‘Lifts your spirits, lifts your mind’: A co‐produced mixed‐methods exploration of the benefits of green and blue spaces for mental wellbeing

Abstract Introduction Mental health problems are a considerable public health issue and spending time in nature has been promoted as a way to access a range of psychological benefits leading to the development of nature‐based interventions for people with severe and enduring mental health problems. Less, however, is understood about the potential benefits and efficacy of day‐to‐day routine access to outdoor green and blue spaces for mental health service users. Methods Using a mixed‐methods design between April and October 2021, we explored the benefits and barriers to spending time outdoors with a purposive sample of mental health service users (N = 11) using qualitative interviews and an online general population survey (N = 1791). Qualitative evidence highlighted the restorative benefits of nature and identified a number of barriers associated with fears around personal safety, social anxiety, fatigue and lack of motivation. COVID‐19 had also restricted access to green and blue spaces. Having social contact and support encouraged people to spend time outdoors. In the quantitative survey, self‐report and standardised measures (the Patient Health Questionnaire and the Warwick–Edinburgh Wellbeing Scale) were used to assess past and current mental wellbeing. Findings Statistically significant differences were found between wellbeing and the use of green and blue spaces. Those with mental health problems spent time outdoors because they: felt guilty; wanted to reduce their anxiety; or rely on someone for encouragement. Those without mental health problems endorsed more positively framed reasons including relaxation, improving physical health or getting exercise. Barriers for people with mental health problems involved safety concerns, feeling anxious and having a poor self‐image. These findings give insight into motivations for an outdoor activity to help inform the design of public mental health interventions. Conclusion Further work is required to improve access and safety to promote the benefits of green and blue spaces for everyone. Patient or Public Contribution The research team included expert experienced researchers with a mental health service provider (Praxis Care) and they were involved in the development of the research idea, funding application, design, data collection, analysis, writing up and dissemination activities.


| INTRODUCTION
Spending time in nature has been connected to physical and mental health benefits and has led to the development of a wide range of nature-based interventions designed to promote wellbeing, physical health and social inclusion for people with severe and enduring mental health problems. 1 Disciplines, such as architecture, urban design, civil engineering and landscape architecture recognise the association between green and blue spaces and creating the physical and social context for people to live well. Mental health and addiction problems affect more than 1 billion people globally, 2 and are estimated to cost over $6 trillion by 2030. 3 People with mental health problems are at greater risk of developing life-limiting health conditions such as cardiovascular disease, diabetes and obesity. 4 Higher prevalence of risk-taking health behaviours and lower levels of physical activity contribute to these risks. 5,6 Structural issues that reduce opportunities for health promotion and treatment disproportionately affect mental health service users. 7,8 Specialist living and care environments can also help reinforce some of these negative health behaviours and do not adequately promote healthy lifestyle changes. [9][10][11] 'Green' spaces are urban or rural settings with natural vegetation, for example, woodland/forest, open countryside or city landscaping such as parkland, city trees, gardens or allotments; 'blue' spaces are characteristic of natural surface water including lakes, rivers or coastal waters but can include constructed urban waterways, canals or ponds.
Spending time outdoors can convey health and wellbeing benefits through a variety of means. Natural environments provide interest and offer opportunities to escape from daily hassles or worries 12 and provide a contrast to overstimulating urban environments that are less restorative. 13 Typically, outdoor space is used for physical activity and the mental health benefits of exercise have been well documented. 14,15 Even low levels of physical activity have the potential to improve cardiovascular health, 16,17 increase bone and muscle strength, improve sleep 18 and generate feelings of wellbeing. 19,20 Physical activity can help improve self-esteem which in turn is associated with healthy lifestyle behaviours. 21,22 Being outdoors creates opportunities to establish social networks and increase social capital that can contribute to wellbeing, [23][24][25][26] improve neighbourhood social cohesion and harness community engagement. [27][28][29] Associations between natural vegetation and lower crime rates have also been observed. [30][31][32] The economic benefits have also been researched. Saraev et al. estimated that visits to the UK's woodlands have helped cut costs associated with anxiety and depression by £185m (in 2020 prices) through a reduction in general practitioner (GP) visits, prescriptions, inpatient care and social services use. 33 Although the evidence base is limited, 34 access to light, fresh air and views of nature may increase wellbeing, job satisfaction, concentration and cognitive performance, and lower stress and depression. 12,13,24,[35][36][37][38] Good architecture acknowledges this established link by creating access to natural light and ventilation, forming landscapes and vistas to promote wellbeing and by limiting the use of toxic construction materials. Maximising the use of natural materials, and indoor and outdoor planting schemes create connections to the outside. 39,40 In healthcare settings, patients recovering from illness achieve better psychological wellbeing and support for their recovery when able to access the outdoors. [41][42][43] Even perceptions of one's health 44 and satisfaction with life may be improved by spending time outdoors. [45][46][47] Brief exposure can have beneficial effects. [48][49][50] As part of a study by the University of Essex, 48 the authors recommended that ecotherapy should be a clinically recognised prescription treatment for mental distress; care planning should consider access to green space and access to green space should be a human right.
National population data in Denmark found an association between a lack of access to green and blue spaces and up to a 55% chance of developing a psychological disorder. 50 People living in more deprived settings typically have less access to green and blue spaces. 51 While the many benefits of green and blue spaces have been explored, it is also possible for individuals to experience negative associations with green and blue spaces. Nature can evoke overwhelming, existential anxieties: climate change, the ruthlessness of survival within nature and the 'perspective-making power of nature, 52,p.376 can lead people to reflect on their life, and 'one's priorities and possibilities, on one's actions and one's goals' 53,p.197 .
Spending time in nature can compound feelings of isolation or be a reminder of how disconnected everyday life can be from the physical world. 54 We know less about the benefits and effectiveness of routine access to green and blue spaces for mental health users. To explore these issues further, we used a mixed-methods design to identify potential barriers to spending time outdoors with a purposive sample of mental health service users (N = 11) and a general population survey accessed online (N = 1791) (April-October 2021).

