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The effect of physical activity in an alpine environment on quality of life is mediated by resilience in patients with psychosomatic disorders and healthy controls

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Objective: Physical activity (PA) in an outdoor environment has been shown to exert positive effects on mental well-being beyond those found for PA indoors. The specific effect of an alpine environment has not been investigated so far. Here we evaluate the association of PA in an alpine environment with resilience and quality of life (QOL) in patients with psychosomatic disorders and controls. Methods: 194 patients with psychosomatic disorders (mostly somatoform disorder and major depressive syndrome) and 326 healthy controls were included in this web-based cross-sectional study. PA was scored using an adapted version of the Global Physical Activity Questionnaire including the environmental aspect (indoor, outdoor, alpine environment). Resilience was assessed using the Resilience Scale-13, QOL using the WHOQOL-BREF. Group comparisons, correlation and mediation analyses were performed. Results: Patients showed significantly lower levels of resilience (p < 0.001) and QOL (p < 0.001) compared to controls. PA in an alpine environment was associated with resilience (patients: r = 0.35, p < 0.001; controls r = 0.18, p < 0.001). There were no significant associations between PA in other environments (outdoor or indoor) and resilience. PA in all three environments correlated with subcategories of QOL. The effect of PA in an alpine environment on QOL was partly mediated by resilience in patients (68% of total effect mediated, p < 0.001) and controls (49% mediated, p = 0.006). Conclusion: There is a positive effect of PA in an alpine environment on mental health beyond that of physical activity itself. Preventive and therapeutic programs should thus include physical activity, but also take additional benefits of natural environments into account.
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European Archives of Psychiatry and Clinical Neuroscience (2019) 269:543–553
https://doi.org/10.1007/s00406-018-0930-2
ORIGINAL PAPER
The effect ofphysical activity inanalpine environment onquality
oflife ismediated byresilience inpatients withpsychosomatic
disorders andhealthy controls
CorneliaOwer2· GeorgKemmler1· TheresaVill2· CarolineMartini2· AndreaSchmitt3,4·
BarbaraSperner‑Unterweger2· KatharinaHüfner2
Received: 5 April 2018 / Accepted: 16 July 2018 / Published online: 25 July 2018
© The Author(s) 2018
Abstract
Objective Physical activity (PA) in an outdoor environment has been shown to exert positive effects on mental well-being
beyond those found for PA indoors. The specific effect of an alpine environment has not been investigated so far. Here we
evaluate the association of PA in an alpine environment with resilience and quality of life (QOL) in patients with psycho-
somatic disorders and controls.
Methods 194 patients with psychosomatic disorders (mostly somatoform disorder and major depressive syndrome) and 326
healthy controls were included in this web-based cross-sectional study. PA was scored using an adapted version of the Global
Physical Activity Questionnaire including the environmental aspect (indoor, outdoor, alpine environment). Resilience was
assessed using the Resilience Scale-13, QOL using the WHOQOL-BREF. Group comparisons, correlation and mediation
analyses were performed.
Results Patients showed significantly lower levels of resilience (p < 0.001) and QOL (p < 0.001) compared to controls. PA in
an alpine environment was associated with resilience (patients: r = 0.35, p < 0.001; controls r = 0.18, p < 0.001). There were
no significant associations between PA in other environments (outdoor or indoor) and resilience. PA in all three environments
correlated with subcategories of QOL. The effect of PA in an alpine environment on QOL was partly mediated by resilience
in patients (68% of total effect mediated, p < 0.001) and controls (49% mediated, p = 0.006).
Conclusion There is a positive effect of PA in an alpine environment on mental health beyond that of physical activity
itself. Preventive and therapeutic programs should thus include physical activity, but also take additional benefits of natural
environments into account.
Keywords Alpine environment· Physical activity· Resilience· Psychosomatic disorders· Quality of life
Introduction
Physical activity (PA) is known to improve physical and psy-
chological well-being [1]. The World Health Organization
(WHO) recommends at least 150min of moderate-intensity
physical activity (PA) throughout the week [2]. Reduced
physical activity is associated with chronic disease, whereas
regular exercise enhances physical and mental health [3].
While the effects of physical activity have been well estab-
lished in chronic somatic diseases, studies in psychosomatic
conditions, especially somatoform disorders, are much less
prevalent [4]. PA is known to improve symptoms of depres-
sion, anxiety and panic disorder [5] as well as enhance meas-
ures of mental well-being like quality of life (QOL) [6] and
resilience [7]. Resilience can be viewed as one’s ability to
* Katharina Hüfner
katharina.huefner@tirol-kliniken.at
1 Department ofPsychiatry, Psychotherapy
andPsychosomatics, University Hospital forPsychiatry
I, Medical University ofInnsbruck, Anichstr. 35,
6020Innsbruck, Austria
2 Department ofPsychiatry, Psychotherapy
andPsychosomatics, University Hospital forPsychiatry
II, Medical University ofInnsbruck, Anichstr. 35,
6020Innsbruck, Austria
3 Department ofPsychiatry andPsychotherapy, University
Hospital, Ludwig Maximilians-University (LMU) Munich,
Munich, Germany
4 Laboratory ofNeuroscience (LIM27), Institute ofPsychiatry,
University ofSao Paulo, SãoPaulo, Brazil
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544 European Archives of Psychiatry and Clinical Neuroscience (2019) 269:543–553
1 3
bend but not break, bounce back, and perhaps even grow in
the face of adverse life experiences. Determinants of resil-
ience include a host of biological, psychological, social and
cultural factors that interact with one another to determine
how one responds to stressful experiences [8]. Additionally,
people with mental health problems recover more rapidly
when regular physical activity is performed [9]. PA, resil-
ience and QOL have been shown to be interconnected: There
is a direct effect of PA on QOL and an indirect effect medi-
ated by resilience [7, 10].
Benefits of PA are even greater when performed outdoors:
For healthy individuals, there is evidence that exercising out-
doors results in greater improvements of mental well-being
than exercising indoors with greater feelings of delight,
energy and revitalization, as well as decreases in frustration,
tiredness and anger [11]. Additionally, in healthy subjects,
contact with nature is known to improve overall life-satisfac-
tion [12], the feeling that one’s life is worthwhile [13], cog-
nitive functioning [14] and QOL [15]. Physical activity in
outdoor, natural environments is linked with improvements
in social networking and feelings of connectivity and com-
panionship, an increased appreciation of nature, improve-
ments in self-esteem and a means of escape from modern
life [11]. The protective effect of physical activity against
depression and suicidal ideation has been shown to be medi-
ated by self-esteem and social support not the activity per
se [16]. Additionally, outdoor physical activity shows higher
adherence rates [17], and the outdoor environment seems
to promote physical activity [18]. By building a personal
bond to individual mountain sides the positive impact of the
outdoor environment on mental well-being is enhanced [19].
Due to urbanization, a lack of contact with nature affects city
dwellers which is associated with a higher prevalence for
psychiatric disorders like mood and anxiety disorders [20].
A limiting factor in the available studies on the effect
of outdoor, natural environments is that mostly subjects
without overt mental health disorders were studied, and the
outdoor environments mostly included parks or forests [21].
Only few studies have examined the effect of outdoor physi-
cal activity in patients with mental health disorders. It is
known that patients with mild to moderate depression feel
more active after PA outdoor than indoor [22]. Exercise in
green spaces (e.g., forest, countryside) improves both self-
esteem and mood irrespective of duration, intensity or men-
tal health status [23].
The effect of PA in an outdoor alpine environment on
mental health has rarely been researched to date. In a pilot
study the therapeutic benefit of the alpine environment was
assessed using a mountain hiking paradigm in a sample of
17 suicidal patients. Results indicate a significant reduc-
tion in depression, hopelessness and suicidal ideation as
well as an improvement in QOL [24]. A comparison with
other environments (outdoor, indoor) was not performed.
Nevertheless, the results suggest therapeutical benefits of PA
in an alpine environment in the treatment of patients with
mental health disorders.
To the best of our knowledge, there is no study assessing
the benefit of PA in an alpine environment in comparison
with the effects of PA in outdoor and indoor environments
on mental health. The aim of the current study was to find
out if there are beneficial effects of outdoor PA which go
beyond that of PA itself, and if the effects might be even
greater in an alpine setting compared to urban outdoor envi-
ronments such as parks. In the present study we investigate
the effect of PA in an alpine environment, in an outdoor
(non-alpine) environment and indoors and their association
with resilience and QOL in patients with psychosomatic dis-
orders and controls. We also assess a possible interaction
between the three components PA, resilience and QOL using
a mediation analysis.
