be seen in these tables and graphs, the distribution of the garden group is shifted
slightly above the distribution in the non-garden for cortisol level improvement, anxiety level
reduction, and negative mood reduction. The distribution of increase in positive mood has
greater spread in the non-garden group than in the garden group, but a similar center, indicating
greater variability in responses when subjects are in a non-garden setting.
Figure 1: Means for improvement
in cortisol levels for non-garden
and garden groups.
non-garden garden
Table 1: Measures of center and spread for improvement in cortisol
levels for non-garden and garden groups.
improvement in cortisol level
8 .2225 .1800 -.16 .56 .22154
6 .5933 .3800 .14 1.36 .45772
14 .3814 .3500 -.16 1.36 .37852
N Mean Median Minimum Maximum
Figure 2: Means for reduction in
anxiety level for non-garden and
garden groups.
non-garden garden
Table 2: Measures of center and spread for reduction in anxiety
level for non-garden and garden groups.
reduction in anxiety
10 1.500 -2.000 -5.0 17.0 6.9960
6 3.500 .500 -2.0 13.0 6.0249
16 2.250 .000 -5.0 17.0 6.5166
N Mean Median Minimum Maximum
Figure 3: Means for reduction in
negative mood level for non-
garden and garden groups.
non-garden garden
Table 3: Measures of center and spread for reduction in negative
mood level for non-garden and garden groups.
reduction in negative mood
10 .400 .000 -5.0 7.0 3.3731
6 1.667 .500 .0 7.0 2.7325
16 .875 .000 -5.0 7.0 3.1172
N Mean Median Minimum Maximum
Figure 4: Means for increase in
positive mood level for non-
garden and garden groups.
non-garden garden
Table 4: Measures of center and spread for increase in positive
mood level for non-garden and garden groups.
increase in positive mood
10 -.300 -.500 -8.0 7.0 4.1379
6 .000 .000 -1.0 1.0 .8944
16 -.188 .000 -8.0 7.0 3.2500
N Mean Median Minimum Maximum
For the interest of the reader, Wilcoxon Rank sum tests were performed to determine significant
differences in the populations of non-garden subjects and garden subjects treating the data as if
they were a random sample. Table 5 gives the p-values for each test, where all hypotheses were
of the form H
: garden level > non-garden level, H
: garden level non-garden level (as a
reminder to the reader, greater levels coincide with improvement in the mood and cortisol and
reduction in anxiety, thus the alternate hypothesis, H
, is that there is more improvement in the
garden group), and all α levels are 0.10. As can be seen below, if these data were a random
sample from the populations of garden subjects and non-garden subjects, there would be
sufficient evidence at the α=0.10 level to conclude that the improvement in cortisol levels of
garden subjects is greater than the improvement in cortisol levels of non-garden subjects.
Differences were not significant for the other dependent variables.
Table 5: Improvement after exposure to garden and non-garden environments.
Wilcoxon Rank Sum Tests
8 10 10 10
6 6 6 6
.1317 .2811 .3564
non-garden sample size
garden sample size
change in
change in
change in
change in
positive mood
All tests are of the form Ha: garden > non-garden Ho:garden <= non-garden
p-value < 0.10
Although only one measure is statistically significant when assuming that the data are a random
sample from the population of interest, the differences between groups are in the hypothesized
direction, and are larger than anticipated for this sample size. The sample distributions of two of
the three psychological outcomes show substantially more positive change for the garden group
(outdoor) than for the combined non-garden groups (indoor). The mean anxiety level was
reduced about twice as much outdoors as indoors (3.50 compared to 1.50). The mean negative
mood level was reduced about four times as much outdoors as indoors (1.67 compared to 0.40).
The mean positive mood level remained constant outdoors while declining slightly indoors: (0.0
compared to –.30). As the study was conducted mid-morning while cortisol levels were
decreasing in the normal circadian cycle, salivary cortisol levels for all but one subject were
reduced during the session. However, the mean cortisol reduction for outdoor subjects was about
two and a half times that of indoor subjects (0.59 ug/dl compared with only 0.22 ug/dl), showing
significantly greater stress reduction in the garden environment. These findings generally agree
with the hypothesis, and with previous findings in other populations showing improved health
outcomes associated with gardens and other nature elements (for an overview, see Ulrich, 1999).