| METHODS
We used a co-produced sequential mixed-methods design. Thematic analysis of qualitative semistructured interviews, along with evidence from the research literature, was used to inform a cross-sectional online survey to answer two questions: 1. How do people experiencing mental health problems use and benefit from green and blue spaces? 2. And are there differences in the frequency and use of green and blue spaces between people with and without mental health problems?

| Impact of COVID-19
The original design involved walking interviews however COVID-19 restrictions meant face-to-face contact with research participants was prohibited. Telephone interviews were conducted instead.
Access to the Closing the Gap: Health and Wellbeing Cohort to sample a population with experience of a severe mental illness (SMI) was no longer possible due to working-from-home restrictions to ameliorate this, we distributed paper questionnaires within Praxis Care's supported living settings.

| Participants
Participants for the qualitative interviews were in receipt of a range of different services (e.g., supported living, day activities and befriending) and were invited to participate by the Head of Research  using the six-phase process described by Braun and Clarke. 55,56 This stepped approach involved (1) data familiarisation and writing familiarisation notes; (2) systematic data coding; (3) generating initial themes from coded and collated data; (4) developing and reviewing themes; (5) refining, defining and naming themes; (6) writing the report.

| Quantitative measures
Findings from the qualitative interviews and the research literature were used to develop a quantitative online survey using the Qualtrics™ platform. The short online survey was advertised online and included the following measures.

| Demographics
Demographic information: year of birth; gender identity; sexual identity; disability status; relationship status; dependents and carer status; employment status; household financial coping; ethnicity; current or previous mental health diagnosis; current medication; city/ country location.

| Mental health problems
Experience of mental health problems was assessed using a selfreport measure, endorsement of any of the following statements was coded as a dichotomous variable 'Yes' ('Yes, I have a current mental health problem diagnosed in the past 12 months'; 'Yes, I have a current mental health problem that was diagnosed MORE than 12 months ago'; 'Yes, I have been diagnosed in the past, but not currently experiencing any problems' or 'Yes, I have problems with my mental health but have never been diagnosed by a doctor') or 'No': 'I have no mental health problems'.

