Mental health rehabilitation in a care farm context: A descriptive review of Norwegian intervention studies

Abstract

Background:
C are farming is a service developed at farms for promoting mental and physical health and is increasingly used in mental health rehabilitation in Norway.

Objective:
This article aims to present a descriptive review of Norwegian intervention research on care farms that provide rehabilitation for people with mental health disorders.

Methods:
This literature review applied a non-systematic search strategy: all articles in the field known to the authors were selected for inclusion. The selected studies were intervention studies that were conducted on farms in Norway, that used adult participants with mental health problems/disorders, and that reported outcome measures related to mental health. The studies and articles presented quantitative and/or qualitative data.

Results:
The findings from the published articles report improvements to mental health problems, such as depression, anxiety, perceived stress, positive affect, rumination, and self-efficacy. Qualitative data describe a variety of positive experiences, such as improved coping ability, increased social support, and appreciation of the care farm activity.

Conclusion:
Participating in interventions on care farms positively influences mental health. Care farming may therefore be used as a supplementary approach in mental health rehabilitation, as it offers meaningful and engaging occupations and social inclusion.

Full text

AUTHOR COPY
Work 53 (2016) 31–43
DOI:10.3233/WOR-152213
IOS Press
31
Mental health rehabilitation in a care farm
context: A descriptive review of Norwegian
intervention studies
Ingeborg Pedersen
a,∗
, Grete Patil
a
, Bente Berget
b
, Camilla Ihlebæk
a
and Marianne Thorsen Gonzalez
c
a
Section for Public Health Science, Department of Landscape Architecture and Spatial Planning
Norwegian University of Life Sciences,
˚
As, Norway
b
Department of Animal and Aquacultural Sciences, Norwegian University of Life Sciences,
˚
As, Norway
c
Institute of Nursing and Health, Diakonhjemmet University College, Oslo, Norway
Received 4 August 2014
Accepted 5 August 2014
Abstract.
BACKGROUND: Care farming is a service developed at farms for promoting mental and physical health and is increasingly
used in mental health rehabilitation in Norway.
OBJECTIVE: This article aims to present a descriptive review of Norwegian intervention research on care farms that provide
rehabilitation for people with mental health disorders.
METHODS: This literature review applied a non-systematic search strategy: all articles in the field known to the authors were
selected for inclusion. The selected studies were intervention studies that were conducted on farms in Norway, that used adult
participants with mental health problems/disorders, and that reported outcome measures related to mental health. The studies and
articles presented quantitative and/or qualitative data.
RESULTS: The findings from the published articles report improvements to mental health problems, such as depression, anxiety,
perceived stress, positive affect, rumination, and self-efficacy. Qualitative data describe a variety of positive experiences, such as
improved coping ability, increased social support, and appreciation of the care farm activity.
CONCLUSION: Participating in interventions on care farms positively influences mental health. Care farming may therefore be
used as a supplementary approach in mental health rehabilitation, as it offers meaningful and engaging occupations and social
inclusion.
Keywords: Animal-assisted interventions, care farming, meaningful occupations, therapeutic horticulture
1. Introduction
People with mental health disorders tend to suffer
from stigmatization, low quality of life, isolation, lone-
liness, and low self-esteem [1–4], and they are often
∗
Address for correspondence: Ingeborg Pedersen, Norwegian
University of Life Sciences, Section for Public Health Sciences,
Department of Landscape Architecture and Spatial Planning, P.O.
Box 5003, NO-1432
˚
As, Norway. Tel.: +47 67 23 12 65; Mobile:
+47 905 02 902; E-mail: ingeborg.pedersen@nmbu.no.
excluded from ordinary work [5]. Participating in a
meaningful, daily occupation has been shown to be
especially important for people in such a situation, as
through work, they can obtain positive experiences, like
feeling needed, getting support and understanding, and
having a purpose in daily life [6–8]. Previous studies
have also shown that having an occupation leads to
lessened symptoms of mental health disorders [9, 10].
The main aim of mental health rehabilitation is to help
individuals suffering from mental health disorders to
1051-9815/16/$35.00 © 2016 – IOS Press and the authors. All rights reserved

