Article

Participation in Outdoor Recreation Program Predicts Improved Psychosocial Well-Being Among Veterans With Post-Traumatic Stress Disorder: A Pilot Study

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Abstract

Purpose: Evaluate the effectiveness of a 2-day, 3-night outdoor recreation intervention involving fly-fishing in reducing the psychological concomitants of stress among 74 veterans (M = 47.27, SD = 14.55 years) with post-traumatic stress disorder (PTSD). Methods: Participants completed repeated assessments of attentiveness, mood, depression, anxiety, and somatic stress across 3 time periods, corresponding to 2 weeks before the trip (baseline), the last day of the trip, and a 6-week follow-up. Assessments of perceptual stress, PTSD symptoms, and sleep quality were also administered during the baseline and follow-up periods. Results: Acute effects were observed for improvements in attentiveness and positive mood states, coupled with significant and sustained reductions in negative mood states, anxiety, depression, and somatic symptoms of stress. Comparisons between the baseline and follow-up periods revealed significant improvements in sleep quality and reductions in perceptual stress and PTSD symptoms. Conclusions: The current findings suggest that combat veterans with PTSD may benefit from participation in group-based outdoor recreation as a means to improve psychosocial well-being.

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... Although limited, several studies have provided preliminary quantitative data supporting the positive influence of recreational and adaptive sports programs on psychological symptoms among veterans and service members. Engagement in various recreation programs, with activities such as fly-fishing, kayaking, and surfing, has resulted in reduced depression (Bennett et al., 2017;Crawford, 2016;Lundberg et al., 2011;Rogers et al., 2014;Walter et al., 2019), PTSD (Bennett et al., 2017;Crawford, 2016;Gelkopf et al., 2013;Rogers et al., 2014;Townsend et al., 2018;Vella et al., 2013;Walter et al., 2019), and anxiety symptoms (Townsend et al., 2018;Walter et al., 2019) following program participation. One study even found immediate improvements in depression/anxiety and positive affect among service members within each session of a surf therapy program (Walter et al., 2019). ...
... One study even found immediate improvements in depression/anxiety and positive affect among service members within each session of a surf therapy program (Walter et al., 2019). Other related psychosocial constructs have demonstrated similar improvements from pre-to postprogram including affect (Duvall & Kaplan, 2014;Walter et al., 2019), functioning (Bennett et al., 2017;Gelkopf et al., 2013;Townsend et al., 2018), social connectedness (Duvall & Kaplan, 2014), insomnia (Vella et al., 2013), and negative mood (e.g., Lundberg et al., 2011). Taken together, these studies offer initial evidence for psychological benefits following recreational and adaptive sports programs. ...
... To this point, there is evidence suggesting that physical activity in a natural environment produces mental health benefits immediately after the activity (e.g., Morita et al., 2007;Thompson Coon et al., 2011;Walter et al., 2019), and data are beginning to emerge regarding whether these benefits are sustained over time. For example, some studies with varying follow-up lengths (1-6 months) have found significant improvements in PTSD symptoms (Crawford, 2016;Townsend et al., 2018;Vella et al., 2013), depression (Crawford, 2016;Vella et al., 2013), anxiety (Vella et al., 2013), and social functioning (Duvall & Kaplan, 2014) at long-term follow-up when compared to baseline. However, there is a lack of consistency in findings pertaining to psychological benefits across studies. ...
Article
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Introduction Recreational and adaptive sports programs are often provided to veterans with a variety of psychological and physical conditions; however, limited data exist regarding the outcomes of these programs. The current study evaluated the psychological outcomes of attendees of the 2017 and 2018 National Veterans Summer Sports Clinic (NVSSC) in San Diego, California. Method Seventy-four veteran participants completed self-report assessments before and after the week-long program, as well as 3 months following program completion. In addition, participants completed brief assessments before and after each of the daily recreational activities (cycling, surfing, sailing, kayaking, and archery/pickleball). Results Findings showed that depression, anxiety, social functioning, and positive and negative affect significantly improved from pre-to postprogram, but returned to baseline levels at 3-month follow-up. Within sessions, depression/anxiety and positive affect significantly improved each day, with no differences in the amount of change across days. Depression/anxiety and positive affect also significantly improved within each activity, regardless of order, with no differences in the magnitude of change across activities. Conclusions The NVSSC produced significant changes in psychological outcomes among veteran participants within immediate and short-term time periods; however, gains were not maintained longer-term. Follow-on engagement in exercise activities is likely necessary for continued benefit; future research, including studies with control groups, would provide greater clarity.
... For the veteran population, outdoor-based TR programs are often designed to regain functioning and reduce the symptoms of PTSD and other comorbid disorders, in order to restore their quality of life (Dustin, Bricker, Arave, Wall, & Wendt, 2011;Hawkins, Cory, & Crowe, 2011;Mowatt & Bennett, 2011). Interventions may include coping skills, stress management, problem solving, communication, selfesteem building, and community reintegration (Bennett, Piatt, & Van Puymbroeck, 2017;Gelkopf, Hasson-Ohayon, Bikman, & Kravetz, 2013;Vella, Milligan, & Bennett, 2013). ...
... Studies reported that outdoor recreation programs result in positive psychological outcomes such as reduction in PTSD symptoms, depression, and other negative mood states (Bennett et al., 2017;Dustin et al., 2011). Although these studies support the general setting of program (e.g., outdoor, nature, or wilderness setting) as beneficial for veterans with PTSD, less is known regarding the characteristics of the programs and how those may affect the social and emotional functioning of veterans with PTSD who participate in the programs (Bennett et al., 2017;Gelkopf et al., 2013;Vella et al., 2013). ...
... The majority (n ¼ 8) of the studies were conducted in the United States (Bennett et al., 2017;Crawford et al., 2016;Duvall & Kaplan, 2014;Hyer et al., 1996;Lundberg et al., 2011;Rogers et al., 2014;Townsend et al., 2018;Vella et al., 2013), and one study was conducted in Israel (Gelkopf et al., 2013). Study sample sizes varied greatly and ranged from 14 (Rogers et al., 2014) to 219 (Hyer et al., 1996). ...
Article
Outdoor-based therapeutic recreation (TR) programs among military veterans diagnosed with posttraumatic stress disorder (PTSD) are becoming increasingly popular. A systematic review was conducted of 3 relevant databases, to examine the relationship between outdoor-based TR programs and psychosocial outcomes among veterans with PTSD. The final selection yielded 13 studies. Four were qualitative studies, whereas the remainder (n = 9) were quantitative studies. Outdoor-based TR programs may offer some important short-term psychosocial improvements in depression, PTSD, stress, and quality of life for veterans with PTSD. However, the methodological quality of all nine quantitative studies was weak, thus reducing confidence in its findings.
... Social interaction is an often-documented, prominent and critically important characteristic of adventure therapy. A sense of social inclusion can be a simultaneously occurring by-product of shared experiences, mutual encouragement, social reassurance and learning to take collaborative approaches to the activities (Cotton & Butselaar, 2013;Kelley, Coursey, & Selby, 1997;Vella, Milligan, & Bennett, 2013). Vella et al. reported that the social support developed through outdoor recreational activity was a lasting and highly important aspect of the intervention for individuals with PTSD (Vella et al., 2013). ...
... A sense of social inclusion can be a simultaneously occurring by-product of shared experiences, mutual encouragement, social reassurance and learning to take collaborative approaches to the activities (Cotton & Butselaar, 2013;Kelley, Coursey, & Selby, 1997;Vella, Milligan, & Bennett, 2013). Vella et al. reported that the social support developed through outdoor recreational activity was a lasting and highly important aspect of the intervention for individuals with PTSD (Vella et al., 2013). In line with Voruganti's biopsychosocial approach (Voruganti et al., 2006), a combination of physical activity, nature and social support is important for positive and sustained health changes (Barton et al., 2012;Granerud & Eriksson, 2014), and these key aspects of occupational therapy are well catered for by an adventure therapy approach. ...
... It is of course important that adventure therapy interventions are tailored to the needs, goals and diagnoses of specific individuals; for example, 'challenge' did not play a large part in an intervention for adults living with PTSD, which achieved reduced stress levels (Vella et al., 2013). Psychological wellbeing can be positively impacted, upon successful completion of welldesigned activities that consider the person's needs and capabilities (Clough et al., 2016;Levack, 2003). ...
... Adventure-based therapy has been shown to be moderately effective in improving psychological, behavioural, emotional, and interpersonal outcomes in children and young adults (Bowen & Neill, 2013). Furthermore, there is a small but growing evidence base suggesting the effectiveness of adventure-based therapy for current and ex-serving military personnel (e.g., Bennett et al., 2014a;Bennett et al., 2017;Bettmann et al., 2019;Bird, 2015;Duvall & Kaplan, 2014;Ewert, 2014;Gelkopf et al., 2013;Harper et al., 2014;Scheinfeld & Spangler, 2013;Vella et al., & 2013). These studies show considerable variability of adventure-based therapy, with the duration of programs ranging from 2 days to 12 months, and the inclusion of both residential and outpatient programs and a variety of adventurous activities (e.g., camping, water rafting), therapeutic components (e.g., peer mentoring, CBT, and inpatient PTSD therapy), and outcome measures (e.g., PTSD symptomology, leisure satisfaction, and self-confidence). ...