| Patient Health Questionnaire (PHQ-8)
The PHQ-8 is a well-validated self-report measure for assessing depressive symptom severity 57 demonstrating good internal consistency reliability (Cronbach's α = .82-.85). 58,59 It asks respondents to report 'Over the last 2 weeks, how often have you been bothered by…' mood, sleep, energy levels, appetite, self-esteem, and concentration. Based on the 9-item measure (PHQ-9), the PHQ-8 omits the suicide risk assessment. This question was excluded for ethical reasons because appropriate follow-up support could not be provided in our anonymised survey. The omission of the suicide risk item does not affect the reliability or validity of the measure. 60 Total scores were calculated by assigning counts to the response categories of 'not at all' (0), 'several days' (1), 'more than half the days' (2), and 'nearly every day' (3). A cut-off of 10 or greater was used to indicate a possible clinically significant level of depressive symptoms.

| Warwick-Edinburgh Mental Wellbeing Scale
The short version of the Warwick-Edinburgh Mental Wellbeing Scale (SWEMWBS) 61     Enjoying wildlife, specifically birds and birdsong, was mentioned by half of those interviewed, and functioned as a way of connecting with nature.
3.1.4 | Pure and cleansing elements of nature Nature was described as calming, soothing, and peaceful and expressed as pure and cleansing, 'I think it clears you and you are sharper, yes, that's the purification thing, it just gives; it's so inspiring' (Female 1, 47 years). Negative elements of the outdoors were also referred to as a source of anxiety including litter, dog fouling, rats and chewing gum on the pavements.

| Fear and safety
Fear and safety issues were raised in a number of different contexts.
Practical safety issues were a concern for some. Personal safety, traffic, lack of footpaths or fear of falling and injury was also a concern, 'I get anxious over my physical issues because I'm scared of falling' (Female, 55 years). Antisocial behaviour, such as alcohol and drug use in public spaces, was also considered a barrier.
Fear relating to social anxiety and experiencing panic attacks was expressed by a number of respondents trying to manage their negative feelings.

| Social aspect
The opportunity that public spaces provide to promote social cohesion also resonated with half of the respondents talking about the social aspect of spending time outdoors, whether this was 'talking and walking' (Male, 60 years) or having the opportunity to 'get to meet people' (Male, 34 years) and 'say hello, there is a kind of little community, social thing' (Female 2, 47 years).

| Impact of COVID-19
Many of those interviewed were vulnerable and became increasingly isolated during the lockdown. Some people relied on others to spend time outdoors, whether this was a family member or friend or the support services that Praxis Care offered. When these services were withdrawn, this impacted considerably their capacity to leave their home. 'Now, we can't meet people. People are important to other people. They help each other' (Male, 40 years).

| Barriers
A number of barriers to spending time in green and blue spaces were discussed. Lack of transport was an issue, especially for those living in rural areas. Physical health and tiredness could be a limiting factor, but problems associated with social isolation impacted being outdoors, 'It's just not a place I would go to on my own, you know, I wouldn't ever think of going to a park' because you would need company to go there (Female, 55 years). Mental health difficulties also could restrict attempts to socialise or leave the home, 'I went and nobody talked to me and then I got really down so that's why I don't go out much' (Male, 47 years).

| Facilitators
All of the interviewers were connected to Praxis Care, either as service users or employees, and reference was made to the support the organisation offered people, from providing social contact over the telephone, 'you know when you get the phone call, it makes you feel better, makes you think that someone is thinking about you "cause you get lonely on your own"' (Male, 47 years) to calling to the house and encouraging them to get some exercise and fresh air,   Table 1. 3.2.2 | Frequency, time of day and reasons for accessing green and blue spaces The majority of participants had access to green (90.8%) and blue spaces (69.6%) ( Table 2). People with no experience of mental health problems reported more frequent use of green and blue spaces, at least once or more than once a day compared to those with experience of mental health problems. A significant relationship was observed between self-reported mental health problems (χ 2 (6, N = 1704) = 23.57, p = .001) or current wellbeing using the PHQ-8 cutoff score of 10 or more (χ 2 (6, N = 1652) = 61.25, p < .000).
Respondents scoring 'high' on the SWEMWBS scale were also more likely than those rated 'low' or 'medium' to spend time outdoors at least once or more than once a day.
Asked to consider their activity over the past month, respondents endorsed the different reasons why they had spent time outdoors (Table 3). Again, statistically significant differences were reported between those with, and those without, mental health problems. Participants disclosing mental health problems were more likely to endorse psychosocial-related reasons for being outdoors including: 'to let off steam'; because I feel guilty when I stay indoors'; MCCARTAN ET AL.  10 scores may reflect the inclusion of a subclinical sample with mild depressive symptoms scoring between 5 and 9 on the PHQ-8.
Participants were also asked if there was a particular time of day that they preferred to go outdoors, multiple items could be endorsed (Table 4). Again significant differences were observed. Those with experience of mental health problems were more likely to endorse