Improvements to Study
Caution is appropriate in drawing inferences from these results, because of the small sample size,
inclusion of only one residential complex, and voluntary selection process. Residents who
volunteered were probably more active, healthy, and outgoing than others, but this might also
characterize residents who would be more likely to use garden settings provided at a facility. As
an exploratory field experiment, the study contained procedural flaws which could be avoided in
future studies. Unforeseen circumstances partially undermined the randomness and
representativeness of assignment. As the findings showed more consistent differences between
treatments than between facility types, it seems unlikely that this substantially affected the
results. One source of possible bias derived from the principal investigator functioning as
research assistant for the outdoor group. Although the purpose was to acquire direct experience
with the process and observe the non-verbal behavior of subjects in an outdoor setting, further
studies should use passive observation, if any, to avoid contaminating the blinded aspect of the
study. The fact that the hypothesis was known to the researcher might have contributed in subtle
ways to the greater improvement seen in the outdoor group. However, the prepared script and
rigorously scheduled activities served to reduce this source of bias.
Methods Tested
A primary purpose of the study was to test methods for further research. Except for the travel
component and the need to schedule based on weather conditions, the process was feasible and
fairly convenient, including the saliva collection process. As all groups showed primarily
positive changes on all measures over the course of the experience, it seems likely the prospect
of an “unknown” experience produced mild pre-session anxiety and subsequent relief. This
unintentional mild stressor probably strengthened the study design by testing the restorative
qualities of the different environments. An important aspect of this approach is that it tested the
two environments holistically, with the attendant sensory perceptions intrinsic to both
environments. For example, the movement and fragrance of the air, the variability of light
conditions, the sounds and other cues which indicate the degree of openness of the surroundings,
all tend to be systematically different between indoor and outdoor environments. All these
elements were quite different in the two settings, as a direct function of the natural
unpredictability of being outdoors, compared with the relatively static quality of being indoors.
This approach has the advantage of capturing the environmental experience more entirely, but
does not establish which elements were responsible for the effect, or to what degree. The
perception of natural environment as a unified and multisensory experience is underscored in the
literature on horticultural therapy (McBey, 1985; Messer, 1996; Salamy, 1996), and was
considered of primary importance in this experiment.
Further Research and Application
Future studies might include a second outdoor setting with similar light conditions, but very little
vegetation, to examine whether cortisol reduction is attributable to higher light levels or the
presence of plants. Although light level alone might have been responsible for greater cortisol
reduction in the garden group, it could be argued that substantially brighter light is inherently
characteristic of the outdoor environment, and is seldom encountered indoors due partly to the
energy cost of bright illumination. It should also be noted that brighter light may affect cortisol
differently, depending on time of day (Scheer & Buijs, 1999; Leproult, Colecchia, L’Hermite-
Baleriaux & Van Cauter, 2001). Cortisol level typically follows a predictable circadian rhythm,
and for this reason the present study took saliva samples simultaneously, at approximately the
same time after the previous meal. Additional measures such as blood pressure and core body
temperature would be worth comparing, especially if unobtrusive monitors could be worn
throughout the session. A neutral relaxing activity could replace the photo books used in this
study, so all environmental stimuli would be direct rather than secondary. The study design
would be greatly strengthened if subjects were assigned to opposite environmental treatments at
alternating sessions, to serve as their own controls (a crossover design). If subjects and facilities
were randomly selected, results could be generalized to the rest of the population. Overall, the
most unexpected result of the study presented here was finding a significant effect with purely
environmental stimuli over a brief time period, in a very small sample. This suggests the value
of following this pilot with a larger study to see if comparable results would be obtained.
Although this study measured the effects of short-term exposure to nature, it seems plausible that
with repeated experiences, modest short-term effects might accumulate into long-term positive
health benefits. If future studies continue to find tangible health outcomes, the implications for
reassessing the value of plants and garden settings could substantially impact the design of
facilities and therapeutic programs for aging.
Brannon, L., & Feist, J. (1997). Health psychology. Pacific Grove, CA: Brooks-Cole.
Coleman, M.T., Looney, S., O’Brien, J., Ziegler, C., Pastorino, C.A., & Turner, C. (2002). The
Eden Alternative: Findings after 1 year of implementation. Journal of Gerontology:
Medical Sciences 57A(7), M422-M427.
