References

Faith groups 1-3 

1. British Religion in Numbers. Church attendance in Britain, 1980-2015. 

Church attendances in the UK have halved since 1980.

2. Office for National Statistics. Religion and Health in England and Wales: February 2020. Analysis of a Range of Health Outcomes of People of Different Religious Identities in England and Wales.
ONS; 2020.

Having religious belief is associated with better self-reported health. Much of this comes from the social cohesion of the groups who attend worship. A higher proportion of adults who identified as Jewish, Buddhist, Christian or "any other religion’" volunteered in the last 12 months than those in other religious groups. Political belief is highest for people identifying as Sikh, Muslim or Jewish. In people with no expressed religion, political belief is of less importance in their self-identity. Muslim or Christian identification is associated with closer sense of neighbourhood belonging than Buddhist or no religion. Neighbourhood trust is highest in adults who identifed as Jewish or Christian. 

3. McDougle L, Handy F, Konrath S, Walk M. Health outcomes and volunteering: the moderating role of religiosity.
Soc Indic Res. 2014;117(2):337-351. doi:10.1007/s11205-013-0336-5

Volunteers who attend public religious practices report better physical and mental health.
'It is possible that individuals who self-identify and affiliate with a particular religious community, but do not attend services on a regular basis may not necessarily internalize the norms and values of that community'

One US study [Hummer 1999 10.2307/2648114] found those never attending religious services have a 1.87 relative risk of dying compared with those attending church more than weekly. At age 20 this translates into a 7 year difference in life expectancy. 

Exercise and activity 4-20 

4. Office for Health Improvement and Disparities. Physical activity: applying All Our Health. Published online March 10, 2022.

Inactivity leads to 1 in 6 deaths in the UK, costing the NHS £6bn annually. 1 in 3 men and 1 in 2 women are not active enough to stay in good health. Physical activity reduces risk of dementia by up to 30%, hip fractures by 68%, depression by 30%, breast cancer by 20%, colon cancer by 30%, type 2 diabetes by 40%, cardiovascular disease by 35% and all-cause mortality by 30%.
UK CMO guidances is for 150 minutes of moderate activity or 75 minutes vigorous activity weekly. Strengthening exercises should be done at least twice weekly. Some examples of good practice for encouraging activity in this paper. 

5. Berryman JW. Exercise is medicine: a historical perspective.
Curr Sports Med Rep. 2010;9(4). 

An overview of the history of exercise in medicine, dating back to Hippocrates (460-370 BCE) and Galen (129-216 CE) who both advocated exercise for health. Promoting control over one's health in this way is empowering. Physical education starting being promoted in the early 1800s, but slowly shifted from medicine into schools. 

6. Momma H, Kawakami R, Honda T, Sawada SS. Muscle-strengthening activities are associated with lower risk and mortality in major non-communicable diseases: a systematic review and meta-analysis of cohort studies.
Br J Sports Med. Published online February 28, 2022 doi:10.1136/bjsports-2021-105061

An hour a week of muscle-strengthening exercises reduced mortality seems to be optimal, reducing all-cause mortality by up to 20%and lessening the risk of diabetes and cancer.

7. Nyman SR. Tai Chi for the prevention of falls among older adults: a critical analysis of the evidence.
J Aging Phys Act. 2021;29(2):343-352. doi:10.1123/japa.2020-0155

Tai Chi is a traditional Chinese mind-body exercise, commonly practiced in groups, reducing the risk of falls by between 19% and 43%.

8. Allender S, Foster C, Scarborough P, Rayner M. The burden of physical activity-related ill health in the UK.
J Epidemiol Community Health. 2007;61(4):344-348. doi:10.1136/jech.2006.050807

Physical inactivity is a considerable public health burden, directly responsible for 35,429 deaths and 3% of DALYs lost in the UK, at an NHS cost of £1.06bn. The indirect costs are £8.2bn in England (not including the extra costs of overweight and obesity of between £6.6bn and £7.6bn) and a total of 287,206 deaths in the UK linked to inactivity. 

9. Woodcock J, Franco OH, Orsini N, Roberts I. Non-vigorous physical activity and all-cause mortality: systematic review and meta-analysis of cohort studies.
Int J Epidemiol. 2011;40(1):121-138. doi:10.1093/ije/dyq104

2.5 hours of moderate activity weekly reduces mortality risk by 19%, while 7 hours weekly reduces the risk by 24% compared with no activity.

10. Cooney GM, Dwan K, Greig CA, et al. Exercise for depression. Cochrane Common Mental Disorders Group, ed.
Cochrane Database Syst Rev. Published online September 12, 2013. doi:10.1002/14651858.CD004366.pub6

A very detailed Cochrane review of exercise for depression finding that exercise redues the risk of depression by 62%. 

11. see note 4, OHID 2022

12. Sport England. Active Lives Adult Survey; 2020.

63% of adults in the UK are active (>150 minutes a week), 12% are fairly active (30-149 mins) while 25% average less than 30 minutes of activity each week. Men are more likely to be active than women (65% vs 61%). Activity reduces with age (69% active aged 16-34, 66% 35-54y, 60% 55-74y, 40% 75+y) and in lower socioeconomic groups (72% in professionals and managers vs 53% in routine occupations and unemployed people). Sport and physical activity reduces loneliness.