Methods
Study design
This is a cross-sectional observational study. The current
data are part of a larger study examining the effect of PA in
an alpine environment on mental health. Innsbruck is one
of the few urban spaces located directly within the Alps
and thus allows for easy access to the alpine environment
(Fig.1). The ethics commission of the Medical University
of Innsbruck reviewed and approved the study protocol.
After being informed in detail about the study aims and
procedures, participants provided informed consent prior to
study participation. Study recruitment was conducted over
a 4-month period in 2016.
Participants
A total of 1029 participants were invited to an open online
survey via email, social media and classified websites or
recruited whilst treated at the Innsbruck University hospital
at the inpatient or outpatient clinic. For the present analysis
participants who terminated the questionnaire early were
excluded [this was defined as: individuals who did not com-
plete at least questions on sociodemographics, Patient Health
Questionnaire, Physical activity and Resilience (n = 414)].
Skipping questions was not possible in this questionnaire.
Additionally individuals with implausible PA values (n = 8)
were excluded from the study. Individuals who screened
positively for alcohol abuse only (n = 54) or for an eating
disorder only (using PA for losing weight: Anorexia nervosa,
Bulimia nervosa; n = 33) were excluded from further analy-
sis (Fig.2). The 520 participants consisted of two groups:
Patients screened positively for mental health disorder on
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545European Archives of Psychiatry and Clinical Neuroscience (2019) 269:543–553
1 3
the Patient Health Questionnaire (PHQ, n = 194) which uses
DSM-IV criteria. Two participants reported a mental health
disorder not screened for in the PHQ and were, therefore,
classified as patients. Participants without positive PHQ
screening (n = 326) built the control group (HC).
Measures
Sociodemographic parameters included information on
age, sex, education and marital status. Mental health was
assessed using the German version of Patient Health Ques-
tionnaire (PHQ), which screens for somatoform disorders,
depressive disorders, anxiety disorders, eating disorders
and alcohol abuse. We used the PHQ as categorical non-
dimensional screening instrument [25]. Additionally, open
text fields were provided for entering psychiatric diagno-
ses. Resilience was measured using the German “Resil-
ienzskala—RS13” which is a short version of the original
RS -25. The minimum score is 13 and maximum score is
91 with values between 65 and 73 representing moderate
resilience, values below indicate low resilience and values
above high resilience [26]. Quality of life was measured
with the WHOQOL-BREF, a 26-question short version
of the original WHOQOL-100. Four domains of QOL are
assessed: “physical health”, “psychological”, “social rela-
tionships” and “environment”. Two questions reflect overall
QOL and general health. The four domains are calculated
with mean values of the relevant items multiplied by four to
ensure comparability with the WHOQOL-100 [27]. PA was
assessed using the Global Physical Activity Questionnaire
(GPAQ-2) of the WHO which is an international standard-
ized tool [28] to measure self-reported PA in a retrospect
of a typical week. PA is calculated using metabolic equiva-
lents (METs) as a unit for energy use. Moderate-intensity
activities are assigned a value of 4 METs; vigorous-intensity
Fig. 1 Photo of the city of
Innsbruck showing the close
proximity between the urban
space and the high mountain
alpine environment. The alpine
environment can be accessed
on foot, bike or skis as well as
using a car, bus or cable car
directly from the city center
Excluded (n=422)
-early termination of
questionnaire (n=414)
-Implausible METs reported
(n=8)
Excluded (n=87)
Single diagnose of:
-Alcohol abuse (n=54)
-Eating disorder (n=33)
Participants (n=1029)
Participants (n=607)
Patients (n=194)
Controls (n=326)
Participants (n=520)
Fig. 2 Flowchart of patient and healthy control recruitment *Early
termination of the questionnaire was defined as termination of the
questionnaire prior to completion of the items sociodemographics,
Patient Health Questionnaire, Physical activity and Resilience
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546 European Archives of Psychiatry and Clinical Neuroscience (2019) 269:543–553
1 3
activities are assigned a value of 8 METs. We used the offi-
cial scoring protocol [29] to calculate total moderate-to-vig-
orous PA in MET minutes/week. In addition to the standard
questionnaire, we used a modified version to identify PA
performed in different environments (indoor, outdoor, and
alpine environment). We defined “PA in an alpine environ-
ment” as PA which involves overcoming vertical energy in
a natural environment which was worded as “PA performed
on the mountain” in the questionnaire. For each environment
we gave multiple examples of PA that would be characteris-
tic for the respective environment, e.g., alpine: ski touring,
skiing, tobogganing, alpine trail running, mountain hiking,
mountain biking; outdoor non-alpine: rollerblading, soccer
on an outdoor field, swimming in an outdoor pool, horse
riding outdoors; indoor: cardio exercises in a fitness studio,
indoor basketball, indoor yoga, indoor dancing.
Statistical methods
Prior to the analysis, metric variables were checked for
deviations from normality by assessing their skewness,
considering values > 0.5 or < −0.5 as deviations from a
symmetric distribution requiring non-parametric testing.
Group comparisons (patients vs. controls) with respect to
sociodemographic and clinical variables were performed
by means of t test, Mann–Whitney U test and Chi-square
test, depending on the variable type (normally distributed,
non-normally distributed metric variables, and categorical
variables, respectively). Group comparisons regarding PA,
resilience, and quality of life were conducted using t test
or Mann–Whitney U test (again depending on the variable
type). The relationship between PA and resilience and QOL
was investigated on a descriptive level by means of correla-
tion analysis. Spearman rank correlation coefficients were
used as most the variables involved showed deviations from
a normal distribution.
To investigate the relationship between PA, resilience
and QOL in more detail several mediation analyses were
performed based on the approach proposed by Preacher and
Hayes using the SPSS macro PROCESS [30]. The model
chosen was motivated by findings of Ho etal. who reported
that resilience mediated the relationship between PA and
mental well-being, assessed with the respective component
score of the SF-12, in a sample of adolescents [7]. Building
on this, we considered PA as the independent variable, QOL
(WHOQOL total score) as the dependent variable, and resil-
ience (RS-13) as a potential mediator between the two vari-
ables. Prior to the analysis, the variable PA was log-trans-
formed to obtain a more symmetrical distribution. Separate
mediation models for patients and controls were fitted. Both
total PA and outdoor PA in alpine surroundings were con-
sidered. Effect sizes of total, direct and indirect effects were
reported as standardized regression coefficients. Moreover,
the relative size of the mediation effect was expressed as a
fraction of the total effect (percentage mediated). Following
Kenny we used the terms partial and complete mediation if
the percentage mediated fell below 80% or lay above this
cut-off value [31].
Results
Sociodemographic characteristics andclinical
features
The sociodemographic characteristics of the total sample
are shown in Table1. The gender distribution was similar
between the groups (Chi-square test, p = 0.273) as well as
city size of residence (Chi-square test, p = 0.274). Patients
had a higher mean age (Mann–Whitney U test, p = 0.02),
lower level of education (Chi-square test, p < 0.001), less fre-
quently employed (Chi-square test, p < 0.001), had a lower
income (Chi-square test, p < 0.001) and were more often
single (Chi-square test, p = 0.003) than HC.
The most common diagnoses in the patient group were
somatoform disorders (54.6%) and major depressive syn-
drome (38.7%) (Table2). One hundred (51.6%) patients
were diagnosed with more than one mental health disorder,
the most common combinations were somatoform disorder
and major depressive syndrome (n = 45/23.2%).
Comparison ofPA indifferent environments
betweenpatients andHC
Patients and HC did not differ significantly on PA in closed
rooms or buildings (PA indoor; Mann–Whitney U test,
p = 0.060; Table 3). The control group had significantly
higher values than the patient group regarding overall PA
(Mann–Whitney U test, p = 0.009), PA in an alpine environ-
ment (PA alpine; Mann–Whitney U test, p < 0.001) and PA
in an outdoor, non-alpine environment (PA outdoor; Mann
Whitney U test, p < 0.001).