... Despite this variability, taken together the results demonstrate significant short-term positive outcomes associated with adventure-based therapy, including improvement in psychological health, quality of life or life satisfaction, self-confidence and self-efficacy, and overall well-being. Limited follow-up data indicates some, but not all, improvements may be maintained over time (Bennett et al., 2017;Bird, 2015;Duvall & Kaplan, 2014;Harper et al., 2014;Scheinfeld & Spangler, 2013;Vella et al., 2013); however, available data precludes any conclusions about the long-term effectiveness of adventure-based therapy, with very few studies reporting more than 1-month follow-up post-intervention (Bennett et al., 2017;Bird, 2015;Harper et al., 2014;Vella et al., 2013), and very few controlled studies. ...
... Despite this variability, taken together the results demonstrate significant short-term positive outcomes associated with adventure-based therapy, including improvement in psychological health, quality of life or life satisfaction, self-confidence and self-efficacy, and overall well-being. Limited follow-up data indicates some, but not all, improvements may be maintained over time (Bennett et al., 2017;Bird, 2015;Duvall & Kaplan, 2014;Harper et al., 2014;Scheinfeld & Spangler, 2013;Vella et al., 2013); however, available data precludes any conclusions about the long-term effectiveness of adventure-based therapy, with very few studies reporting more than 1-month follow-up post-intervention (Bennett et al., 2017;Bird, 2015;Harper et al., 2014;Vella et al., 2013), and very few controlled studies. ...
... The provision of meaningful NBP may be a catalyst for improving overall MIL, which in turn mitigates the effect of PTSD and depression, therefore reducing the likelihood of suicide. The attractiveness and affordability of NBP coupled with evidence of improvements in coping, mood, depression, anxiety, and stress, highlight the value of NBP as a complement to traditional care (Hawkins et al., 2016;Vella et al., 2013). Overall interest in NBP has grown (Cordell, 2008), and this increase has led to researchers exploring the impacts and benefits associated with NBP (Krasny et al., 2010). ...
... Early theoretical work posits that natural environments may contribute to psychological health and well-being (Kaplan, 1995). Studies highlight the role of nature in improving cognition (Berman et al., 2008;Duvall & Kaplan, 2014), and the benefits of nature-based programs also include several emotional benefits such as stress reduction (Kuo, 2001), increased positive emotions (Duncan et al., 2014;Duvall & Kaplan, 2014;Vella et al., 2013), and reduced depressive symptoms (Shanahan et al., 2016;Vella et al., 2013). A growing body of literature indicates nature can improve and support mental health (Burls, 2007;Sneep, 2007). ...
... Early theoretical work posits that natural environments may contribute to psychological health and well-being (Kaplan, 1995). Studies highlight the role of nature in improving cognition (Berman et al., 2008;Duvall & Kaplan, 2014), and the benefits of nature-based programs also include several emotional benefits such as stress reduction (Kuo, 2001), increased positive emotions (Duncan et al., 2014;Duvall & Kaplan, 2014;Vella et al., 2013), and reduced depressive symptoms (Shanahan et al., 2016;Vella et al., 2013). A growing body of literature indicates nature can improve and support mental health (Burls, 2007;Sneep, 2007). ...
Article
As part of a larger research program examining the impacts of nature-based experiences on veterans with Post-traumatic Stress Disorder, this study focused on changes in their depression and meaning in life after participating in a four-day river rafting experience. Results showed that there were statistically significant improvements over time for both depression scores and meaning in life scores. Results also indicated a weak statistically significant, negative association between depression and presence of meaning in life. The study’s results are useful for practitioners who may be considering nature-based programs for their clients, as well as researchers seeking to better understand the psychological health benefits of river rafting.
... Regular/weekly high intensity aerobic exercise programs reduce stress (Pedersen & Saltin, 2015;von Haaren et al., 2015) Active (fly-fishing, gardening) (Van Den Berg & Custers, 2011; Vella et al., 2013) and passive (sitting) (Tyrväinen et al., 2014) outdoor activities can reduce stress symptoms Successful interventions to encourage break-taking include physical access to greenspaces, particularly for men (Lottrup et al., 2013), as well as encouraging self-initiated breaks (Kühnel et al., 2017). Multiple-week mindfulness programs that incorporate training and application can reduce stress (Grossman et al., 2004;Williams et al., 2001). ...
... Among health promotion interventions targeting physical activity, evidence indicates that regular programs featuring higher-intensity, aerobic exercise are the most effective in reducing stress among general and college student populations (Pedersen & Saltin, 2015;von Haaren et al., 2015). Within the scope of outdoor recreation programming, evidence suggests that outdoor recreation activities as varied as fly-fishing and gardening can reduce stress symptoms, likely due to the documented, restorative effects of natural spaces (Van Den Berg & Custers, 2011;Vella et al., 2013). Additionally, short, low-intensity activities such as sitting or walking in a forest environment, in comparison to activities in built and park locations, have been shown to reduce physiological and self-reported stress levels (Tyrväinen et al., 2014). ...
Article
The design and delivery of recreation programs is a core function of the leisure profession. However, recognition of the impact of recreation programming from outside the field, particularly public health, has not always been reciprocated due to differences in how and where scholarly work is published as well as historic differences in the study and promotion of leisure experiences across these two fields. To improve program design, this paper will propose and illustrate the application of a public health conceptual framework for adoption in recreation programming: The Behavior-Determinant-Intervention (BDI) logic model. The BDI logic model aides in development of evidence-based health promotion interventions through a systemic 4-step process. The first step requires delineation of a specific public health outcome to be achieved. In the second step, the relevant individual health behaviors that influence attainment of the health outcome are identified. Then, the determinants of those behaviors are outlined; these include both risk and protective factors that influence adoption of the behaviors listed in Step 2. Finally, interventions (e.g., recreation programs) that address the determinants and behaviors in Steps 3 and 4 are specified. To maintain fidelity to the BDI logic model planning process, sound supporting evidence should be cited at each of the four steps for each outcome, behavior, determinant, and intervention. Ultimately, the completion of a BDI logic model results in the development of a leisure-based intervention that should meaningfully impact an important public health outcome. In our example, we demonstrate the rigorous process of using the BDI logic model by designing a hypothetical recreation-based program that seeks to meaningfully reduce stress within a college student population. Our process reveals that the BDI logic model can be applied within recreation and leisure contexts to address important public health outcomes. By adopting the model, recreation practitioners and researchers can then apply it to their own contexts and develop programs that make meaningful progress on their communities’ most pressing public health problems. The application of the BDI logic model also provides an opportunity for collaboration and communication with colleagues in the field of public health through engaging in shared program-planning processes.
... Recreation activities and experiences such as naturebased or outdoor pursuits, sports, fitness, cultural arts, music, mind-body activities (i.e., yoga, meditation), and social activities, among others, are recognized for their therapeutic benefits and potential for instilling personal agency, and facilitating coping and healing among a variety of populations with disabilities, including those with behavioral health conditions (Benedek & Wynn, 2016;Iwasaki et al., 2005;Kearney et al., 2012;Kleiber et al., 2002Kleiber et al., , 2008Walsh, 2011). Recreational therapy interventions have shown promise in improving symptom management, strengthening social relationships, supporting physical health, and enhancing community reintegration among Veteran and military populations (Bennett et al., 2014;Craig et al., 2020;Lundberg, Bennett, et al., 2011;Lundberg, Taniguchi, et al., 2011;Mowatt & Bennett, 2011;Thompson et al., 2016;Vella et al., 2013;Wheeler et al., 2020). Further, there is a growing evidence-base for the efficacy of RT interventions in facilitating functional outcomes, coping, and posttraumatic growth for Veteran and military populations with PTSD and comorbid behavioral health conditions (Bennett et al., 2017;Duvall & Kaplan, 2013;Hawkins et al., 2016;Price et al., 2015;Rogers et al., 2016). ...
... Results from this study suggest that Northeast Passage's C-BRT™ program may be able to reduce these negative impacts and increase QOL, participation in the community and happiness among this population. This aligns with previous research examining the outcomes of community-based recreational therapy programs for Veterans with various disabilities (Bennett et al., 2014;Craig et al., 2020;Lundberg, Bennett, et al., 2011;Lundberg, Taniguchi, et al., 2011;Mowatt & Bennett, 2011;Thompson et al., 2016;Vella et al., 2013;Wheeler et al., 2020). ...
Article
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Identifying evidenced-based interventions that improve health outcomes for Veterans with behavioral health disorders is a national priority. Thus, this study examined the outcomes of a community-based recreational therapy (RT) program focused on health promotion for Veterans with behavioral health disorders. Fifty-five Veterans with disabilities completed pretest and posttest questionnaires that assessed Quality of Life (QOL), Participation, and Happiness. Significant improvements were found in Overall QOL, Environmental QOL, Psychological QOL, QOL Rated, Satisfaction with Health, Participation, and Happiness. Younger age and female gender were significantly associated with improved Overall QOL. Factors significantly associated with improved Environmental QOL included younger age and non-Caucasian race. Older age was significantly associated with improved Participation. Female gender was positively associated with improved Happiness, while being divorced/separated was negatively associated with Happiness. These results have important implications for the use and expansion of community-based RT health promotion programs for Veterans with behavioral health disorders.
... Narrative accounts of participation in a therapeutic fly-fishing program revealed themes of camaraderie, reflection, and coping with regret as outcomes of involvement (Mowatt & Bennet, 2011;Price, Lundberg, Zabriskie & Barney, 2015). Improvements in attentiveness, mood, depression, anxiety and stress were found in a quantitative examination of the same fly-fishing program (Vella, Milligan & Bennett, 2013). ...