13. Department of Health and Social Care. General practice physical activity questionnaire (GPPAQ). 

The GPPAQ is a simple and quick measure of self-reported activity levels, asking about occupational activity and time spent doing physical exercise, cycling, walking, housework / childcare and gardening / DIY. 

14. Tobin, Simon. parkrun is community adhesive.
parkrun UK Blog. Published May 23, 2022.

"It's the countless, tiny interactions that take place every weekend that make parkrun so special."
"parkrun is so much more than just physical activity, parkrun is community adhesive"

15. ERRATUM. Sorry, this reference has a double transcription error. It should read: Assuming a MET of 4, ✕ 100 people ✕ 2 weeks ✕ 0.00010265 = 0.082 QALYS which is 30 days. At the higher threshold of NICE willingness to pay, this is worth £4,000. See reference 20.
This is more than the cost to the community of setting up a parkrun.  In other words, the value of the health savings (costed at the price we pay for some interventions) meant the setup money would have been saved within 2 weeks. 

100 people starting running or walking a parkrun weekly gains two years of life annually.

16. Mental Health Mates. Peer support & community. Walking & talking for your mental health.

This network of peer support groups connects people with mental health issues to walk together, reducing isolation. 

17. Public Health England. Beat the Street: getting communities moving.

Beat the Street is a 12-month community program to encourage people of all ages to get moving. A Beat the Street card is tapped against sensors located across the local community to earn points, motivating schools and groups to be more active, normalising walking and cycling. Beat the Street increases people meeting physical activity guidance from 40% to 50%. 

18. Hughes K, Ford K, Davies AR, Homolova Lucia, Bellis MA. Sources of Resilience and Their Moderating Relationships with Harms from Adverse Childhood Experiences. Report 1: Mental Illness.
Public Health Wales NHS Trust; 2018.

Participation in sport reduces mental ill health in both children and adults. Childhood participation in sports reduces self harm. Trust in an adult outside of the family is likely to be an important protective factor. Rates of mental illness in adults with four or more adverse childhood experiences (see chapter 2) fell from 23% to 11% in those regularly participating in community groups / social clubs. 

19. Ainsworth, BE, Haskell, WL, Herrmann, SD, et al. The Compendium of Physical Activities Tracking Guide.
Healthy Lifestyles Research Center, College of Nursing & Health Innovation; 2022.

This site gives details of energy expenditure in METs (metabolic equivalent of task) for a wide range of activity. One MET represents one calorie per kg of bodyweight per hour. 

20. Papathanasopoulou E, White MP, Hattam C, Lannin A, Harvey A, Spencer A. Valuing the health benefits of physical activities in the marine environment and their importance for marine spatial planning.
Mar Policy. 2016;63:144-152. doi:10.1016/j.marpol.2015.10.009

Physical activity in aquatic environments saves 24,853 QALYs in England, saving £176mn annually. The paper uses an estimate from NICE of the QALY benefits of activity, which can be applied to other activity by MET (see ref 19). 

Nature 21-34 

21. Pritchard A, Richardson M, Sheffield D, McEwan K. The relationship between nature connectedness and eudaimonic well-being: a meta-analysis.
J Happiness Stud. 2020;21(3):1145-1167. doi:10.1007/s10902-019-00118-6

Much of the increase in mental health problems may be linked to reduced sense of belonging in nature. Feeling connected to nature improves wellbeing and self-reported personal growth.
Measures of nature connectedness: Connectedness to Nature Scale (CNS), Nature Relatedness scale (NR), Inclusion of Nature with Self (INS)

22. Shin JC, Parab KV, An R, Grigsby-Toussaint DS. Greenspace exposure and sleep: a systematic review.
Environ Res. 2020;182:109081. doi:10.1016/j.envres.2019.109081

Exposure to greenspace improves sleep quality and duration.
Economic losses from poor sleep are estimated at 2.28% of GDP ($411bn in the US, 2015). 

23. Twohig-Bennett C, Jones A. The health benefits of the great outdoors: A systematic review and meta-analysis of greenspace exposure and health outcomes.
Environ Res. 2018;166:628-637. doi:10.1016/j.envres.2018.06.030

This meta-analysis of greenspace exposure found reductions in salivary cortisol, heart rate, diastolic BP, risk of preterm birth, diabetes, cardiovascular and all-cause mortality. Practitioners and policymakers should consider how to improve greenspace particularly in deprived areas. 

24. Maas J, Verheij RA, Groenewegen PP, de Vries S, Spreeuwenberg P. Green space, urbanity, and health: how strong is the relation?
J Epidemiol Community Health. 2006;60(7):587-592. doi:10.1136/jech.2005.043125

Greenspace within 1km and 3km increases perceived general health, particularly in lower socioeconomic groups, the elderly and young people. 