Cooper Marcus, C., & Barnes, M. (Eds.) (1999). Healing gardens: Therapeutic benefits and
design recommendations. New York: Wiley.
Cowen, P.J. (2002). Cortisol, serotonin and depression: All stressed out? British Journal of
Psychiatry, 180, 99-100.
Dunnett, N., & Qasim. M. (2000). Perceived benefits to human well-being of urban gardens.
Hortechnology, 10(1), 40-45.
Gerlach-Spriggs, N., Kaufman, R.E., & Warner, S.B. Jr. (1998). Restorative gardens: The
healing landscape. New Haven: Yale University Press.
Hartig, T., Mang, M., & Evans, G.W. (1991). Restorative effects of natural environment
experiences. Environment and Behavior, 23(1), 3-26.
Kane, R.L., & Kane, R A. (2000). Assessing older persons: Measures, meaning and practical
applications. New York: Oxford University Press.
Kirschbaum, C., & Hellhammer, D.H. (1994). Salivary cortisol in psychoneuroendocrine
research: Recent developments and applications. Psychoneuroendocrinology 19(4), 313-333.
Kweon, B.S., Sullivan, W.C., & Wiley, A.R. (1998). Green common spaces and the social
integration of inner-city older adults. Environment and Behavior, 30(6), 832-858.
Leproult, R., Colecchia, E.F., L’Hermite-Baleriaux, Van Cauter, E. (2001). Transition from dim
to bright light in the morning induces an immediate elevation of cortisol levels. Journal of
Clinical Endocrinology & Metabolism 86(1), 151-157.
Langer, E.J., & Rodin, J. (1976). The effects of choice and enhanced personal responsibility for
the aged: A field experiment in an institutional setting. Journal of Personality and Social
Psychology, 34(2), 191-198.
Lawton, M.P., Kleban, M.H., Dean, J., Rajagopal, D., & Parmelee, P.A. (1992). The factorial
generality of brief positive and negative affect measures. Journal of Gerontology:
Psychological Sciences, 47
, P228-P237.
Lewis, C.A. (1996). Green nature / human nature. Urbana: University of Illinois Press.
Lewis, J.F., & Mattson, R.H. (1988). Gardening may reduce blood pressure of elderly people:
Activity suggestions and models for intervention. Journal of Therapeutic Horticulture, 3, 25-
McBey, M.A. (1985). The therapeutic aspects of gardens and gardening: An aspect of total
patient care. Journal of Advanced Nursing, 10(6), 591-595.
Messer, E.R. (1996). The primary colors of nature: The essentials of therapeutic landscapes.
Journal of Therapeutic Horticulture 8, 26-31.
Mooney, P.F., & Milstein, S.L. (1994). Assessing the benefits of a therapeutic horticulture
program for seniors in intermediate care. In M. Francis, P. Lindsey, & J.S. Rice (Eds.), The
healing dimensions of people-plant relations: Proceedings of a research symposium (pp.173-
194). University of California, Davis.
Mooney, P., & Nicell, P.L. (1992). The importance of exterior environment for Alzheimer
residents: Effective care and risk management. Healthcare Management Forum, 5(2), 23-29.
Morrison, M.F., Redei, E., TenHave, T., Parmelee, P., Boyce, A.A., Sinha, P.S., & Katz, I.R.
(2000). Dehydroepiandrosterone sulfate and psychiatric measures in a frail, elderly
residential care population. Biological Psychiatry, 47, 144-150.
Perkins, S. (1998). The value of nature and the outdoors for older adults in congregate living
facilities. Unpublished master’s thesis, Texas A&M University, College Station.
Raff, H., Raff, J.L., Duthie, E.H., Wilson, C.R., Sasse, E.A., Rudman, I. & Mattson, D. (1999).
Elevated salivary cortisol in the evening in healthy elderly men and women: Correlation with
bone mineral density. Journal of Gerontology: Medical Science, 54(9), M479-M483.
Reid, J.D., Intieri, R.C., Susman, E.J., & Beard, J.L (1992). The relationship of serum and
salivary cortisol in a sample of healthy elderly. Journal of Gerontology: Psychological
Science, 47, P176-P179.
Rodin, J., & Langer, E.J. (1977). Long-term effects of a control-relevant intervention with the
institutionalized aged. Journal of Personality and Social Psychology, 35(12), 897-902.
Salamy, V.M. (1996). Stress management through garden design. Journal of Therapeutic
Horticulture, 8, 32-35.
