Journal of Psychosocial Nursing and Mental Health Services

CNE Article 

Effects of an Urban Forest-Based Health Promotion Program on Children Living in Group Homes

Min Kyung Song, PhD, RN; Kyung-Sook Bang, PhD, RN; Sungjae Kim, PhD, PMHNP, RN; Gumhee Lee, MSN, APRN; Yeseul Jeong, BSN, RN

Abstract

Children living in foster care group homes are more likely to have physical, mental, and social health problems due to parental abuse, neglect, and family breakdown. The purpose of the current study was to develop and apply the urban forest-based health promotion program on children living in group homes in Korea to investigate its effects on perceived health, psychological health, and connectedness to nature. Eight children (mean age = 12.13 [SD = 1.25] years) from three group homes participated in the study. The intervention was conducted individually for each group home once per week for 8 weeks. Quantitative and qualitative data were collected and analyzed. Participants showed significant improvement in restoration. Six themes were identified that reflect participants' experience and the effectiveness of the urban forest-based health promotion program. This program may be considered a possible intervention to promote children's psychosocial health and connectedness to nature. Continuous efforts are needed to further examine the program's effectiveness. [Journal of Psychosocial Nursing and Mental Health Services, 58(6), 18–29.]

Abstract

Children living in foster care group homes are more likely to have physical, mental, and social health problems due to parental abuse, neglect, and family breakdown. The purpose of the current study was to develop and apply the urban forest-based health promotion program on children living in group homes in Korea to investigate its effects on perceived health, psychological health, and connectedness to nature. Eight children (mean age = 12.13 [SD = 1.25] years) from three group homes participated in the study. The intervention was conducted individually for each group home once per week for 8 weeks. Quantitative and qualitative data were collected and analyzed. Participants showed significant improvement in restoration. Six themes were identified that reflect participants' experience and the effectiveness of the urban forest-based health promotion program. This program may be considered a possible intervention to promote children's psychosocial health and connectedness to nature. Continuous efforts are needed to further examine the program's effectiveness. [Journal of Psychosocial Nursing and Mental Health Services, 58(6), 18–29.]

According to international statistics, the number of children living in foster care is increasing (Leve et al., 2012). This increase in the number of children requiring protection has been attributed to income inequality, unemployment, changes in family structure, and growing disorganization of the family (Akmese & Kayhan, 2015; Jang et al., 2016). Most of these children are placed in foster care facilities rather than being adopted and living in family homes because of the importance assigned to blood relations in traditional Korean thinking. Foster care placement is categorized as family homes (kin or non-kin), group homes, or others. Group homes or communal homes aim to provide protection, rearing, and self-reliance support services for children (National Law Information Center, 2019).

Children living in foster care have commonly experienced maltreatment in the form of physical, sexual, or emotional abuse and/or neglect (Leve et al., 2012), but they have also experienced abandonment, poverty, and family breakdown (Akmese & Kayhan, 2015; Jang et al., 2016). A systematic review of studies involving children who have been abused has shown that these children experience decreased self-esteem, anxiety, depression, difficulty in forming and maintaining friendships, aggression, and attention-deficit/hyperactivity disorder (ADHD) (Maguire et al., 2015). In addition, children living in foster care exhibit poor functioning throughout their lives, experiencing unemployment, incarceration, substance dependence, and early childbearing (Hambrick et al., 2016). To overcome these difficulties, various programs, including group counseling (Son, 2007), mentoring and skills groups (Taussig & Culhane, 2010), art therapy, and music therapy (Lee et al., 2011), have been implemented and their effects reported. A literature review on programs for children and adolescents in foster care suggests that research should be conducted using an integrated approach in various fields for effective psychoemotional support (Kim et al., 2018).

According to previous studies, children who live or spend time in a natural environment generally have fewer social, emotional, and behavioral problems (Gill, 2014). A natural environment can restore a child's attention, may reduce stress through beneficial physiological responses, and may increase opportunities for creative, adventurous, social, and challenging play (Richardson et al., 2017). Attention restoration theory (ART) (Kaplan, 1995) and stress recovery theory (SRT) (Ulrich et al., 1991) were both used to help guide the current study by describing specific benefits of connectivity to nature, such as cognitive ability and psychosocial health improvement. According to ART, attention, which is the ability to focus on a task that requires effort, is finite and may become fatigued. Contact with nature can restore attention, as well as reduce mental fatigue and aid in psychological recovery (Ohly et al., 2016). SRT describes a natural environment as having a particular aesthetic appeal and a positive effect on stress and anxiety (Ulrich et al., 1991).

