Second or third additional chemotherapy drug for non-small cell lung cancer i...
Gunnar Gunnarsson Master thesis, Friluftsliv And Health
1. What is the potential of Norwegian Outdoor Life Tradition
(Friluftsliv) in the Maintenance phase (III phase) of Cardiac
Rehabilitation?
A literature review with emphasize on selected theories and empirical
studies.
Supervisor: Prof. Yngvar Ommundsen
Norwegian School of Sport Sciences
Gunnar Gunnarsson
European Master in Health and Physical Activity
Norwegian School of Sport Sciences
2008
2. 2
ABSTRACT:
Background: In Norway, as in the rest of the world there is a high
prevalence of cardiovascular diseases (CVD). The main risk group of CVD
is elderly people, and their proportion in the society is growing. Due to
increased knowledge and new technology, there is an increasing survival
rate after cardiac events, creating a growing need for Cardiac Rehabilitation.
However, due to economical and organizational reasons, the rehabilitation
period at hospital and rehabilitation clinics is shortening. This diminishes
the chances that patients adapt to a new lifestyle during rehabilitation, and
they are therefore in danger of abandoning the active lifestyle when
returning back to their home.
Norway has a tradition for outdoor life, called “Friluftsliv”, which is highly
valued and is a popular form of recreational activity. Friluftsliv (Norwegian
outdoor life tradition) consists of dwelling and being physical active in
natural environment. Friluftsliv has developed through the years in a blend
with the Norwegian culture and identity. Together with its pedagogic and
mentoring tradition, Friluftsliv seem to represent an interesting context of
experience and activity in terms of cardiac rehabilitation.
Aim: The main aim of this literature review is to examine the health effects
of participating in Friluftsliv. To this end I search out for the health potential
of Friluftsliv for patients who return back home from rehabilitation clinics,
e.g. during the Maintenance phase of Cardiac Rehabilitation in Norway.
3. 3
Method: There is a lack of studies in Friluftsliv focusing on the health
effects. Hence, it was necessary to also build upon relevant literature from
the fields of Physical Activity and Health in general, and upon Agriculture
and Landscape Architecture (“Nature and Health”), when examine the
health potential of Friluftsliv. The literature review is focused on published
evidence based research identified in PubMed and Cochrane, plus
publications and reports from The Swedish Agricultural University, and
from the European Cooperation in the field of Scientific and Technical
Research (COST).
Conclusion: Friluftsliv seems able to not only support involved patients’
physical and psychological development, but also their social development.
With its own tradition of pedagogy, mentoring and its cultural heritage,
Friluftsliv can be a good alternative in Cardiac Rehabilitation in Norway.
Theoretical and empirical insight from the fields of Physical Activity and
Health and from “Nature and Health” adds validity to this conclusion.
Keywords: Friluftsliv, outdoor life, leisure time activities, outdoor
recreation, cardiac rehabilitation, occupational therapy, horticulture therapy,
Ecopsychology, public health intervention, community-based rehabilitation.
4. 4
TABLE OF CONTENTS:
1 INTRODUCTION: ................................................................................7
2 THEORETICAL AND EMPIRIC BACKGROUND ......................... 10
2:1 CARDIOVASCULAR DISEASES:........................................................... 10
2:1:1 Mental health: .......................................................................... 13
2:1:2 Cardiac Rehabilitation: ............................................................. 14
2:1:3 Cardiac Rehabilitation and Physical activity: ............................ 14
2:1:3:1 Development of Cardiac Rehabilitation: ............................ 17
2:1:3:2 Rehabilitation duration and adherence: .............................. 18
2:1:3:3 Social support and community settings: ............................. 20
2:2 NORWEGIAN OUTDOOR LIFE TRADITION (FRILUFTSLIV): .................. 21
2:2:1 Development of Friluftsliv and its role in personal and social
development...................................................................................... 23
2:2:2 Friluftsliv – instrumental approach: .......................................... 25
2:2:3 How people relate to Friluftsliv: ............................................... 27
2:2:4 Mentoring pedagogy in Friluftsliv: ........................................... 28
2:2:5 Friluftsliv phenomenology: ...................................................... 31
2:2:6 The potential of Friluftsliv in a rehabilitation setting: ............... 33
2:2:6:1 Physical Activity and Health: ............................................ 33
2:2:6:2 ” Nature and Health”: ........................................................ 35
2:2:6:2:1 Ecopsychology: .......................................................... 36
2:2:6:2:2 Horticulture therapy (HT): .......................................... 37
3 AIMS OF THESIS:.............................................................................. 38
5. 5
4 METHOD:............................................................................................ 41
4:1 SEARCH METHOD: ............................................................................ 41
4:1:1 Inclusion and exclusion criteria: ............................................... 42
4:2 LIMITATION: .................................................................................... 42
5 THE POTENTIAL OF FRILUFTSLIV IN CARDIAC
REHABILITATION:.............................................................................. 44
5:1 THE BENEFITS OF FRILUFTSLIV: ........................................................ 44
5:1:1 Physical benefits of Friluftsliv: ................................................. 45
5:1:2 Psychological benefit of Friluftsliv: .......................................... 46
5:1:3 Friluftsliv in a rehabilitation setting: ......................................... 47
5:2 PHYSICAL ACTIVITY AND HEALTH:................................................... 48
5:3 “NATURE AND HEALTH”: ................................................................. 50
5:3:1 Ecopsychology: ........................................................................ 51
5:3:2 Horticultural Therapy ............................................................... 54
5:3:2:2 Viewing natural scenes: ..................................................... 57
5:3:2:3 Being in natural environments: .......................................... 58
5:3:3 The use of nature in rehabilitation: ........................................... 59
6 SUMMARY.......................................................................................... 61
6:1 “NATURE AND HEALTH”: ................................................................. 62
6:1:1 Therapeutic work in “Nature and Health”: ................................ 63
6:2 FRILUFTSLIV AND HEALTH EFFECTS: ................................................. 64
6:2:1 The use of Friluftsliv in rehabilitation setting: .......................... 65
6. 6
6:3 WHAT IS THE POTENTIAL OF FRILUFTSLIV IN CARDIAC
REHABILITATION?.................................................................................. 66
6:4 THE LIMITATIONS OF THIS THESIS: .................................................... 69
6:5 FURTHER RESEARCH: ....................................................................... 70
7 CONCLUSION .................................................................................... 72
REFERENCE LIST................................................................................ 73
LIST OF TABLES:................................................................................. 83
LIST OF FIGURES:............................................................................... 84
7. 7
1 Introduction:
In Norway as in the rest of the world there is a high prevalence of
cardiovascular diseases (CVD) and is the number one reason for early death.
The main risk group of CVD is elderly people and their proportion in the
society is growing. Reports are also showing increasing incidences of CVD
at adulthood. For both groups the main risk factors are inactivity and
overweight, and studies show that these two risk factors are on the increase
in modern society. This result in a growing need for Cardiac Rehabilitation
(CR). Due to economical and organizational reasons the rehabilitation
period at hospital and rehabilitation clinics is shortening. This diminishes
the chances that patients adapt to a new lifestyle during rehabilitation, and
they are therefore in danger of abandoning the active lifestyle when
returning back home. Also, the long distances to rehabilitation clinics in
Norway makes this even more likely to happen.
The Norwegian Outdoor Life Tradition, or Friluftsliv is highly valued and is
a popular form of recreational activity in Norway. Friluftsliv consist of
dwelling and being physical active in natural or near natural environment.
Friluftsliv has developed through the years in a blend with the Norwegian
culture and identity. Together with it’s pedagogic and mentoring tradition
makes Friluftsliv interesting in terms of rehabilitation. The aim of this thesis
is to do a literature review in order to get a closer look at the potential of
Friluftsliv when patients return back home from rehabilitation clinics e.g.
the Maintenance phase or phase III of Cardiac Rehabilitation in Norway.
8. 8
Friluftsliv is included in health’s “White papers” of the Norwegian state and
is also popular as a method in rehabilitation clinics. Most of the studies in
Friluftsliv focus on pedagogic, cultural heritage and tourism, but there are
only few Friluftsliv studies focusing on the health effects of dwelling, or
being physically active in nature. Therefore by including literature of other
related professions, like the field of Physical Activity and Health and the
field of Agriculture and Landscape architecture, it seems warranted to
examine the potential of Friluftsliv.
This field of Agriculture and Landscape Architecture, which focus on the
health effects of nature, have I chosen to call “Nature and Health”. The main
contribution comes from Ecopsychology, with the active and holistic view
of the human-nature relationship. Ecopsychology emphasizes direct
experience of nature by being bodily active in contact with nature. The
studies focuses on the practical work in Ecopsychology, and examines the
health effects of working at farms and out in the countryside. The most
common therapeutic form of Ecopsychology is Horticultural Therapy (HT),
which ranges from the cultivation of plants to the appreciation of landscape.
In a rehabilitation setting, the results from HT studies are helpful when
working with people in need for rehabilitation, people with different
physiological and psychological disabilities, mental illness and mental
fatigue. The vast majority of the Friluftsliv activities, as in HT concern
direct contact between humans and natural environment. Therefore HT is of
9. 9
interest when examining the potential of Friluftsliv in a rehabilitation
setting.