... Fly-fishing helps to promote camaraderie, reflection, and coping with regret as outcomes of involvement (Mowatt & Bennet, 2011;Price, Lundberg, Zabriskie & Barney, 2015). Improvements in attentiveness, mood, depression, anxiety and stress were found in a quantitative examination of the same fly-fishing program (Vella, Milligan & Bennett, 2013). For veterans with an affinity to natural environments, typical adventure or challenge based therapies might include white-water rafting, hiking, kayaking, traversing built and natural challenge courses, backpacking in the wilderness and therapeutic camping. ...
Thesis
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Developing research, anecdotal evidence and a growing focus on non-pharmacological interventions for veterans with post-traumatic stress support the use equine-therapy as a therapeutic outlet; however, programmatic factors that contribute to veteran's desire to attend such programs are under-investigated. Furthermore, evaluative processes in equine therapy for this particular population are scare and vary greatly from program to program. The use of the Importance-Performance Analysis (IPA) tool when applied to social services yields direct, applicable feedback of program success and relevancy. In this study, interviews with the selected population informed the evaluation tool used to assess the importance, and subsequent performance, of various program factors in a national military-specific equine therapy program. Results of this study provided insight into key factors being sought after in similar equine therapy programs to inform the development and maintenance of programs serving the veteran population.
... Alternatively, recreation may be used therapeutically in two ways. The first approach deals with directly increasing the psycho-social well-being while diminishing anxiety and improving the mood (Vella, Milligan, & Bennett, 2013). The second deals with its playful nature, in this manner facilitating the implementation of therapeutic strategies in either an individual or group form (Trejos Parra, Cardona Giraldo, & Cano Echeverri, 2005b), both being demonstrated in the current research, where recreation provided comfort and facilitated the implementation of the psychotherapeutic program. ...
... People are generally highly motivated to engage in outdoor leisure activities, because they want to experience natural environments (Calogiuri & Elliott, 2017). For those with disabilities, leisure-based outdoor activity participation is associated with decreased depression, greater health satisfaction, and improved social relationships (Jakubec, Carruthers Den Hoed, Ray, & Krishnamurthy, 2016;Vella, Milligan, & Bennett, 2013). Furthermore, a comparative study suggested that participation in outdoor activities was more strongly associated with feelings of achievement and growth among people with disabilities than among people without disabilities (McAvoy, Holman, Goldenberg, & Klenosky, 2006). ...
Article
The purpose of this study was to explore the experiences of current and former sailors, staff and volunteers who were involved in an adaptive recreational sailing program and identify the factors that impact their engagement. Using an ethnographic approach, participant observations (n = 20) and qualitative interviews (n = 18) were conducted with sailors, staff and volunteers. We analyzed the data thematically and identified two main themes. 1) “Anchors away: reasons for setting sail,” described the benefits of adaptive sailing including learning opportunities, leaving disability onshore, challenging stigma, building a community and engaging with nature. 2) “Running ashore: challenges with program delivery and logistics,” acknowledged the various issues encountered, including issues around accessibility, equipment, scheduling, safety management, and volunteers/volunteering. The findings emphasize how adaptive sailing offers a multidimensional experience and could reduce prejudices against people with disabilities. Challenges regarding accessibility of facilities and transports as well as volunteers were identified.
... The current research supports previous findings for POST as being beneficial in a veteran population (30,33,34,45 ...
... GE reduces stress, depression and blood pressure, increases self-esteem, mood and wellbeing, and enhances heart rate variability. These benefits seem to be universally obtainable, with evidence of health and wellbeing improvements in children and adolescents [9], adults [1][2][3][4][5][6][7][8] and vulnerable cohorts including disaffected youth [10], adults living with dementia [11] and those experiencing physical and/or mental ill-health such as post-traumatic stress disorders [12]. Wellbeing is important to health because it increases life expectancy, improves recovery from illness [13,14] and is associated with positive health behaviours. ...
Article
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This study investigated the efficacy of medium-term Green Exercise (GE; being physically active within a natural environment) interventions for improving wellbeing, by pooling data collected at the start and end of participants’ engagement with a range of GE interventions. Hypotheses were that (i) interventions would show good efficacy for improving wellbeing in the overall sample; (ii) compared to participants reporting ‘average to high’ wellbeing at the start of their project, participants with ‘low’ starting wellbeing would report greater improvements post-intervention; and (iii) improvements would significantly differ between age groups. The pooled dataset was categorized in line with UK norms (n = 318) and analyzed using a standardized meta-analysis approach. Effect size was large: g = 0.812 (95% CI [0.599, 1.025]), and differences in wellbeing changes associated with project duration, age or sex were not statistically significant. Compared to those reporting ‘average-high’ starting wellbeing, participants reporting ‘low’ starting wellbeing exhibited greater improvements (BCa 95% CI [−31.8, −26.5]), with 60.8% moving into the ‘average-high’ wellbeing category. GE can play an important role in facilitating wellbeing and can provide alternative pathways for health and social care practice. Public health commissioners should consider integrating such interventions for patients experiencing low wellbeing or associated comorbidities.
... A growing literature explores how outdoor activities and exposure to natural environments can foster positive physiological, affective, and cognitive responses to reduce many of the symptoms related to post-traumatic stress and nurture pre-existing strengths (Mowatt and Bennett 2011, Duvall and Kaplan 2014, Poulsen et al. 2015, Dustin et al. 2016, Hawkins et al. 2016, Walter et al. 2019. Although OPVs range from day outings to extended trips lasting several months, even a few days' exposure to outdoor activities has been shown to benefit veterans in their recovery from traumatic experiences (Hyer et al. 1996, Dustin et al. 2011, Mowatt and Bennett 2011, Vella et al. 2013, Duvall and Kaplan 2014. Studies of extended outings are less common, but research on the effects of thru-hiking the Appalachian Trail has found a renewed sense of motivation, enhanced social connection, and improved psychological well-being among participants (Dietrich et al. 2015). ...
Article
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Many veterans returning from military deployment experience stress- or trauma-related symptoms that make reintegration with civilian society difficult. Nature exposure and outdoor recreation can be important parts of alternative and complementary approaches to reduce symptoms and build on veterans’ pre-existing strengths. Multiple outdoor programs now exist for veterans; many of these occur on federal public lands and present a variety of needs, opportunities, and challenges. This paper relies on interviews (n = 36) with public land managers, program providers and participants, health professionals, and veterans to enhance understanding about outdoor programs for veterans (OPVs). We develop a typology of OPVs to help land managers understand current and potential programs, and then describe programs’ varying dimensions. We examine opportunities and challenges for land managers in their interactions with OPVs. Results inform policymakers and public officials interested in developing more effective institutional partnerships and programs that engage and serve veterans and their communities. Study Implications: With growing scientific evidence of the benefits of nature-based therapy, nature exposure, and outdoor recreation for veterans, programming for veterans on public lands has proliferated. Public land-management agencies vary in the extent to which they have systematically organized to provide opportunities for veterans, developed partnerships to support veterans’ health, and explicitly acknowledged agency roles in serving veterans. We describe seven types of outdoor programs for veterans (OPVs) that currently serve this population: supported outdoor activity; guided outdoor activity; retreat; outdoor job training; stewardship or service; horticulture, farming or gardening; and animal-assisted therapy. Each OPV type has different needs for infrastructure, outdoor spaces, and administrative or programmatic engagement. OPVs occurring on public lands typically involve one or more partner organizations, such as commercial outfitters and guides, health providers, veterans’ associations, foundations, corporations, and research institutions. There is potential for public land-management agencies to expand their role as institutional leaders in support of veterans’ health by facilitating the use of public lands as therapeutic landscapes. By enhancing new and existing relations with OPV providers, health providers, and other government agencies, public land agencies could expand benefits to veterans and spur broader societal benefits.
... There is growing evidence that OPVs can be effective either as a complementary or primary therapy for post-traumatic stress and PTSD (Van Puymbroeck and Lundberg 2011; Vella et al., 2013;Duvall and Kaplan 2014;Dietrich et al., 2015;Poulsen et al., 2015;Westlund 2015;Poulsen 2017). Numerous studies and literature reviews provide evidence of health benefits of OPVs for individual cases, but knowledge of how, why, or under what circumstances these programs work remains incomplete (Caddick and Smith 2014;Wynn 2015; Davis-Berman et al., 2018; Greer and Vin-Raviv 2019). ...
Article
In recent decades, scholars have developed ideas about therapeutic landscapes that explore how social processes, symbolism, and physical features generate diverse meanings. We examine here how therapeutic landscapes are produced and utilized for outdoor programs for military veterans, particularly veterans experiencing post-traumatic stress. Outdoor programs for veterans (OPVs) provide restorative opportunities through nature immersion and outdoor recreation. OPVs involve diverse social settings, activity types, durations, geographic and land management contexts, and degrees of therapeutic intervention. In many combinations they can generate therapeutic landscapes conducive to some degree of recovery. Our analysis relies on qualitative data gathered through semi-structured interviews with OPV providers and participants, mental health specialists, and public land officials. Arguing against a reductionistic approach, we suggest that the diversity of OPVs and disparate character of activities, locations, and dosages may contribute in important ways to the efficacy of these programs. Ironically, the very qualities that present challenges for measuring and evaluating the benefits of OPVs may prove to be advantageous with respect to therapeutic outcomes. We highlight how public lands present a distinctive set of attributes that make them particularly well-suited to provide therapeutic opportunities, and that agency policies can shape the development of therapeutic landscapes.