AUTHOR COPY
32 I. Pedersen et al. / Mental health rehabilitation in a care farm context
develop the skills they require to live independent lives
in the local community, with employment in vocational
occupations as a vital element [11].
Daily occupation, social inclusion, belonging, and
social support are issues brought forward as important
both by participants and professionals during studies of
rehabilitation [6, 12–15]. Enhanced social skills, work
performance, and work-related self-efficacy, as well as
social support during rehabilitation, are also seen as
important factors for successful transition into employ-
ment [11, 16, 17]. Care farming is a service that has
developed within the agricultural sector in Europe [18].
It aims to promote mental and physical health [19],
and in Norway, it is increasingly used in mental health
rehabilitation. The main idea of care farming rehabil-
itation is that people in need of health-related support
may on a regular basis participate in farm-related activ-
ities alongside a farmer. Most commonly, these are
group activities, but they should always be adapted to
each individual participant’s mental and physical needs.
Several studies on care farming highlight group partic-
ipation, the social setting, and the farmer’s supportive
supervision as important [20–23]. Furthermore, earlier
qualitative studies have described care farming pro-
grams as a suitable transition between marginalization
related to illness and inclusion in society [22, 24].
Care farming is increasing in many European coun-
tries [25]. In Norway, care farming is especially well
developed, and during the last few years, several inter-
vention studies have been conducted to investigate both
the possible health effects of participation on a care
farm and clients’ experiences. To our knowledge, no
other country has carried out intervention studies on
care farms to the same extent as Norway has; thus, a
descriptive review of existing research related to the
use of care farming in mental health rehabilitation in a
Norwegian context is of interest. The aim of this arti-
cle is to present a review of four studies of Norwegian
intervention that took place on care farms, within the
context of rehabilitation programs on care farms.
2. Methodological approach
This article presents a descriptive review of inter-
vention studies of adults with mental health disorders
participating in either animal-assisted interventions or
therapeutic horticulture programs on a Norwegian care
farms. All the authors have contributed to intervention
studies on care farms in Norway. Therefore, to cover
as much published Norwegian research as possible, all
of the authors collected possible articles for inclusion.
Four intervention studies were located on Norwegian
care farms, and 10 articles from these studies have been
published in peer-reviewed journals. In a descriptive
way, this article will both present how the research was
carried out and summarize key information from the
published articles. To analyze the quantitative research,
we extracted data on study aims, designs, participants,
interventions, outcome measures, and main findings.
To analyze the qualitative data, we reported the main
themes/findings of the articles.
All articles are indexed in one or more of the follow-
ing electronic databases: Cinahl, ISI Web of Science,
MEDLINE (PubMed), and PsycINFO. A combination
of the following keywords may be used to search
for them: care farm, therapeutic horticulture, animal-
assisted interventions, green care, depression, mental
health, and rehabilitation.
3. Presentation of Norwegian care farm
research
The four studies consisted of two randomized con-
trolled trials (RCT) and two single-group design
studies. Six articles report research from animal-
assisted interventions, and four articles report research
from therapeutic horticulture interventions. Of all these,
one article presents qualitative data from individual
interviews, and two articles present qualitative data
from open-ended questions.
In the following, we will discuss the nature of this
research and present its core findings related to these
intervention programs and an overview of the published
articles related to the study and type of interven-
tion/program. Extracted data on key information from
the articles are presented in Table 1.
3.1. Presentation of the research: Methods,
intervention and procedure
3.1.1. Care farming activities with animals
The first study is an RCT study by Berget et al.
[26–28]. This study examined the possible effects on
mental health, quality of life, self-efficacy, and coping
ability of taking part in work tasks with farm animals for
people with various mental health disorders. The study
included 90 participants (60 in the intervention and 30 in
the control group) and was carried out at 15 farms in five
Norwegian counties. The participants were recruited
by their primary contact person in health care services.

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I. Pedersen et al. / Mental health rehabilitation in a care farm context 33
Table 1
Key information from the included studies and published articles on care farming for people with mental health problems
Study Paper Aim Study design/method Sample Intervention/Program Outcome measures Main findings
Animal-assisted interventions
Study 1 Berget et al.
2007 [28]
Examine change in
work ability and
associations
between work
ability and change
in mental health
and psychosocial
measures
Single group study
with pre-test,
post-test design
35 adults (26 females
and nine males,
mean age = 35.7)
with various mental
disorders
(schizophrenia;
affective, anxiety,
or personality
disorders)
Three hours of work
and contact with
farm animals twice
a week for twelve
weeks
Behaviors connected to
work ability (defined as
intensity and
exactness) were rated
on a 5- point scale via
video recordings
conducted early and
late in the intervention.
Generalized
Self-Efficacy (GSE),
Coping Strategies
Scale, Quality of Life
Scale (QOLS-N),
State-Trait Anxiety
Inventory – State
Subscale (STAI-SS),
and Beck Depression
Inventory (BDI)
A statistically
significant increase
in intensity and
exactness of work
during the
intervention. No
correlations were
found between
change in work
ability and change
in mental health
and psychosocial
measures
Study 1 Berget et al.
2008 [26]
Investigate effect of
intervention on
self-efficacy,
coping ability, and
quality of life
Randomized
controlled trial with
multiple measure
points
90 adults (59 females
and 31 males, mean
age = 34.7) with
various mental
disorders
(schizophrenia;
affective, anxiety,
or personality
disorders)
Three hours of work
and contact with
farm animals twice
a week for twelve
weeks
Generalized Self-Efficacy
(GSE), Coping
Strategies Scale, and
Quality of Life Scale
(QOLS-N).
Significant increase in
self-efficacy when
compared with
control group. No
effect on coping
ability and quality
of life
Study 1 Berget et al.
2011 [27]
Investigate effect of
intervention on
state anxiety and
depression
Randomized
controlled trial with
multiple measure
points
90 adults (59 females
and 31 males, mean
age = 34.7) with
various mental
disorders
(schizophrenia;
affective, anxiety,
or personality
disorders)
Three hours of work
and contact with
farm animals twice
a week for twelve
weeks
State-Trait Anxiety
Inventory – State
Subscale (STAI-SS)
and Beck Depression
Inventory (BDI)
Significant decrease in
state anxiety when
compared with
control group. No
effect on depression
(Continued)

