Care farming – a salve for mental health issues?

A reason to delve into social prescribing

A decade ago, I started training and working in the field of mental health. My journey began with two years of residential training at a premier psychiatric hospital. This training focussed on categorizing and labeling distressful experiences to suppress them.

Over the years, I worked and researched in a variety of settings in the field of mental health and was exposed to diverse constructs and discourses. This opened up space to look beyond pharmacotherapy and conventional psychotherapy. I came to learn of alternate approaches that fall into the category of social prescribing. These approaches take into consideration the social determinants of mental health issues and focus on healing, well-being and quality of life as opposed to ‘diagnosis’ and ‘treatment’. A variety of practices connect mental health service users to non-medical services in their communities.

This raises two questions: What is the evidence behind social prescribing methods? Are they effective in addressing mental health challenges?

This blog post would not be able to do justice in discussing the entire ambit of social prescribing activities relating to mental health. Here, we will look at the evidence on care farming.

Care farming – also known as social farming – is the use of commercial farming and agricultural environments to foster mental and physical health through natural farming activities (Hassink et al., 2014).

The Campbell Collaboration has published a systematic review on ‘The impact of care farms on quality of life, depression, and anxiety among different population groups’. (Plain language summary here.) What are its findings?

Methods

Let us first look at the details of the studies included. The spectrum includes RCTs and quasi RCTs, disrupted time series and non-randomized controlled observational trials, uncontrolled before and after studies, and qualitative studies. The review also included studies that outlined theories and offered explanations on how to care farming brought about changes to the tinted glasses through which mental health is viewed. What were excluded from the review were other reviews, overviews, polls, commentaries, and editorials.

The search methods for the review involved sifting through electronic databases in the fields of health, education, the environment, criminal justice, and social science, as well as foraging the repositories of grey literature and multiple websites with special emphasis on sites relevant for care farming in Europe. Armed with indices of Google Scholar and the Web of Science, the authors tracked the main paper citations. The authors explored the Wageningen Journal of Life Science Citation Indices from 2000 onwards by hand. Finally, the academic networks were contacted for any additional studies.

Next was screening. Two independent reviewers undertook the screening. Consensus and dialogue helped iron out the disagreements A detailed screening was done after preliminary screening, to collate all theories related to care farming. Separate data extraction forms were used for capturing contextual data regarding care farming interventions in the study and data collected from qualitative and quantitative research.

Mixed methods synthesis has been carried out employing a sequential exploratory approach that entailed the development of an intervention framework based on existing theories.

The stages of synthesis have been explained in Fig 1

Fig 1: Stages of mixed methods synthesis

Results

What are the major findings of the review? The review found 31 studies with 980 participants. There are 18 qualitative studies, 13 quantitative studies, and one mixed-methods study. The authors did not carry out a quantitative synthesis but suggest there is evidence to support the case for care farms reducing anxiety and depression.

Qualitative studies

The qualitative research came from three European countries (The Netherlands, Norway, and the UK), as well as one from the United States. Personal interviews (n = 12) were used as the sole mode of data collection in the majority of the studies. Two used focus groups, two used a combination of focus groups and individual interviews, and two used film and photography in conjunction with the interview.

Quantitative studies

The quantitative studies were conducted in five countries: Norway, the UK, The Netherlands, Pakistan, and the United States. There were two RCTs and three CBAs, with the other nine using an uncontrolled before and after design (UBAs).

What do the findings mean?

The reviewers were able to construct logic models to explain possible pathways for change for four client groups: mental health and/or drug abuse issues, troubled teens, and people with intellectual disabilities.

The model emphasizes the importance of being in a non-judgmental, disciplined, engaging, and healthy atmosphere that allows for contemplation. This supportive environment assists individuals to recognize themselves; believe that they matter, are appreciated, and respected; establish social relationships; have a sense of accomplishment, happiness, and meaning; acquire new skills; develop social relationships; if desired, allow for the creation and nurturing of a new identity; become physically healthy. The reviewers do not indicate that any mechanism/pathway is more important than the others. However, they discovered potential differences in the way care farms operate for different client groups.

Overall, there is insufficient evidence to conclusively relate the intervention elements to the processes from the findings. The reviewers suggest that in the disaffected youth population, the emphasis on contemplation tends to align with the greater emphasis on the “setting” part of the intervention.

The authors of the review discuss that many of these pathways are expected to work in ways that are not yet known to affect outcomes. A crucial finding of the study was that the intervention elements reflected the theoretical term “restorative results of nature,” but it was not represented at all in the categories of mechanisms. Just four of the 164 results that mapped to the theoretical concept of mental wellbeing could potentially be related to nature. The reviewers state that the absence or near-absence of “nature’s restorative effects” is not a true absence; rather, nature serves as the necessary medium for other, more obvious processes to operate.

Despite being able to develop the logic model for the disabilities client group, the reviewers could not map outcome data to the model due to a lack of quantitative studies.

Based on only two small RCTs, the review lacks sufficient evidence to conclude that care farms have a significant positive effect on the quality of life. The review did discover some small and inconclusive proof that care farming can decrease anxiety. Many Uncontrolled before and after studies found significant improvements in self-esteem, stress, affect, mood, and group cohesion at the end of the intervention.

Conclusions

There is insufficient evidence to assess whether or not care farming improves the quality of life depression and anxiety.

Notwithstanding the lack of robust evidence to support the effectiveness of care farming, there are compelling arguments that persuade the use of an integrated approach to care farming as an alternative or an adjunct to mainstream mental health interventions.

Strengths and limitations

• The review encompasses a whole body of published and grey literature. The review brings out the nuances of mechanisms that facilitate changes in care farming for different population groups by amalgamating a wide range of primary studies.
• The review did not carry out the quantitative analysis.

Implications for practice

The need is for more well-conducted studies with methodological rigour. The authors of the study recommend a more cohesive approach to care farming research.

The review has brought another pertinent question to the fore – what is the evidence on other practices under social prescription? Researchers need to uncover evidence from other green care interventions and social prescriptions that have been helping in dealing with mental health problems.

The review holds a unique significance in the Indian context, where colonial treatment approaches to mental health still dominate. It urges us to reflect on alternate paradigms to address the rising mental health burden.

In my opinion, the review is a breath of fresh air to mental health service providers. It transcends conventional intervention boundaries and paves way for the incorporation of evidence-driven alternatives or adjuncts in mental health practice.

References

Primary paper

Murray, J., Wickramasekera, N., Elings, M., Bragg, R., Brennan, C., Richardson, Z., & Elsey, H. (2019). The impact of care farms on quality of life, depression, and anxiety among different population groups: A systematic review. Campbell Systematic Reviews, 15(4), e1061.

Other

De Bruin, S. R. (2009). Sowing in the autumn season: exploring benefits of green care farms for dementia patients.

Hassink, J., Hulsink, W., & Grin, J. (2014). Farming with care: the evolution of care farming in the Netherlands. NJAS-Wageningen Journal of Life Sciences, 68, 1-11.

Kilgarriff-Foster, A., & O’Cathain, A. (2015). Exploring the components and impact of social prescribing. Journal of Public Mental Health.

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