Figure 1 includes the fields that are examined in this thesis to illustrate the
potential of Friluftsliv in Cardiac Rehabilitation in Norway. Chapter 2 will
focus on the status of Friluftsliv and Cardiac Rehabilitation and chapter 5
will examine empirical studies focusing on the health effects when
participating in Friluftsliv, both in leisure time and in a rehabilitation
setting. Supplemented by theory and empirical studies from the fields of
Physical Activity and Health and “Nature and Health”
The potential of Friluftsliv in rehabilitation setting
Cardiac
Friluftsliv:
with pedagogy and
Rehabilitation
cultural heritage in the Maintenance
phase (Norway)
“Nature Physical Activity
And Health” And Health
Ecopsychology
Horticultural
Therapy
Figure 1: a “bird’s eye view” of the topics of this thesis, which will be examined to
enlighten the potential of Friluftsliv in Cardiac Rehabilitation
10. 10
2 Theoretical and empiric background
2:1 Cardiovascular diseases:
The definition for health by WHO is the following: “A state of complete
physical, mental and social wellbeing, and not merely the absence of disease
or infirmity” (World Health Organization, 1946, p. 303). It emphasize that
it is not enough to cure diseases, but it is important to take into account the
person as a whole. The increasing prevalence of lifestyle diseases (Stene-
Larsen, 2006) will be a burden for both the patient himself and, will also
have a impact on his activity level, mental health, social life, work and
family (Satterfield, Volansky, Caspersen, & Engelgau, 2003). This is taken
into account in the International Classification of Function, Disability and
Health (ICF). The classification system does not only focus on the illness,
but also the patients surroundings, like family, work, leisure activities and
how the patient can manage to function in his own environment.
Worldwide there is an increasing prevalence of chronic diseases, as for
example Type II diabetes, overweight, cardio vascular diseases (CVD).
There are risk factors of these diseases, which are connected to people’s
lifestyle. CVD is globally the number one reason for early death, and two of
the main risk factors for developing CVD are inactivity and obesity. There
is a high level of physical inactivity reported in most industrialized countries
(Pratt, Macera, & Blanton, 1999), including Norway (Søgaard, Bø,
Klungland, & Jacobsen, 2000). In the case of obesity, a recent review
11. 11
reported that the proportion of obese (BMI >30kg/m2) Norwegian adults
has doubled over the last two decades and the situation is described as an
epidemic (Ulset, Rut, & Malterud, 2007).
In Norway, as in the rest of the Western countries, there has been a
reduction in mortality caused by CVD since the 80`. But still in 2004
Cardiovascular Disease was the main cause of death (Figure 1) and Heart
Attack and Stroke were the leading cause of mortality (38%) in Norway
(Nasjonalt Folkehelseinstitutt, 2006)
Cause of death 2004
Mental illness
Pulmonary diseases
Diseases
External reason
Mortality
Cancer
Unknown or undefined reason
Cardiovascular diseases
0 4000 8000 12000 16000
Mortality
Figure 2: In 2004 Cardiovascular diseases were the main cause of death in Norway
(Statistics Norway, 2006)
New statistics from 2006 show that since 2000 there has been 14,6%
increase in hospitalizing caused by CVD. Especially Heart Attack is
increasing (60%). There may be two reasons for this. First, a change was
made in the diagnostic system in 2000, which may have lead to an increase
in registered heart attacks. The other reason is probably reflecting an
12. 12
increase of the group at risk or those who have passed the age of 60. In the
case of Heart Attack, 3 out of 4 hospitalizations where patients older than 60
year old, and 2 out of 3 were men (Statistics Norway, 2007).
In many industrialized countries, the percentage of the population that is
elderly is rising; more people are surviving with conditions that in the past
were fatal, and the prevalence of obesity and a sedentary lifestyle are still
increasing. Due to increasing obesity and sedentary lifestyle, CVD is no
longer a disease only among the elderly but also among the younger
generations. As a result, the number of people living with a chronic illness is
rising rapidly. In Norway there is no registration of how many live with
morbidity as a result of CVD, but in the UK the proportion of people living
with a chronic condition has risen from 21% in 1972 to 35% in 2002. And
17% of those with a chronic condition, have a cardiovascular illness or
hypertension, and approximately 25% have three or more chronic health
problems (Pattenden & Lewin, 2007). This means that more people are in
need of care.
Atherosclerotic cardiovascular diseases are the major cause of death in
middle-aged and older-adults in most western countries, including Europe.
In addition, atherosclerotic diseases, of which coronary artery disease is the
most common, result in substantial disability, a loss of productivity, and
contribute considerably to the escalating costs of health care, especially in
regard to an ageing population. For those patients already identified as
having cardiovascular diseases, the prevention of subsequent cardiovascular
13. 13
events while maintaining adequate physical functioning and independence,
and a good quality of life, are thus major challenges. The results of
EUROSPIRE II (EUROASPIRE II Study Group, 2001) study show that too
many patients are not receiving appropriate therapeutic interventions
(cardiac rehabilitation) or health behaviour advice.
2:1:1 Mental health:
Acute cardiovascular events strongly affect people’s psychological
condition. After a myocardial infarction, about 70% of patients report
fatigue or lack of energy and are concerned about issues like physical
health, return to work, sex life, the possibility of engaging in physical
activities, and of living an enjoyable life in all aspects (Doerfler, Pbert, &
DeCosimo, 1997). Around 15-20% of patients develop signs of depression,
which increases the risk of future cardiac events (Carney et al., 1987; Welin,
Lappas, & Wilhelmsen, 2000), and this is especially the case if there is also
lack of social support (Horsten, Mittleman, & Wamala, 2000). But it has
been shown is several studies that patients, who participate in cardiac
rehabilitation programs, report improvement in well-being, health, and
physical abilities. They also consume less tranquillisers and are less
depressed compared to patients not enrolled in cardiac rehabilitation (Lavie
& Milani, 1997; Milani, Lavie, & Cassidy, 1996).
14. 14
2:1:2 Cardiac Rehabilitation:
The Rehabilitation of cardiac patients, is the sum of activities required to
influence favourably the underlying cause of the disease, as well as to gain
the best possible physical, mental and social conditions, so that they may by
their own efforts, preserve or resume when lost, as normal a place as
possible in community (World Health Organization Expert Committee,
1993).
Cardiac Rehabilitation is by WHO been divided into 3 phases (ibid):
(I) The Acute phases
(II) The Reconditioning phase
(III) The Maintenance phase.
The aims of Cardiac Rehabilitation phase I-III is to facilitate recovery
(Cardiac Rehabilitation) and to prevent future cardiac illness (“secondary
prevention”) (Vanhees, McGee H, Dugmore, Schepers, & Van Daele P,
2002)
2:1:3 Cardiac Rehabilitation and Physical activity:
Therapeutic exercise training is an accepted adjunct to medical therapy in
the management of many chronic diseases. There is evidence that exercise
training leads to potential central (cardiac) and peripheral (skeletal muscle)
beneficial adaptation and can give significant improvements in exercise
tolerance and symptoms in cardiac patients (Belardinelli, Georgiou, Cianci,
15. 15
& Purcaro, 1999). A Cochrane review, confirmed a 27% reduction in all
cause mortality with exercise based cardiac rehabilitation (Jolliffe et al.,
2008) Moreover, systematic physical activity may reduce anxiety and
enhance well-being, and quality of life in these patients (Belardinelli et al.,
1999; Willenheimer, Erhardt, Cline, Rydberg, & Iraelsson, 1998).
In a literature review evaluating the evidence-base of exercise therapy the
authors estimated that physical training has strong or moderate positive
effect on disease pathogenesis in 50% of chronic diseases included in their
review (9 of 18). They documented that physical fitness or strength can be
increased in most diagnoses (strong or moderate evidence in all 18
diagnosis). This shows that good fitness level often means less symptoms
and less disability in daily activities (Pedersen & Saltin, 2006). Also during
maintenance phase (phase III) in Cardiac Rehabilitation, physical training is
favourable because it leads to reinforcement of physical condition and
healthy lifestyle(Vanhees et al., 2002).
Studies in CR show that exercise training of lower intensity can produce
improvements in functional capacity comparable to those produced by
higher-intensity exercise. The lower-intensity exercise is characterized by
greater safety, which is particularly important if exercise sessions are
unsupervised; it causes less discomfort and is more enjoyable, and thus
makes adherence to the recommended exercise regime more likely. Also the
largest benefit in terms of mortality (30-40% reduction), does appear to
accrue though engaging in moderate activity levels. That means activity
16. 16
performed at an intensity of 3-6 MET’s, or like brisk walking for most
adults (Paffenbarger, Hyde, & Wing, 1994). But maybe the most important
is that for each 1 MET improvement in exercise capacity, which is
achievable for most people, is associated with large (10-25%) improvement
in survival (Myers, 2007). And among patients who can safely perform
modest levels of dynamic exercise, the relative safety and substantial value
of low-intensity isometric or resistive (strength training) exercise, have also
been identified (Mathes, 2007). An increasing amount of recent research has
demonstrated that resistance training not only improves both muscular
strength and cardiovascular endurance, but it also has positive influence on
existing conditions such as hypertension, hyperlipidemia, obesity, and
diabetes (Graves & Franklin, 2001).