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34 I. Pedersen et al. / Mental health rehabilitation in a care farm context
Table 1
(Continued)
Study Paper Aim Study design/method Sample Intervention/Program Outcome measures Main findings
Animal-assisted interventions
Study 2 Pedersen
et al. 2011 [35]
Examine associations
between change in
behaviors (work
and contact with
farm animals)
during the
intervention and
change in mental
health and
psychosocial
measures
Single group study
with pre-test,
post-test design
14 adults with
clinical
depression
(three men and
11 women,
mean
age = 37.4)
Three hours of work
and contact with
farm animals
twice a week for
twelve weeks
Time spent doing work
tasks (e.g., milking,
feeding, moving
animals, cleaning,
grooming, and
mucking), dialog with
the farmer, and contact
with animals was
estimated from video
recordings carried out
early and late in the
intervention.
Generalized
Self-Efficacy (GSE),
State-Trait Anxiety
Inventory – State
Subscale (STAI-SS),
and Beck Depression
Inventory (BDI)
Time spent doing work tasks
increased during the
intervention. Increased
time spent on difficult
work tasks (milking and
moving animals) was
associated with a decline in
anxiety and depression.
High levels of dialog with
the farmer correlated with
a decline in anxiety
Study 2 Pedersen
et al. 2012 [34]
Examine effect of
intervention on
generalized
self-efficacy, state
anxiety, and
depression
Randomized
controlled trial with
multiple measure
points
29 adults with
clinical
depression (23
women and six
men, mean
age = 37.8)
Three hours of work
and contact with
farm animals
twice a week for
twelve weeks
Generalized Self-Efficacy
(GSE), State-Trait
Anxiety Inventory –
State Subscale
(STAI-SS), and Beck
Depression Inventory
(BDI)
Improvement in depression
levels and self-efficacy in
intervention group. No
significant difference in
change in outcome
measures compared to the
control group.
Study 2 Pedersen
et al. 2012 [36]
To obtain the
participants
experience with the
intervention
Individual qualitative
interviews
Eight adults with
clinical
depression (six
females and
two males,
between 25 and
54 years) who
had finished the
intervention
Three hours of work
and contact with
farm animals
twice a week for
twelve weeks
Themes and subthemes
from the interviews
were identified
Experiencing ordinary work
life and feeling appreciated
were important themes, but
also the distraction from
their illness. Flexibility in
the intervention, made
coping possible. The
farmers’ commitment and
good conduct were
essential
(Continued)

