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Study Finds Nature-Based Interventions at School Does Not Reduce Children’s Poor Mental Health Symptoms
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The authors recommend that longer assessments with lengthier interventions should be performed to assess potential benefits.
Observational studies have previously indicated that time outdoors can benefit the mental health of both adults and children. Based on prior research, authors of a study published in JAMA Network Open hypothesized that a nature-based intervention method for elementary school-aged children will also lead to reductions in poor mental health symptoms.
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The study was a 2-arm, cluster randomized clinical trial that was conducted from February 27, 2023, to June 16, 2023, that examined the effectiveness of the Open Sky School Program in grades 5 and 6 in French-language elementary schools from Quebec. Participation of classes within participating schools was voluntary, with teachers providing written informed consent. Although students could not opt out of class activities, parents provided written informed consent and students provided assent for assessments.
Study randomization was performed solely to avoid contamination bias at the school level, but all students from the same school were allocated and assigned to the same group. Both teachers and students completed questionnaires at baseline and immediately following intervention, which was at 12 weeks (T1). Additionally, students completed the follow-up secondary measures at 3 months after the intervention’s end (T2).
Intervention involved an activity toll kit designed by educational and clinical psychology experts. Teachers brought their class to a nearby green space for 2 hours per week for 12 weeks. Sessions were either singular 2-hour sessions or 2 sessions each lasting an hour, on or off school property. Additionally, students used the tool kit and other teacher-initiated activities, engaging in basic subjects (eg, language, math, and science) and in mental health improvement activities (eg, mindfulness, philosophy, and art therapy) over the intervention period.
The primary outcome was change in child mental health from baseline and T1 (eg, internalizing or externalizing symptoms, social problems), as measured by the adapted 30-item Social Behavior Questionnaire (SBQ), which was completed by both teachers and students. The SBQ evaluates symptom frequency over the past 2 months on a 3-point scale, with 0 meaning “never or not true,” 1 “sometimes or somewhat,” and 2 “often or very true.” Secondary outcomes included changes in mental health, attitudes and behaviors related to the environment, and nature connectedness, as self-reported by students at baseline, T1, and T2.
A total of 33 schools with 53 grade 5 and 6 teachers and 1015 agreed to complete the questionnaire. The intervention group consisted of 16 schools with 25 teachers and 515 students, whereas the control group included 17 schools with 28 teachers and 500 students. The mean age of students was about 10.9 years and most (50.7%; n = 507) were girls. Additionally, about half of all students in both groups had teachers without prior experience teaching outdoors (intervention: n = 219, 42.5%; and control: n = 238, 7.6%).
Teacher logbooks recorded a mean of about 116 minutes (range: 85-217 minutes) per week of outdoor teaching, of which most occurred in a schoolyard, park, or wooded area. Additionally, only 192 students (40.8%) in the intervention group received the full 2-hour weekly requirement. Teachers also completed a mean of 7.5 mental health activities (range: 0-15 activities), 6 (23.1%) in the intervention group met the required 10 mental health activities, and 12 (46.2%) achieved about 80% adherence (≥8 activities). Teachers also conducted a mean of 5 tool kit activities (range: 0-13) and 11 teacher-initiated activities (range: 2-21). In the control group, approximately 48.1% of teachers (n = 13) reported outdoor activities at least once, with 77 students engaging in over 2 hours per week.
The findings demonstrated that change in mental health immediately after intervention was not statistically significant. The adjusted mean difference in SBQ scores between the 2 for externalizing symptoms was about −0.04 (95% CI, −0.13 to 0.04) in the intent-to-treat analysis and −0.06 (95% CI, −0.16 to 0.04) in the per-protocol analysis. Further, other mental health results were similar to the results for externalizing symptoms. The authors reported an inability to analyze T2 data because of high attrition.
According to the investigators, potential limitations of the study include the inability for intervention to be “blind,” relying on teacher logs as measures of implementations, and lack of information on the quality of the chosen green space during intervention. Additionally, the authors suggested that for longer-term assessments, studies should be scheduled earlier in the school year to offset any potential differences between summer classes and the traditional school year.