To assure congruence of the results in the patient popula-
tion across different diagnostic groups we performed com-
parisons between the most prevalent mental health disor-
ders diagnosed in the study (somatoform disorders, major
depressive syndrome and other anxiety syndromes, Table2).
Patients who screened positively for either somatoform dis-
order or major depressive syndrome did not differ signifi-
cantly on total PA (Mann–Whitney U test, p = 0.143) nor
on PA in the three investigated environments (Mann–Whit-
ney U test, all ps > 0.05) Similar results were found for the
comparison of patients with somatoform disorder and those
with other anxiety syndromes (Mann–Whitney U test, all
ps > 0.05).
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547European Archives of Psychiatry and Clinical Neuroscience (2019) 269:543–553
1 3
Comparison ofresilience andQOL inpatients
andHC
The mean score of the RS-13 was significantly lower in
patients than in HC (t test, p < 0.001; Table3). Additionally,
low resilience—represented by a score of less than 65—was
measured more often in patients than HC (Chi-square test,
p < 0.001). Likewise, the total score and all subscores of the
WHOQOL-BREF were significantly lower in patients than
in HC (Mann–Whitney U test, p < 0.001).
Correlation betweenPA, resilience andQOL
Resilience correlated significantly with PA alpine (patients:
r = 0.35, p < 0.001 and HC r = 0.18, p = 0.001), but not with
PA outdoor or PA indoor in patients and HC (Table4). In
Table 1 Sociodemographic characteristics of patients and healthy controls
a Mean±standard deviation
b 16.7% missing values
c Absolute number (percent)
d Number of inhabitants
Variable Groups Comparison
Patients (n = 194) Controls (n = 326) Test statistics Df p value
Age in yearsa,b 35.9 ± 12.8 32.9 ± 11.8 Z = 2.30 0.021
Female genderc126 (64.9) 196 (60.1) χ2=1.20 1 0.273
Regular psychiatric medicationc68 (35.1) 8 (2.5) χ2=73.25 1 < 0.001
Educationc– – χ2=57.51 3 < 0.001
University 46 (23.7) 115 (35.3)
Secondary school 67(34.5) 138(42.3)
Vocational training 54(27.8) 35 (10.7)
Compulsory school and other 27 (13.9) 38 (11.7)
Marital statusc– – χ2=11.98 2 0.003
Single 113 (58.2) 199 (61)
Married 58 (29.9) 114 (35)
Separated/divorced/widowed 23 (11.9) 13 (4)
Employmentc– – χ2=67.91 2 < 0.001
Full-/part-time employment 80 (41.2) 184 (56.4)
In education/study/vocational training 53 (27.3) 126 (38.7)
Unemployed 61 (31.4) 16 (4.9)
Income in eurosc– – χ2=19.85 3 < 0.001
< 1000 83 (42.8) 99 (30.4)
1000–2000 60 (30.9) 81 (24.8)
2000–4000 44 (22.7) 106 (32.5)
> 4000 7 (3.6) 40 (12.3)
City size of residence in n of inhabc,d – – χ2=2.987 2 0.225
< 10,000 62 (32.0) 105 (32.2)
10,000–130,000 (eg. Innsbruck) 109 (56.2) 165 (50.6)
> 130,000 23 (11.9) 56 (17.2)
Table 2 Psychiatric diagnoses according to PHQ screening
a Sums exceed 100% because of multiple diagnosis
Mental health disorder of patients (n = 194) N/(%)a
Somatoform disorder 106/(54.6)
Major depressive syndrome 75/(38.7)
Other depressive syndrome 35/(18.0)
Panic syndrome 36/(18.6)
Other anxiety syndrome 46/(23.7)
Alcohol abuse 32/(16.5)
Binge eating disorder 24/(12.4)
Bulimia nervosa 10/(5.2)
Others 2 (0.4)
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548 European Archives of Psychiatry and Clinical Neuroscience (2019) 269:543–553
1 3
patients QOL total score and all subscales correlated with
PA alpine and the same held true for HC, except that in HC
the QOL environmental domain did not correlate with PA
alpine (Table4). In patients, not so in HC, several additional
correlations between QOL subscores and PA outdoor and PA
indoor were found (Table4).
Mediation analyses
The relationship between PA, resilience and QOL was inves-
tigated in more detail by mediation analysis. Findings are
shown in Fig.3 (PA alpine as the independent variable)
and Fig.4 (total PA as the independent variable). Media-
tion analysis in HC revealed a significant total effect of PA
alpine on participants’ QOL (c = 0.164, p = 0.004; Fig.3a).
This effect was partly mediated by resilience (cc = 0.081,
p = 0.006) amounting to a proportion of 49% of the total
effect. The remaining direct effect of PA alpine on QOL
lost its significance (c=0.083, p = 0.106). However, as the
direct effect represented 51% of the total effect there was
no indication of complete mediation. Mediation analysis
in patients also yielded a highly significant total effect of
PA alpine on QOL (c = 0.319, p < 0.001; Fig.3b). Again,
this effect was partly mediated by resilience. The size of
the total effect was reduced by approximately 68% through
the mediation (from c = 0.319 to c = 0.103). The remaining
direct effect of PA alpine on QOL attained only trend-level
significance (p = 0.087).
Results for total PA were broadly similar to those for PA
alpine (Fig.4a, b). However, here the proportion of the total
effect attributable to mediation by resilience was larger in
the control group (63% of the total effect) than in the patient
group (46% of the total effect). In the latter group the direct
effect (i.e., the part of the total effect not attributable to the
mediator) now reached statistical significance (p = 0.005).
Discussion
In the present study we evaluated the association of physical
activity in an alpine environment with resilience and quality
of life in patients with psychosomatic disorders. The major
findings were: (1) Patients with psychosomatic disorders had
lower values in resilience and QOL compared to HC, (2) PA
alpine, but not in other environments, correlated with resil-
ience in patients and HC, (3) PA in all three environments
correlated with QOL in patients and HC and (4) Resilience
was found to partially mediate the effect of PA alpine on
QOL in patients and HC.
Resilience andQOL inpatients withpsychosomatic
disorders
We found that patients with psychosomatic disorders display
lower levels of resilience and QOL. This confirms previous
studies showing that patients with mental disorders have
impaired levels of resilience [32] which improve within the
process of recovery [33]. Likewise, QOL has been shown
to be reduced in patients with mental disorder [34]. This
could be due to the fact that both, resilience and QOL are
Table 3 Comparison of scores
of resilience, quality of life
and physical activity between
patients and HC
RS -13 resilience scale 13, WHOQOL-BREF WHO quality of life-short version, PA physical activity, MET
metabolic units, min minutes
a 3.7% missing data
b p values were calculated with Chi-square test for categorical variables and Mann–Whitney U test for con-
tinuous variables
Variable Groups Comparison
Patients (N = 194)
Mean ± SD
Controls (N = 326)
Mean ± SD
Test statistics p valueb
RS -13 score 57.3 ± 16.8 72.8 ± 9.0 t=−13.70 < 0.001
WHOQOL-BREFa score in points
 Total 13.4 ± 2.9 16.9 ± 1.6 Z=−13.27 < 0.001
 Physical 13.5 ± 3.6 17.8 ± 1.6 Z=−14.01 < 0.001
 Psychological 12.0 ± 3.7 16.6 ± 2.0 Z=−13.21 < 0.001
 Social 12.6 ± 4.2 15.7 ± 2.9 Z=−8.24 < 0.001
 Environmental 15.4 ± 2.7 17.4 ± 1.7 Z=−8.33 < 0.001
PA in MET min/week
 Overall 5931.0 ± 6805.6 6702.1 ± 6449.0 Z=−2.63 0.009
 Alpine 1927.8 ± 3212.6 2733.4 ± 3120.7 Z=−4.74 < 0.001
 Outdoor 1007.2 ± 1578.2 1285.0 ± 1739.4 Z=−3.22 < 0.001
 Indoor 2996.0 ± 5170.0 2683.7 ± 3927.7 Z = + 1.88 0.060
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549European Archives of Psychiatry and Clinical Neuroscience (2019) 269:543–553
1 3
influenced by similar factors such as social support [35],
coping strategies in stressful situations [36] and self-respect
[10] which can be impaired in patients with psychosomatic
disorders. Additionally, certain personality factors have been
found to be connected to resilience as well as QOL [37, 38].