Samuels, S.C., Furlan, P.M., Boyce, A., & Katz, I.R. (1997). Salivary cortisol and daily events in
nursing home residents. The American Journal of Geriatric Psychiatry, 5(2), 172-176.
Scheer, F.A., Buijs, R.M. (1999). Light affects morning salivary cortisol in humans. Journal of
Clinical Endocrinology and Metabolism 84(9), 3395-3398.
Spielberger, C.D., Gorsuch, R.L., Lushene, R., Vagg, P.R., & Jacobs, G.A. (1983). Manual for
the State-Trait Anxiety Inventory (STAI). Palo Alto, CA: Consulting Psychologists Press.
Spielberger, C.D., Jacobs, G., Crane, R., Russell, S., Westberry, L., Barker, L., Johnson, E.,
Knight, J., & Marks, E. (1979). State-Trait Personality Inventory (STPI): Preliminary
manual. Tampa: Human Resources Institute, University of South Florida.
Stoneham, J., & Jones, R. (1997). Residential landscapes: Their contribution to the quality of
older people’s lives. In S.E. Wells (Ed.),
Horticultural therapy and the older adult
population, Part 1 (pp.17-26). New York: Haworth Press.
Talbot, J.F., & Kaplan R. (1991). The benefits of nearby nature for elderly apartment residents,
International Journal of Aging and Human Development, 33(2), 119-130.
Ulrich, R.S. (1999). Effects of gardens on health outcomes: Theory and research. In C. Cooper
Marcus and M. Barnes (Eds.), Healing gardens: Therapeutic benefits and design
recommendations (pp.27-86). New York: Wiley.
Ulrich, R.S., & Parsons, R. (1992). Influences of passive experiences with plants on individual
well-being and health. In D. Relf (Ed.), The role of horticulture in human well-being and
social development (pp.93-105). Portland, OR: Timber Press.
Ulrich, R.S., Simons, R.F., Losito, B.D., Fiorito, E., Miles, M.A., & Zelson, M. (1991). Stress
recovery during exposure to natural and urban environments. Journal of Environmental
Psychology, 11, 201-230.
Vogt, T.M. (1992). Aging, stress and illness: Psychobiological linkages. In M.G. Ory, R.P.
Abeles, & P.D. Lipman (Eds.), Aging, health and behavior (pp.214-218). Newbury Park:
Whall, A.L., Black, M.E., Groh, C.J., Yankou, D.J., Kupferschmid, B.J., & Foster, N.L. (1997).
The effect of natural environments upon agitation and aggression in late stage dementia
patients. American Journal of Alzheimer’s Disease, 12(5), 216-220.
Wolkowitz, O.M., & Reus, V.I. (1999). Treatment of depression with antiglucocorticoid drugs.
Psychosomatic Medicine, 61, 698-711.
The author gratefully thanks the residents, staff, and administration of Crestview Retirement
Community, Bryan, Texas, for their participation in this project. Paul Beathard and Mike Adams
were especially helpful.
Susan Rodiek is a registered architect with national certification, and teaches architectural
design at Texas A&M University, where she is a Fellow of The Center for Health Systems and
Design. She is registered with the PhD program at the Welsh School of Architecture, Cardiff
University, Wales, U.K. Correspondence should be addressed to: Department of Architecture,
Mail Stop 3137, Texas A&M University, College Station, TX 77843-3137, or
Journal of Therapeutic Horticulture, Volume XIII, 13-21. 2002
... One study assessed the effect of staying on affective states [56]. Rodiek [56] reported that staying in an outdoor garden for 2.5 h increased positive affect and reduced negative affect. ...
... One study assessed the effect of staying on affective states [56]. Rodiek [56] reported that staying in an outdoor garden for 2.5 h increased positive affect and reduced negative affect. ...
... In one of the studies, observations were conducted indoors or in horticultural gardens for 2.5 h, and the variation in the Spielberger State-Trait Anxiety Inventory (STAI) score-a measure of anxiety state-was compared. It was reported that the effect of observing in the horticultural garden was not significant but tended to relieve anxiety [56]. Another study compared the results of the Hospital Anxiety and Depression Scale measurementsa measure of anxiety and depression-in groups of waitlist control with groups that regularly spent time in solitude in the forest for 11 weeks. ...