There are studies showing that exercise-based CR not only increases
exercise tolerance, as maximum oxygen consumption, but also health-
related quality’s of life (HRQoL) (Friedman, Thoresen, & Gill, 1986; Rees,
Bennett, West, Davey, & Elbrahim, 2004). But the patient’s own perception
of health status does also have an influence on clinical outcomes; for
example, the perceived ability to exercise correlates better with the
resumption of work than the objective measurements of exercise capacity
during formal testing. And there is substantial correlation between
perception of health status and returning to usual family and community
activities, and recreational and occupational pursuits. And most importantly,
this perception can be favourably altered by education and counselling
(Friedman et al., 1986)
17. 17
2:1:3:1 Development of Cardiac Rehabilitation:
Initially physical activity in Cardiac Rehabilitation was done outdoors and
the intension was to improve symptoms and physical capacity. For more
than 200 years ago, Herberden observed the beneficial effects in a patient
being advised to saw wood for 30 minutes daily over a 6-month period.
And the first person to introduce exercise systematically into the therapy of
cardiovascular disease was M. Oertel in 1875 (Oertel, 1891). He
successfully treated a patient with overweight and shortness of breath with
an increasing number of steps in a hilly terrain, the “Terrain-Kur”, which
became popular in the ensuing years. In Europe the rehabilitation clinics
were build in rural surroundings, but the tendency now a days is that when
the economy is lagging, the number of rehabilitation centers decline, and are
being replaced by ambulatory programs for outpatients (Mathes &
Halhuber, 1982).
The use of home-based rehabilitation programs is now also more frequently
used after hospital discharge and sometimes even after an ambulatory
program. The disadvantage of home-based rehabilitation is the lack of
contact with other people. That is why specialized sports clubs or
specifically designed heart groups may be better to facilitate long-term
secondary/preventive lifestyle (Vanhees et al., 2002). But the use of home-
based exercise training is safe, and studies even demonstrate higher
symptomatic benefit after combined home- and hospital-based training
18. 18
programs, than in the hospital-based only programs (Piepoli, Flather, &
Coats, 1998).
The exercise training programs for cardiac patients have different level of
supervision, depending on the time after the cardiac event and the risk for
developing cardiac complications during exercise. For patients who are
evaluated at low-risk at 12 weeks after the cardiac event, there is no
supervision needed. The use of electrocardiographic monitoring may be
appropriate during the first 6 to 12 sessions, but being gradually reduced to
once a week or once a month. For patients, which are evaluated at low-risk
12 weeks after index may enter a gymnasium- or community-based program
that offer controlled exercise in an enjoyable environment. This is the ideal
setting to promote self-confidence and risk factor control. Patients have the
opportunity to exchange experiences with each other, and group activities
help them to increase exercise adherence. For low-risk patients, home
exercise rehabilitation is an alternative to supervised group programs
(Moraes & Ribeiro, 2006).
2:1:3:2 Rehabilitation duration and adherence:
Despite the knowledge of beneficial effects of cardiac rehabilitation is there
low adherence to cardiac rehabilitation programmes; in USA it is only 10-
20%, and in UK 14-23%. A study done among patients from one of the
private cardiac hospitals in Norway, Feiringkliniken (n=398) reported
similar percentage. Only 20% of patients after ACB or PCI did participate in
19. 19
cardiac rehabilitation (Grimsmo & Vold, 2005). Further, in addition to this,
in 2006 there was a 16% reduction in rehabilitation capacity in Norway
(Norsk Pasientregister, 2006). This fact together with other difficulties, such
as lack of motivation, financial problems, the need for speedy job
resumption or timetable conflicts also prevent patients from participating in
a CR program - the first step in a lifetime intervention. Moreover, the Health
care systems, insurance companies and financial restrictions have lowered
the payment and reimbursement for CR in the last decades. Consequently,
interventions have shortened from the typical 3-6 months to some weeks, a
time period insufficient to promote long-lasting behaviour change. This was
supported by the EUROASPIRE II study conducted in 15 European
countries. Results showed that there was a large potential and need for
secondary implementation, because many patients have not adopted
appropriate lifestyle or are even not taking the medications as recommended
(EUROASPIRE II Study Group, 2001). By being a long-lasting intervention
with significant financial and personal costs, the maintenance phase (III
phase) carries a significant risk of being quickly abandoned. Patients may be
frequently asymptomatic, previously sedentary and not wishing to do any
lifestyle changes (Ockens, Hayman, & Pasternak, 2002). This often results
in progressive decay in program compliance by the patients. In a study by
Dorn and coworkers, only 13% of the participants were still exercising 3
years after the program started (Dorn, Naughton, & Imamura, 2001). By
being aware of the typical drop-out factors (Ockens et al., 2002) and at the
same time organize the programmes in cooperation with the patients,
20. 20
enhanced compliance can be ensured. Performing the exercise in groups
might be preferred for the maintenance phase as the patient will benefit
from psychosocial support within the group (Donovan & Blake, 1992).
2:1:3:3 Social support and community settings:
There is a good deal of evidence to support the use of peer mentors with at-
risk patients. Peer Mentors can provide social support to decrease heart
disease-related depression, encourage healthy recovery, and decrease
hospital readmission rate (Cashen, Dykes, & Gerber, 2004). And peer
support groups for people 12 months after a cardiac event, led to an increase
in physical activity and smoking cessation (Hildingh & Fridlund, 2003).
Not only do studies show positive results for the patient but also for the peer
mentor/advisor (Whittemore, Rankin, & Callahan, 2000).
Rehabilitation intervention are often implemented at a hospital or
rehabilitation clinic (inpatient/outpatient) but emerging evidence support the
safety and effectiveness of rehabilitation in other settings, such as
community centres and homes (Marchonni et al., 2003). Three decades ago
the World Health Organisation (WHO) introduced the community-based
rehabilitation (CBR) strategy, and in a modern health care system
encouraging cost-effective methods, CBR is becoming an attractive method
because of the low cost profile (Sharma, 2007). The primary aim of CBR is
to provide primary care and rehabilitative assistance to persons with
disabilities, by using human and other resources already available in their
21. 21
communities. In most countries CBR has been connected to the health care
system but most of the success histories comes from where CBR is
connected to private institutions or organisations (Ingstad, 2001). In
Scandinavia it is especially private organisations that has used CBR in their
organisations, adapting the CBR to the ideology of Scandinavian
rehabilitation of normalisation, integration and equal opportunities for
everybody (Ingstad & Eide, 2007).
2:2 Norwegian Outdoor Life Tradition (Friluftsliv):
In this thesis the focus is on rehabilitation and secondary prevention. Hence,
the spectrum of Friluftsliv will be limited to daily activities in local outdoors
environments, or tours varying no more than one day (Norwegian: Nærmiljø
Friluftsliv).
The definition for Friluftsliv used in this thesis is: “Friluftsliv includes both
dwelling and being physically active in the outdoors in leisure time, to
achieve a change of environment and to experience nature”(my translation)
(White Paper no 39 (2000/2001), 2001, p. 11)
This is a vast and open definition, which includes almost every form of
recreation in leisure time but the emphasis is on experiencing nature. The
main issue is to regard Friluftsliv as a simple and ecologically responsible
way of spending time outdoors. It should be practised in an
environmentally responsible way, where ecological diversity is cared for.
The emphasis is also on non-competitive activities and use of non-motorised
22. 22
and simple equipment. The essence is the good balance between man and
nature, as well as the social fellowship between people when spending time
outdoors (Westersjø, 2007).
Norway has a population of 4.6 million people and Friluftsliv has enormous
popularity and is highly valued by the nation. For example, more than 80%
of the Norwegian population practice some kind of outdoor activity at least
10 times a year (Vaage, 2007). And the strongest reason for why people like
to be active in Friluftsliv is experiencing nature and silence, and
contemplation (MMI/FRIFO, 1993). But also the excitement of mastering
Friluftsliv activities, playing and having fun, the social aspect and the
feeling of responsibility when participating in Friluftsliv (Vorkinn M.,
Vittersø, & Riese, 2000). When asked about what is necessary for living a
good and healthy life and what is important for the individual identity, 19
out of 20 Norwegian mentioned “nature”(White Paper no 39 (2000/2001),
2001).
In White Paper nr. 39, the Norwegian government has stated that Friluftsliv
may be the road to a better quality of life (White Paper no 39 (2000/2001),
2001). Also the white paper called “Prescription for a healthier Norway”, an
official document on Norwegian Health Policy, includes Friluftsliv in the
chapter called “To choose a healthier lifestyle” (White Paper no 16
(2002/2003), 2003) Given this common acceptance and statements from the
state of Norway, Friluftsliv is often used as a part of rehabilitation
interventions(Bischoff, Marcussen, & Reiten, 2007). This seems the case
23. 23
despite of the shortage of evidence based studies evaluating the health
effects of Friluftsliv and supporting the use of it in rehabilitation settings.
2:2:1 Development of Friluftsliv and its role in personal and
social development.
Friluftsliv is heavily influenced by the Norwegian culture of harvesting by
Norwegian small –holders but also by English mountaineers, the explorer
Fridtjof Nansen and the Deep Ecology movement of the 1970s. The
Norwegian outdoor tradition is reputed for its holistic approach to living
close to nature. The industrialisation came late to Norway and same with the
urbanisation. There were few landowners and a negligible aristocracy.
