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The Effect of Nature therapy for Stress, Anxiety, Depression and Demoralization on Breast Cancer Patients

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Abstract

Background: Patients with breast cancer experience extreme stress that may cause mental disorders. Research has found that exposure to natural landscapes and gardening improves the mental wellbeing of patients. Objective: To investigate the effects of exposure to natural landscapes and gardening on the physiological health (salivary cortisol and blood cortisol) and mental health (anxiety, depression, and demoralization) of patients with breast cancer. Methods: Thirteen patients with breast cancer participated in this study and were divided into an experimental group (n = 10) and control group (n = 8). The experimental group underwent two weeks of nature therapy (exposure to natural landscapes and gardening), whereas the control group underwent no treatment. The participants’ physiological and psychological indicators of stress (cortisol), anxiety, depression, and demoralization were tested before and after the nature therapy. The independent variables were breast cancer and nature therapy; the dependent variables were stress, anxiety, depression, and demoralization. The tools used were the Hospital Anxiety and Depression Scale, the demoralization scale, and saliva and blood tests for stress hormones. The research methods focused on quantitative statistics, and SPSS 20 software was used to perform the Wilcoxon signed-rank test and Mann–Whitney U test. Qualitative analysis was secondary. Results: The Wilcoxon signed-rank test found significant differences in blood cortisol and demoralization for the experimental group (z = −2.483; p ≤ 0.05; z = −2.023; p ≤ 0.05, respectively). Significant differences were discovered between the group’s posttest saliva (z = −2.176; p ≤ 0.05) and demoralization scores (z = −2.575; p ≤ 0.05). Conclusions: Exposure to natural landscapes and gardening had positive psychological effects on the patients with breast cancer; thus, in addition to medications for stress, anxiety, depression, and demoralization, nature therapy can be used to treat patients. These results can be used by medical professionals to treat physical and psychological ailments.
1
The Effect of Nature therapy for Stress, Anxiety, Depression and
Demoralization on Breast Cancer Patients
Yun-Chen Chang 1, Tzuhui A.Tseng, 2 Shih-Che Chiu 3
Abstract
Background: Patients with breast
cancer experience extreme stress that may
cause mental disorders. Research has found
that exposure to natural landscapes and
gardening improves the mental wellbeing of
patients. Objective: To investigate the effects
of exposure to natural landscapes and
gardening on the physiological health
(salivary cortisol and blood cortisol) and
mental health (anxiety, depression, and
demoralization) of patients with breast cancer.
Methods: Eighteen patients with breast
cancer participated in this study and were
divided into an experimental group (n = 10)
and control group (n = 8). The experimental
group underwent two weeks of nature
therapy (exposure to natural landscapes and
gardening), whereas the control group
underwent no treatment. The participants’
physiological and psychological indicators of
stress (cortisol), anxiety, depression, and
demoralization were tested before and after
the nature therapy. The independent
variables were breast cancer and nature
therapy; the dependent variables were stress,
anxiety, depression, and demoralization. The
tools used were the Hospital Anxiety and
Depression Scale, the demoralization scale,
and saliva and blood tests for stress hormones.
The research methods focused on quantitative
statistics, and SPSS 20 software was used to
perform the Wilcoxon signed-rank test and
MannWhitney U test. Qualitative analysis
was secondary. Results: The Wilcoxon
signed-rank test found significant differences
in blood cortisol and demoralization for the
experimental group (z = −2.483; p 0.05; z =
−2.023; p 0.05, respectively). Significant
differences were discovered between the
group’s posttest saliva (z = −2.176; p 0.05)
and demoralization scores (z = −2.575; p ≤
0.05). Conclusions: Exposure to natural
landscapes and gardening had positive
psychological effects on the patients with
breast cancer; thus, in addition to
medications for stress, anxiety, depression,
and demoralization, nature therapy can be
used to treat patients. These results can be
used by medical professionals to treat
physical and psychological ailments.