25. Louv R. Last Child in the Woods: Saving Our Children from Nature-Deficit Disorder. Algonquin Books of Chapel Hill; 2008.
ISBN 978-1848870833

'Nature-deficit disorder'.

26. Wood CJ, Smyth N. The health impact of nature exposure and green exercise across the life course: a pilot study.
Int J Environ Health Res. 2020;30(2):226-235. doi:10.1080/09603123.2019.1593327

Exposure to nature and green exercise in childhood predicts continuing into adulthood.
Physical activity is important throughout the life course but in teenage years most strongly prevents cognitive loss in later life. 

27. Alcock I, White MP, Wheeler BW, Fleming LE, Depledge MH. Longitudinal effects on mental health of moving to greener and less green urban areas.
Environ Sci Technol. 2014;48(2):1247-1255. doi:10.1021/es403688w

Moving to greener areas leads to sustained better mental health, while moving to less green areas worsens mental health. Planning strategy can have an important role to play in sustainable public health. 

28. Mitchell R, Popham F. Effect of exposure to natural environment on health inequalities: an observational population study.
The Lancet. 2008;372(9650):1655-1660. doi:10.1016/S0140-6736(08)61689-X

Greener environments mitigate the effects of income deprivation on health inequalities, reducing the impact of deprivation on circulatory and all-cause mortality by about half. Physical environments promoting good health can reduce socioeconomic health inequalities. 

29. Ulrich RS. View through a window may influence recovery from surgery.
Science. 1984;224(4647):420-421. doi:10.1126/science.6143402

Patients stayed in hospital following surgery for shorter periods when they had a view of trees rather than a brick wall. 

30. Ulrich RS, Simons RF, Losito BD, Fiorito E, Miles MA, Zelson M. Stress recovery during exposure to natural and urban environments.
J Environ Psychol. 1991;11(3):201-230. doi:10.1016/S0272-4944(05)80184-7

Stress-recovery theory: nature is restorative by shifting towards more positive emotional and physiological states, improving sustained attention. 

31. Bird, William. Natural Thinking: Investigating the Links between the Natural Environment, Biodiversity and Mental Health.
RSPB; 2007. 

One of the best summaries of nature and health, covering theories of nature, children, the elderly, ADHD, crime, dementia and community and sense of place. 

32. Wilson EO. Biophilia: The Human Bond with Other Species.
Harvard Univ. Press; 1994. ISBN 978-0674074422

Biophilia describes the innate affiliation humans have for other life, our evolutionary heritage. 

33. Kaplan S. The restorative benefits of nature: toward an integrative framework.
J Environ Psychol. 1995;15(3):169-182. doi:10.1016/0272-4944(95)90001-2

Exposure to nature reduces attentional fatigue which improves cognition and mood (attentional restoration theory).  

34. Taylor AF, Kuo FE, Sullivan WC. Coping with ADD: the surprising connection to green play settings.
Environ Behav. 2001;33(1):54-77. doi:10.1177/00139160121972864

Time spent in natural environments improves attention in children with ADD. (Taylor 2001, DOI: 10.1177/00139160121972864)

Blue prescribing 35-37 

35 Mental Health Foundation. Nature, how connecting with nature benefits our mental health.
Mental Health Awareness Week 2021. 

A survey of UK adults found 73% said that connecting to nature helped their mental health during the pandemic. 65% said that spending time by water positive for their mental health. Access to nature in particular helps to reduce the impact of inequality.
Feeling connected to nature matters more than the number of visits to natural environments. Contact with nature can be intentional, incidental, or indirect, for example on television. Campaigns such as 30 Days Wild improve relationships with nature. 

Five pathways to a relationship with nature:

• senses - noticing, mindfulness

• emotion - joy, calm

• beauty - art, patterns

• meaning - culture, natural cycles

• compassion - taking action to benefit nature

36. Knechtle B, Waśkiewicz Z, Sousa CV, Hill L, Nikolaidis PT. Cold water swimming—benefits and risks: a narrative review.
Int J Environ Res Public Health. 2020;17(23):8984. doi:10.3390/ijerph17238984

Cold water swimming causes beneficial physiological changes which bring cardiovascular and immune benefits, reduce stress hormones and can improve mood. 

37. Maund, Irvine, Reeves, et al. Wetlands for wellbeing: piloting a nature-based health intervention for the management of anxiety and depression.
Int J Environ Res Public Health. 2019;16(22):4413. doi:10.3390/ijerph16224413

Spending time in wetlands improves well-being, physical health and reduces social isolation in people with depression. Support from staff and transport provision increases the effectiveness by facilitating more interactions with nature.

Green therapies 38-45 

38. Rosa CD, Larson LR, Collado S, Profice CC. Forest therapy can prevent and treat depression: Evidence from meta-analyses.
Urban For Urban Green. 2021;57:126943. doi:10.1016/j.ufug.2020.126943

Shinrin Yoku, (forest bathing) provides CBT in woodland setting, showing a reduction in symptoms of depression, more than similar in urban or hospital environment. Providing CBT in a woodland setting is twice as likely to achieve remission as in a hospital environment, and 13 times more likely than in an urban environment. 