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Over the past decade, clinical trials of forest-based interventions have increased, leading to their recognition as preventive medicine. However, little is known about the differences in health effects according to the activity characteristics of interventions. This study aimed to understand the types of activities and their associated health effects to identify differences in health effects between activities. PubMed, PsycINFO, Web of Science, and Scopus databases were searched, and methodological quality was assessed using Cochrane ROB2. A total of 32 randomized controlled trials (RCTs) met the eligibility criteria. Health outcomes were collected from 6264 participants aged 6–98 years, and the sample size was 12–585. The Interventions were walking (n = 21), staying (n = 7), exercise (n = 4), indirect exposure (n = 4), and the activity time was between 10 and 240 min. Overall, walking showed consistent positive health effects, and there were differences in effects on anxiety and depression, cognitive function, stress hormone, and inflammation according to the activity. However, most of the included studies had a high risk of bias, and interventions were limited to specific activities, durations, and frequencies. Although a few limitations remain, the findings in this study are of great significance in providing the basis for the design of forest-based interventions.
... Some studies further examined the environmental needs of older adults with mobility disabilities. Shumway-Cook et al. (2003;2002) found that older adults with mobility disabilities reported fewer encounters with and greater avoidance of environmental challenges than those without mobility disabilities regarding temporal factors, physical load, terrain, and postural transitions. The physical activity of older adults with poor lower extremity function was negatively associated with a high variation in vegetation and poor perceived safety and positively associated with the presence of water; these associations were not found for those with intact function (Gong et al., 2014;Keskinen et al., 2018;Sakari et al., 2017). ...
... Many benefits that people receive from nature accrue through the five senses (Franco et al., 2017), but sensory impairments cause older adults to perceive and respond to the physical environment in different ways (Christenson, 1990). Theme 1 revealed the psychological benefits of the natural environment (Finlay et al., 2015;Rodiek, 2002) and highlighted the need for positive sensory stimuli from nature (Bengtsson & Carlsson, 2013;Orr et al., 2016). The attractiveness of natural elements to older adults with dementia implies that multisensory stimulation in a specially designed natural environment may be as beneficial as a Snoezelen room (Sánchez et al., 2013). ...
Older adults with disabilities are very dependent on the physical environment, but evidence concerning outdoor activity-friendly environments is limited. This study developed the functioning and environment model to analyse the interactions among body functions and structures (physiological or psychological functions of body systems and anatomical parts of the body), outdoor environments, and outdoor activities in older adults with disabilities. Demographic and health surveys of older adults (N = 95), interviews with older adults (N = 95) and staff members (N = 28), and behavioural observations of older adults (N = 12) were conducted at a typical Chinese long-term care facility. Environmental needs were revealed by thematic analysis in five themes: natural environments with positive sensory stimuli, accessible and personalized gardening spaces, safe and comfortable walking environments, spaces and equipment for playful exercise, and gathering spaces mixing diverse people. The results showed that the outdoor environment could facilitate outdoor activities by compensating for impairments and utilizing remaining body functions and structures, which could further improve body functions and structures. This study enriches understanding of the relationship between functioning and the environment, providing a new perspective for interdisciplinary cooperation between medical and design fields on environments for healthy ageing.
... While sitting in the garden was not always as consciously valued as active nature engagement, there was evidence of a shift towards greater recognition of the value of 'just sitting' and being in the garden, which was not necessarily recognised pre-COVID. Previous research on passive nature engagement in gardens provides support for health and wellbeing outcomes for vulnerable populations for both outdoor [77,78] and indoor settings [79,80]. Similar to previous research [59,[81][82][83][84], participants in the present research considered private garden space to be restorative during COVID-19, through direct and immediate access to sunshine and fresh air, inducing feelings of calm/peace, reducing stress, improving mood and cognition. ...