Hence huge tracts of common land were accessible to the Norwegian
people. Furthermore, the judiciary which “advanced the land user rather that
the landowner’s right” supported liberal land ownership, which encouraged
people to journeying and harvesting in the woods, mountains and coastal
waters (Tordsson, as cited in (Westphal, 2006, p. 134)). Due to this easy
access to land, gathering berries, fishing and hunting for food this became
one of the main strands of Friluftsliv. And in 1957 the Parliament ensured
by the law: “Friluftsloven” (Outdoor Recreation Act), that Norwegians
could continue travelling through both uncultivated and cultivated land
when accessing recreational areas. This right is called: “Allemannsretten”
(Mytting & Bischoff, 2001). In this way nature became a resource, and
together with Friluftsliv became a part of the Norwegian identity. The
explorer and scientist, Fridtjof Nansen (1861-1930) was one of the most
24. 24
important figures for Norwegian Friluftsliv. Nansen said in a speech to
students in 1921: “In the wilderness, in the loneliness of the forest, with a
view towards the mountains and a distance from glamour and confusion –
this is where personalities are formed.” (Reed & Rothenberg, as cited in
(Westphal, 2006, p. 144)). And in the years after World War I Friluftsliv
was gradually perceived as means of smoothing or even solving society’s
problems such as the moral and physical decay, which was prevalent at that
time. Also, The Norwegian Trekking Association (DNT) started in 1932 to
organize group tours into the mountains, which was increasingly
acknowledged as an effective tool for personal and social development
(Westphal, 2006).
In the 1970s and 1980s came a massive protest against western societies and
its excessive exploitation of natural resources (Breivik, as cited in
(Westphal, 2006)). The modern society was believed to be on a collision
course with nature. Friluftsliv acted as an antidote to this development and
at the same time the “Deep Ecology” emerged. This branch of Ecological
philosophy considers mankind as an integral part of its environment and
gets its inspiration from the philosophical works of Spinoza, Buddhism and
Gandhi (Næss, as cited in (Westphal, 2006)). It was acknowledged that
Deep-Ecological Friluftsliv could offer its followers the opportunity to
acquire life-skills that would “tackle life as such” and transfer systemic
symbolic experience such as “the seasonal rhythm of the year, the rhythm
with landscapes and waves” into holistic skills needed to support the work-
25. 25
life balance of daily routines (Myksvold, as cited in (Westphal, 2006, p.
151)).
In the years after World War II Norway had enormous increase in wealth,
resulting in massive demographic change. For instance in pre-war Norway
only 30% of Norwegian lived in urban or populated areas, whereas this
figure rose to more than 70% by the end of the century. As a result, the
harvesting tradition in rural areas became less important and Friluftsliv
became an outdoor activity for the “urbanized well-to do people from the
cities” in their leisure time (Pedersen, as cited in (Westphal, 2006, p. 155)).
Gradually Friluftsliv lost its political force to improve society (Tordsson, as
cited in (Westphal, 2006)) at the same time the emphasis on deep-ecological
Friluftsliv waned and the strands of Friluftsliv assumed a character of
diversity.
2:2:2 Friluftsliv – instrumental approach:
One of the new dimensions of friluftsliv that grew up was an instrumental
approach, where Friluftsliv was used as an instrument or a pedagogic
method to gain a goal. The working areas were therapeutic groups,
management training, integration of ethnic groups, and personal
development where teamwork (Bischoff & Odden, as cited in (Westphal,
2006)). At the same time Scandinavians (Norway, Denmark and Sweden)
became introduced to the Anglo-American approach of using outdoor life to
personal and social development (Sjong, as cited in (Westphal, 2006)). And
26. 26
some innovative rehabilitation clinics, like Beitostølen Helsesportsenter,
Valnesfjord Helsesportsenter and Atføringssentret i Rauland embraced a
Friluftsliv-inspired therapeutic approach to learning, and they demonstrated
their faith and commitment to Friluftsliv as a worthy educational tool
(Bischoff et al., 2007). But despite its apparently growing acceptance in
Norwegian practice, the instrumental strands of Friluftsliv holds less sway
as a solidly anchored concept compared to traditional Friluftsliv (Westphal,
2006). The Anglo-American personal and social development approach in
outdoor life is far more consolidated and explicit in its practice than the
Norwegian Friluftsliv, which favour the implicit nature of personal social
development-related learning in the context of Friluftsliv (Norwegian: “Det
kommer av seg selv” My translation: It will emerge by itself) (Sjong, as
cited in (Westphal, 2006)). The Anglo-American approach utilises the
outdoors in order to empower the individual (Wood, as cited in (Westphal,
2006)) by focusing on individual competence like `self-development`, `self-
esteem` and `self-efficacy` (Bischoff, as cited in (Westphal, 2006)).
However, this focus on individual competence does not fit so easily into the
Norwegian tradition of Friluftsliv with its value and belief system which is
historically rooted in ego suppressive and lateral thinking through its
egalitarian tradition (Westphal, 2006). In the Friluftsliv’s tradition the
potential as personal and social development instrument lies implicit in it. It
is represented as values that may contribute to human development. It is
possible to explore and utilise these values by selecting the proper
environmental context and the challenge level of the tour. This is labelled
27. 27
“inherent pedagogy”, which is “pedagogy which builds on the ability to see
the inherent qualities, potential and leadings in situations. The pedagogue
has the job to find, pick up and clarify, structure and use situations which in
their own way to communicate the message” (Tordsson, as cited in
(Westphal, 2006, p. 209)).
2:2:3 How people relate to Friluftsliv:
There are 3 different explanation models on how people relate to
Friluftsliv:
• The biological explanation is that we as human beings belong to the
nature. When on hike we fall into a way of living, which we as
human beings are adapted to and in which simple rules of surviving
are ruling. The idea is that as a result of long evolution, we have
developed and adapted to the environment in ways, which has given
us the best possibility of surviving.
• The second explanation, Friluftsliv is a socio-cultural phenomenon,
is most commonly used one in Norwegian studies of Friluftsliv.
According to this view, Friluftsliv is important as a cultural identity
and cultivates important values in Norwegian society. Friluftsliv is
something as we as a nation has sculptured, and we are proud of it.
Friluftsliv is something that is learned, embedded in the culture and
is taught from one generation to the next generation.
28. 28
• The third and last explanation model is more of an
phenomenological perspective in the view of Friluftsliv as a
phenomenon of its own. In this way Norwegian Friluftsliv is
explained from the inside, from how we arrange Friluftsliv in a way,
which is a contrast to our everyday living. And gives us the
possibility to experience life in another way than in our routine life.
This is where phenomenology and Merleau-Ponty enters the scene
with the aspect of studying phenomenon from the inside and
emphasize how the body and our behaviour are important for how
we experience our environment. In Friluftsliv, this can be
understood as every situation has its own possibilities, problems and
pedagogic potential: each situation communicates different message,
which we need to percept and the body will react to by adjust to the
situation (for further details see chapter 2:2.5). In this way,
Friluftsliv can give the feeling of meaningfulness where information,
both conscious and unconsciously, is creative and reflectively
processed. (Tordsson, 1999).
2:2:4 Mentoring pedagogy in Friluftsliv:
Through the years Friluftsliv has developed its own mentoring didactic,
which emphasize group development, situational and process orientated
mentoring. At the same time it focuses on experiencing the nature, both as a
goal on its own but also as a method to influence people with respect to
environmental issues. The Norwegian Friluftsliv mentoring didactic is
29. 29
influenced by gestalt pedagogic, which emphasize experience of wholeness
and relatedness between human being and the environment. The Deep
Ecology movement, which has influenced the development of Friluftsliv,
states that it is not possible to separate nature, consciousness, ego and the
society surrounding us (Sendstad, 1992).
When participating in Friluftsliv, everyone has the change to try out new
roles as for example being a leader or having a role that includes
responsibility. This is not only meant as an individual challenge but also as
a part of a socialisation process in to the group, which they are apart of. In
that way the participants are able to experience how their decision will
affect others and try to predict consequences of their choices. The
participants need to learn from their own decision-making, and the group as
a whole, which will act as a reference on how well it worked. All group
members are considered equal and have experience, knowledge and
motivation, which is important for the group. The knowledge exchange
often happens while being active, but will also happen automatically when
sitting around the campfire. People experience situations differently and will
therefore have different perceptions, which gives the participants the chance
to learn from one another and make each other more conscious of different
angles of view. The campfire is a context that invites participants to dwell,
reflect and share experiences and knowledge. The situation is one where
culture, language and context melt together and includes everybody sitting
around the campfire.
30. 30
One definition of mentoring in Friluftsliv is: “a special process orientated
mediation method, which focus on groups activities and direct contact with
nature” (My translation) (Tordsson, 1993) Mentoring in Friluftsliv is meant
to help people with individual problem solving, and by working in groups
find solutions to challenges. And at the same time by using the context of
Friluftsliv, participants experience joy, teamwork, satisfaction, quality of
life, responsibility for them self and nature.
The goals by mentoring in Friluftsliv have been formulated by Tellnes as:
• Mediate the experience of untouched nature, which can give the
feeling of happiness and quality of life
• Developing deeper connection to the untouched nature, which may
lead to the feeling of responsibility in environmental issues
• Develop the ability of critical analyse of the way of living in modern
society, and be aware of the consequences these may lead to.
