title: Rehabilitation of individuals on long-term sick leave due to sustained stress-related symptoms: a comparative follow-up study.
abstract: OBJECTIVE
  Nature-assisted therapy for mental health problems receives increased attention. However, quantitative evaluations are rare. This study evaluates the effects of an all-outdoors vocational rehabilitation program for individuals on long-term sick leave due to sustained stress-related symptoms.
  
  
  METHODS
  In a comparative pre-post intervention design the intervention group contained 48 participants from Mariendal Gardens (MG), while 45 participants at Stress- & Jobmanagement (SJ) formed the comparison group. At MG all activities took place outdoors, while activities at SJ were mainly indoors. Questionnaires were completed at baseline, 3- and 6-month follow-up. Outcomes included Perceived Stress Scale (PSS-10) and measures of sleep, mindfulness, self-efficacy, daily functioning, and work ability. Data were analyzed using mixed model repeated measures analysis of variance.
  
  
  RESULTS
  At baseline the MG-group PSS-10 mean score was 25.15 points (SD=7.20), while the SJ-group mean score was 23.91 (SD=7.48). At 3-months the MG within-group score dropped 4.61 [2.71; 6.52] points (p<0.01), corresponding to at standardized mean difference (Cohen's d) of d=0.64 [0.38; 0.91], while the SJ within-group score dropped 4.16 [1.73; 6.59] points (p<0.01), corresponding to d=0.56 [0.23; 0.88]. The between-group mean difference was not significant (p=0.77). Similarly, results for sleep, mindfulness, self-efficacy, daily functioning, and work ability demonstrated significant within-group effects and minimal between-group differences.
  
  
  CONCLUSIONS
  Both interventions demonstrated small to large pre-post effect sizes. Negligible differences were observed between the effects of the two interventions, indicating no added effect of the all-outdoors setting. Results should be interpreted with caution as unequal lost to follow-up rates threatens the comparability of changes in the two groups.
authors.affiliation: Danish Ramazzini Centre, Department of Occupational Medicine, Aarhus University Hospital, Region Midt, Denmark morten.willert@aarhus.rm.dk.
authors.forename: Morten Vejs
authors.initials: MV
authors.lastname: Willert
authors.affiliation: ArbejdsmiljøCentret, previously at the Centre for Social Medicine and Rehabilitation, Region Midt, Denmark.
authors.forename: Joanna
authors.initials: J
authors.lastname: Wieclaw
authors.affiliation: Danish Ramazzini Centre, Department of Occupational Medicine, Aarhus University Hospital, Region Midt, Denmark.
authors.forename: Ane Marie
authors.initials: AM
authors.lastname: Thulstrup
mesh_terms: D000328:Adult; D000529:Complementary Therapies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D019368:Nature; D015397:Program Evaluation; D012050:Rehabilitation, Vocational / Q000379:methods*; D018582:Sick Leave / Q000706:statistics & numerical data*; D013315:Stress, Psychological / Q000517:prevention & control / Q000534:rehabilitation*; D013997:Time Factors; D016896:Treatment Outcome
keywords: Stress management; nature-assisted therapy; stress rehabilitation; vocational rehabilitation