... Studies were also heavily represented by small sample sizes, with eight of the 13 studies including 20 participants or less, which is appropriate for many qualitative approaches. (2015), Ewert (1988) Butler-Collins (2017), Christensen, Wilson, and Holt (2013), Gathright, Yamada, and Morita (2006), Korpela et al. (2014), Li et al. (2012), Mang (1985), Morrow, Rodriguez, and King (2017), Vella, Milligan, and Bennett (2013), Weng and Chiang (2014), Wilson and Christensen (2012), Wolsko and Lindberg (2013), Zebrack, Kwak, and Sundstrom (2017) Natural Green-Spaces 8 Irani (1996), Jakubec et al. (2016) Buchecker and Degenhardt (2015) Hartig, Kaiser, and Strumse (2007), Harris (1996) Table Formatting (Stern, Powell, and Hill 2014). *Some sources operationalized nature-based recreation in multiple ways. ...
Article
The demand for mental health services around the world has risen dramatically. Many researchers and practitioners are looking for alternative mental health treatments, including nature-based recreation. However, reviews examining nature-based recreation’s therapeutic effectiveness are limited. The purpose of this study was to conduct a systematic review of available research regarding the potential mental-health benefits of nature-based recreation. Following the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) guidelines, a global standard established to ensure consistency and quality in literature reviews, a systematic search generated 51 articles for review. Most articles (n = 46, 90%) observed at least one positive association between nature-based recreation and mental health, including improvements in affect, cognition, restoration, and well-being, and decreases in anxiety and depression symptoms. Trends regarding the setting, population, methodology, and theoretical orientation of existing research, as well as recommendations for future research, are discussed in this review.
... A small number of studies have explored outdoor recreation's effect on veterans' PTSD symptomatology (Gelkopf et al., 2013;Poulsen et al., 2015;Vella et al., 2013), but these studies have not examined specifically how the duration of nature exposure affects PTSD symptomology. Therefore, the present study is unique in examining links between duration of nature exposure and PTSD symptomatology. ...
Article
Objectives: Duration, frequency, and intensity of nature exposure link to different physical and psychological benefits. The present study aimed to determine how time outdoors affected military veterans' posttraumatic stress disorder (PTSD) symptomology during PTSD treatment. Method: Hypotheses regarding time outdoors and the effect of program duration on PTSD symptoms were examined using multilevel models. The authors hypothesized that hours outdoors, both within- and between-persons, would predict reduced PTSD symptomology, program duration would predict reduced PTSD symptomology, and that hours outdoors and program duration would be significant when accounting for the other. Results: The present study found that time outdoors correlated with participants' decreased PTSD symptomology: the more time participants spent outdoors, the greater the reduction in their PTSD symptoms. Conclusion: The effect of time outdoors was significant within-person, not between persons, suggesting that nature exposure may be used as an adjunct to traditional mental health treatment where exposure or dosage should be person-specific.
... The impact of specific types of leisure on posttraumatic growth has also been explored. Research on adapted sports (Bennett, Townsend, Van Puymbroeck, & Gillette, 2014;Crawford, Gayman, & Tracey, 2014;Lundberg, Bennett, & Smith, 2011;Tasiemski, Kennedy, Gardner, & Taylor, 2005) and nature-based outdoor recreation activities such as fly fishing, hunting, river running, surfing, and other adventure activities (Bennett, Van Puymbroeck, Piatt, & Rydell, 2014;Caddick, Smith, & Phoenix, 2015;Dustin, Bricker, Arave, Wall, & Wendth, 2011;Hawkins, Townsend, & Garth, 2016;Rogers, Loy, & Brown-Bochicchio, 2016;Vella, Milligan, & Bennett, 2013) showed that these leisure activities played a significant role in posttraumatic growth. Caddick and Smith (2014) conducted a meta-analysis of several studies on posttraumatic growth through sport and outdoor recreation and found, across all studies, participation in these activities had a positive and lasting impact on subjective and psychological well-being, motivation, and posttraumatic growth. ...
... This situation provides an outcome for individuals to gain more control over their lives when dealing with hereditary or acquired diseases (Nimrod & Hutchinson, 2012). Further, it improves psychosocial wellbeing (Vella et al., 2013) and re-integration and adaptability of individuals within the community (Hawkins et al., 2015). ...
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This study aims to examine the relationship between university students’ perceived health outcomes and happiness levels that result from engaging in recreational activities. The study evaluates this relationship using certain variables. The data were gathered from 652 students from various universities in Turkey. Appropriate sampling methods were used. The initial findings indicate that the highest score was obtained in the ‘improvement condition’ of health outcomes among university students. It shows that they are more likely to engage with physical activities for health purposes. Furthermore, all sub-dimensions of PHORS and the happiness scale significantly differed according to income and active-passive participation variables. This study further demonstrates a significant positive relationship between perceived health outcomes sub-scales and happiness among the students.
... PEBs amongst outdoor recreationists are of specific interest because when they are enacted in recreationally used ecosystems, they hold the potential to offset anthropogenic stressors. By providing individuals with opportunities to relieve psycho-social stress, relax, socialize, and connect with nature, outdoor recreation has been shown to increase wellbeing and generate positive emotions, whilst lowering obesity rates amongst those who participate (Vella et al., 2013;Korpela et al., 2014;Outdoor Industry Association, 2017;Eigenschenk et al., 2019). Outdoor recreation also supports a wide range of economic activities (e.g., recreational fishing, snorkeling, bird watching, kayaking) and creates jobs in rural regions. ...
Article
Pro-environmental behaviours (PEBs) are important for mitigation and restoration efforts in the Anthropocene. As recreationists are motivated to engage in leisure activities to increase their own personal wellbeing, we submit that threats to wellbeing (an egocentric motivator) predict engagement in PEBs amongst recreationists. We also predict that differences in experiences across groups of recreationists leads to differences in PEB engagement. Using an online survey, we test our two hypotheses (if recreationists perceive there is a threat to their wellbeing and that their behaviours can yield environmental successes, then they will be more likely to engage in PEBs, and if recreationists differ in recreational experiences then they will demonstrate differences in PEB engagement) amongst outdoor recreationists, specifically Canadian rainbow trout and steelhead anglers in British Columbia (n = 894 respondents). We define ‘threat to wellbeing’ as the interaction of environmental threat-perceptions of used environments for fishing, and level of centrality fishing has to one's lifestyle. To test our first hypothesis, we conducted three linear regressions corresponding to three different PEBs related to catch-and-release (C&R) fishing. Our egocentric predictor ‘threat to wellbeing’ was only significant for one out of the three PEBs tested, showing mixed support for our first hypothesis. It is of note that ‘environmental threat perceptions’ and one's belief in successes resulting from PEB engagement were found to be significant predictors for all three PEBs tested. These results suggest that predictors of PEB may not always be transferable across PEBs relating to recreational activities, and environmental threat perception and one's belief in successes resulting from PEB engagement are strong predictors of PEBs amongst recreationists. To test our second hypothesis, we conducted a Kruskal Wallis test to determine if there were significant differences across angler groups in PEB predictor scores and PEB engagement and conducted pairwise population Z-tests to determine proportional participation rates across angler groups for the three PEBs and PEB predictors investigated. Experiences were found to shape predictors of PEBs, as well as likelihood to engage in PEBs, as different angler groups targeting different fish (i.e., rainbow trout vs steelhead) and using different aquatic habitats (i.e., rivers vs. lakes) demonstrated significantly different scores for PEB predictors, as well as significantly different likelihood to engage in two of the three PEBs tested. These findings support the notion that recreationists are not a homogenous group, and that their beliefs and resulting behaviours during recreational activities are determined by their experiences in nature and can be influenced by the species with which they interact, and the habitats they use for recreation.
... Alternatively, recreation may be used therapeutically in two ways. The first approach deals with directly increasing the psycho-social well-being while diminishing anxiety and improving the mood (Vella, Milligan, & Bennett, 2013). The second deals with its playful nature, in this manner facilitating the implementation of therapeutic strategies in either an individual or group form (Trejos Parra, Cardona Giraldo, & Cano Echeverri, 2005b), both being demonstrated in the current research, where recreation provided comfort and facilitated the implementation of the psychotherapeutic program. ...
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Presentamos una investigación experimental controlada y aleatorizada con pre y pos-prueba, llevada a cabo en 47 niños internados por maltrato en cua-tro centros de protección. Se utilizó una escala graduada según los criterios del DSM-5 para el trastorno de estrés postraumático (TEPT). El programa com-prendió seis sesiones que implementaron Técnicas de Liberación Emocional (EFT) junto con expresión plástica recreativa. La Expresión Plástica fue apro-piada, considerando las habilidades verbales en desarrollo y la hipoactivación del área del lenguaje del TEPT, y facilitó la aproximación a los recuerdos en un entorno seguro y grupal. La recreación brindó bienestar que ayudó a contra-rrestar la evitación que está en la génesis del TEPT. La EFT produjo una rápida disminución de la respuesta de alarma y contribuyó a la pronta elaboración del recuerdo. El Programa disminuyó significativamente el nivel del TEPT, fa-cilitó el aprendizaje de nuevas formas eficaces de afrontamiento y aportó al pensamiento de un proyecto de vida personal.
... For example, exercise augmentation to usual care was shown to reduce PTSD and depressive symptoms (Fetzner & Asmundson, 2015;Powers et al., 2015). Recreational therapy, like participation in group outdoor recreational programmes such as fly-fishing (Vella, Milligan, & Bennett, 2013) and horsemanship activities (Lanning & Krenek, 2013), was shown to improve the quality of life of veterans suffering from PTSD and reduce symptoms of depression (Wynn, 2015). ...