Association ofPA withresilience andQOL
The link between PA and QOL is well known though it has
rarely been evaluated in a population with psychosomatic
disorders. In patients with depression physical and psycho-
logical subdomains of QOL show improvements following
regular exercise [39], However, most outpatients with men-
tal disorders do not reach recommended levels of PA [40].
Theories on the mechanisms through which physical activ-
ity could influence QOL have been generated, and much is
based on psychoimmunological aspects. Multiple large stud-
ies [41, 42] have consistently shown that there is an inverse,
independent, dose–response relation between level of PA
and immune cytokines (e.g., IL-6 and CRP), while depres-
sion is associated with increased plasma levels of immune
cytokines [43].
PA not only influences QOL, but there is also a con-
nection with resilience, which has been demonstrated for
healthy subjects [44] as well as individuals with depression
[45] or cancer [46]. The relationship between the PA and
resilience seems to be non-linear, in contrary, there might
be an optimal amount of PA for building resilience [44]. In
the present study, we could identify resilience as a mediator
between PA and QOL, consistent with findings from previ-
ous studies [7, 10].
The effect ofthealpine environment
The effect of PA in an outdoor alpine environment on men-
tal health has rarely been researched to date. In the present
study exercise in the alpine environment was the only one
associated with resilience, while this association was not
found for PA in an outdoor non-alpine environment or for
PA indoors. The principal feasibility of a program includ-
ing physical activity in an alpine environment has been
demonstrated in a group of patients with mixed psychiatric
disorders (mostly depression, emotionally instable person-
ality disorder, and substance abuse) who participated in a
mountain hiking program [24]. Other studies have evaluated
the benefit of “outdoor adventure therapy” in patients with
mental illnesses. Following activities like mountain biking,
raft building and group exercises, adults and youth with
mental illness experienced significant improvements in self-
esteem, mastery and resilience [47, 48]. However, in these
studies the adventure therapy comprised therapeutic sessions
in addition to the outdoor activities and the activities took
Table 4 Correlations between physical activity, resilience and quality
of life in patients with psychosomatic disorders and controls
RS -13 resilience scale 13, WHOQOL-BREF WHO quality of life-
short version, PA physical activity, r correlation coefficient, p p value
*p < 0.05, **p < 0.01, ***p < 0.001
a p values were calculated using Spearman Rank correlations
b 3.7% missing data
PA alpine PA outdoor PA indoor
Controls (n = 326)
RS-13 score
r0.18** 0.08 0.09
pa0.001 0.15 0.10
WHOQOL-BREF scoreb
Total
r0.16** 0.08 0.04
p0.01 0.14 0.48
Physicalhealth
r0.11** 0.06 0.03
p0.05 0.30 0.65
Psychological
r0.13** 0.07 0.02
p0.02 0.22 0.78
Socialrelationships
r0.12** 0.07 0.04
p0.03 0.23 0.52
Environmental
r0.07 0.03 0.03
p0.23 0.63 0.56
Patients (n = 194)
RS-13 score
 r 0.35*** 0.11 0.14
p < 0.001 0.12 0.06
WHOQOL-BREF scoreb
Total
r0.31*** 0.15* 0.16*
p< 0.001 0.04 0.03
Physicalhealth
r0.36*** 0.14 0.18**
p< 0.001 0.05 0.02
Psychological
r0.28*** 0.06 0.15**
p< 0.001 0.38 0.04
Socialrelationships
r0.20** 0.19** 0.15**
p0.01 0.01 0.04
Environmental
r0.23*** 0.10 0.09
p< 0.001 0.17 0.22
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
550 European Archives of Psychiatry and Clinical Neuroscience (2019) 269:543–553
1 3
place in mixed environments, a differential analysis of the
diverse environments for PA is missing.
The American Psychological Association suggests 10
ways to build resilience, which includes maintaining a
good relationship with friends and/or family, advice on
stress management, moving towards ones goals, taking
decisive actions in adverse situations, looking for oppor-
tunities of self-discovery, developing self-confidence and
to exercise regularly [49]. Looking at this agenda, physical
activity in an alpine environment seems an ideal measure
joining those points in one single process. During physi-
cal activity in an alpine environment also many factors not
related to the exercise per se, and more related to aspects
of companionship, self-esteem, pursuing ones’ goals, risk
management and contact to nature come into play. This is
important since nature experiences (from gardening to wil-
derness activities) increase a sense of healthy internal locus
of control and self-efficacy [50]. Programs which include
outdoor activities have been found to be effective through
nature itself [51]. A study from England compared different
outdoor environments: greater connectedness to nature and
restoration was observed following visits to rural and coastal
locations compared with urban green space, and to sites of
higher environmental quality (operationalized by protected/
designated area status, for example, nature reserves) [52].
During PA in an alpine environment moderate manageable
(a)Healthy controls
(b)Patients
Indirect effect of resilience:
c-c’ = 0.216 (p< 0.001)
PA alpine
ln (MET min/week)Total effect: c = 0.319(p<0.001)
Resilience
RS-13 score
Direct effect: c‘ = 0.103 (p=0.087)
a= 0.357
(p<0.001)b = 0.606
(p<0.001)
WHOQOL-BREF
total score
PA alpine
ln (MET min/week)Total effect: c = 0.164 (p=0.004)
Resilience
RS-13 score
Direct effect: c‘ = 0.083 (p=0.102)
a = 0.176
(p=0.002)b = 0.463
(p<0.001)
WHOQOL-BREF
total score
Indirect effect of resilience:
c-c’= 0.081 (p= 0.006)
Fig. 3 Effect of resilience on the relationship between physical activ-
ity in an alpine environment and QOL—results of mediation analy-
sis. Numbers shown in the diagram are standardized regression coef-
ficients. Solid lines indicate statistically significant effects, dashed
lines indicate non-significant effects. MET metabolic equivalent, Min
minutes, PA alpine physical activity in an alpine environment, WHO-
QOL-BREF World Health Organization Quality of Life Score-short
form. a = effect of PA alpine on the mediator RS-13 score. b = effect
of resilience (RS-13 score) on WHOQOL-BREF total score, adjusted
PA alpine. c = total effect of PA alpine on WHOQOL-BREF total
score. c = direct effect of PA alpine on WHOQOL-BREF total score,
after adjusting for resilience (RS-13 score). c − c’: Indirect effect
of resilience on the relationship between PA alpine and WHOQOL-
BREF total score
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
551European Archives of Psychiatry and Clinical Neuroscience (2019) 269:543–553
1 3
risks are encountered which have to be overcome, a process
which increases resilience resulting in increased QOL [7].
Additionally PA alpine often requires a high level of social
interaction which could provide social support and improve
resilience as well as mental health problems [7, 45].
Limitations
The main limitation of the study is that in a survey study
no causal relationship between the physical activity meas-
ures and the psychometric assessments can be obtained.
However, this is inherent to this kind of study and can
only be addressed in a prospective intervention study. To
minimize the distorting effect of the reported self-per-
ception, we used questionnaires like the Global Physical
Activity Questionnaire which are established worldwide
and showed good validity and reliability [28]. We did not
record whether individuals were undergoing psychother-
apy and there might also be an effect of psychiatric medi-
cation on resilience and QOL. The present study does not
allow the differentiation which components of the alpine
environment lead to the observed positive effects, this
should be addressed in a follow-up intervention study.
(a) Healthy controls
(b)Patients
Resilience
RS-13 score
Physical activity
ln (MET min/week)Total effect: c = 0.295 (p<0.001)
Indirect effect of resilience:
c-c’ = 0.135 (p= 0.006)
Direct effect: c
‘ = 0.160 (p=0.