| Facilitators and barriers to accessing Green and blue spaces
What encourages you to spend time outdoors?: Facilitators for those with experience of any mental health problems included 'my mood', 'the right clothing/shoes' and 'to get a break from other people'. For those without self-reported mental health problems were more likely to be encouraged by the weather to go outdoors than those with experience of problems (χ 2 (1, N = 1791) = 5.85, p = .016) ( Table 5).
The weather was also statistically significant for those scoring under  (Table 6). They were also more likely to find it 'difficult to   Relying on external motivators was more likely to be endorsed such as walking a pet and having someone to encourage them to get outdoors. There were no differences between the two groups in a number of aspects including taking part in planned outdoor activities such as walking groups and outdoor gyms. Spending time outdoors to improve concentration, and motivation or to work through a problem was also similar. Meeting up with friends and family was equally important to both groups. Like the participants in our study, the general public value the importance and benefits of green and blue spaces for wellbeing. 28 Given the imminent pressures of climate change, green and blue spaces can play a role in helping mitigate some of the environmental challenges of climate change 65,66 and integrate the central role that public and private access to green and blue spaces has in public mental health promotion. 67, 68 We face sustainability challenges, that require innovative and bold decision-making to transform urban and rural planning, incentivise environmentally sensitive building design and provide outdoor recreation and safe spaces for social activity. [69][70][71][72] Too often, poor housing stock in deprived areas serves mental health service users in residential settings, with limited access to quality green and blue spaces. 65

| Implications for policy and practice
It is clear that there are different barriers and facilitators for people who are experiencing mental health problems. The emerging evidence on the contribution that green and social prescribing can make to reduce mental health inequalities is encouraging. Mental health providers, GPs, social workers, education and workplace settings should be encouraged to respond to and incorporate the research learning to establish opportunities and experiences to engage with nature in recognition of its therapeutic benefits. The development of policy guidance would be a welcome starting point and would acknowledge the need to adopt and embed sustainable practices. Inequalities extend to access to green and blue spaces and planning policies already address the need for improving access but this does not tackle existing estate and the fact that social housing stock is often located in areas of social deprivation. Interventions that promote feelings of safety, and reduce anxiety via buddy systems/ could promote the social gateway to green and blue spaces.
Promoting the benefits of being outdoors should use appropriate and relevant language and identify goals for those experiencing mental health problems such as improving self-image, reducing anxiety, increasing social contact and enhancing mood. Improving access to green and blue spaces is a joint responsibility across government departments and policy needs to reflect this. The longerterm impact of COVID-19 on mental health is also an area of developing concern and we need to understand whether the impact of isolation has reinforced anxieties about being in now less familiar, crowded public spaces.

| Strengths and limitations
We were unable to access an SMI sample because of Covid restrictions.
To account for this deficit, we contacted service users living in supported living settings despite our directed efforts to recruit an SMI population, analyses found that almost half of the online participants reported mental health problems, including SMI. The majority of participants in the qualitative study were older adults therefore we cannot generalise these findings to younger people. Using MTurk to access a general population that included a large number of US participants and people were paid a small amount to participate, it is unlikely that participants were a random sample and therefore we are unable to generalise any findings to the United Kingdom.

| CONCLUSION
Promoting green and blue spaces as a mental health prevention, early intervention or treatment option could be a valuable public mental health approach, but it is important that access to safe spaces is improved through public planning and policy. Ways of providing access, on whatever scale, within the existing estate of supported housing for people with mental health problems should be considered. The importance of appropriate messaging could help promote the appeal of green and blue spaces to different users. More research is required into the routine use of green and blue spaces and the potential positive impact on wellbeing.