I. INTRODUCTION
Research has shown that patients with
breast cancer experience extreme stress that may
cause mental disorders (Iwamitsu, Shimoda, Abe,
Tani, Kodama, & Okawa, 2003). Mild stress is
beneficial for cognitive work and performance;
however, constant levels of high stress can cause
mental disorders (Singh, Goyal, Tiwari,
Ghildiyal, Nattu, & Das, 2012). Cancer can be
an immense shock to patients, causing fear and
2
uncertainty (Ryan, Schofield, Cockburn, Butow,
Tattersall, Turner, Girgis, Bandaranayake, &
Bowman, 2005). As breasts are a defining
physical trait for women, the impact of losing
the breasts to cancer along with the
socio-cultural norms associated with women can
cause patients to worry about their body image
(Paterson, Lengacher, Donovan, Kip, Tofthagen,
2016). In addition, the myriad side effects from
treatments can cause stress and depression,
which can impact patients' quality of life. Past
research on the health benefits of natural
landscapes and gardening found that short-term
exposure improved patients' mental wellbeing
(Zelenski & Nisbet, 2014), cognitive functions
(Hartmann & Apaolaza-Ibáñez, 2010) and
attention (Berman, Jonides, & Kaplan, 2008),
while also helping to relieve stress (Tyrväinen,
Ojala, Korpela, Lanki, Tsunetsugu, & Kagawa,
2014), anger, sadness, anxiety and fatigue
(Bowler, Buyung-Ali, Knight, Pullin, 2010), in
addition to relieving pain or even healing illness
(Cimprich, 1993; Taylor, Kuo, & Sullivan,
2001). Continued exposure to natural
environments stimulated life goals and important
matters that needed to be completed (Mayer,
Frantz, Bruehlman-Senecal, Dolliver, 2009) and
inspired new ways of thinking and life directions
(Van Den Berg, Maas, Verheij, Groenewegen,
2010). However, few studies have investigated
how to use complementary and alternative
medicine (CAM) to improve the effects of the
autonomic nervous system (ANS) and stress
hormone cortisol in cancer patients. Cortisol is a
steroid hormone excreted by the adrenal gland to
cope with stress (Kim, Woo, & Chae, 2005);
thus, it is called an anti-stress hormone
(Mitranescu, Terbea, Tudor, Ilie, Lataretu, &
Furnaris, 2012). Excessive cortisol weakens the
immune system and reduces drug efficacy
(Cassileth, 1996). Studies have shown that
normal breast tissue does not contain cortisol.
Some breast cancer biopsies have contained high
levels of cortisol. High concentrations of cortisol
suppress the immune system and can lead to a
poor Prognosis (Mitranescu et al., 2012). In
summary, breast cancer patients bear various
physiological and psychological burdens and
short-term exposure to natural environments and
plants can relieve stress, improve comfort and
reduce salivary cortisol (Tyrväinen et al., 2014).
Therefore, this study investigated the effects of
nature therapy on the physiological and
psychological states of breast cancer patients in
order to help patients improve their quality of
life through a non-drug intervention.
II. HEALTH AND PSYCHOLOGICAL
STATE OF CANCER PATIENTS
A. Stress
Being diagnosed with breast cancer can
cause extreme stress that may result in mental
disorders (Iwamitsu, Shimoda, Abe, Tani,
Kodama, & Okawa, 2003). Mild stress is
beneficial for cognitive work and performance;
however, constant levels of high stress can cause
mental disorders (Singh, Goyal, Tiwari,
Ghildiyal, Nattu, & Das, 2012), cardiovascular
disease, gastrointestinal diseases, or immune
deficiencies (Nillsson, Sangster, & Konijnendijk,
2011). Cortisol concentrations are widely used
as stress marker. In the presence of a stressor,
the brain receives a stress stimulus signal and
releases cortisol by activating the hypothalamus,
which regulates corticotropin-releasing hormone
(CRH) and vasopressin; together, these two
3
hormones cause the anterior pituitary gland to
release adrenocorticotropic hormone (ACTH),
which is carried through the bloodstream to the
adrenal cortex, where cortisol is released into the
blood. Most of the cortisol combines with
corticosteroid-binding globulin (CBG) once it
enters the blood, while activation of the
hypothalamic-pituitary-adrenal Axis (HPA)
influences impulsivity. The increase of cortisol
in the circulation indicates the secondary
increase in CRH (Seplaki, Goldman, Weinstein,
& Lin, 2004). The changes in cortisol levels are
reflected in the blood, urine, seminal fluid, saliva
and sweat. Saliva testing is common in
psychobiology because it is a noninvasive,
convenient and reliable the method of testing
stresses indicators (Kirschbaum & Hellhammer,
1989).