005)
a= 0.222
(p=0.003)b = 0.607
(p<0.001)
WHOQOL-BREF
total score
Physical activity
ln (MET min/week)Total effect: c = 0.120 (p=0.034)
Resilience
RS-13 score
Direct eect: c‘ = 0.044 (p=0.378)
a = 0.161
(p=0.004)b = 0.470
(p<0.001)
WHOQOL-BREF
total score
Indirect effect of resilience:
c-c’= 0.076 (p= 0.009)
Fig. 4 Effect of resilience on the relationship between total physical
activity and QOL—results of mediation analysis. Numbers shown in
the diagram are standardized regression coefficients. Solid lines indi-
cate statistically significant effects, dashed lines indicate non-signif-
icant effects. WHOQOL-BREF World Health Organization Quality
of Life Score-short form, MET metabolic equivalents, Min minutes.
a = effect of physical activity on the mediator RS-13 score, b = effect
of resilience (RS-13 score) on WHOQOL-BREF total score, adjusted
for PA, c = total effect of physical activity on WHOQOL-BREF total
score, c = direct effect of physical activity on WHOQOL-BREF total
score, after adjusting for resilience (RS-13 score), cc: indirect
effect of resilience on the relationship between physical activity and
WHOQOL-BREF total score
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
552 European Archives of Psychiatry and Clinical Neuroscience (2019) 269:543–553
1 3
Conclusion
Physical activity in an alpine environment correlates with
resilience and QOL in patients with psychosomatic disor-
ders and healthy controls. Since alpine environments are
regionally limited other natural settings should be explored
as an alternative. To identify more specifically the factors
comprising the positive effect of the alpine environment a
prospective study comparing the effects of an alpine environ-
ment with those of other environments should be performed.
To better underpin the effectiveness of PA in an alpine envi-
ronment a dose–response relationship should ideally be
demonstrated [53].While these scientific questions remain
to be addressed we propose from a practical perspective that
the shown positive effects of the alpine environment should
be used in everyday clinical practice: Therapies should not
only include gym-based programs or classical Nordic walk-
ing in streets or yards, but take the additional effects of out-
door natural environments into account.
Acknowledgements Open access funding provided by University of
Innsbruck and Medical University of Innsbruck. We thank Dr. Thomas
Post, Dr. Ulrike Weber-Lau, Dr. Barbara Mangweth-Matzek for help
with patient recruitment and Dr. Christian Widschwendter for helpful
discussion.
Funding This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Compliance with ethical standards
Conflict of interest The authors have no competing interests to report.
Open Access This article is distributed under the terms of the Crea-
tive Commons Attribution 4.0 International License (http://creat iveco
mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribu-
tion, and reproduction in any medium, provided you give appropriate
credit to the original author(s) and the source, provide a link to the
Creative Commons license, and indicate if changes were made.
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... Resilience can be defined as one's ability to cope with and recover from adverse life events. Resilience is improved by physical activity performed in a natural outdoor environment but is not associated with physical activity performed indoors [32]. When the natural environment is used to perform physical activity the positive effects of physical activity and natural environments can be combined: there is evidence that exercising outdoors results in greater improvements of mental well-being than exercising indoors with greater feelings of delight, energy and revitalization, as well as decreases in frustration, tiredness and anger [38]. ...
... It was not possible to skip one question or a questionnaire. The current data is part of a larger study examining the effect of physical activity in an alpine environment on mental health, part of which has been published [32]. Innsbruck is one of few urban spaces located directly within the Alps and thus allows for easy access to the alpine environment. ...
... Participants and recruiting procedure are described in [32], participant numbers vary slightly compared to the previous publication due to missing data in individual participants. In brief, a total of 1029 individuals participated in an open online-only survey. ...
Article
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Background: Patients with somatoform, depressive or anxiety disorders often don't respond well to medical treatment and experience many side effects. It is thus of clinical relevance to identify alternative, scientifically based, treatments. Our approach is based on the recent evidence that urbanicity has been shown to be associated with an increased risk for mental disorders. Conversely, green and blue environments show a dose-dependent beneficial impact on mental health. Methods: Here we evaluate the effect of viewing stimuli of individuals in an alpine environment on emotional analytics in 183 patients with psychiatric disorders (mostly somatoform, depressive and anxiety disorders) and 315 healthy controls (HC). Emotional analytics (valence: unhappy vs happy, arousal: calm vs excited, dominance: controlled vs in control) were assessed using the Self-Assessment Manikin. Further parameters related to mental health and physical activity were recorded. Results: Emotional analytics of patients indicated that they felt less happy, less in control and had higher levels of arousal than HC when viewing neutral stimuli. The comparison alpine>neutral stimuli showed a significant positive effect of alpine stimuli on emotional analytics in both groups. Patients and HC both felt attracted to the scenes displayed in the alpine stimuli. Emotional analytics correlated positively with resilience and inversely with perceived stress. Conclusions: Preventive and therapeutic programs for patients with somatoform, depressive and anxiety disorders should consider taking the benefits of natural outdoor environments, such as alpine environments, into account. Organizational barriers which are preventing the implementation of such programs in clinical practice need to be identified and addressed.
... Three observational studies were identified, although none recruited a clinical sample restricted to participants with clinical depression [21][22][23]. In a web-based, cross-sectional survey, Ower et al. [21] compared levels of physical activity (PA) developed indoors, outdoors, or in an alpine environment in healthy controls and patients with psychosomatic disorders, mostly somatoform disorder, and major depressive disorder (MDD). ...
... Three observational studies were identified, although none recruited a clinical sample restricted to participants with clinical depression [21][22][23]. In a web-based, cross-sectional survey, Ower et al. [21] compared levels of physical activity (PA) developed indoors, outdoors, or in an alpine environment in healthy controls and patients with psychosomatic disorders, mostly somatoform disorder, and major depressive disorder (MDD). In addition, possible mediating variables such as an individual's resilience and quality of life were analyzed. ...
... Several intervention studies were identified [24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39]. Of them, a minority included patients with MDD only [24][25][26][27][28][29], and the majority [21,[30][31][32][33][34][35][37][38][39] recruited mixed samples including patients with depressive disorders, although separate results for that group were not reported. ...
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Recent lifestyles changes have favored increased time in contact with screens and a parallel reduction in contact with natural environments. There is growing awareness that nature exposure and screen time are related to depression. So far, the roles of how these environmental lifestyles affect depressive symptoms and disorders have not been reviewed simultaneously. The aim of this review was to gather the literature regarding the role of nature exposure and screen time in depression. An emphasis was made on clinical samples of patients with well-defined depression and the different methodological approaches used in the field. A second goal was to suggest an agenda for clinical practice and research. Studies were included if they assessed depressive symptoms in patients with a clinical diagnosis of depression. An overview of the published literature was conducted using three scientific databases up to December 2021. Several interventions involving nature exposure have shown positive effects on depressive symptoms and mood-related measures. The most consistent finding suggests that walks in natural environments may decrease depressive symptoms in patients with clinical depression. Less researched interventions, such as psychotherapy delivered in a forest or access to natural environments via virtual reality, may also be effective. In contrast, fewer observational studies and no experimental research on screen time have been conducted in patients with clinical depression. Thus, recommendations for practice and research are also discussed. Scarce research, diverse interventions, and several methodological shortcomings prevent us from drawing conclusions in this area. More high-quality experimental research is needed to establish interventions with proven efficacy in clinical depression. At this stage, it is too early to formulate practice guidelines and advise the prescription of these lifestyles to individuals with depression. The present findings may serve as a basis to develop strategies based on nature exposure and screen time targeting clinical depression.
... Resilience can be de ned as one's ability to cope with and recover from adverse life events. Resilience is improved by physical activity performed in a natural outdoor environment but is not associated with physical activity performed indoors (Ower et al. 2018). When the natural environment is used to perform physical activity the positive effects of physical activity and natural environments can be combined: there is evidence that exercising outdoors results in greater improvements of mental well-being than exercising indoors with greater feelings of delight, energy and revitalization, as well as decreases in frustration, tiredness and anger (Thompson Coon et al. 2011). ...
... It was not possible to skip one question or a questionnaire. The current data is part of a larger study examining the effect of physical activity in an alpine environment on mental health, part of which has been published (Ower et al. 2018). Innsbruck is one of few urban spaces located directly within the Alps and thus allows for easy access to the alpine environment. ...
... Participants and recruiting are described in Ower et al. 2018, participant numbers vary slightly compared to the previous publication due to missing data in individual participants. In brief, a total of 1029 individuals participated in an open online-only survey. ...