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Background Post-Traumatic Stress Disorder (PTSD) symptoms include re-experiencing, avoidance, hyperarousal, and cognitive deficits, reflecting both emotional and cognitive dysregulation. In recent years, non-pharmacological approaches and specifically animal-assisted therapy have been shown to be beneficial for a variety of disorders such as Attention-Deficit/Hyperactivity Disorder, Autism Spectrum Disorder, and PTSD. However, little is mentioned in the literature about the reciprocal effects of the animal–human interaction. Objective To evaluate the effects of a one-year dog training programme on PTSD symptomatology in youngsters with PTSD and on dogs’ behaviour. Methods Fifty-three adolescents, previously exposed to interpersonal trauma, were clinically diagnosed with PTSD and assigned to a dog-training programme group (n = 30) and a control group (n = 23) that engaged in other training programmes (e.g. cooking, hairstyling, etc.). Both groups were evaluated at baseline and following 12-months by The Clinician-Administered PTSD Scale for DSM-5 in Children and Adolescents (CAPS-CA-5) and Beck-Depression Inventory (BDI). Additionally, we physiologically measured both emotional and attention dysregulation. Results Post-12-months training, a significant alleviation of PTSD symptomatology accompanied by lower depression severity was observed in the dog-training group, compared with a insignificant recovery in the control group. Furthermore, improved emotional and attentional regulation was observed in the dog-training group. Measuring the dogs’ behaviour revealed increased anxiety and decreased selective attention performance, which was inversely correlated with the beneficial effects observed in the dog-training programme group. Conclusions Our findings emphasize the role of emotional and attentional regulations on the dog–handler interface, as evidence-based support for the beneficial effects of the dog-training programme, as either a non-pharmacological intervention or as complementary to anti-depressants treatment of PTSD. Though pharmacological treatments increase the patients’ well-being by treating certain PTSD symptoms, our suggested dog-training programme seems to influence the PTSD diagnostic status, thus may be implemented in civilians and veterans with PTSD.
... The SA/VWA appears to be a unique and promising alternative for veterans and others who have traumatogenic experiences, providing a meaningful escape that helps them regain their functioning while providing a service to communities. Subjects: Social Sciences; Gender Studies -Soc Sci; Mental Health Keywords: nature-based recreational therapy; outdoor therapy; veterans; posttraumatic stress disorder; Hawkin's Model An extensive body of English-language literature exists regarding the usefulness of recreational therapy in producing positive emotional, cognitive and behavioral outcomes for individuals who have survived traumatogenic experiences (Townsend, Hawkins, & Bennett, 2015;Van Puymbroeck & Lundberg, 2011;Vella, Milligan, Bennett, 2013). However, little is known about the potential benefits of programs contextualized in the outdoors for individuals diagnosed with trauma and stress-related disorders such as posttraumatic stress disorder (PTSD) (Hawkins, Townsend, & Garst, 2016;Norton & Watt, 2013). ...
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A growing body of evidence highlights benefits of recreational outdoor therapy for veterans experiencing posttraumatic stress disorder. We employed the Hawkins Model for “Nature as Strengths-based Recreational Therapy Intervention for Military Members” to assess the Swamp Apes/Volunteer Wilderness Alliance (SA/VWA) in South Florida, which has among its key objectives ridding the Everglades National Park of invasive species (e.g., Burmese python). Focus group and interviews with 10 veterans and seven non-veterans (i.e., family, health providers) were conducted to assess benefits, risks, and potential for developing SA/VWA activities into a formal therapy program for veterans rooted in the American Therapeutic Recreation Association’s standards. Data analysis via ATLAS.Ti yielded findings of: reduced trauma symptoms, improved family relationships, facilitation of transition to civilian life, experience of trust with team members, restored sense of purpose, and feeling unique and safe. SA/VWA activities are consonant with Hawkins model’s essential components of successful recreational therapy programs (i.e., harnessing internal strengths and existing military assets, building on existing character strengths and skillsets of veterans). The SA/VWA appears to be a unique and promising alternative for veterans and others who have traumatogenic experiences, providing a meaningful escape that helps them regain their functioning while providing a service to communities.
... Outdoor recreation activities contribute positively to both physical and mental health [1][2][3]. Outdoor recreation helps maintain lower body fat percentages and lead to lower blood pressure and cholesterol level [4,5] while also helping stress management and reducing anxiety or depression [6][7][8][9]. Nearly half of Americans aged six and older participate in various types of outdoor recreation activities such as hiking, camping, and fishing, among many others [10]. ...
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This paper uses over 30 million individual-level trips in federal recreation locations to investigate the impact of short-term temperature shocks on outdoor recreation activities. Our results show that in the short term, a 1◦C temperature increase during the last 6 months increases the total trip duration by 1.197 days (or a 4.12% increase) and the total number of trips by 0.472 (or a 5.44% increase) at the zipcode-month level. The positive effect is primarily driven by the increased number of trips and more in- state travel. We find that the impact of temperature on the number of recreation trips generally increases under a higher temperature. When the monthly temperature is below < 5◦C, the temperature increase will reduce the number of trips as individuals in low-temperature regions is likely to reduce travel demand when the temperature gets warmer.
... 26,27 Outcomes from adventure or challenge-based programs have shown increases in coping skills and self-efficacy, especially when programing was coupled with the emotional support from fellow service members. [28][29][30][31][32] Additionally, the controlled practice of deep-breathing and meditation in yoga has contributed to a reduction in post-traumatic stress disorder (PTSD) symptoms. [33][34][35][36][37] EAT is another growing recreation-based CAM used with the veteran population. ...
Article
Equine-assisted therapy is being increasingly used as a therapeutic modality for veterans who have been injured during military service; however, little research has examined the quality of equine programs, especially from a veteran’s perspective. In this study, an Importance-Performance Analysis (IPA) was used to provide direct, applicable feedback of program quality and relevancy to a military-specific equine-assisted therapy program. Veteran participants in the program informed the IPA tool used to assess the importance and performance of various program factors. Results provided insight into the quality of the equine-assisted therapy program factors, shedding light on those specifically being sought by veterans. Some of the key program factors included the horse being central to the program, the program catering to veteran needs, and sessions being held in a relaxed setting. Full results may be considered for other veteran-serving equine-assisted therapy programs.
... Leisure is sometimes seen as compensation for other areas of life, probably because individuals can gain a deep sense of satisfaction in their perceptions of freedom, competence, and intrinsic motivation 48 . Moreover, positive leisure experiences could effectively reduce people's stress and depression 49 , which are often seen as risk factors for aggression 50 . ...
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Previous research has shown that both the daily experiences and personal traits of adolescents are linked to aggression. Our aim was to further investigate the relationship between leisure experience, self-esteem, and aggression according to the general aggression model. In addition, within frustration-aggression theory, we proposed that leisure experience and aggression have a negative correlation. Furthermore, based on broaden-and-build theory, we explored the mediating role of self-esteem between leisure experience and aggression. The participants included 660 Chinese teenagers with an average age of 14.3. Among them, male students accounted for 310 (49.4%) and female students accounted for 318 (50.6%). The results showed that leisure experience was positively correlated with self-esteem and negatively correlated with aggression, while self-esteem was also negatively correlated with aggression. Additionally, self-esteem fully mediated the relationship between leisure experience and aggression. Our study could enrich research on leisure and provide a basis for protective factors of aggression in adolescents.
... Growing evidence indicates recreation participation as a contributor to individuals' health and overall wellness, including physical, psychological and social benefits (Fenton et al., 2017;Vella, Milligan, & Bennett, 2013;Wolsko & Lindberg, 2013). Participation in specific types of recreation activities such as team sports can enhance physical health and reduce stress while improving social interaction and social support (Eime, Young, Harvey, Charity, & Payne, 2013;Moon & Kim, 2013;Murphy & Carbone, 2008). ...
... 30 A growing body of literature is emerging that supports the use of recreation and recreational therapy with injured Veter ans and their supporters. [28][29][30][31][32][33][34][35][36] ...
Article
Introduction: Women are an ever-growing and integral part of the U.S. military. However, the research on community reintegration (CR) for injured female Veterans is limited. The purpose of this study was to identify the contextual factors influencing CR for injured female Veterans. Methods: Female Veterans reporting a physical or psychological injury acquired during military service ( N = 31) completed the Community Reintegration of Service Members’ Extent of Participation (EOP) and Satisfaction with Participation (SWP) subscales, the Craig Hospital Inventory of Environmental Factors, and the New General Self-Efficacy Scale to identify personal and environmental factors affecting CR. Statistical analyses were conducted to determine the clustering of participants on the basis of CR scores and the effect of environmental factors and self-efficacy on CR. Results: Levels of CR were organized into low, moderate, and high CR clusters. General self-efficacy was significantly related to CR, and a significant difference was observed between high and low CR clusters. CR was not related to time served in the military, total time deployed, history of suicidal ideation, or having a dependable social support system. Discussion: Findings indicate that general self-efficacy had the strongest relationship with CR for injured female Veterans. Results also suggest that participants had varying levels of CR, and those with lower levels of CR were more likely to perceive environmental factors as barriers to CR. Future research should explore the influence of environmental barriers on CR for injured female Veterans with a larger sample.