Cortisol increases the heartbeat, breathing,
blood pressure, muscle output and peristalsis and
slows down gastric emptying to help face
outside stress. When stress is constantly present,
the elevated concentrations of cortisol within the
body influence immunoregulation, making the
body more susceptible to infection,
inflammation and neoplasms (Licinio, Gold, &
Wong, 1995). Cortisol combines with
metastasis-associated tumor genes, such as
MAT-1 (a gene cloned from breast cancer tumor
cells), activating the gene expression which
causes the cells to produce tumor tissue (Licinio
et al., 1995). A survey of patients with severe
depression found that the administration of
cortisol blockers caused decreases in cortisol
concentrations in spinal fluid and depression
indices, indicating that cortisol is significantly
correlating to emotions (De Bellis, Gold,
Geraciotijr, Listwak, & Kling, 1993). Another
study showed that healthy breast tissue does not
contain cortisol, yet some breast cancer biopsies
(27/40) contained high concentrations of cortisol
(Ciocca, Puy, Fasoli, Tello, Aznar, & Gago et al.,
1990). Thus, negative emotions such as stress
and depression can affect hormones and increase
the risk of cancer. Abnormal stress influences
diurnal cortisol which can significantly predict
breast cancer patients' prognosis and early
mortality (Sephton et al., 2006). Breast cancer
patients have higher cortisol concentrations than
healthy individuals (McGregor & Antoni, 2009).
Roe, Thompson, Aspinall, Brewer, Duff, Miller,
Mitchell and Clow (2013) found a correlation
between the green coverage ratio near homes in
Scotland and stress. Sailvary cortisol was
collected at 3, 6 and 9 hours after waking up for
two consecutive days to test the changes in stress.
Linear regression found that stress decreased as
the green coverage ratio increased. Ho, Fong,
Chan and Chan (2013) tested 181 breast cancer
patients using the anxiety and depression scale
and salivary cortisol samples collected at
wake-up, 12:00, 17:00 and 21:00 for two
consecutive days and found that poor social
support, lack of health perceptions, poor sleep
quality, late wake-up time and lack of sleep
caused abnormal HPA axis function. Stress
hormones are not all bad; they warn of possible
harm and moderate secretion and normal levels
help maintain physical and mental balance.
Cortisol secretion is cyclic with changes
throughout the day; concentrations increase
during the morning and decrease at night
(Sephton, Giese-Davis, Taylor, & Kraemer,
2006). Therefore, to prevent experimental errors
due to the collected cortisol and changes within
the body, the pre-test and post-test samples in
4
this study had to be collected at the same times
for all participants. The participants were
reminded not to take any antidepressants,
nicotine, or oral steroids or smoke on the days of
collection to increase the accuracy of the
hormone concentration tests (Roe et al., 2013).
B. Demoralization
Demoralization is a psychological state that
is defined as a psychological response to existing
pain or despair that can range from mild dismay
to low spirits or deep despair (Clarke & Kissan,
2002). There is a lack of consensus on the
definition of demoralization among international
scholars. Engel (1967) first proposed that
demoralization associated with giving up or
being abandoned, indicating a combination of
frustration, powerlessness and helplessness.