• Inspire to change lifestyle; to more simple and “richer” life
• Mediate the individual ability to cooperate, responsibility and to
personal development (Tellnes, 1992)
Friluftsliv has developed some pedagogic principles, like “tur etter evne”
(my translation: adapted tour to ones ability). This means the abilities of the
participations should always be attuned to the demand of the tour. This is
not only meant as to secure a pleasant hike but is an important security
principle which will allow the mentor and the participants to accomplish
their tour goal. The mentor needs to be experienced to accomplish this, and
31. 31
by doing so this will train the participant in their ability to evaluate if they
have the ability to sustain the demands of the nature. By following this
principle of “tur etter evne” (adapted tour to ones ability) there will be a
progression in the ability by the participations by every tour they do. An all
to soon progression will act as guiding and leave out the support that
enables the participant for self-help (Tordsson, 1993).
2:2:5 Friluftsliv phenomenology:
It is a common belief in Norway that Friluftsliv includes everyone who
wants to participate and gives the opportunity to explore nature, not only by
being physically active but also by dwelling and experience the nature.
Friluftsliv is a holistic physical activity, which includes people physically,
psychologically and intellectually. When in nature you need to be active, not
only with your body but also intellectually when experiencing/sensing the
natural environment. Mother Nature can be friendly and hostile, warm or
cold, beautiful or horrific and more, all at the same time. At the same time
as we explore and react to the nature, we do explore our self, how we react
both physically and psychologically. The interaction between people and
nature in Friluftsliv has been explained as:
1. In Friluftsliv we perceive the nature by its different qualities. To
experience the nature is to acknowledge these qualities and accept
them.
32. 32
2. In Friluftsliv we belief that the nature communicates with us. Nature
approaches us as a whole person; our body with it’s capacity to
perceive intellectually and emotionally.
3. We express our understanding of nature by specific bodily action
where we interact with the nature
4. In the fundamentals of Friluftsliv lies the belief that the experiences
in nature add in a valuable way to us as human beings. Not only do
we explore the nature, but also our self in the interaction with nature,
which can give us the experience of happiness as well as contribute
to personal and social development (Tordsson, 1999).
Friluftsliv often seek to the philosophic ideas of Merlau-Ponty, because one
of the key elements of his phenomenology is that it is not possible to
separate body and mind. The one can’t work without the other. Or as
Merleau-Ponty says: “We are our bodies” and for him consciousness was
not just something that goes on in our heads. Rather, our intentional
consciousness is experienced in and through our bodies (Duesund, 1995, p.
31). We experience our body, both as subject when we are physically active
and as object when reflecting about our self. The objective body is visible
when we reflect over the body. Such visibility is not possible without the
subjective body. The body cannot be only subject or object and it is not
possible to make them independent of one another. Merleau-Ponty argued
that it is when being physically active that we come close to experience of
the subjective and objective body at the same time. We are being active
33. 33
without thinking about what we are doing or in other words we forget our
bodies and are just active (Duesund L., 1999).
2:2:6 The potential of Friluftsliv in a rehabilitation setting:
Traditional Friluftsliv includes many different activities as hiking, canoeing,
cross-country skiing, climbing, gathering berries and mushrooms, which
require different levels and type of physical activity. In some form of
Friluftsliv, physical activity is important but in other not so important. In
traditional Friluftsliv experiencing nature has been key elements (Hegge,
1990) and from a phenomenological perspective this is only possible
through the use of body. Physical activity is a important part of Friluftsliv
and the arena is the nature, but there are only few studies of the health
benefits of physical activity and nature in participating in Friluftsliv.
Therefore, will this thesis now introduce the fields of Physical Activity and
Health and “Nature and Health”, but chapter 5 will look closer into the
research question.
2:2:6:1 Physical Activity and Health:
Physical activity is a fundamental means for improving physical and mental
health. But as the case for too many people, has the physical activity been
removed from everyday life, with dramatic effects for health and well-
being. Physical inactivity is estimated to account for nearly 600 000 deaths
per year in the WHO European Region. Tackling this leading risk factor
34. 34
would reduce the risks of cardiovascular diseases, non-insulin- dependent
diabetes, hypertension, some forms of cancer, musculoskeletal diseases and
psychological disorders. In addition, physical activity is one of the keys to
counteracting the current epidemic of overweight and obesity that is posing
a new global challenge to public health (World Health Organization Europe,
2006). Over the past decades, knowledge has been accumulating concerning
the significance of exercise in the treatment of a number of chronic diseases.
Today, exercise is indicated in the treatment of a large number of medical
disorders. In the medical world, it is traditional to prescribe the evidence-
based treatment known to be the most effective and entailing the fewest side
effects or risks. The evidence suggests that in selected cases, exercise
therapy is just as effective as medical treatment – and in special situations
more effective – or adds to the effect (Pedersen et al., 2006).
Table 1: Summary of the health effects associated with physical activity (World Health
Organization Europe, 2006)
Condition Effect
Heart disease Reduced risk
Stroke Reduced risk
Overweight and obesity Reduced risk
Type 2 diabetes Reduced risk
Colon cancer Reduced risk
Breast cancer Reduced risk
Musculoskeletal health Improvement
Psychological well-being Improvement
Depression Reduced risk
35. 35
Physical activity has major beneficial effects on many chronic diseases
(Table 1). These benefits are not limited to preventing or limiting the
progression of disease, but include improving physical fitness, muscular
strength and the quality of life. The strongest evidence indicates that the
greatest benefit of physical activity is in the reduction of CVD risk. Inactive
people have up to twice the risk of heart disease of active people. Physical
activity also helps to prevent stroke and improves many of the risk factors
for CVD, including high blood pressure and high cholesterol (World Health
Organization Europe, 2006).
2:2:6:2 ” Nature and Health”:
One of the main issues in the Norwegian definition of Friluftsliv is
experiencing nature, and surveys conducted in Norway show that this is one
of the main reason why people join Friluftsliv. For the purpose of this paper,
nature is defined as an organic environment where the majority of
ecosystem processes are present (e.g. birth, death, reproduction,
relationships between species. This includes the spectrum of habitats from
wilderness areas to parks in urban environment.
To get closer look at the interaction between human beings and nature, and
health benefits of nature will the thesis now turn to Ecopsychology and
Horticultural Therapy. Ecopsychology is more the theoretical and the
philosophical background and Horticultural Therapy is the practical
36. 36
application of how plants in healing garden and landscape in more natural
environment, can benefit the human health.
2:2:6:2:1 Ecopsychology:
“Human sanity requires some less-than-obvious connections to nature as
well as the necessity for food, water, energy, and air. We have hardly begun
to discover what those connections may be....” (Sherpard and McKinley, as
quoted in (Fisher, 1999, p. 2)).
Ecopsychology can be described as a synthesis between ecology and
psychology, placing human psychology in an ecological context, and
mending the divisions between mind and nature, humans and earth. A
fundamental concept for Ecopsychology is that it is psychologically
damaging for humans to live disconnected from their ecological context, as
most of us do in contemporary urban industrial cultures. Nature is not
supposed to serve humans instrumental purpose and be separated from us
human beings (Schroll, 2007). Ecopsychology emphasizes direct experience
of nature by being bodily active in contact with nature. The Ecopsychology
elevates phenomenology as a useful philosophical foundation for thinking
about the connection or disconnection between humans and their ecological
context (Fisher, 1999).
Theodore Roszak was the first one to use the term Ecopsychology and
defined it as:
37. 37
1) The emerging synthesis of ecology and psychology.
2) The skilful application of ecological insights to the practice of
psychotherapy.
3) The discovery of our emotional bond with the planet.
4) Defining “sanity” as if the whole world mattered. (Roszak, 1992)
2:2:6:2:2 Horticulture therapy (HT):
Most of the studies concerning nature health effects, which are referred to in
this thesis is originated from Horticulture therapy. HT is defined as “a
process utilizing plants and horticultural activities to improve social,
educational, psychological and physical adjustment of persons thus
improving body, mind, and spirit of people.” (Relf, 2005, p. 3).
Traditionally has Horticulture therapy been associated with plant cultivation
as a tool of occupational therapy, but nowadays a broader definition is
recognised, ranging from plant cultivation to appreciating landscape
(Braastad & Bjørnsen, 2006). Such therapy is used in rehabilitation and
vocational centres, youth outreach programs, nursing homes and senior
centres, hospitals, hospices, war veteran centres, homeless shelters,
penitentiaries, mental health facilities, schools, community gardens, and
botanic gardens. In cases when non-professional therapists lead these
activities, they are considered as activities with a therapeutic value.
38. 38
3 Aims of thesis:
There is a high prevalence of cardiovascular diseases (CVD), not only in
Norway but also in the rest of the world. The main risk group of CVD is
elderly people and their proportion in the society is growing, which means
increased incidence of CVD. Reports are also showing increasing
incidences of CVD at adulthood. For both groups, the main risk factors are
inactivity and overweight, and studies show these two risk factors are on the
increase in modern society. And together with higher survival rate, results in
a growing need for Cardiac Rehabilitation (CR). Due to economical and
organizational reasons, the rehabilitation period at hospital and
rehabilitation clinics is shortening. This diminishes the chances that patients
adapt to a new lifestyle during rehabilitation, and they are therefore in
danger of abandoning the active lifestyle when returning back to home.
The distance from south to north in Norway is the same as the distance from
Oslo, the capital of Norway, to Rome in Italy. And due to long distances to
hospitals and rehabilitation clinics there is a need for activity-
form/method/intervention in the home community of the patient. Since
Friluftsliv is a widespread form of physical activity in Norway and is highly
valued both by the state and the population of Norway it might have an
unrealised potential when it comes to be included in cardiac rehabilitation in
Norway. Hence, the aim of this thesis is to conduct a literature review to
examine the potential of Friluftsliv to be used as a method in Cardiac
rehabilitation. To get a closer look at the potential of Friluftsliv, studies
39. 39
focusing on health benefits of Friluftsliv will be included, supplemented
with studies from the fields of Physical Activity and Health and “Nature and
Health” (figure 3).