39. Whall AL, Black ME, Groh CJ, Yankou DJ, Kupferschmid BJ, Foster NL. The effect of natural environments upon agitation and aggression in late stage dementia patients.
Am J Alzheimers Dis. 1997;12(5):216-220. doi:10.1177/153331759701200506

Decline in agitated behaviour when using food and natural images and sounds when washing. 

The 'remembrance of things past' which are laid down in early memory may result in clarity and thus pleasure for people with dementia.

40. Clark, Patrick, Mapes, Neil, Burt, Jim, Preston, Sarah. Greening Dementia: A Literature Review of the Benefits and Barriers Facing Individuals Living with Dementia in Accessing the Natural Environment and Local Greenspace.
Natural England; 2013. 

Dementia affects 800,000 people & 670,000 carers. prevalence will double in next 30y. Each person with dementia costs economy £27,647 per year. Health & social care costs per person £12,521 (cf CVA £2,559 & £2,283 for cancer). NHS costs £23bn, trebling by 2040 [Alz Soc 2012]. Dementia costs more than cancer & heart disease combined. 

2/3rds live in own homes, at earlier end of condition. Most of cost met by unpaid carers. Social care costs £9bn, health £1.2bn. 

Dementia adventure is a charity providing outdoor holidays for people with dementia. 

41. Detweiler MB, Sharma T, Detweiler JG, et al. What is the evidence to support the use of therapeutic gardens for the elderly?
Psychiatry Investig. 2012;9(2):100. doi:10.4306/pi.2012.9.2.100

The use of horticulture to calm the senses dates as far back as 2000 BC in Mesopotamia. Around 500 BC, the Persians began creating gardens to please all of the senses by combining beauty, fragrance, music (flowing water) and cooling temperatures. Horticultural therapy has been found to reduce stress, to increase feelings of calm and relaxation, to foster a sense of accomplishment and to improve self-esteem. There is a higher attentional response to environmental cues such as trees and natural features associated with landscapes providing sources of food and water. Sunlight improves awareness of diurnal variation. 

Residents who can see a natural setting but find the doors to the garden locked may experience increased agitation.

42. Mapes, Neil, Milton, Steve, Nicholls, Vicky, Williamson, Toby. Is It Nice Outside?: Consulting People Living with Dementia and Their Carers about Engaging with the Natural Environment.
Natural England; 2016.

83% of carers believe that dementia impairs the ability to use outdoor spaces, compared 20% of people with dementia. 

Carers tend to focus on comfort & safety, people with dementia want to be able to make choices. Need to balance against the risks of not taking someone out into nature. 

43. Hewitt P, Watts C, Hussey J, Power K, Williams T. Does a structured gardening programme improve well-being in young-onset dementia? A preliminary study.
Br J Occup Ther. 2013;76(8):355-361. doi:10.4276/030802213X13757040168270

Social and therapeutic horticulture facilitates health & well-being through belonging, a term defined as the interpersonal connection of people to each other as they engage in occupation. Community gardening is a meaningful activity, enabling participants to be recognised as active, capable and useful. Attending the groups gave talking points and helped orientation during the week. 

44. Healy V. The Hospice Garden: Addressing the patients’ needs through landscape.
Am J Hosp Care. 1986;3(6):32-36. doi:10.1177/104990918600300607

Gardens provide a space for reflection on mortality. Design should appeal to all five senses. 

45. Bell S de, White M, Griffiths A, et al. Spending time in the garden is positively associated with health and wellbeing: Results from a national survey in England.
Landsc Urban Plan. 2020;200:103836. doi:10.1016/j.landurbplan.2020.103836

Private gardens are a health resource, improving activity and wellbeing. 

Food and nutrition 46-51 

46. Spano G, D’Este M, Giannico V, et al. Are community gardening and horticultural interventions beneficial for psychosocial well-being? A meta-analysis.
Int J Environ Res Public Health. 2020;17(10):3584. doi:10.3390/ijerph17103584

Community gardens have a positive effect on wellbeing, most noticably in more individualistic cultures. Community gardens increase the benefit of horticultural interventions. 

47. Porter R, McIlvaine-Newsad H. Gardening in green space for environmental justice: food security, leisure and social capital.
Leisure/Loisir. 2013;37(4):379-395. doi:10.1080/14927713.2014.906172

While improved food security led people to community gardening, meeting new people and socialising became important generators of social capital. Providing communal areas to interact is important.
Communal gardens (such as 'victory gardens' during the war) are helpful responses to crises, producing cheap and health food. This environmentally just and socially conscious activism is a type of 'agresistance'. 
There are ongoing benefits from activity and socialisation while reducing the corporatisation of food provision. Large-scale agriculture reduces local food availability. While large farms are typically under contract to resellers, making produce available locally brings the farm into the local community and encourages low mileage, fresh seasonal food.

48. Parr H. Mental Health and Social Space: Towards Inclusionary Geographies?
Blackwell; 2008. ISBN 9781405168939 doi: 10.1002/9780470712924

Community gardening offers the potential for those stigmatised by illness to be ‘re-imagined as active, expert, capable and productive community members'.