Frank (1973) stated that demoralization is a form
of pessimism where an individual feels
powerless due to repeated failure to regulate
stress or feelings of despair, social isolation, or
rejection due to a loss of extrinsic expectations
that result in feeling that life has no meaning or
value. De Figueiredo (1993) indicated that
demoralization is a sense of loss of individual
control where an individual feels powerless or
that their life has lost meaning has low
self-esteem, humiliated, isolated, helpless,
hopeless and pain which leads to a longing for
death. Demoralization syndrome is applicable
for cancer patients as their physiological pain is
unable to be completely removed, they face the
threat of death and may feel that life has lost its
meaning and hope for death to end their pain.
This study used the demoralization scale
Mandarin version (DS-MV). The Mandarin scale
has the same 24 questions as the original
questionnaire. This scale can be widely used in
clinical settings or studies to improve cancer
care (Lee, Fang, Yang, Liu, Leu, Wang, Chang,
Hsieh, Chen, Tsai, Liu, Chen, 2012). The
DS-MV has good reliability and validity;
therefore, it was used in this study to measure
participants' levels of demoralization.
C. Anxiety and Depression
Risk of depression and anxiety for cancer
patients is double that for the general population
and after the onset of depression, the risk of
suicide is five times higher (Lutgendorf, Sood
anderson, McGinn, Maiseri, Dao, Sorosky,
Geest, Ritchie, & Lubaroff, 2005). One study
found that the prevalence of anxiety and
depression is 21-66% higher in cancer patients
(Jadoon, Munir, Shahzad, & Choudhry, 2010).
Cancer can be an immense blow to patients that
cause fear and uncertainty (Ryan, Schofield,
Cockburn, Butow, Tattersall, Turner, Girgis,
Bandaranayake, & Bowman, 2005), especially
breast cancer patients. Anxiety and depression
occur at diagnosis and during treatment and are
often overlooked which can influence therapy,
recovery and quality of life (Ryan et al., 2005).
According to Burgess, Cornelius, Love, Graham,
Richards and Ramirez (2005), 50% of breast
cancer patients experience anxiety and
depression within the first year of diagnosis,
depression continues into the second year for
25% of breast cancer patients and 15% of breast
cancer patients experience depression for five
years after diagnosis. Jehn, Kuhnhardt,
Possinger and Flath (2005) tested 93 cancer
patients and found a correlation between anxiety
levels and increasing in cortisol concentrations.
Okamura, Yamawaki, Akechi, Taniguch and
Uchitomi (2002) found that 22% of breast cancer
patients experienced depression due to fear of
5
relapse. In patients with depression and breast
cancer metastasis, cortisol concentrations were
found to increase (Giese-Davis et al., 2006) and
breast cancer survivors found to discontinue
follow-up treatment (Giese-Davis et al., 2011).
Harris, Borsanyi, Messari, Stanford, Cleary,
Shiers, Brown and Herbert (2000) observed the
psychological states and changes in cortisol of
116 women without recent depression for 13
months and found that participants with higher
concentrations of salivary cortisol in the
morning was to be more severe depression in the
future. Lutgendorf, Weinrib, Penedo, Russell,
DeGeest, Costanzo, Henderson, Sephton,
Rohleder, Lucci, Cole, Sood and Lubaroff (2008)
studied 137 ovarian cancer patients with
depression, collecting saliva samples for three
consecutive days before surgery, pre-operative
blood samples and peritoneal fluid samples
during the surgery and found a high correlation
between depression and cortisol.
However, in a cross-sectional study that
lasted over 14 months, Hsiao, Chang, Kuo,
Huang, Liu, Lai, Jow, Ho, Ng and Chan (2013)
examined the correlation between salivary
cortisol and depression in 76 post-treatment
breast cancer patients and found that patients did
not suffer from depression. Breast cancer
patients are more likely to experience depression
within the first year after diagnosis (Fann,
Thomas, Katon, Cowley, Pepping, McGregor, &
Gralow, 2008), yet in their study, the participant
was diagnosing an average 1.99 years prior.