Article
Individuals with disabilities do not experience full participation in society. Research suggests that a focus on quantity as opposed to quality of participation may be responsible for this disparity. The Quality Parasport Participation Framework was developed to fill this gap by highlighting the PA program conditions and elements indicative of quality experiences. The aim of the current study was to fill remaining knowledge gaps by (a) exploring what outcomes military veterans with physical disabilities link to quality PA experiences, and (b) determining what contexts may foster these outcomes. Military veterans with physical disabilities (n = 18) took part in semi-structured interviews. Data analyses consisted of two phases. In phase one, an inductive thematic analysis was conducted to generate PA outcomes linked to quality experiences. In phase two, an inductive thematic analysis identified contexts that may foster quality outcomes, while a deductive thematic analysis determined potential linkages to the Quality Parasport Participation Framework. Three overarching outcomes were linked to quality experiences: PA promotes psychological benefits, the importance of social and societal growth, and opportunities for advancement. These findings advance knowledge by identifying the subjective perspectives of veterans with physical disabilities regarding specific outcomes indicative of quality experiences, as well as how these outcomes may be fostered within quality PA programs. Knowledge of which outcomes are indicative of quality PA experience is necessary to promote full PA participation. Results provide a foundation for research exploring how to optimally deliver and evaluate adapted PA programming.
Article
Physical activity (PA) is promoted to support the psychosocial recovery of military personnel with illnesses and injuries. The aim of this scoping review was to (1) identify existing research examining the psychosocial aspects of military adapted PA and (2) determine key knowledge gaps. Forty-one articles met inclusion criteria. Around half of the included studies were qualitative (51.21%), with additional studies quantitative (36.59%) or mixed methods (12.20%). Most studies (90.24%) focused on military personnel, with a small number including partners (4.88%) or program staff (4.88%). Therapeutic recreation was the most common type of PA examined. A thematic synthesis of qualitative data identified an emphasis on benefits of PA participation, as well as contextual factors linked to benefits of participation. Quantitative studies also focused on psychosocial outcomes of participation, particularly self-efficacy (n = 11) and quality of life (n = 4). Based on these findings, six knowledge gaps were identified, including a need for longitudinal research, examination of diverse types of PA, consideration of systemic influences, representation of women, examination of diverse psychosocial constructs, and consideration of program implementation. As researchers fill these gaps, we can begin to develop evidence-based PA programing and policy that promotes long-term recovery and psychosocial well-being.
Article
Introduction: In this study, we evaluate the physical activity (PA) participation of Veterans with a physical disability, particularly the role of experiential elements of quality participation in facilitating desired program outcomes. We hypothesized that quality elements would mediate the relationship between quality program conditions and participation outcomes. Methods: Forty-nine Veterans with a physical disability (mean age = 43.61 [SD 8.81] y) completed questionnaires before and after PA event participation, as well as at a 3-month follow-up. Results: Results demonstrated that an indicator of the quality element belongingness mediated the relationship between coach interpersonal skills and two PA indicators (i.e., planning and intentions) after event participation. The same quality indicator also mediated the relationship between coach interpersonal skills and family integration after event participation and at the 3-month follow-up. Discussion: These findings provide preliminary evidence linking quality PA program conditions and elements to PA participation outcomes.
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There is increasing interest in the potential use of outdoor water environments, or blue space, in the promotion of human health and wellbeing. However, therapeutic nature-based practices are currently outpacing policy and the evidence base for health or wellbeing benefits of therapeutic interventions within blue space has not been systematically assessed. This systematic review aims to address the gap in understanding the impacts of blue space within existing interventions for targeted individuals. A systematic review was carried out, searching Google Scholar, SCOPUS, PubMed, etc. through to August 2017. Only blue space interventions were included that were specifically designed and structured with a therapeutic purpose for individuals with a defined need and did not include nature-based promotion projects or casual recreation in the outdoors. Thirty-three studies met the inclusion criteria and were assessed. Overall, the studies suggest that blue care can have direct benefit for health, especially mental health and psycho-social wellbeing. The majority of papers found a positive or weak association between blue care and health and wellbeing indicators. There was also some evidence for greater social connectedness during and after interventions, but results were inconsistent and mixed across studies with very few findings for physical health. This is the first systematic review of the literature on blue care. In summary, it has been shown that mental health, especially psycho-social wellbeing, can be improved with investment in blue spaces. Key areas for future research include improving understanding of the mechanisms through which blue care can improve public health promotion.
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This paper probes into the relationship between Neighbourhood Parks and their efficiency as a potential stress reliever from the outdoor environment. It consists of the introduction to the relationship between stress and outdoor environment, background research on recent issues of Neighbourhood Park and it then continues with the context of perceiving Neighbourhood Park as a stress reliever. This paper looks into the previous studies that employed observations, survey, interviews, and instruments as methods in proving Neighbourhood Parks as a potential stress reliever. Relevant findings were highlighted and recommendations for improving the design and planning were suggested to generate more quality living environment in the future.
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Physical activity (PA) for military veterans that are wounded, injured and/or sick (WIS) is becoming increasingly recognized as an advantageous method of increasing wellbeing. A narrative synthesis approach was used to systematically review current quantitative evidence exploring the psychological effects of PA on veterans that are WIS. Key databases were searched resulting in the inclusion of 19 studies. PA was shown to have a positive effect on post-traumatic stress, depression, anxiety, stress, quality of life, social wellbeing, sleep quality, perceived functional impairment, participant mindfulness, and positive/negative affect; with improvements in stress, social well-being, and positive/negative effect being greater among veterans that are WIS with lower health statuses. After comparing PA types, outdoor recreation appeared to more consistently reduce PTSD symptoms post-intervention; whereas, yoga and horse riding were more effective in reducing anxiety and stress. Furthermore, where significant others were included in PA interventions/programs for veterans that are WIS, longer-lasting benefits have been reported. However, in line with other reviews in this area, the methodological weaknesses of current research and non-standardized delivery of PA interventions limits the generalisability of the findings of this review.
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BİREYİN KENDİNİ GERÇEKLEŞTİRMESI İÇIN VAZGEÇİLMEZ BİR PENCERE : REKREASYONEL FARKINDALIK
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Exposure to the natural environment is increasingly considered to benefit psychological health. Recent reports in the literature also suggest that outdoor exposure that includes recreational pursuits such as surfing or fishing coupled with opportunities for social interaction with peers may be beneficial to Armed Forces Veterans experiencing Post-Traumatic Stress Disorder (PTSD). Two studies were conducted to evaluate this possibility. In particular, these studies aimed to test the hypothesis that a brief group outdoor activity would decrease participants’ symptoms as assessed by established measures of PTSD, depression, anxiety and perceived stress, and increase participants’ sense of general social functioning and psychological growth. Experiment one employed a repeated measures design in which UK men and women military veterans with PTSD (N = 30) participated in a group outdoor activity (angling, equine care, or archery and falconry combined). Psychological measures were taken at 2 weeks prior, 2 weeks post, and at 4 month follow up. We obtained a significant within participant main effect indicating significant reduction in PTSD symptoms. Experiment two was a waitlist controlled randomised experiment employing an angling experience (N = 18) and 2 week follow up. In experiment 2 the predicted interaction of Group (Experimental vs. Waitlist Control) X Time (2 weeks pre vs. 2 weeks post) was obtained indicating that the experience resulted in significant reduction in PTSD symptoms relative to waitlist controls. The effect size was large. Additional analyses confirmed that the observed effects might also be considered clinically significant and reliable. In sum, peer outdoor experiences are beneficial and offer potential to complement existing provision for military veterans with Post Traumatic Stress Disorder. Trial registration The authors confirm that all ongoing and related trials for this intervention are registered. The studies reported in this manuscript are registered as clinical trials at ISRCTN: Pilot ID– ISRCTN15325073 RCT ID– ISRCTN59395217
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Several studies revealed some mood disorders such as depression and burnout in nursing parents as a result of difficulties brought by Autism Spectrum Disorder (ASD) symptoms. On the other hand, recreative activities have a therapeutic effect on mental health. The aim of the study was to determine the effect of physical activity-based recreation on mothers' depression and burnout levels. Fifteen mothers of children with ASD were included in the single-group pre-test and post-test experimental design study. Beck Depression Inventory and Maslach Burnout Inventory were applied to mothers to determine depression and burnout levels before and after the one-week camp. According to the results of the paired sample t-test, the depression levels of the mothers decreased significantly after the camp, whereas burnout levels remained the same. While depression and burnout levels of the mothers were moderately correlated before the recreation camp, they did not correlate following the recreation camp. It can be concluded that burnout emotional state in parents of children with ASD may correlate with depression which that might be reduced as a result of physical activity based recreative activities. Further longitudinal studies including quantitative and qualitative research methods are needed to determine the cause-effect relationship and create effective recreational programs for families of children with ASD.