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The importance of natural environments in supporting health and wellbeing has been well evidenced in supporting positive mental and physical health outcomes, including during periods of crisis and stress. Given the disproportionate impacts of the COVID-19 pandemic have been greatest for those who are most vulnerable, understanding the role of natural environment and alternative forms of nature engagement in supporting health and wellbeing for vulnerable groups is important. This study explored how nature engagement supported health and wellbeing in those with a pre-existing health condition during the first UK lockdown. Semi-structured interviews were conducted with 17 adults with a pre-existing health condition and analysed using Interpretative Phenomenological Analysis (IPA). Four themes were identified: COVID-19 versus nature; Nature as an extension and replacement; Nature connectedness; and Therapeutic nature. The findings show the importance of nature in supporting health and wellbeing in those with a pre-existing health condition through engagement with private and public natural environments, micro-restorative opportunities, nature connection as an important pathway, and the therapeutic benefits of nature engagement. The present research extends the evidence-base beyond patterns of nature engagement to a deeper understanding of how those with existing health conditions perceived and interacted with nature in relation to their health and wellbeing during the first UK lockdown. Findings are discussed in relation to health supporting environments, micro-restorative opportunities, and policy implications
... Evidence shows that access to green space is associated with a lower likelihood of obesity (Nielsen and Hansen, 2007;Xiao et al., 2020). It has been documented that exposure to nature is beneficial for children (Tillmann et al., 2018), teenagers (Tillmann et al., 2018), and older adults (Rodiek, 2002), but little is known about the potential benefits to obese people. ...
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Evidence shows that physical activity has multiple health benefits for the body and mind of oneself, but little is known about the impacts of the setting and the intensity on exercise experience, especially for obese people. This study investigated the physiological and psychological effects of four walking conditions with different settings (park vs. gym) and intensity (slow vs. fast) on young obese adults. Subjects were 18–21 years old Chinese university students (N = 77), who were diagnosed as obese. They were randomly assigned to participate in one of the four activities in the field: slow walk in the park (2.8 km/h), fast walk in the park (5.5 km/h), slow walk in the gym, and fast walk in the gym. Physiological indices, including blood pressure and heart rate, were measured before and after the walk. Psychological responses were measured by the Symbol Digit Modalities Test, the mood states scale, and the semantic differential scale. This study of obese people aged 18–21 years confirmed the previous findings that exercising in natural environments better relieved stress and restored attentional level than indoor activities. The results suggested that the mood states of the participants and their environmental perceptions may be influenced by the walking conditions with different setting and speed. The findings can be used in planning and designing urban green spaces for promoting physical activity and making exercise plans for obese people.
... When surveyed, residents that used the outdoor spaces of these communities were associated with higher quality of self-reported health (Rappe et al., 2006;Stoneham and Jones, 1997). Studies that have monitored physical representations of the health of these residents through quantification of cortisol levels (Rodiek, 2002) or their amount of movement through use of an accelerometer (Kerr et al., 2011) closely reflected the findings of these survey results. However, the outdoor environment must be deemed suitable and afford usage by residents, in terms of accessibility, attractiveness, and protection from the elements, for it to be used regularly by residents (Bardenhagen and Rodiek, 2015;Bengtsson and Carlsson, 2006;Kearney and Winterbottom, 2006;Rodiek, 2006). ...
Projections show that Earth's climate will continue to warm concurrent with increases in the percentage of the world's elderly population. With an understanding that the body's resilience to the heat degrades as it ages, these coupled phenomena point to serious concerns of heat-related mortality in growing elderly populations. As many of the people in this age cohort choose to live in managed long-term care facilities, it's imperative that outdoor spaces of these communities be made thermally comfortable so that connections with nature and the promotion of non-sedentary activities are maintained. Studies have shown that simply being outside has a positive impact on a broad range of the psychosocial well-being of older adults. However, these spaces must be designed to afford accessibility, safety, and aesthetically pleasing experiences so that they are taken full advantage of. Here, we employ an integrative review to link ideas from the disciplines of climate science, health and physiology, and landscape architecture to explain the connections between heat, increased morbidity and mortality in aging adults, existing gaps in thermal comfort models, and key strategies in the development of useable, comfortable outdoor spaces for older adults. Integrative reviews allow for new frameworks or perspectives on a subject to be introduced. Uncovering the synergy of these three knowledge bases can contribute to guiding microclimatic research, design practitioners, and care providers as they seek safe, comfortable and inviting outdoor spaces for aging adults.
... We note that the cultural context of the present study significantly differs from the few existing studies on the mental health benefits of gardening which are based on data collected in high income countries, where participation in gardening is largely regarded as a voluntary leisure activity, unlike in large areas of sub-Saharan Africa, where participating in gardening activity is often essential for livelihood (Park et al., 2009;Rodiek, 2002;Van Den Berg and Custers, 2010). In the context of the present study, where food insecurity (for example) is widely prevalent, it is possible that food insecurity could confound our estimates: food insecurity has been linked to depression and mental health problems in diverse settings across sub-Saharan Africa (Dewing et al., 2013;Tsai et al., 2012Tsai et al., , 2016bWeaver and Hadley, 2009) and people who are food insecure may be more likely to engage in gardening activity. ...