Moreover, the past the literature stated that 30%
of breast cancer survivors still suffered from
mild depression (Holzner, Kemmler, Kopp,
Moschen, Schweigkofler, Dunser, Ramoni,
Margreiter, Fleischhacker, &
Sperner-Unterweger, 2001). Many past studies
have investigated the psychological burdens of
breast cancer patients and many have used the
hospital anxiety and depression scale as a
predominant screening tool. Thus, the scale was
included in this study.
III. TREATMENT OF BREAST CANCER
Breast cancer curative and palliative treatment
of symptoms
Treatment for breast cancer is currently
divided into surgery, chemotherapy,
radiotherapy, targeted therapy and hormone
therapy. While the treatments are effective and
reduce the chances of relapse, metastasis and
mortality, the post-operative incidence the rate to
relapse and metastasis is 7-13% (Brewster,
Hortobagyi, Broglio, Kau, Santa-Maria, Arun,
Buzdar, Booser, Valero, Bondy, & Esteva, 2008)
and patients still face threats to their quality of
life and the possibility of death.
IV. COMPLEMENTARY AND
ALTERNATIVE MEDICINE
Breast cancer and its sequela often have a
profound impact on the mind and body; for
instance, the loss of hair, headaches, upper
respiratory tract infections and muscle spasms
that may occur due to chemotherapy (Swain,
Baselga, Kim, Ro, Semiglazov, Campone,
Ciruelos, Ferrero, Schneeweiss, Heeson, Clark,
Ross, Benyunes, Cortés, 2015). Therefore, breast
cancer patients suffer from physiological,
psychological and spiritual stress. Many physical
and mental therapies are non-invasive, have no
side effects, are inexpensive and are widely used
by cancer patients in many countries (Taylor &
Mamier, 2005). The National Center for
Complementary and Alternative Medicine
6
(NCCAM) defines CAM as "a group of diverse
medical and health care systems, practices and
products that are not presently considered to be
part of conventional medicine" (NCCAM, 2010).
The NCCAM divides CAM into natural products,
mind-body medicine, manipulative and
body-based practices and other treatments
(NCCAM, 2010). Mind-body medicine focuses
on the interactions between the brain, mind and
body to produce physiological effects and
promote health by influencing the mind, thereby
improving anxiety, depression and quality of life
(Nidich, 2009). Yoga, qigong, art therapy and
gardening which all are forms of mind-body
medicine. Mind-body medicine is the form of
CAM most used by cancer patients (Nidich et al.,
2009).
Landscape, gardening activity and Benefits
English, Wilson and Keller-Olaman (2008)
proposed that natural landscapes, historical
landscapes and medical environments can
improve quality of life in a short period of time
and provide relaxation, peace, restorative
feelings. Bowler et al. (2010) used meta-analysis
to compare the emotions of individuals in natural
environments and those in cities and found that
exposure to natural environments increased the
level of recovery and that activities in natural
environments reduced negative emotions (anger,
sadness, anxiety and fatigue) and increased
positive emotions (peacefulness and energy). In
light of past literature, this study investigated
whether exposure to nature could reduce
negative emotions and increase positive
emotions in patients. Pretty, Peacock, Sellens,
Griffin (2005) divided exposure to nature into
three levels. First, looking at natural landscapes
or being in nature: Pretty et al. (2005) had
participants walk on an indoor treadmill while
looking at scenic pictures and found high
restorative effects; therefore, exercising in
greenery has positive benefits. Natural window
scenery can also reduce nervousness and anxiety
(Chang & Chen, 2005). Kaplan (2001)
concluded that workplaces with windows can
lower stress and anxiety and increase work
enthusiasm and that many people in workplaces
without windows use potted plants and pictures
of nature. Evans, Wells, Chan and Saltzman
(2000) created a detailed housing scale
instrument for measuring the natural
environment. The level of nature included four
questions regarding the amount of nature seen
from windows, the number of indoor plants and
the materials in the outside yard. The questions
included, "How many outdoor-facing windows
are in the living room and kitchen?" "How many
living plants are in the room?" and "Are there
more than three potted plants in the living
room?" In summary, increased amounts of
greenery in the home and outside windows have
higher positive benefits. Second, activities in
nature: green exercise refers to physical exercise
undertaken in natural environments as opposed
to man-made environments (Mackay & Neill,
2010). Green exercise provides the benefits of
both contact with nature and physical exercise
(Pretty, Peacock, Hine, Sellens, South, & Griffin,
2007) and is, thus, more beneficial than either
activity individually (Mackay & Neill, 2010).