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I. Pedersen et al. / Mental health rehabilitation in a care farm context 35
Table 1
(Continued)
Study Paper Aim Study design/method Sample Intervention/Program Outcome measures Main findings
Therapeutic horticulture programs
Study 3 Gonzalez
et al. 2009 [38]
Assess changes in
depression and
perceived
attentional capacity
Single group study
with multiple
measures points
18 adults (3 men
and 15 women,
mean
age = 49.7) with
depression or
bipolar II
disorder
Three hours’
therapeutic
horticulture in
groups twice a
week for twelve
weeks
Beck Depression
Inventory (BDI),
Attentional Function
Inventory (AFI),
Perceived
Restorativeness Scale
(PRS)
Significantly lower
depression scores after
intervention and at
three-month follow-up;
significant
improvement in
perceived attentional
capacity during
intervention
Study 3 Gonzalez
et al. 2010 [37]
Examine change in
brooding,
depression, and
perceived
attentional capacity,
and possible
mediation via
experience of being
away from home
and fascination
with the farm
environment
Single group study
with multiple
measures points
28 adults (21
women and 7
men, mean
age = 44.1) with
clinical
depression
Three hours’
therapeutic
horticulture in
groups twice a
week for twelve
weeks
Beck Depression
Inventory (BDI),
Attentional Function
Inventory (AFI), Being
Away and Fascination
subscales from
Perceived
Restorativeness Scale
(PRS), Brooding
Subscale from
Ruminative Response
Scale
Significant decline in
depression, perceived
attentional capacity,
and brooding during
intervention. Change in
depression and
attentional capacity
was mediated through
being away from home
and fascination with
the farm. Depression
scores remained low at
three-month follow-up
assessment
Study 3 and 4
Gonzalez et al.
2011 [40]
Assess change in
depression and
existential issues,
and investigate
participants own
experience in
existential terms
Single group studies
with multiple
measures points
Two samples: 1)
18 adults (3
men and 15
women, mean
age = 49.7) with
depression or
bipolar II
disorder and
Three hours’
therapeutic
horticulture in
groups twice a
week for twelve
weeks
1) Life Regard Inventory
Revised (LRI-R), Beck
Depression Inventory
(BDI), four questions
exploring the
existential experience
(1 = totally agree;
5 = totally disagree),
one open-ended
question related to the
experience of the
intervention
1) Depression declined
significantly; Life
Regard Inventory
increased, but not
significantly. The
intervention was
experienced as a
meaningful activity; it
gave a sense of taking
care of nature and
changed their view of
life
(Continued)

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36 I. Pedersen et al. / Mental health rehabilitation in a care farm context
Table 1
(Continued)
Study Paper Aim Study design/method Sample Intervention/Program Outcome measures Main findings
Therapeutic horticulture programs
2) 28 adults (21
women and 7
men, mean
age = 44.1) with
clinical
depression
2) Beck Depression
Inventory (BDI),
Sense of Coherence
Scale (SOC – 13)
2) Depression
declined
significantly; Sense
of Coherence
increased, but not
significantly. A
significant
correlation between
changes in the two
outcome measures
was seen
Study 3 and 4
(pooled data)
Gonzalez et al.
2011 [39]
Investigate
covariation of
changes in outcome
measures and how
the participants
evaluated the social
dimension of the
intervention
Single group study
with multiple
measures points
Pooled sample: 46
adults (10 men
and 36 women,
mean
age = 46.3) with
depression or
bipolar II
disorder
Three hours’
therapeutic
horticulture in
groups twice a
week for twelve
weeks
State-Trait Anxiety
Inventory – State
Subscale
(STAI-SS), Beck
Depression
Inventory (BDI),
Positive and
negative Affect
Schedule –Positive
Affect subscale
(PANAS-PA),
Perceived Stress
Scale (PSS),
Therapeutic Factors
Inventory
Cohesiveness Scale
(TFI-CS), one
open-ended
question related to
the experience of
the intervention
Improvements in all
mental health
measures correlated
positively but not
significantly with
change in group
cohesiveness.
Qualitative data
revealed the
significance of
being in a group
expressed through
mutual trust and
respect, and the
importance of
meeting others in a
similar situation