Article
Introduction Traumatic brain injury (TBI) or concussion is a known risk factor for multiple adverse health outcomes, including disturbed sleep. Although prior studies show adverse effects of TBI on sleep quality, its compounding effect with other factors on sleep is unknown. This meta-analysis aimed to quantify the effects of TBI on subjective sleep quality in the context of military status and other demographic factors. Materials and Methods A programmatic search of PubMed database from inception to June 2020 was conducted to identify studies that compared subjective sleep quality measured using Pittsburgh Sleep Quality Index (PSQI) in individuals with TBI relative to a control group. The meta-analysis included group-wise standard mean difference (SMD) and 95% CI. Pooled means and SDs were obtained for TBI and non-TBI groups with and without military service, and meta-regression was conducted to test for group effects. Exploratory analysis was performed to test for the effect of TBI, non-head injury, military status, sex, and age on sleep quality across studies. Results Twenty-six articles were included, resulting in a combined total of 5,366 individuals (2,387 TBI and 2,979 controls). Overall, individuals with TBI self-reported poorer sleep quality compared to controls (SMD = 0.63, 95% CI: 0.45 to 0.80). Subgroup analysis revealed differences in the overall effect of TBI on PSQI, with a large effect observed in the civilian subgroup (SMD: 0.80, 95% CI: 0.57 to 1.03) and a medium effect in the civilian subgroup with orthopedic injuries (SMD: 0.40, 95% CI: 0.13 to 0.65) and military/veteran subgroup (SMD: 0.43, 95% CI: 0.14 to 0.71). Exploratory analysis revealed that age and history of military service significantly impacted global PSQI scores. Conclusions Poor sleep quality in TBI cohorts may be due to the influence of multiple factors. Military/veteran samples had poorer sleep quality compared to civilians even in the absence of TBI, possibly reflecting unique stressors associated with prior military experiences and the sequelae of these stressors or other physical and/or psychological traumas that combine to heightened vulnerability. These findings suggest that military service members and veterans with TBI are particularly at a higher risk of poor sleep and its associated adverse health outcomes. Additional research is needed to identify potential exposures that may further heighten vulnerability toward poorer sleep quality in those with TBI across both civilian and military/veteran populations.
Article
Background: Skepticism of therapy and stigma are significant barriers for veterans with mental health issues. Therapeutic adventure shows promise in addressing veterans’ mental health needs while circumventing the stigma many veterans face in initiating treatment. Purpose: Given the small group model of therapeutic adventure programs, such programs may be ideal to provide social support for veterans and reduce mental health symptomology. The present study investigated: can a brief peer-led therapeutic adventure program modify veterans’ mental health symptoms? Methodology/Approach: The study's sample included 56 participants attending one Sierra Club Military Outdoors trip lasting at least three days and two nights and involving camping. Participants completed study measurements assessing depression, anxiety, stress, Post-Traumatic Stress Disorder symptoms, substance misuse symptoms, and suicidality at pre-trip, post-trip, one-month post trip, six-months post trip, and 12-months post trip. Six-month and 12-month post-trip data was collected during the COVID-19 pandemic. Findings/Conclusions: Results indicated significant reduction in mental health symptomology from pre-trip to post-trip, but showed few longer-term changes in mental health symptomology. Implications: The present study's findings are consistent with research suggesting improvements in overall psychological well-being immediately following a nature-based intervention and suggest the need for on-going, community-based interventions to support optimally military veterans’ mental health.
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(1) Background: Current military members, veterans, and Royal Canadian Mounted Police (RCMP) experience higher rates of posttraumatic stress disorder (PTSD) and moral injury (MI). Trauma-oriented retreats have been offered as a means of addressing these concerns. This article aims to explore the impact of a non-evidence-based trauma-oriented retreat for the above populations experiencing PTSD or MI; (2) Methods: This qualitative study, nested within the larger mixed-methods pre/post longitudinal follow-up study, examined the experiences of 124 military members, veterans, and RCMP who participated in the retreat. Data were collected from semi structured interviews and first-hand observations of the organization. Analysis was conducted using thematic analysis while being informed by realist evaluation principles; (3) Results: The results showed that important contextual elements were related to participants being ready, having multiple comorbidities and using the program as a first or last resort. Effectual mechanisms included a home-like setting; immersion; credibility of facilitators; experiential learning; an holistic approach; letting go, and reconnecting to self. Outcomes included: re-finding self, symptom management, social connection, and hope for a meaningful life. The gendered analysis suggested less favorable results; (4) Conclusions: Care is warranted as the evidence-base and effectiveness of trauma-oriented retreats yet needs to be established prior to broad use.
Article
Objectives: Our purpose was to investigate the relationships between leisure types and coping, happiness, and life satisfaction among veterans. Methods: Our sample was 106 veterans. We used hierarchical multiple regression analysis to examine the relationships of the previously identified variables. Demographic variables were entered into the first block of the regression model, and all the demographic variables and types of leisure activities were then entered into the second block. Results: Age, disability status, sports, and volunteer activities were positively associated with the problem-solving coping strategy. Only outdoor activities were positively related to the social support coping strategy. Home-based activities were positively associated with the avoidance coping strategy. Disability status, outdoor activities, and social activities were positively associated with life satisfaction. Age and social activities were positively associated with happiness. Conclusions: Overall, participation in social and outdoor activities was positively associated with active coping, social-seeking coping, life satisfaction, and happiness. This finding supports the literature on leisure and health, suggesting the value of leisure activities as an effective coping strategy and a positive influence on the mental health of veterans.
Chapter
Following on from the review of the prevalence and diagnosis of PTSD in Chapter 2, this chapter first takes a critical stance in considering the ways in which different conceptualisations of normality and deviance are socially constructed.
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In recent decades, the need for veterans' mental health treatment has increased dramatically. But while utilization of Veterans Affairs services has risen, a large number of veterans who could benefit from its resources either drop out from services early or do not access them at all. Given veterans' reluctance to engage in traditional modalities of treatment, the psychological benefits of nature- and adventure-based interventions are of particular interest as an alternative approach to address veterans' mental health needs. Although current literature suggests that therapeutic adventure produces positive outcomes for veteran participants, existing literature does not explain the mechanisms by which therapeutic adventure impacts veterans' mental health. The authors conducted a thorough literature review on nature-based interventions and adventure-based intervention with veterans. Using existing research, this article presents a conceptual argument and conceptual map for how nature-based therapeutic adventure impacts veterans' mental health. Nature and time in the wilderness are effective in improving the physical and psychological well-being of individuals. As a result, veterans may greatly benefit from utilizing therapeutic adventure. In addition, therapeutic adventure includes a group component, allowing for relationship skill building and meaningful connection with peer veterans. Nature- and adventure-based interventions should be considered as potentially strong treatment approaches for veteran populations.
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The influence of leisure in coping with negative life events likely derives from its powers to distract, to generate optimism about the future, and to preserve a sense of self in the face of trauma (Kleiber, Hutchinson, & Williams, 2002). While there is recent evidence of leisure's role in coping with daily hassles and normative life stressors (e.g., Iwasaki & Mannell, 2000), the nature and extent of leisure's utility in coping with a life-altering event, such as a traumatic injury, is not well understood. The purpose of this paper is to examine how individuals used leisure in coping with a traumatic injury or the onset of a chronic illness. Qualitative data from two studies involving people with either a spinal cord injury or chronic illness were used for this analysis. Findings support suggestions from earlier research: leisure served to buffer effects of immediate life circumstances and it sustained their coping efforts in various ways. The authors end by discussing the data in light of recent theoretical propositions about the role of positive affect and meaning in coping.
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The purpose of this article is to examine the empirical evidence and describe theoretical perspectives that address under what conditions and why leisure can be therapeutic and contribute to health and well-being. This review of the literature provides empirical evidence that leisure can contribute to physical, social, emotional and cognitive health through prevention, coping (adjustment, remediation, diversion), and transcendence. After examining this empirical evidence, the article addresses why leisure is therapeutic and concludes by presenting two concepts useful to practitioners who desire to provide leisure guidance to help people avoid risk and maximise the therapeutic possibilities of leisure.
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Three studies examine the effects of exposure to nature on positive affect and ability to reflect on a life problem. Participants spent 15 min walking in a natural setting (Studies 1, 2, & 3), an urban setting (Study 1), or watching videos of natural and urban settings (Studies 2 & 3). In all three studies, exposure to nature increased connectedness to nature, attentional capacity, positive emotions, and ability to reflect on a life problem; these effects are more dramatic for actual nature than for virtual nature. Mediational analyses indicate that the positive effects of exposure to nature are partially mediated by increases in connectedness to nature and are not mediated by increases in attentional capacity. The discussion focuses on the mechanisms that underlie the exposure to nature/well-being effects.
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Post-traumatic stress disorder (PTSD) can result from a traumatic experience that elicits emotions of fear, helpless or horror. Most individuals remain asymptomatic or symptoms quickly resolve, but in a minority intrusive imagery and nightmares, emotional numbing and avoidance, and hyperarousal persist for decades. PTSD is associated with psychiatric and medical co-morbidities, increased risk for suicide, and with poor social and occupational functioning. Psychotherapy and pharmacotherapy are common treatments. Whereas, research supports the efficacy of the cognitive behavioral psychotherapies, there is insufficient evidence to unequivocally support the efficacy of any specific pharmacotherapy. Proven effective pharmacologic agents are sorely needed to treat core and targeted PTSD symptoms, and for prevention. This review describes current and emerging pharmacotherapies that advance these goals.
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The purpose of this study was to investigate how serious leisure and flow contribute to subjective well‐being (SWB) in the daily lives of older adults. Twenty‐two older adults were recruited from a local aging agency in a midwestern city in the USA. Experience Sampling Method was used to collect data on the daily experiences of the older adults. Hierarchical Linear Modelling was used to predict levels of SWB from experience variables (i.e. serious leisure, flow) and individual difference variables (i.e. gender, retirement). One‐way analyses of variance, random coefficient, and intercepts and slopes‐as‐outcomes models were tested. Serious leisure was positively associated with positive affect (PA), and flow had a significant negative relationship with PA. The results of this study confirm previous findings that SWB is an important consequence of serious leisure in everyday life.