Kaplan and Kaplan (1989) pointed out that
natural park environments are important as they
can improve wellbeing, promote spiritual clarity
and sharpen the mind. Harte and Eifert (1995)
tested the health benefits of physical activity by
comparing running outdoors and running on a
7
treadmill in a laboratory; the former resulted in
fewer negative emotions. Hull and Michael
(1995) interviewed 186 people who enjoyed
outdoor recreation and concluded a correlation
between stress and the length of time spent at
parks. In other words, stress decreased as the
time spent at parks increased. In addition, they
also found that participants were calmer and had
less anxiety at parks than at home. There are
many experimental studies that investigate the
correlation between anxiety and natural
environments including physical activity in
parks. For example, Mackay and Neill (2010)
used a state anxiety scale to measure the effects
of different types of exercise on anxiety levels
and found that a natural the environment was
important to reducing state anxiety. Third,
gardening activities: gardening is considered as a
form of psychosomatic medicine (NCCAM,
2010). The American Horticultural Therapy
Association (AHTA) broadly defines
horticultural therapy (HT) as a process that uses
plants and plant-related activities through which
participants strive to improve their well-being
through active or passive involvement (AHTA,
2012). Utilized in a patient the setting, HT refers
to the use of the outdoor environment, including
plants, garden tools and plant material, as a
mediated moderator to help the patient heal or
recover and improve their health or wellbeing
(Söderback, Söderstom, & Shälander, 2004).
Chang and Chen (2005) stated that HT could
improve peoples' lives, including learning, work
and reducing physical and mental discomfort.
Analysis of the physiological effects of
gardening activities have found that when
viewing nature, the amplitude of alpha waves in
the brain (which are producing when conscious
and relaxed) significantly increases and
electromyography signals (muscle tension) and
the decrease compared to people viewing
hand-made environments (Chang & Perng,
1998), indicating that natural environments
make people feel relaxed. HT activities help
satisfy biophilia, make people feel safe and
protected and fulfill hopes while admiring the
beauty (Fried & Wichrowski, 2008). Liu et al.
(2003) found that 34 female university students
had the lower beta brainwaves activity and
electrodermal activity when one potted plant was
placed in the room compared to when no plants
were in the room. Park et al. (2004) found that
among 90 female university students who
underwent the cold pressor test for pain,
electrodermal activity was lower when there
were 10 potted plants in the room compared to
when no plants were in the room. HT helps
lower the heart rate and emotional barriers for
patients undergoing cardiorespiratory recovery
and improved emotional states and reduced
stress (Wichrowski et al., 2005). According to
Chen, Tu and Ho (2010), there are five aspects
of the general attitude towards gardening: it
improves emotional states improves the
environment is a leisure activity, promotes social
interaction and promotes escapism. This shows
that most people believe gardening is a leisure
activity that can help escape from daily stress
and improve emotions, social interaction and the
environment and is an activity that benefits both
the individual and the environment. However,
when gardening is using as a form of therapy,
the focus is placed on the health benefits of
contact with plants. The health benefits of plants
have been verified in past studies. In short,
horticultural therapy is a planned and purposeful
8
activity that provides therapy. It is a form of
psychosocial intervention commonly used in the
medical field to deliver physical and
psychological benefits to patients through
gardening and interaction with nature.