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Background: Patients with somatoform, depressive or anxiety disorders often don´t respond well to medical treatment and experience many side effects. It is thus of clinical relevance to identify alternative, scientifically based, treatments. Our approach is based on the recent evidence that urbanicity has been shown to be associated with an increased risk for mental disorders. Conversely, green and blue environments show a dose-dependent beneficial impact on mental health. Methods: Here we evaluate the effect of viewing stimuli of individuals in an alpine environment on emotional analytics in 183 patients with psychiatric disorders (mostly somatoform, depressive and anxiety disorders) and 315 healthy controls (HC). Emotional analytics (valence: unhappy vs happy, arousal: calm vs excited, dominance: controlled vs in control) were assessed using the Self-Assessment Manikin. Further parameters related to mental health and physical activity were recorded. Results: Emotional analytics of patients indicated that they feel less happy, less in control and had higher levels of arousal than HC when viewing neutral stimuli. The comparison alpine>neutral stimuli showed a significant a positive effect of alpine stimuli on emotional analytics in both groups. Patients and HC both felt attracted to the scenes displayed in the alpine stimuli. Emotional analytics correlated positively with resilience and inversely with perceived stress. Conclusions: Preventive and therapeutic programs for patients with somatoform, depressive and anxiety disorders should consider taking the benefits of natural outdoor environments such as alpine environments, into account. Organizational barriers which are preventing the implementation of such programs in clinical practice need to be identified and addressed.
... Contrary to previous literature [54], we found that location does not influence resilience and QOL. The research on how location effects exercise and resilience is in its infancy, with studies having focused on the attachment between the self and environment, drawing on Bowlby and Ainsworth attachment theory [55]. ...
... Therefore, research has mostly focussed on infants, and it is unknown whether this can be applied to adult's attachment with the environment. In-line with our hypothesis on the relationship between location exercise, QoL and resilience, and previous literature [54,56,57], this was reversed during lockdown, where more people began to exercise in rural locations and demonstrated higher resilience levels. However, this was not statistically significant. ...
Article
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Background: Resilience is central to positive mental health and well-being especially when faced with adverse events. Factors such as exercise, location, sleep, mental health, and personality are moderators and mediators of resilience. However, the impact of these factors on resilience during severe adverse events are unknown. The present study examined how the COVID-19 pandemic affected resilience and its moderators and mediators by investigating whether there was a difference in resilience and quality of life between people with varying levels of exercise, including those who changed their exercise levels pre and during a COVID-19-related lockdown, and whether location affected the relationship between levels of exercise and resilience and quality of life. Methods: Following ethical approval, a cross-sectional online survey capturing data on self-reported key moderators and mediators of resilience before and during the COVID-19 lockdown imposed on the 23rd March 2020 in the UK was distributed via social media and completed over a three week time period during July 2020 via a self-selecting sample of the general population (N = 85). The key moderators and mediators of resilience the survey assessed were exercise, location, life-orientation, mental health, and sleep quality. All data were self-reported. Results: Participants' exercise intensity level increased as resilience increased (F(2,82) = 4.22, p = .003: Wilks' lambda = .82, partial n2 = 0.09). The relationship between exercise, and resilience and quality of life was independent of sleep and mental health status pre-lockdown (p = .013, p = .027 respectively). In the face of the COVID-19 pandemic, this relationship was dependent on mental health but not sleep quality (p = <.001 for resilience p = .010 for quality of life). There were no statistically significant differences between participants living in urban or rural locations. Conclusion: Exercise is strongly correlated to resilience and during a pandemic such as COVID-19 it becomes a mechanism in which to moderate resilience. The relationship between exercise and resilience is supported by this study. The influence that a pandemic had on mental health is mediated by its effect on quality of life.
... Resilience to stress, is a condition theoretically correlated with 'acute stress' [26][27][28] and 'psychosomatic symptoms'. [29][30][31] Therefore, in the present study, the proposed a specified interest in individuals with health-related stress. [13][14] As a result, these scales are identified as less suitable for a study interested in researching the resilience level of the gen- ...
... The results provided by the validation testing indicate a negative correlation between resilience, acute stress and psychosomatic symptoms. These results are in line with previous findings supporting the negative correlation between resilience and 'acute stress'[26][27][28] and 'psychosomatic symptoms'.[29][30][31] Evidently, a high resilience score is associated with reduced levels of 'acute stress' and reduced psychosomat-ic symptoms. ...
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Introduction: ‘Psychological Resilience’ is one of the key elements in human behavior that interplays with stress in mental disorders and physical illnesses in both healthy and unhealthy populations, regardless of their biopsychosocial background. Therefore, a reliable and valid resilience questionnaire for clinical and research use is of great necessity.Aim: Hence, the present study was conducted in order for the original English version of ‘Nicholson McBride Resilience Questionnaire’ (NMRQ) to be adapted in the Greek population.Methods & Materials: The original English NMRQ consists of 12 items measuring resilience. It is a self-reported questionnaire, while each respective item is measured through a 5-Likert scale point system. The design of the study was developed to firstly translate the original English questionnaire in Greek, and secondly to test the new version upon its ‘item consistency’, ‘internal correlation’, ‘internal consistency’, ‘consistency validity’, and finally perform a ‘factor analysis’ after recruiting a Greek sample.Results: The results show 80% validity (Cronbach’s alpha=.800) of the new Greek version. The number of participants (N= 1,158) provided to the study an ‘a priori’ odds ratio of 1.274, a critical z of 1.6448 and an actual power of 95%. The Greek translation was considered accurate, while the new version maintained a good item consistency.Conclusion: It is proposed that the Greek version of NMRQ may be adapted in the Greek population in clinical and research related to resilience and stress, as well as for any future studies to test-retest its validity and reliability.
... Research in outdoor recreation has focussed on healthy individuals, rather than clinically diagnosed patients, though a few studies have compared healthy and unhealthy subjects (Ower et al., 2018). Mental health benefits from activities in outdoor nature have been summarised in several recent reviews and meta-analyses (Bratman et al., 2019;Buckley & Brough, 2017a;Frumkin et al., 2017;Kondo et al., 2018;Oh et al., 2017;Seymour, 2016;Shanahan et al., 2016). ...
... Our participants are drawn from the clientele of an Australian tourism enterprise that offers three relevant products. The first consists of one-day hiking tours, now a widespread tourism product (Davies, 2018;Ower et al., 2018). The second consists of multiweek wilderness hiking and trekking tours worldwide, part of the global adventure tourism sector. ...
Article
Mental and social health outcomes from a portfolio of women's outdoor tourism products, with ~100,000 clients, are analysed using a catalysed netnography of >1000 social media posts. Entirely novel outcomes include: psychological rescue; recognition of a previously missing life component, and flow-on effects to family members. Outcomes reported previously for extreme sports, but not previously for hiking in nature, include psychological transformation. Outcomes also identified previously include: happiness, gratitude, relaxation, clarity and insights, nature appreciation, challenge and capability, and companionship and community effects. Commercial outdoor tourism enterprises can contribute powerfully to the wellbeing of women and families. This will be especially valuable for mental health recovery, following deterioration during COVID-19 coronavirus lockdowns worldwide.
... Time in nature supports physical health, mental health and overall quality of life. 1 Historically used as a therapeutic modality, 2 nature-based interventions (NBI) have seen a resurgence in the modern era. 3 As medicine has evolved, so have NBI. For example, treating tuberculosis with fresh air in the countryside has transformed into treating an array of maladies, including, but not limited to, high blood pressure, 4 psychosomatic disorders 5 and post-traumatic stress disorder 6 in a variety of settings ranging from city parks 7 to wildland areas. 4 8 With the emergence of NBI in the modern era, researchers are currently working to build empirical support and guidance for these interventions, including the NBI locations, outcomes and dose-response relationship. ...
Article
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Introduction Nature provides an array of health benefits, and recent decades have seen a resurgence in nature-based interventions (NBI). While NBI have shown promise in addressing health needs, the wide variety of intervention approaches create difficulty in understanding the efficacy of NBI as a whole. This scoping review will (1) identify the different nomenclature used to define NBI, (2) describe the interventions used and the contexts in which they occurred and (3) describe the methodologies and measurement tools used in NBI studies. Methods and analysis Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols Extension for Scoping Reviews, four databases will be searched (PubMed, Web of Science, Scopus, ProQuest Dissertations and Theses Global) as well as cross-referencing for published and unpublished (masters theses and dissertations) studies on NBI in humans. Eligible studies must employ intervention or observational designs, and an English-language abstract will be required. Database searches will occur from inception up to the date of the search. Animal-based therapies and virtual-reality therapies involving simulated nature will be excluded. Independent dual screening and data abstraction will be conducted. Results will be analysed qualitatively as well as with simple descriptive statistics (frequencies and percentages). Ethics and dissemination Since this is a scoping review of previously published summary data, ethical approval for this study is not needed. Findings will be published in a peer-reviewed journal. This protocol has been registered with Open Science Framework ( https://osf.io/mtzc8 ).