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The purpose of this study was to test the hypothesis that leisure-generated social support (companionship and friendship) and the self-determination disposition (perceived freedom and intrinsic motivation) buffer the adverse effects of life stress on mental and physical health problems. Data were provided by 252 subjects who were 18 to 65 years old and practitioners of Taekwondo sport as a leisure activity. Results indicated that life stress was positively related to mental and physical illness symptoms and negatively related to perceived health, regardless of any moderating variables. Hierarchical multiple regression analyses, however, showed that leisure companionship moderated the effect of life stress on mental illness (depression) symptoms, whereas leisure friendship did the same for physical illness symptoms. Data provided no support for the positive moderating effect of the self-determination disposition. In general, results confirm the importance of social support derived from leisure activity participation and suggest that it is the activity and things done with friends/companions that buffer the adverse effects of stress on physical and mental health.
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This paper aims at advancing the conceptualization of leisure as a contributor to quality of life (QOL) in an international and multicultural context, based on an extensive and critical review of literature on leisure and QOL from a global, international perspective. Given the central role of culture in conceptualizing this notion, this paper gives attention to various cultural contexts world-wide. To illustrate the diversity of our societies, examples are introduced specifically from three culturally unique contexts in this paper – i.e., Asian, Middle-East, and Indigenous contexts. Also, some examples are drawn from other cultural groups in global and international contexts, particularly, in non-western contexts. Then, the final section of this paper aims at integrating and synthesizing the knowledge gained from this review to develop a tentative/working proposition about how leisure can contribute to QOL from international and cross-cultural perspectives. Specifically, based on such integration, this paper identifies and describes major pathways linking leisure to QOL. Overall, an overarching theme common to almost all cultural contexts examined appears to be the role of leisure-like activities as a context or space for creating meanings which then help to promote the quality of people’s lives. Major pathways or mechanisms that can facilitate meaning-making and life-quality-enhancement highlighted in this review include: (a) positive emotions and well-being experienced from leisure, (b) positive identities and self-esteem gained from leisure, (c) social and cultural connections and a harmony developed through leisure, and (d) leisure’s contribution to learning and human development across the life-span. Also, emphasized in this paper is the role of leisure as a context for realizing and utilizing human strengths and resilience. It is important, however, to stress that in people’s quest for a meaningful life, the benefits of meaning-making through leisure involve both “remedying the bad” and “enhancing the good,” as shown throughout this paper. Despite these benefits, we should not ignore that leisure experiences are socially and culturally constructed and shaped by the inequalities of society. Thus, the reality of power imbalance and inequalities should be acknowledged and appropriately addressed socially, culturally, and politically. Particularly, providing culturally relevant and meaningful leisure opportunities for less privileged population groups world-wide is clearly a top priority.
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Little research to date has examined the ability of self-report measures to assess changes in symptom severity and diagnostic status as a function of treatment. This study investigated the validity of the posttraumatic stress disorder (PTSD) checklist (PCL) as a measure of symptomatic change following programmatic treatment. A sample of 97 Vietnam veterans with combat-related PTSD was assessed using the clinician-administered PTSD scale (CAPS) and the PCL prior to, and 9 months following, participation in a PTSD treatment program. Using the CAPS as the “gold standard” measure of PTSD symptomatology, the PCL demonstrated high diagnostic accuracy pre- and posttreatment. However, significant variations in accuracy were evident in the ability of the PCL to determine the presence and severity of individual symptoms at each time point. In addition, as symptoms improved from pre- to posttreatment, and approached the threshold criteria, the PCL demonstrated reductions in diagnostic accuracy. As a measure of overall symptomatic change, the PCL underrated improvement in comparison to the CAPS. The results supported the use of an overall cut-off score of 50 on the PCL for a diagnosis, and an item score of 3 for symptom criterion, in this population.
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Directed attention plays an important role in human information processing; its fatigue, in turn, has far-reaching consequences. Attention Restoration Theory provides an analysis of the kinds of experiences that lead to recovery from such fatigue. Natural environments turn out to be particularly rich in the characteristics necessary for restorative experiences. An integrative framework is proposed that places both directed attention and stress in the larger context of human-environment relationships.
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Persons with more types of social relationships live longer and have less cognitive decline with aging, greater resistance to infectious disease, and better prognoses when facing chronic life-threatening illnesses. We have known about the importance of social integration (engaging in diverse types of relationships) for health and longevity for 30 years. Yet, we still do not know why having a more diverse social network would have a positive influence on our health, and we have yet to design effective interventions that influence key components of the network and in turn physical health. Better understanding of the role of social integration in health will require research on how integrated social networks influence health relevant behaviors, regulate emotions and biological responses, and contribute to our expectations and world views.
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Pregnant women who are placed on hospitalized bed rest experience increased antepartum-related distress. We sought to examine the efficacy of a single session music or recreation therapy intervention to reduce antepartum-related distress among women with high-risk pregnancies experiencing extended antepartum hospitalizations. In a randomized, single-blinded study, participants (n = 80) received 1 hour of music or recreation therapy or were placed in an attention-control group. Antepartum-related distress was measured by the Antepartum Bedrest Emotional Impact Inventory, which was administered before and after the intervention and at a follow-up period between 48 and 72 hours. Significant associations were found between the delivery of music and recreation therapy and the reduction of antepartum-related distress in women hospitalized with high-risk pregnancies. These statistically significant reductions in distress persisted over a period of up to 48-72 hours. Single session music and recreation therapy interventions effectively alleviate antepartum-related distress among high-risk women experiencing antepartum hospitalization and should be considered as valuable additions to any comprehensive antepartum program.
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Despite the prevalence of sleep complaints among psychiatric patients, few questionnaires have been specifically designed to measure sleep quality in clinical populations. The Pittsburgh Sleep Quality Index (PSQI) is a self-rated questionnaire which assesses sleep quality and disturbances over a 1-month time interval. Nineteen individual items generate seven "component" scores: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction. The sum of scores for these seven components yields one global score. Clinical and clinimetric properties of the PSQI were assessed over an 18-month period with "good" sleepers (healthy subjects, n = 52) and "poor" sleepers (depressed patients, n = 54; sleep-disorder patients, n = 62). Acceptable measures of internal homogeneity, consistency (test-retest reliability), and validity were obtained. A global PSQI score greater than 5 yielded a diagnostic sensitivity of 89.6% and specificity of 86.5% (kappa = 0.75, p less than 0.001) in distinguishing good and poor sleepers. The clinimetric and clinical properties of the PSQI suggest its utility both in psychiatric clinical practice and research activities.
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Synopsis This is an introductory report for the Brief Symptom Inventory (BSI), a brief psychological self-report symptom scale. The BSI was developed from its longer parent instrument, the SCL-90-R, and psychometric evaluation reveals it to be an acceptable short alternative to the complete scale. Both test-retest and internal consistency reliabilities are shown to be very good for the primary symptom dimensions of the BSI, and its correlations with the comparable dimensions of the SCL-90-R are quite high. In terms of validation, high convergence between BSI scales and like dimensions of the MMPI provide good evidence of convergent validity, and factor analytic studies of the internal structure of the scale contribute evidence of construct validity. Several criterion-oriented validity studies have also been completed with this instrument
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This paper presents evidence from three samples, two of college students and one of participants in a community smoking-cessation program, for the reliability and validity of a 14-item instrument, the Perceived Stress Scale (PSS), designed to measure the degree to which situations in one's life are appraised as stressful. The PSS showed adequate reliability and, as predicted, was correlated with life-event scores, depressive and physical symptomatology, utilization of health services, social anxiety, and smoking-reduction maintenance. In all comparisons, the PSS was a better predictor of the outcome in question than were life-event scores. When compared to a depressive symptomatology scale, the PSS was found to measure a different and independently predictive construct. Additional data indicate adequate reliability and validity of a four-item version of the PSS for telephone interviews. The PSS is suggested for examining the role of nonspecific appraised stress in the etiology of disease and behavioral disorders and as an outcome measure of experienced levels of stress.
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The authors took advantage of a 50-year prospective study of World War II veterans to examine the predictors and correlates of combat exposure, symptoms of posttraumatic stress disorder (PTSD), and trait neuroticism. The subjects were 107 veterans who had been extensively studied before and immediately after serving overseas in World War II. All served as members of the study until the present time, and 91 completed questionnaires of both PTSD symptoms and neuroticism. In this study group, variables associated with positive psychosocial health in adolescence and at age 65 predicted combat exposure. Combat exposure and number of physiological symptoms during combat stress--but not during civilian stress--predicted symptoms of PTSD in 1946 and 1988. Combat exposure also predicted early death and study attrition. Psychosocial vulnerability in adolescence and at age 65 and physiological symptoms during civilian stress--but not during combat stress--predicted trait neuroticism at age 65. Combat exposure predicted symptoms of PTSD but not nonspecific measures of psychopathology. Premorbid vulnerability predicted subsequent psychopathology but not symptoms of PTSD.
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The Pittsburgh Sleep Quality Index (PSQI) measures sleep quality and disturbance retrospectively over a 1-month period using self-reports. Although the PSQI has been used in a variety of populations, published psychometric data are limited. The goal of this study was to examine psychometric properties of the PSQI among four populations: bone marrow transplant patients (n=155); renal transplant patients (n=56); women with breast cancer (n=102); and women with benign breast problems (n=159). Results supported PSQI internal consistency reliability and construct validity. Cronbach's alphas were 0.80 across groups and correlations between global and component scores were moderate to high. PSQI scores were moderately to highly correlated with measures of sleep quality and sleep problems, and poorly correlated with unrelated constructs. Individuals with sleep problems, poor sleep quality, and sleep restlessness had significantly higher PSQI scores in comparison to individuals without such problems.