V. MATERIALS AND METHODS
A. Sample
Eighteen breast cancer patients were
recruited for this study, 8 of whom were
assigned to the experimental group and 10 to the
control group. The experimental group took
walks in the green space of a park and cared for
potted plants, whereas the control group did not
undergo any nature therapy. This experimental
study lasted for 2 weeks. Purposive sampling
was used to select patients with breast cancer at
Hsinchu Mackay Memorial Hospital, and
recruitment for the study lasted from November
2014 to April 2015.
B. Measures
Consent forms: Participants signed forms
confirming that they agreed to join this study
and fully understood its purpose and procedures.
Gardening tools: Succulents, pots, colored
stones, chopsticks, spades, and soil.
Physiological indicator tools: Salivary
cortisol and blood collection.
C. Procedure
The pretest and posttest samples in this study
were collected from all participants at the same
clock time, because it was impossible to collect
saliva and blood at the optimal times. The
experimental group underwent two weeks of
nature therapy, while the participants in the
control group continued their normal daily
routines. Saliva samples were immediately
stored at −20°C until all had been collected.
They were then packed in dry ice and sent to
Chung Shan Medical University Hospital for
testing.
D. Data Analysis
The sample in this study was small, and
nonparametric statistical analysis was used. A
Wilcoxon signed rank test was used to identify
any significant differences in the postnature
therapy physiological indicators. A
MannWhitney U test was used to detect any
discrepancies in physiological indicator changes
for participants who underwent nature therapy.
VI. RESULTS
A. Experimental group Versus Natural dose
As shown in Table I, There were 18 samples
of natural therapy and the average number of
samples for the Saliva Pre test was 0.48, Saliva
Post test sample average is 0.50. The average
sample of Blood Pre test is 10.74. The average
number of samples for the Blood Post test is
9.38.
TABLE I. DESCRIPTIVE STATISTICS SCALE
N
Min
value
(ug/dl)
Max
value
(ug/dl)
Average
Standard
deviation
Saliva Pre
test
18
0.22
1.13
0.48
0.24
Saliva Post
test
18
0.30
1.16
0.50
0.20
Blood Pre
test
18
4.90
24.30
10.74
5.03
Blood Post
test
18
4.40
23.60
9.38
5.17
9
As shown in Table II, Wilcoxon Signed
Ranked Test found blood cortisol significant
differences for experimental group pre-test
physiological indicators and post-test
psychological indicators (z=-2.483; p≤0.05).
Based on the positive values, which indicating
that the post-test blood cortisol value was
significantly lower than the average pre-test
value. In other words, stress levels decreased in
the post-tests.
TABLE II. WILCOXON SIGNED RANKED TEST
Blood Post test -
blood Pre test
Z-TEST
-2.483C
ASYMPTOTIC
SIGNIFICANCE
(TWO-TAILED)
.013
As shown in Table III. Mann-Whitney U
Test found Saliva cortisol significant differences
between the experimental group and the control
group (z=-2.05; p≤0.05). The postoperative
measured salivary cortisol in the experimental
group was lower than that in the control group,
indicating that natural therapy was effective for
the patient
TABLE III. MANN-WHITNEY U TEST
Saliva
Post test
saliva
Pre test
blood
Pre test
Blood
Post test
MANN-WHITNEY
U STATISTICS
17.000
31.000
23.000
30.500
WILCOXON
W STATISTICS
53.000
67.000
59.000
66.500
Z-TEST
-2.050
-0.801
-1.510
-0.845
ASYMPTOTIC
SIGNIFICANCE
(TWO-TAILED)
0.040
0.423
0.131
0.398
PRECISE
SIGNIFICANCE [2
*
(SINGLE-TAILED
SIGNIFICANT)]
0.043B
0.460B
0.146B
0.408B
VII. CONCLUSION
In the Wilcoxon Signed Ranked Test
explore the experimental group before and after
participation in natural prescription differences
were found improvement in terms of cortisol in
the blood.
In the Mann-Whitney U Test test section,
to explore the experimental group and the
control group differences, found that saliva
cortisol has improved.