Given that the short in-hospital period is beneficial for the patient but does
not give the patient enough time to adapt new lifestyle. Moreover, it is hard
for the patient after in-clinic rehabilitation to keep on exercising on his or
her own. That is why this thesis will focus on the Maintenance phase (Phase
III) in rehabilitation and try to discover if Friluftsliv can play a role in this
phase of the rehabilitation after Cardiovascular Diseases.
The potential of Friluftsliv in rehabilitation setting
Cardiac
Friluftsliv:
with pedagogy and
Rehabilitation
cultural heritage in the Maintenance
phase (Norway)
“Nature Physical Activity
And Health” And Health
Ecopsychology
Horticultural
Therapy
Figure 3: studies focusing on the health benefits of nature and physical activity are
included to enlighten the potential of Friluftsliv in Cardiac Rehabilitation
40. 40
The research question is:
What is the potential of Norwegian Outdoor Life Tradition (Friluftsliv)
in the Maintenance phase (III phase) of Cardiac Rehabilitation?
41. 41
4 Method:
4:1 Search method:
This thesis is based on literature review of studies related to cardiac
rehabilitation, Friluftsliv, Ecopsychology and Horticultural Therapy. My
interest is on how Friluftsliv can been used in the health care sector. There is
almost non-existing literature or studies on the health effects of participating
in friluftliv1. Therefore I found it necessary to search for evidence-based
research from Agricultural and Landscape Architecture studies. Both in
Friluftsliv and Agricultural studies, the nature is as an arena and there are
published high quality studies in Horticulture therapy. I have searched for
published literature on Pubmed and Cochrane but it has also been useful to
search for work on www.google.com and http://scholar.google.no/. In
search for literature on databases I used the following search words:
Friluftsliv, outdoor life, leisure time activities, outdoor recreation, cardiac
rehabilitation, comprehensive cardiac rehabilitation, horticulture therapy,
ecotherapy, Ecopsychology, rehabilitation intervention, community-based
rehabilitation and health promotion in community setting. I have also
searched for thesis publications from the universities of most relevance. In
this case for Friluftsliv, it has been Norwegian, Swedish and Danish
universities of sports. In the case of Ecopsychology and Horticultural
1
In order to get a closer look at the area of this thesis I participated in workshops focusing
on Cardiac Rehabilitation (www.feiringklinikken.no) and Friluftlsiv and Mental health
(www.nakuhel.no)
42. 42
Therapy, has publications and reports from The Swedish Agricultural
University, and the European Union project COST Action 866: Green Care
in Agriculture, been a helpful source.
4:1:1 Inclusion and exclusion criteria:
Inclusion criteria:
• Published literature in scientific journals
• Thesis published by universities in the area of Physical Activity and
Health, Ecopsychology and Horticulture Therapy.
• Studies with adult participants
• Studies focusing on rehabilitation or secondary prevention after
cardiovascular diseases or their risk factors.
Exclusion criteria:
• Theoretical and empirical studies conducted on Wilderness therapy
and Adventure therapy, as these therapy forms of outdoor life
usually are a trip done over 2-4 days or more. The focus in this thesis
is on daily activities in nearby natural or near natural environment.
4:2 Limitation:
This thesis search for theories and empirical studies from 4 different areas:
physical activities and health, Friluftsliv (Norwegian Outdoor Life
Tradition), Ecopsychology and Horticulture. Comparing and using studies
from different technical perspective is a challenging task. I have tried to be
43. 43
true to both the aims of this thesis and of each of these areas, while at the
same time be open for new evidence based research, which might add to the
knowledge of Friluftsliv in Cardiac Rehabilitation.
44. 44
5 The potential of Friluftsliv in Cardiac Rehabilitation:
More than 80% of the Norwegian population practice some kind of outdoor
activity at least 10 times a year (Vaage, 2007). The government has stated in
a White Paper nr. 39 that Friluftsliv may be the road to a better quality of
life (White Paper no 39 (2000/2001), 2001). And Friluftsliv is regarded as a
popular method in rehabilitation clinics and as a tool to promote physical
activity in public health interventions. This is a paradox, because little
research evidence exists supporting directly that Friluftsliv promote better
health.
5:1 The benefits of Friluftsliv:
In traditional Friluftsliv, nature is considered as a partner and not just as a
background for one’s recreational activities. The arena is commonly remote
wide-open nature, but with increased urbanisation there is increasing
utilisation of nearby nature areas for recreational purpose. The strongest
reason for why people like to be active in Friluftliv is experiencing nature,
experiencing silence, excitement, mastering, play and having fun,
responsibility, social aspects (Vorkinn M. et al., 2000) and contemplation
and peace (MMI/FRIFO, 1993). Participating in Friluftsliv has not only a
physical component but also involves the possibility of improving
psychological and social wellbeing (Table 2).
45. 45
Table 2: The benefits of Friluftsliv on physical, psychological and social well-being (White
Paper no 39 2000/2001, 2001)
Category of health Benefits of Friluftsliv
• Physiological improvement (endurance, strength, motor
skills)
Physical well-being
• Loss of weight
• Prevention of illnesses and injuries
• Experience of nature and culture
Psychological
• Reaching or overcoming ones individual boundaries
wellbeing
• Silence, (self-) reflection, room for philosophy
• Experience
Social wellbeing
• Interacting and sharing with others
5:1:1 Physical benefits of Friluftsliv:
There are only few studies, which have focused on the physiological
benefits of Friluftsliv, but two are worth mentioning. Both of them deal
with participants, which were tested both pre- and post-hunting season. The
first study concluded, after comparing result based on interviews and tests
of pulse and cholesterol from the test group (n=22) and the control group
(n=16), the increased activity level during preparing for and under hunting
season, had positive effect on the physiological health of the participations
(Okstad, 1994). The other study showed that the participants (n=22) had a
significant increase in VO2 max, or 46,81 ml/kg pr. min. from pre-hunting
season compared to post-hunting season, 48,21 ml/kg pr. min. (Kleiven &
Bekkevold, 1994).
Given that physical activity is a part of the definition of Friluftsliv, it is
natural to look at research studies on the health benefit of physical activity.
And evidence based research show that physical activity has diverse
46. 46
beneficial physiological effects to the muscle- and skeleton system,
cardiovascular system and energy metabolism(Pedersen et al., 2006). I will
come back to this in 5:2.
5:1:2 Psychological benefit of Friluftsliv:
It is well known that moderate physical activity improves mental health like
the feeling of being calm, relaxed and improved cognitive functions
(Martinsen, 2004) (Moe, Retterstøl, & Sørensen, 1998). When speaking of
psychological benefits of Friluftsliv, this has not been studied in great detail.
However, there are some studies which point to psychological benefits of
Friluftsliv. A study conducted back in 1994 indicated that the everyday level
of mental distress was a lot higher for inactive people in comparison to
active participants in Friluftsliv (Ingebrigtsen, 1994). Further, in a study
published in 2002, only 30% of the participants who did exercise training
reported positive psychological health effects of their participation
compared to 60% of those who where active in Friluftsliv (Myrvang, 2002).
In Sweden, where Friluftsliv has similar status and popularity as in Norway,
a study with 10.000 participant was conducted on how leisure time
activities, work, place of residence, economy and their social network
influenced their quality of life (Norling, 2001). Results from the study
showed that involvement in leisure time activities correlated strongly with
subjective evaluation of quality of life. And participants placed Friluftsliv as
second most important leisure time activity (60%). In Norway, several
47. 47
projects has been conducted in which Friluftsliv have been used as a method
with the objectives of increased physical and psychological health. These
projects have been argued to be successful, but studies with evaluation of
the outcome has not been conducted (Bischoff et al., 2007).
5:1:3 Friluftsliv in a rehabilitation setting:
As mentioned earlier Friluftsliv is often used at rehabilitation clinics as a
method in a comprehensive rehabilitation in the case of as obesity,
orthopaedic and amputation, rheumatism, mental disorder and
cardiovascular diseases (Bischoff et al., 2007). Further, the fruitfulness of
using Friluftsliv has been supported by showing that Friluftsliv activities in
a rehabilitation setting, help patients with Rheumatism mastering their
perception of pain (Hobbelstad, 2004). Studies also indicate that Friluftsliv
may be a good alternative when working with patients dealing with
challenges of modern society (Bjørnå, 2005) or overweight (Marcussen,
2006). Further, for patients with mental disorders has outdoor life as
walking/ light tour been shown to be a good alternative to exercise training
in particular, because it results in lower drop out rate compared to jogging
(Martinsen, 2000) and increases social capacity (Eikenes, Gude, Hoffart,
Strumse, & Aarø, 1999).
48. 48
5:2 Physical Activity and Health:
Physical activity is an important part of Friluftsliv and studies show that
physical activity has beneficial effects on both physical and psychosocial
health. Regular physical activity increases the exercise capacity and the
degree of change depends primarily on the initial stage of fitness and
intensity of training. The training increases exercise capacity by increasing
both maximal cardiac output and the ability to extract oxygen from the
blood. And these physiological benefits of a training program can be
classified as morphologic, hemodynamic, and metabolic (Table 3).