In recent years, various attempts have been made to use forest therapy to promote mental and physical health around the world (Kamioka et al., 2012; Lee, Choi, et al., 2017). Forest therapy refers to visiting forests or participating in various activities in the forest environment, such as viewing, walking, and meditating in the forest (Lee, Choi, et al., 2017; Li, 2013). Forest therapy or activity programs in the forest environment have been developed and implemented and are gradually expanding to include children. A forest program for children has reported positive effects on pediatric environmental diseases, such as atopic dermatitis and asthma (Seo et al., 2015), as well as positive psychological and social effects, such as depression and anxiety reduction, increased self-esteem, emotional adjustment ability, sociality, and school adaptability (Bang, Kim, Song, et al., 2018; Gill, 2014; Song & Bang, 2017). In addition, forest-based programs for vulnerable groups, such as children from low-income families, have shown positive effects on self-esteem, sociality, depression, aggression, and stress in previous studies (Cho et al., 2011; Kim, Shin, et al., 2012). Findings indicating that forest activities can positively change children's psychosocial health suggest the usefulness in developing and implementing appropriate forest experience programs for children who live in group homes. Most current programs implemented for children who live in group homes have been conducted indoors, because it is difficult to provide opportunities for group-home– based forest experiences due to labor shortages and overworked childcare employees.

Children living in group homes require attention and interventional programs to manage the various health problems caused by abuse or neglect. In a meta-analysis of social-emotional development programs for children and adolescents, the mean effect size of group homes was largest at 0.926 (Lee et al., 2011). This result suggests that it is necessary to implement a social-emotional development program, because group homes may not provide adequate social and emotional support for each child's development. Findings indicating that forest activities can positively change children's psychosocial health suggest the usefulness in developing and implementing these programs for children who live in group homes.

Therefore, it is expected that appropriate forest-based programs for children living in group homes will have a positive impact on psychosocial health and connectedness to nature. The specific objectives of the current study were: (1) to develop a mental and physical health promotion program using urban forests for school-aged children living in group homes; and (2) to evaluate the effects of the program on children's depression, self-esteem, perceived stress, emotional state, and connectedness to nature.

Method

Study Design and Participants

The current study was derived from the dissertation work of the first author (Song, 2019) and is a mixed-methods pilot study based on a one group pre-/posttest design and individual interviews with children after the intervention. The research methodology was based on concurrent triangulation design, in which the quantitative and qualitative data were concurrently collected and separately analyzed on the same phenomenon. The results were then used to validate, confirm, and corroborate the quantitative results with the qualitative results. The triangulation model of applying more than one method to find a solution related to similar aspects can enhance the credibility of research findings (Creswell & Clark, 2011).

The urban forest-based health promotion program was administered to children living in group homes in Seoul, Korea. Each of these group homes typically houses five to seven children and adolescents age ≤18, along with two social workers. Participants were upper elementary and middle school students living in the group homes who were given the opportunity to participate by responding to the questionnaires.

The study was conducted from June 2018 to November 2018 in accordance with the Declaration of Helsinki and was approved by the Institutional Review Board of Seoul National University. Information about the study and a recruitment message were posted on the homepage of the Seoul Support Center for Children group home website, and three group homes were recruited for participation. All participants were informed about the purpose and method of the study, the ability to withdraw at any time, and that anonymity and confidentiality would always be maintained. Children and parents, or guardians of children, were asked for written informed consent. Because the children in the group homes did not live with their parents, the parents' or guardians' permission to participate in the study was obtained with the cooperation of the group home director. This study was conducted for those children who agreed to participate and also had parents or guardians who agreed.

There were nine children recruited across three group homes; however, one child returned to his family of origin during the intervention period, and the remaining eight children participated in the study. Study details, including the purpose, procedure, method, and the possibility of discontinuing the study at any time, were explained to participants and legal representatives, and written consent was obtained. Tests were conducted before the start of the program and after the 8-week intervention, and individual interviews were conducted within 2 weeks after the program ended.

Program Development

The health promotion program using urban forests was based on a previous study, which developed an after-school community center program for vulnerable children and evaluated its effectiveness (Bang, Kim, Song, et al., 2018). Individual interviews were conducted with key informants, including psychiatrists, psychological counselors, and social workers, at the group homes. These interviews identified the problems faced by children living in group homes and the main therapeutic factors of interventions for these problems. An integrated literature review of intervention studies for children living in group homes in Korea was also conducted. Based on this process, the program was revised, detailed information about the program was provided to the director of the participating facilities, and an agreement was reached concerning the program contents. Program themes comprised the following: Forming Rapport, Exploring and Expressing Emotion, Increasing Self-Awareness and Awareness of Others, and Improving Interpersonal Relationships (Table 1).

Program Session Themes, Objectives, and Contents

Table 1:

Program Session Themes, Objectives, and Contents

Implementation Process

The program comprised eight weekly sessions of group-based forest activities aimed at improving the perceived health status and psychological health of elementary and middle school students living in group homes. Each session comprised 120 minutes of forest activities, including travel time. The health promotion program for two of the group homes was implemented from June to August 2018, and for the other group home from September to November 2018. The program was conducted individually for each group home in nearby urban forests (i.e., parks) within a 10-minute walking distance from the home. Each session was conducted in three phases, excluding travel time: (1) warm-up and ice breaking (20 minutes); (2) forest activities (70 minutes); and (3) wrap-up (10 minutes). In the warm-up and ice-breaking phases, participants performed stretching exercises and talked about themselves, describing a week in their lives, and researchers explained the day's agenda. Forest activities were organized based on each session's theme, and during the wrap-up phase, participants shared impressions and feelings about the day's activities.