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I. Pedersen et al. / Mental health rehabilitation in a care farm context 37
There were 41 participants completing the intervention
and 28 participants completing in the control group. The
participants traveled to and from the farm using public
transport or their own car, or the farmer picked them up
at home due to a lack of available transport or due to
personal issues. Participants in the intervention group
continued their ordinary treatment in addition to visiting
the farm for three hours twice a week for three months.
The participants in the intervention group attended the
farm twice a week for twelve weeks. They were on the
farm for 3 hours each time and there were 1 or 2 partic-
ipants working along with the farmer at the time. They
did ordinary work tasks related to the care of farm ani-
mals, like feeding, milking, grooming, or cleaning the
barn. The work tasks chosen depended on each partic-
ipant’s capacity and interest, but they always had an
opportunity for physical contact with the animals. The
most common animals at the farms were dairy cows,
cattle, sheep, or horses. All farms also had small ani-
mals, like rabbits, poultry, pigs, cats, or dogs, as a part
of the animal milieu.
The severity of participants’ anxiety was examined
using the Spielberger State-Trait Anxiety Inventory
- State Subscale [STAI-SS,29], the severity of their
depression by using the Beck Depression Inventory
[BDI,30], their quality of life by using the Norwegian
version of the Quality of Life Scale [QOLS-N,31], their
self-efficacy by using the Generalized Self-efficacy
scale [GSE,32], and their coping ability by using the
Coping Strategies Scale [Coping Strategies Scale, 33].
Scores in these self-rated measures were obtained
before the intervention, at the end of the intervention,
and six months after the end of the intervention.
In addition 35 participants (26 females and nine
males) were videotaped for a whole session at the farm
both early (during the two first weeks) and late (dur-
ing the last two weeks) in the intervention period. The
video recordings were used to examine whether the
participants’ working ability changed during the inter-
vention through observing and measuring the intensity
and exactness of the work. Intensity was measured
by the speed and effectiveness of a certain work task,
while exactness was measured by the quality and accu-
racy of the work that was performed. Both categories
were scored from 1 (“very low”) to 5 (“very high”)
in one minute intervals for the whole recording. A
questionnaire related to the participants’ experiences
was developed. Its questions included the following: To
what extent has the contact and work with the animals
affected their coping ability in daily life, your mood,
your self-esteem, and your working ability? A question
in regard to the importance of physical contact with the
animals was also a part of the questionnaire. All ques-
tions were answered on a 5-point scale from 1 (“much
worse/very little”) to 5 (“much better/very much”).
The second study of interventions with farm animals
is an RCT study by Pedersen et al. [34] in which the pri-
mary aim was to examine the effect of the intervention
on depression, state anxiety, and self-efficacy among
people suffering from depression and to compare the
results with changes observed in a control group under-
going treatment as usual. A second aim was to examine
the associations between various work tasks conducted
during the intervention and changes in mental health.
Finally, participants were interviewed to uncover their
own experience of the intervention at the farm and what
they perceived as important elements of the intervention
in relation to their mental health.
Thirty-four people were recruited via health person-
nel, advertisement in newspapers, or letters of invitation
sent via the Norwegian Labor and Welfare Administra-
tion. All participants had a Beck Depression Inventory
score of 14 or above, indicating clinical depression.
After giving their written consent, the participants were
randomly assigned to one of two groups: an intervention
group or a waiting-list control group. Some partici-
pants withdrew from the study before the interventions
started, and the final sample was made up of 29 partic-
ipants (23 women and 6 men).
Eleven dairy farms from six Norwegian counties took
part. The majority of the participants traveled by public
transport or in their own car to and from the farm, but
in agreement with the farmers, some were picked up at
home by the farmers, due to lack of available transport
or due to personal issues. No limit was set in regard
to the distance between the participants’ own homes
and the farms, but in practice, more than one hour of
travel each way was too inconvenient. The participants
in the intervention group attended the farm twice a week
for twelve weeks. They usually worked alone with the
farmer, but at some farms, two participants worked with
the farmer at the same time. They conducted ordinary
daily work tasks with farm animals (mainly cows), like
feeding, cleaning, and milking.
To meet the primary aim of the study, the Beck
Depression Inventory [BDI, 30] was used to mea-
sures participants’ levels of depression, the Spielberger
State-Trait Inventory - State Subscale [STAI-SS,29]
to measures their state anxiety, and the General Self-
Efficacy Scale [GSE,32] to measure their self-efficacy.
The assessments were filled out by the participants at
the time of their recruitment, before start of the inter-