Table 3: Physiological adaptations to physical training in human (Perk J et al., 2007)
• Hemodynamic adaptations:
Increased cardiac output
Increased blood volume
Increased en-diastolic volume
Increased stroke volume
Reduced heart rate for any submaximal workload
• Metabolic adaptations:
Increased mitochondrial volume and number
Greater muscle glycogen stores
Enhanced fat utilitzation
Enhanced lactate removal
Increased enzymes for aerobic metabolism
Increased maximal oxygen uptake
• Morphologic adaptations
Myocardial hypertrophy (likely only in younger
individuals)
49. 49
For patients with heart disease, the most important physiological benefit of
training occur in the skeletal muscle. That is the metabolic capacity of the
skeletal muscle is enhanced through increases in mitochondria volume and
number, capillary density, and oxidative enzyme content. These adaptations
all together, enhance perfusion and the efficiency of oxygen extraction. In
addition, exercise training has positive influence on the cardiovascular risk
profile (Table 4) and a improvement in both insulin sensitivity and
endothelium function. Recent studies also suggest that programs of regular
exercise have favourable effects on plasma concentrations of inflammatory
risk markers like C-reactive protein and homocysteine (Myers, 2007).
Table 4: Changes in risk factors influenced by exercise training (Perk J et al., 2007)
• Decrease in blook pressure
• Increase in high-density lipoprotein cholesterol
level
• Reduction in plasma inflammatory risk markers
(C-reactive protein, homocysteine)
• Augmented weight reduction efforts
• Psychological effects:
Less depression
Reduced anxiety
• Improved glucose tolerance
• Improved fitness level
Empirical studies show that exercise-training result in both lower morbidity
and mortality, but there are also other benefits of exercise training. Those
who get exercise cardiac rehabilitation, have higher event-free survival rate
and a lower hospital readmission rate compared to the controlled
50. 50
group(Belardinelli et al., 2001). But for more empirical studies on the
outcome of exercise training in cardiac rehabilitation go to chapter 2:1:2.
5:3 “Nature and health”:
As stated in the Norwegian definition of Friluftsliv, nature is an important
part of Friluftsliv: “Friluftsliv includes both dwelling and being physically
active in outdoors environment in leisure time, to achieve a change of
environment and to experience nature”(my translation) (White Paper no 39
(2000/2001), 2001, p. 11). Here the words “outdoors environment” and
“experiencing nature” have the connection to nature. For the purpose of this
paper, nature is defined as an organic environment including both
wilderness areas and parks in urban environments. Most of the studies in
this field focuses on the benefits of contact with nature in park environments
for urban-dwelling individuals, and explores the potential of contact with
nature for promotion of health. In 1986 WHO published the Ottawa Charter,
which identifies the importance of environments supportive of health. The
charter also states that the inextricable links between people and their
environment represents the basis for a socio-ecological approach to health.
The Charter advocates for protection of natural and built environments, and
conservation of natural resources as essential in any health promotion
strategy. And the central theme has been promotion of health by
maximizing the health value of everyday settings, which includes places
where people live, work and play (World Health Organization, 1986). This
51. 51
includes how people in urban, rural and more out in the countryside areas
relate to their environment.
The idea that contact with nature is good for human health and wellbeing,
has been the subject of research in diverse disciplines such as psychology,
environmental health, psychiatry, biology, ecology, landscape preferences,
horticulture, leisure and recreation, wilderness, and public health policy and
medicine. The central notion is that as well as being totally dependent on
nature for material needs (food, water, shelter, etc.) is the interacting with
nature beneficial, perhaps even essential, to human health and wellbeing
(Maller, Townsend, Brown, & Leger, 2002; Wilson, 1984)
5:3:1 Ecopsychology:
Ecopsychology integrates ecology and psychology. Among its contributions
are the application of psychological principles and practices to
environmental education and action. By also bringing ecological thinking
and the values of the natural world to psychotherapy and personal growth, it
would seem easier to aim for fostering lifestyles that are both ecologically
and psychologically healthy. Most of its practitioners and theorists are based
in the USA, with a growing movement in Australia, South Africa and the
UK. Ecopsychology suggests that there is a synergistic relation between
planetary and personal wellbeing. Although only relatively recently adopted
in modern western society, Ecopsychology is essentially modern
52. 52
interpretation of ancient views of humans and nature held by many
indigenous peoples. Ecopsychologists believe that disconnection from
nature has a heavy cost in impaired health and increased stress (Schroll,
2007).
In Ecopsychology there are 3 different models, which explain the positive
health effects nature has on people:
• The “evolutionary theory” states that, visual patterns of the natural
environment are easiest to interpret, because people use their
involuntary attention (Kaplan & Kaplan, 1989). This form of
attention is preferable and may release negative stress. This
assumption is explained by the brain’s pre-programmed
preparedness to sort out different stimuli in a natural environment,
where man was originally meant to live. The opposite is directed
attention, which occurs when humans are bombarded by information
from the urban, artificial, environment, which has to be sorted out.
This attention requires much energy leading to overloading and
negative stress, i.e. easy distraction, difficulties in planning and
implementing and to feeling of impatience and irritability (Jernberg,
2001).
• The “cultural learning theory”; individuals adapt to the natural
environment where grown up, leading to a preference for familiar
trees and flowers (Relf, 1992). This statement contributed to the
53. 53
formulation of the theory of “the living environment” (Grahn, as
cited in (Söderback, Söderström, & Schälander, 2004, p. 249). This
theory prompted the suggestion that environments should be created
to facilitate memories of competence and experience among people
with dementia.
• The “psycho-evolutionary theory” states that, humans have long
adapted positively to nature for survival, and therefore react with
positive emotional physiological responses when in natural or
nature-related environments (Ulrich, Simons, & Losito, 1991b). This
theory has been proved acceptable through several studies (Ulrich et
al., 1991b; Ulrich, 1981; Ulrich, 2000; Ulrich, 1984).
Many Eco-psychologists have turned to the phenomenology of Merlau-
Ponty as a philosophical source for Ecopsychology. One perspective is that
Merleau-Ponty’s phenomenology can be used to make people aware of their
direct, embodied being in the world. As such, we may well discover more
emotional and/or spiritual experiences of the natural world around us (de
Jonge, 2002). The American Eco-psychologist, Andy Fisher, emphasizes on
being present in our experiences, “…pay attention both to our experience of
nature and to the nature in our experience;…)(Fisher, 1999, p. iv). Fisher
states that modern society “… lack the contexts necessary to bear our pain
and suffering, and so to stay above the healing threshold.”(ibid, p. 299) In
his work he refer to the nature as the context, which can enable healing.
“Bearing pain is always a matter of placing it in a larger context so that it
54. 54
both loses its overwhelming power and is given the space it needs to
move.”(ibid, p. 303).
5:3:2 Horticultural Therapy
Eco-psychologists use different types of practical methods when working
with patients. The most used method is Horticultural therapy, but other
forms comprise Wilderness therapy, Nature-guided therapy and Animal
assisted therapy (Schroll, 2007). The most studied method is Horticultural
therapy. Therefore, studies originating from Horticultural Therapy are
considered here.
Studies from Horticultural Therapy have showed that the experience of
nature affects people differently and is largely depending on their life
situation (Ottosson & Grahn, 1998a). Figure 4 shows that a person in a life
crises is in need for peaceful and non-demanding environments when
processing fundamental questions about his life. At the bottom of the
pyramid is the directed inwards involvement level where mental power is
very weak. The type of physical activity that can be undertaken tends to be
private, like walking, picking berries, or collecting wood a short distance
into the forest, and disturbances are disliked (Ottosson, 2001).
55. 55
Figure 4: The x-axel shows the human need for nature and the y-axel shows humans
mental state (Stigsdotter & Grahn, 2002)
Studies done at the Swedish Agriculture university in Alnarp, show that
those green-marked areas who have number of spatial qualities or basic
characteristics (table 5) are generally more popular, more appreciated and is
visited more often than a green-marked area with only one or few of the
basic characteristics (Berggren-Bärring & Grahn, 1995). And the most
valuable and health beneficial for stressed and vulnerable people, is if the
living environments has the basic character of serene, space, wild, rich in
species (plants, trees and animals) and in some cases essence of culture
(Grahn, 2005).
56. 56
Table 5: The eight basic characteristics, which influences the popularity of green areas
(Grahn, 1991a)
The eight basic Character of the garden room Sketches showing
characteristics what the garden
rooms might look
like
1. Serene Peace, silence and care.
Sounds of wind, water, birds
and insects. No rubbish, no
weeds, no disturbing people.
2. Wild Fascination with wild nature.
Plants seem self-sown. Lichen-
and moss-grown rocks, old
paths.
3. Rich in Species A room offering a variety of
species of animals and plants.
4. Space A room offering a restful feeling
of “entering another world”, a
coherent whole, like a beech
forest.
5. The Common A green, open place providing
vistas and inviting you to stay.
6. The Pleasure An enclosed, safe and secluded
Garden place, where you can relax and
be yourself and also experiment
and play.
7. Festive A meeting place for festivity and
pleasure
8. Culture A historical place offering
fascination with the course of
time
People with access to nearby natural settings have been found to be
healthier overall than other individuals. The long-term, indirect impacts of
nearby nature also include increased levels of satisfaction with one’s home,
one’s job and with life in general (Kaplan et al., 1989). Access to nearby
natural setting means to be in interaction with nature on a daily bases, ether
by viewing or by being in natural environments.