... Together with a regional above average participation in winter sport activities (13), due to effects of climate change on exercise behavior are believed to be large in Austria. Given the importance of outdoor exercise and previous findings of additional physical and mental health benefits of exercising in alpine environments in various populations (5,(14)(15)(16)(17)(18), it seems important to analyze determinants of exercise behavior in the context of climate change. ...
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Exercise, including winter sport activities, shows positive effects on physical and mental health, with additional benefits when participating in natural environments. Winter sport activities are particularly vulnerable to climate change, since global warming will decrease the duration and amount of snow. In the context of climate change in alpine environments, little is known on the determinants of winter sport behavior. Thus, the following study primarily aimed at comparing the effect of being exposed to a climate change affected scenario (CCA) or to a climate change unaffected scenario (CCU) on the intention to engage in recreational winter sport activities. Secondly, we aimed to analyze the role of anticipated affective responses during exercising based on the Theory of Planned Behavior (TPB). An experimental cross-sectional web-based study design was used. Participants were randomly allocated to pictures of either CCA or CCU. TPB variables and affective responses with regard to the displayed scenarios were assessed. Statistical analyses included Mann-Whitney- U Tests, linear regression, and mediation analyses. Significant group differences were seen in all TPB variables, p < 0.038; −0.13 < r < −0.30, as well as in affective responses, p < 0.001; −0.24 < r < −0.85. Lower intention to engage in winter sport activities and lower anticipated affective valence during exercising was found in CCA compared to CCU. Attitude toward winter sport was significantly positively associated with intention to engage in winter sport, beta = 0.66, p < 0.001. The effect of group allocation on attitude was mediated by anticipated affective valence, indirect effect = 0.37, p < 0.001. Intention to engage in recreational winter sport activities was lower in participants exposed to the climate change affected winter sport scenario. Since affective valence seems to influence attitude and consequently intention to exercise, the role of non-cognitive variables with regard to climate change related exposure should be considered in future studies. Therefore, winter sport resorts may consider altered winter sport behaviors due to the consequences of climate change as well as the importance of providing an optimal framework to enhance affective valence of their guests in order to mitigate potential changes in winter sports behavior.
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Common knowledge implies that individuals engaging in outdoor sports and especially in regular and extreme mountaineering are exceptionally healthy and hardened. Physical activity in outdoor environments has a positive effect on physical and mental health. However, regular and/or extreme mountaineering might share similarities with behavioural addictions and could thus also have a negative impact on health. In this cross-sectional web-based questionnaire study, we collected data on exercise and mountaineering addiction (Exercise Addiction Inventory; original and adapted version for mountaineering; Exercise Dependence Scale adapted version for mountaineering). Further surveyed parameters included mountaineering habits, Risk-Taking Inventory, Sensation-Seeking/Emotion Regulation/Agency Scale (SEAS), resilience, self-perceived stress, physical activity in metabolic units and mental health. Comparisons were performed between individuals with symptoms of addiction to mountaineering (MA) and individuals without symptoms of addiction to mountaineering or sports in general (CO) using non-parametric analyses. We analysed data from 335 participants, n = 88 thereof with addiction to mountaineering (MA) and n = 247 control participants (CO). The MA group scored significantly higher with regards to self-perceived stress ( p < 0.001) and included a significantly higher number of individuals affected by symptoms of depression ( p < 0.001), symptoms of anxiety ( p < 0.001), symptoms of eating disorders ( p < 0.001), alcohol abuse or dependence ( p < 0.001), illicit drug abuse ( p = 0.050), or current and history of psychiatric disorders ( p < 0.001). Individuals with MA showed higher values in all SEAS subscales as well as increased risk-taking ( p < 0.001). Regular and extreme mountaineering can display features of a behavioural addiction and is associated with psychiatric disorders. Behavioural addiction in mountaineering is associated with higher levels of sensation-seeking, emotion regulation, and agency, as well as increased risk-taking.
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Objective - This study aims to elaborate business resilience of small medium enterprises and to test the impact of rational and irrational antecedents of business resilience during COVID-19 crisis. Methodology/Technique - It is cross-sectional and causal study for testing five hypothesizes. Convenience approach was used as non-probabilistic sampling method. It involved 506 small medium enterprises in Jawa and Sumatera, the biggest islands in Indonesia. Collected data were structured with PLS based Structural Equation Modelling. Findings – The result explained that business resilience is influenced positively, directly, and significantly by business flexibility and workplace spirituality. Business flexibility is influenced by workplace spirituality, pro-social leadership, and alliance capability. Pro-social leadership of owners and/or managers influences implementation of health protocol and alliance capability. Novelty - This study has proved that business resilience has both sides of antecedents - in rational and irrational perspectives. Type of Paper: Empirical. JEL Classification: L26, L29. Keywords: Business Resilience, Small Medium Enterprise Reference to this paper should be made as follows: Saputra, N; Herlina, M.G. (2021). Double-Sided Perspective of Business Resilience: Leading SME Rationally and Irrationally During COVID-19, Journal of Management and Marketing Review, 6(2) 125 – 136. https://doi.org/10.35609/jmmr.2021.6.2(4)
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Background: The study of health-related quality of life (HRQOL) is an important topic in mental health around the globe. However, there is the need for more evidence about the cumulative influence of psychological variables on HRQOL. The main aim of the study was to evaluate how specific personality traits might explain scores in HRQOL and to explore how this relationship might be mediated by coping styles and psychological distress. Methods: Young Colombian subjects (N = 274) were included (mean age: 21.3; SD = 3.8). The Short-Form Health Survey was used to measure HRQOL. For assessment of psychological variables, the Hospital Anxiety and Depression Scale, the Zung Self-Rating Anxiety Scale, The Coping Inventory for Stressful Situations and the short version of Big Five Inventory were used. Results: The personality trait that was the best predictor of HRQOL was openness to experience, forming an explanatory model for HRQOL, along with emotional coping style and depressive and anxious symptoms. Emotional coping style and psychological distress were significant mediators of the relationship between openness and HRQOL. Conclusions: Our findings provide additional data about the cumulative influence of specific psychological variables on HRQOL, in a mostly young female Latin American sample.
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Sports psychiatry has developed for the past 3 decades as an emerging field within psychiatry and sports medicine. An International society has been established in 1994 and also national interest groups were implemented, mostly within the national organizations for psychiatry, some also containing the topic of exercise treatment of mental disorders. Where are we now 30 years later? We systematically but also selectively review the medical literature on exercise, sport, psychiatry, mental health and mental disorders and related topics. The number of publications in the field has increased exponentially. Most topics keep remaining on the agenda, e.g., head trauma and concussion, drug abuse and doping, performance enhancement, overtraining, ADHD or eating disorders. Supported by the growing literature, evidence-based recommendations have become available now in many clinical areas. A relatively new phenomenon is muscle dysmorphia, observed in weightlifters, bodybuilders but also in college students and gym users. Further, sports therapy of mental disorders has been studied by more and more high-quality randomized controlled clinical trials. Mostly as a complementary treatment, however, for some disorders already with a 1a evidence level, e.g., depression, dementia or MCI but also post-traumatic stress disorder. Being grown up and accepted nowadays, sports psychiatry still represents a fast-developing field. The reverse side of the coin, sport therapy of mental disorders has received a scientific basis now. Who else than sports psychiatry could advance sport therapy of mental disorders? We need this enthusiasm for sports and psychiatry for our patients with mental disorders and it is time now for a broadening of the scope. Optimized psychiatric prevention and treatment of athletes and ideal sport-related support for individuals with mental disorders should be our main purpose and goal.