49. Rayner M. The burden of food related ill health in the UK.
J Epidemiol Community Health. 2005;59(12):1054-1057. doi:10.1136/jech.2005.036491

Poor nutrition costs the NHS £6bn annually, mainly due to cardiovascular disease and cancer increases.

50. Dauchet L, Amouyel P, Hercberg S, Dallongeville J. Fruit and vegetable consumption and risk of coronary heart disease: a meta-analysis of cohort studies.
J Nutr. 2006;136(10):2588-2593. doi:10.1093/jn/136.10.2588

Risk of coronary heart disease decreases by 4% for each portion of fruit and vegetables a day, and by 7% for fruit intake. 

51. Monlezun DJ, Kasprowicz E, Tosh KW, et al. Medical school-based teaching kitchen improves HbA1c, blood pressure, and cholesterol for patients with type 2 diabetes: results from a novel randomized controlled trial.
Diabetes Res Clin Pract. 2015;109(2):420-426. doi:10.1016/j.diabres.2015.05.007

A teaching kitchen for patients living in a food desert in USA (75% black) gave improved blood pressure and cholesterol.

Learning 52-60 

52. Feinstein L, Hammond C, Woods L, University of London, Institute of Education, Centre for Research on the Wider Benefits of Learning. The Contribution of Adult Learning to Health and Social Capital.
Institute of Education; 2003. 

Adult learning increases civic participation and exposes learners to more diverse range of people, improving health and social capital. Adult learners are more likely to engage in other positive health behaviours such as stopping smoking (3.3% reduction) and increasing exercise (from 38% to 45%).

53. u3a. University of the Third Age.

54. Office for National Statistics. National Life Tables – Life Expectancy in the UK: 2018 to 2020.
ONS; 2021. 

Men have a life expectancy three years less than women, and are less likely to engage in health-seeking behaviour. 

55. Office for National Statistics. Suicides in England and Wales: 2020 Registrations.
ONS; 2021. 

Suicide rates in men are 15.4 deaths per 100,000, in women 4.9 per 100,000, peaking at age 45-49.
The Samaritans have produced media guidance for responsible reporting of suicide. 

56. Milligan C, Payne S, Bingley A, Cockshott Z. Place and wellbeing: shedding light on activity interventions for older men.
Ageing Soc. 2015;35(1):124-149. doi:10.1017/S0144686X13000494

In the move to a post-industrial society, men may be struggling more with mental and emotional wellbeing. Many activities such as crafts and cooking may be regarded as for women and thus less acceptable to older men, who may prefer activities with a practical outcome. Casting older men as co-participants in shared group activities is most effective. Men's Sheds invert the stereotype of sheds as somewhere to 'escape' to be alone.
"Women communicate face-to-face whilst men communicate 'shoulder-to-shoulder'".

57. Milligan C, Dowrick C. Men in Sheds: Improving the Health and Wellbeing of Older Men through Gender-Based Activity Interventions: A Systematic Review and Scoping for an Evaluation.
School for Public Health Research; 2013. 

Attending sheds benefits mental health and wellbeing via social inclusion which reduces isolation. 

58. Kelly D, Steiner A, Mason H, Teasdale S. Men’s Sheds: A conceptual exploration of the causal pathways for health and well‐being.
Health Soc Care Community. 2019;27(5):1147-1157. doi:10.1111/hsc.12765

With the loss of work can come the loss of colleagues, networks, social support and autonomy. 

Attending Men's sheds leads to: sharing & developing skills; more to talk about back home with families; walking and standing more while at sheds, which had led to increased mobility and decreased feelings of frailty; increased sense of purpose; increased sense of pride, achievement and satisfaction from producing things of value, such as woodwork; and an increased confidence through the development of skills and educational opportunities. 

Having a sense of purpose and meaning was found to lead to increased feelings of self‐worth and empowerment, increased sense of masculine identity, confidence and self‐esteem and a sense of independence and control in life. 

59. Milligan C, Neary D, Payne S, Hanratty B, Irwin P, Dowrick C. Older men and social activity: a scoping review of Men’s Sheds and other gendered interventions.
Ageing Soc. 2016;36(5):895-923. doi:10.1017/S0144686X14001524

‘More than a place to do things but also a place of belonging, friendships and purpose’. 

Limited evidence for positive effects of sheds  on physical health. Significant positive effects in terms of improved mental health and wellbeing among participants immediately before and after attending sheds.

‘Shedders’ tend to view themselves as volunteers or members.  Shed members may not necessarily recognise or welcome the notion of Sheds as an intervention. This more informal ‘health by stealth’ approach to health promotion amongst older men may be one of the key benefits of Men’s Sheds.

60. Pit, Lianne. An Explorative Research on the Reasons Why People Repair Their Product at the Repair Café.
Wageningen University; 2020. 

Repair cafés [Moalem 2021, 10.3390/su132212351]: Repair cafés are examples of community repair in which the community aspect is in the foreground and the drivers to repair are based on shared value creation or sustainable thinking. People are invited in to learn to collaboratively repair / engage in shared repairing.