VIII. DISCUSSION
Contact with the natural landscape and
gardening activities can induce positive benefits
breast cancer patients and patients are very sure
the benefits of natural active prescription.
According to a qualitative interview, the
patient said that after taking the park green space,
you can get positive feelings such as relieving
anxiety, reducing stress, clearer minds and
engaging in gardening activities, bringing a
sense of accomplishment and enhancing positive
emotions and calmness.
The results of this study support past
scholars to study through the park green and
horticultural activities to improve patient pain,
increased attention and pain and other negative
emotions (Kaplan et al., 1989Hull et al., 1995
Chen et al., 2010Mackay et al., 2010).
IX. LIMIT AND SUGGESTIONS
There are still some problems are not
significant, therefore, to improve the overall
physiological negative feelings, need to
long-term impact and the study time is only two
weeks, it cannot see the difference. In addition,
many of the research gardening courses will
allow subjects to participate in more than 6 to 8
courses (Gonzalez, Hartig, Patil, Martinsen, &
10
Kirkevold, 2010), see the results and this study
only one-time participation gardening and
Mainly for the interior space of the curriculum
activities, which is the lack of research and
restrictions, not only the subjects were enough
and the results are not easy to see. As this study
considers the limitations of cost, So only
collected pre test and post-test a total of two
times. Future funding may be designed to collect
four times a day for three consecutive days. We
used purposive sampling method to select breast
cancer patients Mackay Memorial Hospital in
Hsinchu Branch, so the inference result can only
be explained in breast cancer research groups. It
is suggested that follow-up studies can increase
the number of samples and apply more widely to
the study results for different cancer and sex,
contribute to the stability of the theoretical
model and the disturbance of symptoms and pain
caused by treatment may affect the study As a
result, the study did not collect relevant
information. This study is only for outpatients.
Suggesting that the future can be tried for
hospitalized patients, in the hospital's functional
treatment and horticultural treatment, the process
by the researchers to observe, record or with the
interview, do more in-depth data collection and
explore.
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First Author The author was born in 1985 in North Dakota,
USA; I am specialized in psychotherapy, horticulture and
psychological support for patients with cancer. Currently, I
am working as RN in the Cancer Center, Hsinchu Mackay
Memorial Hospital, Taiwan. At the same time, I am a
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University.
... Direct evidence was provided by Mao et al. in favor of forest therapy being beneficial for patients with chronic heart failure and therefore it was considered that it has the potential to be used as an adjuvant therapy for cardiovascular disorders [34]. With regard to cancer patients, previous studies have stated that forest healing therapy not only increased physiological factors such as natural killer cell activity [36][37][38][39], but also psychological status such as depression, anxiety, and sleep quality [36,[40][41][42]. ...
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Growth hormone-releasing hormone and somatostatin-like
  • D R Ciocca
  • L A Puy
  • L C Fasoli
  • O Tello
  • J C Aznar
  • F E Gago
  • S Papa
Ciocca, D. R., Puy, L. A., Fasoli, L. C., Tello, O., Aznar, J. C., Gago, F. E., & Papa, S. (1990). Growth hormone-releasing hormone and somatostatin-like
Horticultural therapy: A psychosocial treatment option at the Stephen D
  • G G Fried
  • M J Wichrowski
Fried, G. G., & Wichrowski, M. J. (2008). Horticultural therapy: A psychosocial treatment option at the Stephen D.
Heart rate variability in psychiatry
  • W Kim
  • J M Woo
  • J H Chae
Kim, W., Woo, J. M., & Chae, J. H. (2005). Heart rate variability in psychiatry. Journal
©The Author(s) 2017. This article is published with open access by the GSTF 10 11 of
GSTF Journal of Nursing and Health Care (JNHC) Vol.5 No.1, December 2017 ©The Author(s) 2017. This article is published with open access by the GSTF 10 11 of Korean Neuropsychiatric Association. 44:176-184.