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38 I. Pedersen et al. / Mental health rehabilitation in a care farm context
vention, as well as after four and eight weeks of the
intervention, respectively, and at the end of the inter-
vention. Follow-up registrations were completed after
three months. In both groups, there were 12 participants
who completed the study.
To examine the associations between various work
tasks conducted during the intervention and changes
in the participants’ mental health, 14 participants in the
intervention group were recorded on video while work-
ing with the animals [35]. This recording took place
twice during the intervention: once at the beginning
and once in the end. The recordings were catego-
rized into different behavioral categories with respect
to animal contact, conversation with the farmer, and
work tasks undertaken (e.g., milking, feeding, clean-
ing, mucking, grooming, moving animals in free range
systems). Time spent in the various behavioral cate-
gories was registered, and correlations with change in
the above-mentioned mental health measures were cal-
culated. Finally, to uncover the participants subjective
experiences, thematic individual interviews were con-
ducted with eight of the participants who had completed
the intervention [36].
3.1.2. Care farming with horticultural activities
Gonzalez et al. [37–40] have carried out two single-
group design studies of the possible benefits to people
with clinical depression of participating in a horticul-
tural activities on four urban farms. Both aimed to
examine changes in depression and perceived atten-
tional capacity. Further, they analyzed the possible
mediating roles of the experience of being away and
fascination on depression and perceived attentional
capacity, as well as examining changes in anxiety,
brooding, and existential issues. Another aim of their
studies was to investigate the covariation of changes in
outcome measures and how the participants evaluated
the social dimension of the intervention. A final aim
was to investigate the participants’ own experiences in
social and existential terms.
The two studies were carried out in 2008 and
2009. The studies both had a convenience sample of,
respectively, 18 (3 men, 15 women) (study 1) and 28
participants (21 women and 7 men) (study 2), with
the inclusion criterion of having a Beck Depression
Inventory (BDI) score greater than 15. The participants
were recruited from general practitioners and through
advertisements in newspapers. Potential participants
contacted the researchers directly by phone.
The participants traveled to and from the farm using
either public transport or their own car or bicycle,
and participants were assigned to farms in such a
manner that it would be convenient to travel back
and forth. A group-based therapeutic horticulture pro-
gram (three to seven participants in each group) was
carried out over twelve weeks, during which time
participants met twice a week for three hours at a
time. The programs were facilitated by the farmer and
included activities like sowing, germinating, potting,
planting, composing beds, cultivating vegetables, pick-
ing flower bouquets, and watching birds, insects, and
the landscape. The intervention supplemented the par-
ticipants’ regular treatment, which mainly consisted of
attending psychotherapy sessions at varying frequen-
cies, use of antidepressants, or a combination of the
two. All the farms have strong historical and cultural
identities, and they are all are situated in open, hilly
landscapes.
Data were collected prior to, twice during, immedi-
ately after, and three months following the program.
The Beck Depression Inventory [BDI,30] was used to
measure depression severity, the Attentional Function
Index [AFI,41] was used to measure attentional func-
tion, the Being Away and Fascination subscales from
the Perceived Restorativeness Scale [PRS,42] were
used to assess the perceived restorativeness of the envi-
ronment, the Spielberger State-Trait Anxiety Inventory
- State Subscale [STAI - SS,29] was used to measure
state anxiety, the Brooding Scale [43] was used to mea-
sure rumination, the Perceived Stress Scale [PSS,44]
was used to measure stress levels, the Positive and Neg-
ative Affect Scale [PANAS-PA,45] was used to measure
positive affect, and the Therapeutic Factors Inventory
Cohesiveness Scale [TFI-CS,46] was used to measure
group cohesion. Existential issues were measured using
the Life Regard Index – Revised Version (LRI – R)
[47] in study 1, and were measured in the second using
Antonovsky’s 13-item version of the Sense Coherence
Scale, developed from the original 29-item version
[48, 49]. The participants answered four questions
regarding the existential experiences of therapeutic
horticulture on a scale from 1 (“totally agree”) to 5
(“totally disagree”), as well as several open-ended ques-
tions related to the experience of participating in the
program.
3.2. Presentation of the research findings related
to intervention
3.2.1. Care farming activities with animals
In the first described study on animal-assisted inter-
ventions, by Berget et al. [26, 27], the treatment was

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I. Pedersen et al. / Mental health rehabilitation in a care farm context 39
not found to have any effect on depression, anxiety,
and self-efficacy during the intervention period; how-
ever, a significant decrease in anxiety score and an
increase in self-efficacy scores were found between the
pre-treatment self-rated assessment and the six-month
follow-up assessment. The participants with the largest
reduction in depression reported the largest increases
in perceived coping ability, mood, and self-esteem.
Reported quality of life, however, showed no significant
change or any significant differences between groups
at any of the times it was measured [26]. A significant
increase in coping ability within the treatment group
was seen between the pre-treatment assessment and the
six-month follow-up assessment; however, when com-
pared with changes in the control group’s assessments,
no significant differences were found [26]. There was a
significant increase in the intensity and exactness of the
work the participants carried out with the animals by
the end of the intervention. No significant correlations
were found between physical contact with animals and
changes in depression levels [28].
In the second described study, by Pedersen et al. [34],
a statistically significant decline in depression levels
between recruitment and the end of the intervention was
observed in the intervention group but not in the con-
trol group. Six participants in the intervention group
experienced a clinically significant change in depres-
sion levels, while just one in the control group did.
During the same period of time, a positive and statis-
tically significant change in self-efficacy occurred in
the intervention group, but not in the control group.
However, changes in mental health measures showed
no statistically significant differences between the two
groups.
The video recordings [35] show that time spent on
work activities described as complex and challeng-
ing, like milking cows and moving animals between
the cowshed and outdoor spaces, was significantly and
favorably correlated with changes in mental health
(depression and anxiety) but that there was an unfa-
vorable correlation between time spent on work tasks
that could be described as beginners’ activities (like
grooming animals and mucking) and positive changes
in mental health. A favorable, significant association
between dialogue with the farmer and changes in anx-
iety levels was detected.
In the interview study by Pedersen et al. [36], the
possibility of being useful and the experience of an
ordinary work setting were emphasized as important by
the participants. The farmers’ attitudes and sensitivity
towards the participants’ situations and illnesses were
described as essential. The participants also expressed
the importance of the intervention as a source of dis-
traction from their illness. The intervention’s flexibility
was experienced as vital and as making it possible
for the participants to adjust the work undertaken in
relation to their daily condition. A majority of the
participants expressed that they coped with the work
tasks at the farm. This served as a foundation for other
positive experiences, described as having increasing
self-confidence, feeling independent, and learning new
skills.
3.2.2. Care farming with horticultural activities
The results of the studies by Gonzalez et al. [38, 40]
show a statistically significant decline in depression lev-
els during the therapeutic horticulture intervention, with
the most significant change occurring after four weeks.
When compared to participants’ pre-intervention mea-
surements, this decline was still present and significant
in a three-month follow-up assessment. Improve-
ments in anxiety levels, positive affect, and perceived
stress levels between the beginning and end of the
intervention were all statistically significant [40]. Per-
ceived attentional capacity increased significantly and
perceived rumination decreased significantly during
the intervention. Changes in depression levels and
attentional capacity were mediated through being
away from everyday environment and fascination
[37]. The participants reported high levels of group
cohesiveness, and the levels of group cohesiveness
correlated positively, although not statistically sig-
nificantly, with improvements in depression severity,
anxiety levels, positive affect, and perceived stress lev-
els. The participants positively evaluated the social
aspects of the therapeutic horticulture intervention,
and more than a third of the participants reported
increased social activity after having participated in the
intervention [39].
There were no significant changes in existential
outcomes. There was, however, a positive correlation
between changes in existential issues and changes in
depression severity. The participants described their
experience of and participation in the program as mean-
ingful, interesting, and instructive. In the open-ended
questions given at the end of the program, themes like
excitement about and absorption in the growth process
during the season were articulated. A vast majority of
the participants agreed with statements regarding exis-
tential experiences of therapeutic horticulture: it was
seen as a meaningful activity, gave a sense of taking
care of nature, and changed their view of life [40].