Occupation and identity [Christiansen 1999, 10.5014/ajot.53.6.547]: Occupations are key not just to being a person, but to being a particular person, and thus creating and maintaining an identity. Our identities provide us with the context through which we interpret and derive meaning from the events we experience. Research on psychosocial theories of depression have shown that depression can be averted when people are given an opportunity to gain personal meaning from everyday activities, when their sense of optimism is renewed, and where they believe that there is choice and control in their lives

Mentoring 61 

61. Jarrott SE, Bruno K. Intergenerational activities involving persons with dementia: An observational assessment.
Am J Alzheimers Dis Other Demen. 2003;18(1):31-37. doi:10.1177/153331750301800109

People with dementia show improved affect and more behaviours supporting personhood when spending time with children. 

Arts and creativity 62-69 

62. Eno, Brian. 2015 John Peel lecture. Delivered September 27, 2015. 

"What are we doing when we make art, and what are we doing when we consume it? So I’m going to start with a definition of culture. This is treading on very thin ice because a lot of people have attempted this and a lot have failed. So I’m going to make a quite narrow definition of culture. And I’m going to call culture the creative arts. But I’m going to make a very broad definition of what art is. And my definition is quite simply art is everything that you don’t have to do."

63. Palacios-Sánchez L, Botero-Meneses JS, Pachón RP, Hernández LBP, Triana-Melo J del P, Ramírez-Rodríguez S. Stendhal syndrome: a clinical and historical overview.
Arq Neuropsiquiatr. 2018;76(2):120-123. doi:10.1590/0004-282x20170189

Stendhal syndrome, an ecstatic faint, is named after the writer who had a transcendent experience on seeing frescoes in a Florentine church.
"Sitting on the step of a genuflection stool, with my eyes diverted from the pulpit to be able to contemplate the ceiling, Volterrano’s Sibyls gave me perhaps the greatest pleasure that any painting had ever given me...I reached the emotional state in which we experience the celestial feelings that only the beauties of art and sentiments of passion can offer."

64. Angus J, University of Durham, Centre for Arts and Humanities in Health and Medicine, NHS Health Development Agency. A Review of Evaluation in Community-Based Art for Health Activity in the UK.
Health Development Agency; 2002. 

Arts within health settings usually sit within one of the following roles:

• art and design within the healthcare environment

• visual and other art forms to improve the environment for patients, visitors and staff

• medical humanities, teaching communication skills to clinicians

• psychotherapy using art

• community groups using art for wellbeing

65. Raw A, Lewis S, Russell A, Macnaughton J. A hole in the heart: confronting the drive for evidence-based impact research in arts and health.
Arts Health. 2012;4(2):97-108. doi:10.1080/17533015.2011.619991

A protected space for creation encourages participation, playfulness and improvisation. 

66. Crone DM, O’Connell EE, Tyson PJ, Clark-Stone F, Opher S, James DVB. ‘Art Lift’ intervention to improve mental well-being: An observational study from UK general practice.
Int J Ment Health Nurs. 2012;22(3):279-286. doi:10.1111/j.1447-0349.2012.00862.x

Arts for health interventions in UK general practices improved wellbeing especially in women, older people and those from lower socioeconomic groups. 

67. Hacking S, Secker J, Spandler H, Kent L, Shenton J. Evaluating the impact of participatory art projects for people with mental health needs.
Health Soc Care Community. 2008;16(6):638-648. doi:10.1111/j.1365-2524.2008.00789.x

Participatory arts projects improve social inclusion, mental health and especially empowerment. 

68. Opher, Simon. Cost-Benefit Evaluation of Artlift 2009-2012: Summary.
Artlift and NHS Gloucestershire; 2011. 

Artists working out of GP surgeries provided creative activities for patients. Poetry, writing, singing, ceramics, drawing, mosaic and painting.

Significant improvement in WEMWBS score. Cost per patient = £360, total reduction in NHS costs per patient = £576, so ROI of 0.6.

69. Venter E van de, Buller A. Arts on referral interventions: a mixed-methods study investigating factors associated with differential changes in mental well-being.
J Public Health. 2014;37(1):143-150. doi:10.1093/pubmed/fdu028

Arts on referral programs improve wellbeing scores especially in females and those of minortised ethnicity. 

Bibliotherapy 70-75 

70. Frude N. Book prescriptions — a strategy for delivering psychological treatment in the primary care setting.
Ment Health Rev J. 2005;10(4):30-33. doi:10.1108/13619322200500037

A summary of Books on Prescription schemes which make trusted self-help resources more accessible. 

71. Berthoud E, Elderkin S. The Novel Cure: An A-Z of Literary Remedies.
Canongate; 2013. ISBN 978-1786891044

72. The Reading Agency. Reading Well booklists for children. 

These are helpful books for different ages to share with children. Often it is easier for a child to discuss issues via someone in a story than confront difficult emotions head on. It also helps to give a vocabulary to describe and help understand these feelings, to:

73. ‘Give sorrow words; the grief that does not speak knits up the o-er wrought heart and bids it break.’ Shakespeare succinctly sums up how talking therapies work.  
Macbeth, Act 4 Scene 3

Inside out is a wonderful animated film about how sorrow is important to acknowledge.