57. 57
5:3:2:2 Viewing natural scenes:
The healing effects of a natural view is increasingly being understood in
stressful situations or environments such as workplaces, hospitals and
nursing homes (Lewis, 1996). In these environments, as well as for people
who work in windowless offices, studies show that seeing nature is
important to people and is an effective means of relieving stress and
improving well-being (Lewis, 1996; Kaplan, 1992a). A study examining
recovery rates of patients who underwent gall bladder surgery found that
those with a natural view recovered faster, spent less time in hospital, had
better evaluation form nurses, required fewer painkillers and had less
postoperative complications compared with those that viewed an urban
scene (Ulrich, 1984). In another study by Ulrich colleagues they compared
physiological effects of different natural and urban scenes on subjects who
had just watched a stressful film. The physiological data measured in this
study, suggests that natural settings elicit a response that includes a
component of the parasympathetic nervous system associated with the
restoration of physical energy (Ulrich, Dimberg, & Driver, 1991a).
Evidence has also been presented to show that even by only watching
nature, results in psychological responses like the feeling of pleasure,
sustained attention or interest, and diminution of negative emotions, such as
anger and anxiety (Rohde & Kendle, 1994).
58. 58
5:3:2:3 Being in natural environments:
Early research found that in the act of contemplating in nature, the brain is
relieved of “excess” circulation (or activity) and the nervous system activity
is reduced (Yogendra, 1958). Experiencing nature can help strengthen the
activities of the right hemisphere of the brain, and restore harmony to the
functions of the brain as a whole (Furnass, 1979).
Kaplan and Kaplan described restorative environments as those settings that
foster recovery from mental fatigue (Kaplan, 1992b). According to their
findings and other studies, restorative environments require four elements:
• Fascination (an involuntary form of attention requiring effortless
interest, or curiosity)
• A sense of being away (temporary escape from one’s usual setting or
situation)
• Extant or scope (a sense of being part of a larger whole)
• And compatibility with an individual’s inclinations (opportunities
provided by the setting and whether they satisfy the individual’s
purpose) (Kaplan et al., 1989; Hartig, Mang, & Evang, 1991).
Empirical, theoretical and anecdotal evidence demonstrates that contact with
nature positively impacts blood pressure, cholesterol, outlook on life and
stress reduction (Kaplan et al., 1989; Ulrich et al., 1991b; Lewis, 1996;
Kaplan, 1992a; Rohde et al., 1994; Hartig et al., 1991; Leather, Pyrgas, &
Lawrence, 1998; Parsons, Tassinary, Ulrich, Hebl, & Grossman-Alexander,
1998). A study from Norway showed that walking in natural environment
59. 59
increased the parasympathetic activation, resulting in lower heart rate and
lower blood pressure. But this was not the case after similar activity in an
urban environment (Laumann, 2004). These outcomes have particular
relevance in areas of mental health and cardiovascular disease, categories
that are set to be the two biggest contributors to disease worldwide by the
year 2020 (Murray & Lopez, 1996).
5:3:3 The use of nature in rehabilitation:
There are many examples that natural environments/green areas are used in
therapeutic activities. The participants are often elderly, people with
different physiological and psychological disabilities, mental illness, mental
fatigue or people in need of rehabilitation. Horticultural therapy is a therapy
form which includes interventions mediated by nature-oriented views and
spaces, such as gardens and everything associated with them, the plants and
material related to them, garden tools and garden occupations performed
among disabled people for healing and for restoring or improving health and
wellbeing or for rehabilitation (Parr, 2005). An outdoor recreation provides
an opportunity to increase quality of life and heighten social interaction, and
thus helps to enhance community spirit and foster a more socially inclusive
society (Scottish Natural Heritage, as cited in (Morris, 2003)). Ryan (1997
as cited in (Morris, 2003)) describes the impact of incorporating therapeutic
gardening into reminiscence work for people with dementia, regaining
mobility, dexterity and co-ordination after a stroke, to regain confidence and
self-esteem.
60. 60
Studies show that interaction with plants and earth enables sensory
stimulation, provides an opportunity to keep warm through activity, and
exposes the body to fresh air. It can also help people gain basic and social
skills, obtain qualifications, rebuild their lives, and maintain or improve
quality of life. It provides something to talk about, a chance for enthusiasts
to impart knowledge, it 'humanises' institutions, provides motivation,
induces aesthetic satisfaction, status and self-esteem (Ryan, as cited in
(Morris, 2003)).
Studies have further shown that recreation in parks, healing gardens and in
natural environments positively influence health. Moreover, it seems that
particularly those with poor general health, benefits the most (Ottosson &
Grahn, 1998b). A study composed on effects of Horticulture Therapy on
mood and heart rate in patients participating in an inpatient
cardiopulmonary rehabilitation program, showed significant lower heart rate
and improved mood state after intervention. The study compared patient
educational classes supplemented with Horticulture Therapy, and a group
given only educational classes. They concluded that given that stress
contributes to coronary heart diseases, findings support the role of
Horticulture therapy as an effective component of cardiac rehabilitation
(Wichrowski, Whiteson, Haas, Mola, & Rey, 2005)
61. 61
6 Summary
The objective of this thesis is to study the potential of Friluftsliv as a
method in Cardiac Rehabilitation. The starting point is the high prevalence
of cardiovascular diseases (CVD) not only in Norway but also in the rest of
the world. The main risk group of CVD are elderly people and their
proportion in the society is growing, which means increased incidence of
CVD. Reports are also showing increasing incidences of CVD at adulthood.
For both groups, the main risk factors are inactivity and overweight, and
studies show these two risk factors are on the increase in modern society.
And together with higher survival rate, results in a growing need for Cardiac
Rehabilitation (CR). Due to economical and organizational reasons, the
rehabilitation period at hospital and rehabilitation clinics is shortening. This
diminishes the chances that patients adapt to a new lifestyle during
rehabilitation, and they are therefore in danger of abandoning the active
lifestyle when returning back home. Also, the long distances to
rehabilitation clinics in Norway, makes this even more likely to happen.
Friluftsliv has developed through the years in a blend with the Norwegian
culture and identity. Also the inherent pedagogic and mentoring didactical
potential of Friluftsliv mixed with deep ecology, makes Friluftsliv
potentially unique in terms of rehabilitation. Friluftsliv is an activity form
and is practised in natural or a near natural environment. Friluftsliv is highly
valued and is a popular form of recreational activity in Norway. Hence, it
seems interesting to look closer at the potential of Friluftliv in CR when
patients return back home, from rehabilitation clinics e.g. the Maintenance
62. 62
phase or phase III of CR. The literature review reveals some Norwegian
Friluftliv studies, showing the potential physiological and psychological
health benefits of practising Friluftsliv. There is however, a lack of good
studies, in particular on the potentially physiological effects of practising
Friluftsliv and on the physiological and psychological benefits of dwelling
in nature. Therefore in including literature of other related professions like
the field of Physical Activity and Health and “Nature and Health” (Figure
3), seem warranted to examine the potential of Friluftsliv.
6:1 “Nature and Health”:
In a attempt to examine the field of “Nature and Health” has this thesis
looked closely into Ecopsychology and empirical studies conducted on
Horticultural Therapy. The main contribution from Ecopsychology in the
scheme of this thesis is the active and holistic view of the human-nature
relationship. The Ecopsychology states, that it is psychologically damaging
for humans to live disconnected from their ecological context. But
Ecopsychology also emphasizes direct experience of nature by being bodily
active in contact with nature. Ecopsychology turns to Phenomenology in
search for a philosophical foundation, and in order to explain the value of
human interacting with their environment (Fisher, 1999). Similar statements
can be found in Friluftsliv, which focus on the interaction between people
and nature. That nature communicates with us, and the experience in nature
has something valuable to give to us human beings (Tordsson, 1999).
63. 63
6:1:1 Therapeutic work in “Nature and Health”:
The studies focusing on the practical work in Ecopsychology examine the
health effects of working at farms and out in the countryside, and on how
animals, plants, and the landscape can be used in recreational or work-
related activities for different patient groups. These studies include
participants such as psychiatric patients, mentally disabled persons, people
with learning disabilities, with burnout problems, people with drug
problems, young people, elderly people, and clients of social services. The
most common therapeutic form is Horticultural Therapy, which ranges from
cultivating plants to appreciation of landscape. Horticultural Therapy (HT)
is the most studied therapeutic form within the context of Ecopsychology.
Although Friluftsliv includes activities with animals, like horse riding, is the
vast majority of the Friluftsliv activities as in HT, concerns direct contact
between humans and natural environment. Therefore HT is of interest when
examining the potential of Friluftsliv in a rehabilitation setting.
Studies on Horticultural Therapy or therapeutic horticultural activities,
reveal that it is possible to relieve stress, improve well-being (Kaplan,
1992b; Lewis, 1996) and elicit restoring physical energy (Ulrich et al.,
1991a) only by viewing natural scenes. Also studies have shown that by
experiencing nature, this can have positive effects on brain function
(Furnass, 1979), cholesterol level, and people’s outlook on life (Hartig et al.,
1991; Kaplan et al., 1989; Kaplan, 1992b; Lewis, 1996; Parsons et al., 1998)
plus lowering heart rate and blood pressure (Laumann, 2004). In the case of