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Introduction: Physical activity (PA) can play an important role in improving the mental and physical health in patients with mental disorders but is not well studied in this population. The aim of this study was to assess the status of PA in outpatients with mental disorders, compare the convergence of self-rating and accelerometer measurement and examine the influence of social cognitive variables from the Motivation-Volition (MoVo) model and clinical measures on PA. Methods: Eighty-four patients were recruited from three psychiatric outpatient clinics and local psychiatrists (Distribution of ICD-10-Diagnoses: F3.x = 59.5%, F4.x = 20.2%, F2.x = 17.9%, F1.x = 2.4%). PA, Self-efficacy, Outcome-expectancies, Intention, Self-concordance, Action- and Coping-planning, Health-related Quality of Life (SF-12) and Psychiatric Symptoms (SCL-27) were assessed through questionnaires. PA was assessed objectively by accelerometers. Results: Most of the participants did not reach PA recommendations. Subjective and objective measurement of PA showed good accordance for total PA on group level but lower accordance on individual level. Motivational and volitional determinants of health behavior change showed a similar pattern of correlations with PA as in populations without mental disorders. Conclusion: Outpatients with mental disorders have the ability and are willing to perform PA but a large proportion of our sample did not meet PA recommendations. To assess group levels of PA, subjective and objective measurement seem equally apt, for individual diagnostics, a combination of both should be considered. Social cognitive determinants of health behavior change seem to be as helpful for the design of PA interventions for patients with mental disorders as they are in other populations.
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The aim was to investigate the relationships between landscape-related personal and collective identity and well-being of residents living in a Swedish mountain county (N = 850). It was shown that their most valued mountain activities were viewing and experiencing nature and landscape, outdoor recreation, rest and leisure, and socializing with friends/family. Qualitative analyses showed that the most valued aspects of the sites were landscape and outdoor restoration for personal favorite sites, and tourism and alpine for collective favorite sites. According to quantitative analyses the stronger the attachment/closeness/belonging (emotional component of place identity) residents felt to favorite personal and collective sites the more well-being they perceived when visiting these places. Similarly, the more remembrance, thinking and mental travel (cognitive component of place identity) residents directed to these sites the more well-being they perceived in these places. In both types of sites well-being was more strongly predicted by emotional than cognitive component of place-identity. All this indicates the importance of person-place bonds in beneficial experiences of the outdoors, over and above simply being in outdoor environments.
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Background Regular physical exercise has been reported to reduce depressive symptoms. Several lines of evidence suggest that physical exercise may prevent depression by promoting social support or resilience, which is the ability to adapt to challenging life conditions. The aim of this study was to compare depressive symptoms, social support, and resilience between Japanese company workers who engaged in regular physical exercise and workers who did not exercise regularly. We also investigated whether regular physical exercise has an indirect association with depressive symptoms through social support and resilience. Methods Participants were 715 Japanese employees at six worksites. Depressive symptoms were assessed with the Center for Epidemiologic Studies Depression (CES-D) scale, social support with the short version of the Social Support Questionnaire (SSQ), and resilience with the 14-item Resilience Scale (RS-14). A self-report questionnaire, which was extracted from the Japanese version of the Health-Promoting Lifestyle Profile, was used to assess whether participants engage in regular physical exercise, defined as more than 20 min, three or more times per week. The group differences in CES-D, SSQ, and RS-14 scores were investigated by using analysis of covariance (ANCOVA). Mediation analysis was conducted by using Preacher and Hayes’ bootstrap script to assess whether regular physical exercise is associated with depressive symptoms indirectly through resilience and social support. Results The SSQ Number score (F = 4.82, p = 0.03), SSQ Satisfaction score (F = 6.68, p = 0.01), and RS-14 score (F = 6.01, p = 0.01) were significantly higher in the group with regular physical exercise (n = 83) than in the group without regular physical exercise (n = 632) after adjusting for age, education, marital status, and job status. The difference in CES-D score was not significant (F = 2.90, p = 0.09). Bootstrapping revealed significant negative indirect associations between physical exercise and CES-D score through the SSQ Number score (bias-corrected and accelerated confidence interval (BCACI) = −0.61 to −0.035; 95 % confidence interval (CI)), SSQ Satisfaction score (BCACI = −0.92 to −0.18; 95 % CI), and RS-14 score (BCACI = −1.89 to −0.094; 95 % CI). Conclusion Although we did not find a significant direct association between exercise and depressive symptoms, exercise may be indirectly associated with depressive symptoms through social support and resilience. Further investigation is warranted.
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Adventure therapy offers a prevention, early intervention, and treatment modality for people with behavioural, psychological, and psychosocial issues. It can appeal to youth-at-risk who are often less responsive to traditional psychotherapeutic interventions. This study evaluated Wilderness Adventure Therapy (WAT) outcomes based on participants’ pre-program, post-program, and follow-up responses to self-report questionnaires. The sample consisted of 36 adolescent out-patients with mixed mental health issues who completed a 10-week, manualised WAT intervention. The overall short-term standardised mean effect size was small, positive, and statistically significant (.26), with moderate, statistically significant improvements in psychological resilience and social self-esteem. Total short-term effects were within age-based adventure therapy meta-analytic benchmark confidence intervals, except for the change in suicidality which was lower than the comparable benchmark. The short-term changes were retained at the three-month follow-up, except for family functioning (significant reduction) and suicidality (significant improvement). For participants in clinical ranges pre-program, there was a large, statistically significant reduction in depressive symptomology, and large to very large, statistically significant improvements in behavioural and emotional functioning. These changes were retained at the three-month follow-up. These findings indicate that WAT is as effective as traditional psychotherapy techniques for clinically symptomatic people. Future research utilising a comparison or wait-list control group, multiple sources of data, and a larger sample, could help to qualify and extend these findings.
Article
Exposure to nature can strengthen an individual’s sense of connectedness (i.e., emotional/cognitive bonds to the natural world) and enhance psychological restoration (e.g., feeling relaxed/refreshed). To date, there have been few large studies looking at the role that type and quality of natural environments may have on these outcomes. The present study used data from a large survey in England (sample analyzed = 4,515), which asked participants to recall a recent visit to nature. After controlling for covariates, respondents recalled greater connectedness to nature and restoration following visits to rural and coastal locations compared with urban green space, and to sites of higher environmental quality (operationalized by protected/designated area status, for example, nature reserves). A series of structural equation analyses provided evidence for a bidirectional association between connectedness and restoration. Consideration of the psychological benefits associated with different types and quality of environment has implications for human health, environmental management, and conservation.
Article
Despite growing interest in the relationships between natural environments and subjective wellbeing (SWB), previous studies have various methodological and theoretical limitations. Focusing on urban/peri-urban residents (n=7272) from a nationally representative survey of the English population, we explored the relationships between three types of exposure: i) ‘neighbourhood exposure’, ii) ‘visit frequency’, and iii) ‘specific visit’; and four components of SWB: i) evaluative, ii) eudaimonic, iii) positive experiential and iv) negative experiential. Controlling for area and individual level socio-demographics and other aspects of SWB, visit frequency was associated with eudaimonic wellbeing and a specific visit with positive experiential wellbeing. People who visited nature regularly felt their lives were more worthwhile, and those who visited nature yesterday were happier. The magnitude of the association between weekly nature visits and eudaimonic wellbeing was similar to that between eudaimonic wellbeing and life circumstances such as marital status. Findings are relevant for policies to protect and promote public access to natural environments.
Article
Background: Few studies have examined the effects of resilience on quality of life (QOL) in patients with bipolar disorder (BD). Therefore, this study investigated the association between resilience and QOL in patients with BD and compared it to the relationship between resilience and QOL in healthy individuals. Methods: Participants were 68 euthymic patients with BD and 68 age-, sex-, and length of education-matched controls. Sociodemographic characteristics and clinical variables of the two groups were obtained using face-to-face interviews, and all participants completed the Connor-Davidson Resilience Scale, the World Health Organization QOL-Brief Form. Results: The QOL of the BD group was significantly impaired compared with that of the controls. Degree of resilience, number of depressive episodes, Clinical Global Impression scores, degree of impulsivity, and length of education were significantly correlated with QOL in the BD group. Resilience was significantly associated with overall QOL, physical subdomains of QOL, psychological subdomains of QOL, social subdomains of QOL, and environmental subdomains of QOL in the BD group, even after controlling for confounders. In the control group, resilience was significantly associated with overall QOL, the physical subdomains of QOL, psychological subdomains of QOL, and social subdomains of QOL. Limitations: The number of participants in each group was 68, which is a relatively small sample size. Conclusions: Resilience in patients with BD was independently and positively correlated with various areas of QOL. Various strategies to reinforce resilience in patients with BD are needed to improve the low QOL in this population.