74. Unjudge someone. The Human Library Organization.

75. Pennebaker JW, Seagal JD. Forming a story: the health benefits of narrative.
J Clin Psychol. 1999;55(10):1243-1254. doi:10.1002/(SICI)1097-4679(199910)55:10<1243::AID-JCLP6>3.0.CO;2-N

Writing for 15 minutes about important personal experiences in an emotional way quickly improves in mental and physical health with a reduction in doctor visits. 

'The guiding assumption of the present work is that the act of constructing stories is a natural human process that helps individuals to understand their experiences and themselves. This process allows one to organize and remember events in a coherent fashion while integrating thoughts and feelings. In essence, this gives individuals a sense of predictability and control over their lives. Once an experience has structure and meaning, it would follow that the emotional effects of that experience are more manageable. Constructing stories facilitates a sense of resolution, which results in less rumination and eventually allows disturbing experiences to subside gradually from conscious thought.' There is also an appreciation of the listener's perspective. 

Music 76-80 

76. Cohen GD, Perlstein S, Chapline J, Kelly J, Firth KM, Simmens S. The impact of professionally conducted cultural programs on the physical health, mental health, and social functioning of older adults—2-year results.
J Aging Humanit Arts. 2007;1(1-2):5-22. doi:10.1080/19325610701410791

Choir vs usual care. Mean age ~80. Intervention group had fewer doctor appts, less medication use, fewer falls, better rated overall health, better morale, less loneliness. Increase in activity persisted afterwards. Medication use went up in both groups, but less so in intervention group.

77. Vella-Burrows T. Singing and People with Dementia.
Sidney De Haan Centre for Arts and Health, Canterbury Christ Church University; 2012. 

'Accessing tunes, singing, humming familiar songs, swaying or moving rhythmically and a comforting connection with the musical tonic appears to be independent of higher cognitive function.'

The dorsal medial pre-frontal cortex (associated with autobiographical memories and emotions) is relatively preserved in dementia and highly stimulated during music activities. 

Listening to music and singing has also been shown to alleviate some of the commonly reported psychosocial symptoms of dementia, leading to melatonin release, which helps with sleep regulation, and reduced stress hormones.

78. McNamara RJ, Epsley C, Coren E, McKeough ZJ. Singing for adults with chronic obstructive pulmonary disease. Cochrane Airways Group, ed.
Cochrane Database Syst Rev. 2017;2019(2). doi:10.1002/14651858.CD012296.pub2

Statistically significant improvement in the SF-36 Physical Component Summary (PCS) score favouring the singing group. Benefits were from employment of diaphragmatic breathing, altered posture, and improved breathing co-ordination.
'Qualitative studies of singing and health report that singing can enhance mood, provide social support and friendship, help develop self esteem and self confidence, relieve stress, promote good posture and distract attention from personal worries'.

79. Clift S. An Evaluation of Community Singing for People with COPD Chronic Obstructive Pulmonary Disease: Final Report. [UPDATED LINK]
Canterbury Christ Church University; 2013. 

Improvement in FEV1 & FVC in people with COPD joining a community choir. 3.3 point improvement St George's respiratory questionnaire (4 points is considered minimum clinically significant change).

80. Morrison I, Clift, Stephen. Singing and People with COPD (Chronic Obstructive Pulmonary Disease).
Sidney De Haan Centre for Arts and Health, Canterbury Christ Church University; 2012.

Qualitative study of community choir for people with COPD, found benefits were

• positive beliefs - sense of joy, positive mood. 

• expectation & hope - look forward to each week. achievement from building up to performance

• self-belief - change in social identity to being part of group

• skills improvement. concentration eg learning new parts

• social support / networking

• structure from attending weekly

Rythmic auditory cues change the walking pace of people with early Parkinson's disease, offering ways that music can be used to maintain mobility. [Howe 2003, 10.1191/0269215503cr621oa] 

Prescribing social capital 81-83 

81. Antonovsky A. Unraveling the Mystery of Health: How People Manage Stress and Stay Well.
Jossey-Bass; 1987. ISBN 978-1555420284

Why do some people stay healthy in stressful situations while others do not? Sense of coherence comes from the confidence that internal and external environments are predictable, that resources to deal with challenges are available, and the engagement is worthwhile. Generalised resistance resources are those factors that facilitate responses to stressors. 

82. Bandura A. Self-efficacy: Toward a unifying theory of behavioral change.
Adv Behav Res Ther. 1978;1(4):139-161. doi:10.1016/0146-6402(78)90002-4

Much human behaviour develops from modelling via observation of others, which guides actions and encourages belief in individual capabilities. The confidence gained is transferable to other situations.