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Evidence from high-income settings suggests that gardening is associated with reductions in depression, anxiety, and stress. The benefits of gardening are less well understood by mental health practitioners and researchers from low- and middle-income countries. Our study estimated the association between participation in gardening and symptoms of depression, anxiety, and stress among caregivers of people living with dementia in rural, southwestern Uganda. In a cross-sectional study, we interviewed 242 family caregivers of people with dementia to elicit their gardening activities; symptoms of depression, anxiety, and stress (Depression Anxiety Stress Scales); and caregiving burden (Zarit Burden Interview). Linear multivariable regression models estimated the association between participation in gardening and symptoms of depression, anxiety, and stress. Out of 242 participants, 131 (54%) caregivers were involved in gardening. Severe to extremely severe symptoms of depression were less prevalent among those who were involved in gardening compared with those who were not (0 [0%] vs. 105 [95%], P<0.001), as were severe to extremely severe symptoms of anxiety (36 [27%] vs. 110 [99%], P<0.001) and stress (2 [2%] vs. 94 [85%], P<0.001). In regression models adjusting for covariates,we found statistically significant associations between participation in gardening and symptoms of depression (b = -18.4; 95% CI, 20.5 to -16.3), anxiety (b=-16.6; 95% CI, -18.6 to –14.6), and stress (b=-18.6; 95% CI, -20.6 to –16.6). Caregivers of people with dementia who participate in gardening have lower symptoms of depression, anxiety, and stress. Gardening interventions in this at-risk population may ameliorate symptoms of depression, anxiety, and stress.
... And a study in United states found that more than 50% of people are negatively affected by stress (Fink, 2009). Seventeen of the adults, aged between 71 and 98, showed positive and negative moods and a significant increase in stress levels, although there was no significant change in mood after engaging in outdoor gardening activities (Rodiek, 2002). American Psychological Association (2021) mentioned that, anxiety is a feeling caused by physical changes, such as stress, anxious thoughts, and high blood pressure. ...
Full-text available
The main purpose of this research paper is to identify how home gardening affects the mental well-being of people. Secondary source of data was used to thematically analysis the impact of gardening on an individual's mental wellbeing. Thus, purposive sampling method was employed to select relevant literature for understanding effect of home gardening towards mental wellbeing. By reviewing the sources of relevant literature made it possible to identify factors which are related to home gardening effects on mental well-being of people. The results shows that gardening helps to reduce depression, stress, anxiety, improve life satisfaction and self-esteem. As future research implication, researchers can use this factors to investigate notion of home gardening impact on person's mental wellbeing in different context and age groups.
Background: Natural views are an important design strategy for the application of ecological resources in built environments. Numerous clinical studies have indicated that views of nature-for example, plants-can effectively promote patient recovery by relieving their postoperative pains and negative emotions during hospitalization. Aims: This study demonstrates an intelligent method that develops algorithms of using collision detection techniques in Building Information Modeling to evaluate outdoor plant visibility for patients. Methods: These algorithms are digitized into a Revit plug-in program, which can be viewed as a design-aided tool for architects with the purpose of informing healthcare environment design in the decision-making process. Results: Its acceptability and effectiveness are evaluated based on the consultations in beta tests. Conclusions: It is believed that this method can improve the work efficiency of evaluating natural views in wards and help architects implement an informed design of built environments for better health performance. All findings in this study can contribute to the development of computational intelligence and social sustainability in the near future.
Gardening activities can offer a sense of calm, purpose, and self-worth and help improve physical and mental health, but research on these benefits within veteran populations is limited. In collaboration with a local garden, this Veterans Affairs (VA) program evaluation explored perceived benefits of gardening for veterans from two VA programs. Focus groups and photovoice methods revealed four main benefits of participation: supporting mental and emotional wellbeing, improving socialization and comradery, nurturing life and identity, and learning new skills. Findings align with VA's Whole Health (WH) approach, and support collaborations between community gardens and the VA to benefit veteran populations.