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40 I. Pedersen et al. / Mental health rehabilitation in a care farm context
4. Discussion
In the following, we will first discuss the main men-
tal health outcomes across the presented interventions.
We will then further discuss how participating in care
farming may promote their health through improved
self-efficacy and coping, as well as through the care
farms’ environmental and social context. Finally, we
will point to design aspects that might guide future
research.
4.1. Mental health outcomes related to care
farming
Across the intervention studies here examined, par-
ticipants experienced improvements in depression and
anxiety levels, positive affect, perceived stress lev-
els, and rumination. However, in the RCT study on
animal-assisted intervention by Berget et al. [27], these
improvements were only found in anxiety levels and
were only observed during a six-month follow-up
assessment. In the single-group studies by Gonzalez
et al. [37, 38] on therapeutic horticulture, the decreases
in participants’ depression levels observed during the
intervention remained present three months after the
end of the intervention. Even though the improvements
to most outcomes were small, the findings point to
the possible mental health benefits for those suffering
from mental health disorders of participating in care
farm rehabilitation programs. The declines in depres-
sion reported by both Pedersen et al. [34] and Gonzalez
et al. [37, 38] were both statistically and clinically
significant, implying that the decline in depression is
experienced by the study participant as an improve-
ment in mental health. It is worth pointing out that
this was observed across programs covering different
farm-related occupations, like animal and horticultural
activities. It is, however, important to bear in mind that
for these studies, the recruited participants were to a
large degree motivated to participate in care farming
activities. For this reason, the findings are relevant only
for a group of people suffering from depression and
who are motivated for these kinds of interventions.
4.2. Self-efficacy and coping related to work
activities on care farms
The studies presented here have, in particular, studied
the benefits of care farming for mental health promo-
tion in relation to self-efficacy and coping. Berget et al.
[26, 28] found increased self-efficacy among partic-
ipants placed at care farms, and they also observed
increased intensity and exactness in the participants’
work with the animals at the farm. In Pedersen et al.
[35], a positive association between acquiring new and
improved work skills and an increase in self-efficacy
was seen as indicating an increase in engagement with
the work. In the study by Pedersen et al. [36], the
ability to cope with the given tasks was reported to
be important for the participants, and this gave them
an opportunity to develop their self-confidence. This
is in line with the findings of other qualitative stud-
ies describing improved self-confidence and increased
feeling of achievement as a result of participating
in care farm activities [22, 23]. Hassink et al. [50]
describe these kinds of interventions as empowerment-
oriented and coping-based from interviews with 41
clients, 33 care farmers, and 27 health care profes-
sionals. Positive coping experiences are associated with
increased self-efficacy [48], and improved work skills
and work-related self-efficacy is highlighted as impor-
tant in several studies within vocational rehabilitation
and mental health rehabilitation [7, 49–51]. There is
a huge variation in the work tasks that can be carried
out on a farm. Care farms make use of this variation
to adapt the rehabilitation process to individual partic-
ipants’ physical and mental health and capacities on a
day-to-day basis. The authors of this paper believe that
the flexibility in possible occupations offered by the
farm may be one of the key criteria for the observed
increase in self-efficacy.
Through the care farm programs, the participant takes
part in occupations that demand attention to daily rou-
tines, like getting up in the morning, being on time,
calling to inform the farmer of one’s absence, and, when
possible, being responsible for their own transportation
to the farm. Based on such aspects, clients describe their
activities at the care farms as “natural” labor [52], and
rehabilitation professionals emphasize that care farms
are a suitable transitional work place, as they offer the
possibility to enhance work and social skills, as well as
motivating participants to try to reach further vocational
goals [24].
4.3. The care farms’ environmental context
Care farms are a complex intervention for promoting
mental health with many possible acting components
at stake. Apart from providing meaningful work tasks,
they provide a natural environment in which to work.
Gonzalez et al. [37] have used an environmental psy-
chology and cognitive perspective, and they identified
both a sense of being away from daily routines and