83. Maier SF, Seligman ME. Learned helplessness: theory and evidence.
J Exp Psychol Gen. 1976;105(1):3-46. doi:10.1037/0096-3445.105.1.3

Learned helplessness comes when behaviour and outcomes are independent. Lack of control induces a passive state, an uncontrollable situation affecting motivation, cognition and emotion. 

Flow 84 

84. Csikszentmihalyi M. Flow and the Foundations of Positive Psychology.

Springer Netherlands; 2014. ISBN 9789401790888. doi:10.1007/978-94-017-9088-8

https://www.academia.edu/39728351/Flow_and_the_Foundations_of_Positive_Psychology_The_Collected_Works_of_Mihaly_Csikszentmihalyi

Flow is a transcendant feeling of complete absorption, 'being in the moment'. This is most likely to happen when the level of challenge is equal to the level of skill. Mastering a skill encourages us to continue exploration and development. 

Tables

Table 6.1 Activity

a. Woodcock J, Franco OH, Orsini N, Roberts I. Non-vigorous physical activity and all-cause mortality: systematic review and meta-analysis of cohort studies.
Int J Epidemiol. 2011;40(1):121-138. doi:10.1093/ije/dyq104

Half an hour of moderate activity five times a week reduces all-cause mortality by 19%. Increasing this to an hour reduces mortality by a further 5%.

b. Hanson S, Jones A. Is there evidence that walking groups have health benefits? A systematic review and meta-analysis.
Br J Sports Med. 2015;49(11):710-715. doi:10.1136/bjsports-2014-094157

Walking reduces coronary heart disease risk by 6% and stroke by 15%, improving cardiovascular parameters such as BMI, blood pressure and cholesterol.  

c. France, Jonathan, Sennett, James, Jones, Andy, et al. Evaluation of Walking for Health: Final Report to Macmillan and the Ramblers.
University of East Anglia, Ecorys; 2016:191.
https://bit.ly/CCH6_walkingHealth 

Walking for Health programs have a return on investment of 3.36, costing £3,775 per QALY gained. 

d. National Institute for Health and Care Excellence. Falls in Older People: Assessing Risk and Prevention. NICE; 2013.

The annual cost of falls to the NHS is more than £2.3bn. 

Table 6.2 QALY gains from activity

a. Ainsworth, BE, Haskell, WL, Herrmann, SD, et al. The Compendium of Physical Activities Tracking Guide.
Healthy Lifestyles Research Center, College of Nursing & Health Innovation; 2022.
see ref 19

b. Papathanasopoulou E, White MP, Hattam C, Lannin A, Harvey A, Spencer A. Valuing the health benefits of physical activities in the marine environment and their importance for marine spatial planning.
Mar Policy. 2016;63:144-152. doi:10.1016/j.marpol.2015.10.009
see ref 20

Table 6.3 Health benefits of being outdoors

a. Stone, Dave. An Estimate of the Economic and Health Value and Cost Effectiveness of the Expanded WHI Scheme 2009.
Natural England; 2013. doi.org/10.13140/RG.2.1.4190.4720

Access to greenspace increases physical activity by 24%, which would save the NHS £2.1bn annually if available to all in England. 

b. Twohig-Bennett C, Jones A. The health benefits of the great outdoors: A systematic review and meta-analysis of greenspace exposure and health outcomes.
Environ Res. 2018;166:628-637. doi:10.1016/j.envres.2018.06.030

Access to greenspace reduces mortality by 31% (see ref 23). 

c. White MP, Elliott LR, Taylor T, et al. Recreational physical activity in natural environments and implications for health: a population based cross-sectional study in England.
Prev Med. 2016;91:383-388. doi:10.1016/j.ypmed.2016.08.023

There are 1.23bn visits to natural environments in England annually, gaining 109,164 QALYs at a saving of £2.18bn. 

d. Bagnall, Anne-Marie, Freeman, Charlotte, Southby, Kris, Brymer, Eric. Social Return on Investment Analysis of the Health and Wellbeing Impacts of Wildlife Trust Programmes.
The Wildlife Trusts; 2019. 

SROI of 6.88 for nature conservation targeted at people with low wellbeing, and 8.5 for people with average to high wellbeing.

e. Papathanasopoulou E, White MP, Hattam C, Lannin A, Harvey A, Spencer A. Valuing the health benefits of physical activities in the marine environment and their importance for marine spatial planning.
Mar Policy. 2016;63:144-152. doi:10.1016/j.marpol.2015.10.009
see ref 20

Table 6.4 Food and nutrition

a. Rayner M. The burden of food related ill health in the UK.
J Epidemiol Community Health. 2005;59(12):1054-1057. doi:10.1136/jech.2005.036491
see ref 49

b. Tyler, Gloria. Food Banks in the UK.
House of Commons Library; 2021:31. 

Food bank distributions in the UK increased by sixty times in the ten years since 2009. 2.5mn emergency food parcels were given out in 2020-21. 

c. WRAP. Food Surplus and Waste in the UK – Key Facts.
Waste and Resources Action Programme; 2020:16. 

9.5mn tonnes of food were wasted in the UK in 2018, representing 69kg per person and generating 25mn tonnes of greenhouse gases. 

Figures