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Background: Based on recent experiences with the COVID-19 pandemic, designers and design researchers are crafting guidelines for the development of future environments. In this context, this paper focuses on future best practices regarding environments for health, hospitality and senior care. Methods: An extensive literature review was conducted, the results of which were distributed to a group of experts (N=12) specializing in health, hospitality and design. After receiving their input, expert focus groups were conducted to further explore the proposed concepts. The document was revised based on the contributions of these field experts, resubmitted for additional input, and ultimately summarized in this paper. Results: Based on the literature review and expert input, dozens of recommendations were made regarding post-COVID health, hospitality and seniors environments. Healthcare facilities will require additional space, access to the outdoors, service hubs, and additional infrastructure to all conversion of garages for emergency use. Hospitality settings will employ new cleaning methods, use of robotics, improved HVAC, Wellness programming, workspace options, and flexible food service operations. Senior facilities will engage more technology, socially distance visiting facilities, increase access to nature, and smaller scale residential clusters. Discussion: By considering health and hospitality simultaneously, we come to understand the symbiotic benefits of applying goals from one sector to the other. Senior living environments are an excellent example of this approach in action. By implementing some of the proposed design recommendations generated by this research, we will be better prepared to face future challenges.
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For older adults, social integration and the strength of social ties are profoundly important predictors of well-being and longevity. Can the physical environment be designed to promote older adults' social integration with their neighbors? We examined this possibility by testing the relationships between varying amount of exposure to green outdoor common spaces and the strength of ties among neighbors. Results of interviews with 91 older adults (between the ages of 64 and 91 years) from one inner-city neighborhood show that the use of green outdoor common spaces predicted both the strength of neighborhood social ties and sense of community. Although the strength of these relationships were modest, the findings suggest that the characteristics of outdoor common spaces can play a role in the formation and maintenance of social ties among older adult residents of inner-city neighborhoods. The results have implications for designers, managers, and residents of housing developments.
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Evidence shows that environments especially designed for cognitively impaired seniors can maintain or increase their level of functioning. Little emphasis has so far been placed on the prosthetic role that may be played by exterior environments. This study attempted to determine the value that specially designed exterior spaces may have in reducing undesired behaviours, thereby minimizing risks to the patients and potential liability to the institution. The researchers tested that (a) poor environments increase residents' frustrations and can precipitate catastrophic behaviour and (b) freedom of movement and opportunities to avoid crowding, noise and excess stimulation minimize the frequency of aggressive behaviour. The researchers found that the use of exterior environments reduced incidents of aggressive behaviour, and contributed significantly to a risk management program.
Private gardens occupy a significant proportion of the total surface area of a British city. For many people, the garden represents their only contact with nature and their chance to express themselves creatively. Yet relatively little research has been carried out on the role and value of such gardens to human well-being. We report in this paper on a major survey on the role of private, urban gardens in human well-being, conducted with a wide cross-section of randomly selected garden owners from the city of Sheffield, England, over the summer of 1995. In particular, we discuss the perceived value that gardens have to the well-being of people, both individually through the enjoyment of their own gardens and collectively through the contribution of city gardens to environmental enhancement. We relate these values to age, gender and social demographics.
The utility of different theoretical models of restorative experience was explored in a quasi-experimental field study and a true experiment. The former included wilderness backpacking and nonwilderness vacation conditions, as well as a control condition in which participants continued with their daily routines. The latter had urban environment, natural environment, and passive relaxation conditions. Multimethod assessments of restoration consisted of self-reports of affective states, cognitive performance, and, in the latter study, physiological measures. Convergent self-report and performance results obtained in both studies offer evidence of greater restorative effects arising from experiences in nature. Implications for theory, methodology, and design are discussed.
The assessment of cortisol in saliva has proven a valid and reliable reflection of the respective unbound hormone in blood. To date, assessment of cortisol in saliva is a widely accepted and frequently employed method in psychoneuroendocrinology. Due to several advantages over blood cortisol analyses (e.g., stress-free sampling, laboratory independence, lower costs) saliva cortisol assessment can be the method of choice in basic research and clinical environments. The determination of cortisol in saliva can facilitate stress studies including newborns and infants and replace blood sampling for diagnostic endocrine tests like the dexamethasone suppression test. The present paper provides an up-to-date overview of recent methodological developments, novel applications as well as a discussion of possible future applications of salivary cortisol determination.