AUTHOR COPY
I. Pedersen et al. / Mental health rehabilitation in a care farm context 41
tasks and a fascination with being in the intervention
context as the active components of the therapeutic
horticulture intervention at care farms. This implies
that the change in environment, from the home to the
farm (being away), and the experience of the farm and
its horticultural activities as fascinating are important
factors in explaining the observed decline in depres-
sion and improvement in perceived attentional capacity.
It is anticipated that future studies will show that an
improvement in perceived attentional capacity might
both contribute to recovery processes and to improved
coping resources. Further, both Gonzalez et al. [37]
and qualitative studies on therapeutic horticulture inter-
ventions in other rehabilitation settings [51] point to
gardening occupations as enjoyable in a safe environ-
ment and as contributing to a feeling of balance in
everyday life.
4.4. The care farms’ social context
Other common features of care farming interventions
are group-related activities lead by the farmer. In the
study by Gonzalez et al. [39], levels of group cohesive-
ness correlated positively with improvements in mental
health and perceived stress. A majority of participants
rated the social component of the intervention as impor-
tant and reported a higher rate of social activity after the
intervention. In the only qualitative article in this review
by Pedersen et al. [36], being a colleague and sharing
a considerate relationship with the farmer were themes
brought forward by the participants as positive. In the
same study, a favorable correlation between dialog with
the farmer and a decrease in anxiety was detected [35].
Several studies on care farming highlight the group, the
social setting, and the support of the farmer as important
[20–23, 36, 52]. Leck et al. [15] describe a whole range
of positive effects connected to the experience of social
inclusion within a care farming context. Social sup-
port, social contact, and the development of social skills
are fundamental for a successful mental health recov-
ery process [53–55], and programs that facilitate the
enhancement of social skills and provide social support
are important during mental health and vocational reha-
bilitation [16]. Future research on care farming needs
to consider the inclusion of outcome measures related
to social support.
4.5. Recommendations for further research
The four intervention studies described above
had a particular focus on either animal-assisted or
therapeutic horticulture interventions, since previous
research indicates the mental health benefits of these
kind of interventions [56–58]. Even though nature
experiences and activity connected to animals and/or
horticulture are important at care farms, the studies do
not examine all components of the care farm context,
as care farming programs in Norway are complex in
nature. Future studies should address this complexity.
In addition, further studies should investigate the rele-
vance of care farming for improvements in work skills,
occupational function, and ultimately, work attendance
or return to work rate.
Further, in vocational rehabilitation, randomized
controlled trials are commonly conducted to compare
different rehabilitation strategies [59–61]. A similar
approach for comparing care farms with other tran-
sitional workplaces during vocational rehabilitation
could be useful. In three of the studies, a homogenous
target group was selected, namely people with depres-
sion. The selection of a single target group helps to
focus the research questions but presents a challenge
to the recruitment of participants. Further studies need
to address these challenges in order to reach statistical
validity.
5. Conclusions
Interventions at care farms provide a variety of oppor-
tunities for participants with mental health problems to
engage in meaningful occupations. These experiences
are connected with an improvement in mental health,
self-efficacy, coping ability, and perceived attentional
capacity. Participants’ feeling of being away from their
everyday environment, their fascination with the farm
environment, their perception of good social support
within the care farm environment, and their increase in
social activity are reported as positive results of their
participation. Taking into consideration the positive
reported findings reviewed here, we can conclude that
care farms as a place and care farming as an intervention
program have potential as a supplementary approach
in mental health rehabilitation and that participation
on care farms helps to prepare people for a return to
ordinary work.
Acknowledgments
We appreciate the invitation to present the present
review on Norwegian intervention studies of care
farming, and we are thankful to the editor and guest

AUTHOR COPY
42 I. Pedersen et al. / Mental health rehabilitation in a care farm context
editors for their valuable comments on early drafts of
the paper.
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