The program was conducted by a research team comprising nurses who majored in child health or psychiatric nursing. One nurse was a certified forest guide for young children and a forest therapy instructor. The program included a 4-hour forest camp operated by an external certified forest therapy instructor.

Measurements

Self-report questionnaires were provided to participants. To determine whether the questions would be understood and able to be answered by children in this age group, a pilot survey using self-report questionnaires was conducted on elementary school students in grade 4 who did not participate in the current study. As a result, it was confirmed that grade 4 students did not have any difficulty in completing the questionnaire.

Participants completed the pretest questionnaire on the first day of the intervention, before the program was initiated. On the last day, upon completion of the program, all participants completed the posttest questionnaire and satisfaction survey. Participants were encouraged to ask any questions if they did not understand the questionnaire. It took approximately 20 minutes to complete the questionnaire. In addition, a questionnaire survey regarding the restoration effects of the program was conducted before and after the end of each session and took approximately 5 minutes. The specific instruments included on the questionnaire were as follows.

Perceived Health Status. Perceived health status was assessed by a single-sentence question rated on a 5-point Likert scale, ranging from 5 (very good) to 1 (very bad): “How do you feel about your overall health condition?”

Self-Esteem. Self-esteem was measured by the Rosenberg Self-Esteem questionnaire (Rosenberg, 2015), which contains 10 items. The items were rated on a 4-point Likert scale, ranging from 1 (strongly disagree) to 4 (strongly agree). Negative item scores were reverse-coded. The scores for all items were added to obtain the total score, which ranged between 10 and 40; a higher score indicates a higher level of self-esteem. At the time of tool development, Cronbach's alpha was 0.88 (Rosenberg, 1979); Cronbach's alpha in the current study was 0.81.

Depression. The Korean version of the Children's Depression Inventory (CDI) (Han & Yoo, 1994) was used to evaluate participants' depressive symptoms. The CDI is a widely used measure of children's depression comprising 27 items. Each item is rated on a 3-point Likert scale scored as 0 (absence of symptoms), 1 (mild or probable symptoms), or 2 (definite symptoms); a higher CDI score indicates a higher number of depressive symptoms. Cronbach's alpha for the CDI in a study of elementary and middle school students was 0.81 (Han & Yoo, 1994); Cronbach's alpha in the current study was 0.87.

Perceived Stress. Perceived stress was measured using the 10-item Korean version of the Perceived Stress Scale (PSS), which was revised to be understandable to elementary school students. The questions in the PSS ask about feelings and thoughts during the past 1 month. In each case, respondents are asked how often they felt a certain way. Each statement is rated on a 5-point Likert scale ranging from 4 (very often) to 0 (very rarely). PSS scores are obtained by reversing responses to the four positively stated items and then summing across all scale items. A higher score indicates a higher level of perceived stress. Lee (2013) reported a Cronbach's alpha of 0.66 in Korean adolescents; Cronbach's alpha in the current study was 0.62.

Behavior Problems. Problem behavior was measured with the Korean youth self-report (Oh et al., 1997), which was a standardized and translated (Korean) version of the scale developed by Achenbach (1991). This scale measures the tendency for problem behavior through self-evaluation of adolescents' and children's adaptation, emotion, and behavior. Items are rated on a 5-point Likert scale, ranging from 1 (not at all) to 5 (very often); a higher score indicates a higher level of the problem behavior. Cronbach's alpha was 0.86 for the Korean youth self-report (Oh et al., 1997); Cronbach's alpha in the current study was 0.96.

Restoration Outcome Scale. The nine-item Restoration Outcome Scale (ROS) (Korpela et al., 2008) was used to measure perceived restoration outcomes. Restoration refers to healing effects, including fatigue and stress relief, that are experienced through exposure to nature. The ROS can measure the degree of subjective vitality and relaxation experienced by individuals. Items are rated on a 7-point Likert scale, ranging from 1 (not at all) to 7 (completely). A higher score indicates a higher level of restoration. At the time of tool development, Cronbach's alpha was 0.92 (Korpela et al., 2008); Cronbach's alpha in the current study was 0.93.

Connectedness to Nature. Participants' connectedness to nature was measured using the Connectedness to Nature Scale (Mayer & Frantz, 2004) translated into Korean to measure an individual's affective, experiential connection to nature. The scale comprises seven items rated on a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). A higher score indicates a higher connectedness to nature. At the time of tool development (Mayer & Frantz, 2004), Cronbach's alpha was 0.84; Cronbach's alpha in the current study was 0.91.

Qualitative data were collected within 1 week of the end of the program to supplement the interpretation of the quantitative research and to gain a deeper understanding of the program participation experience. All participants voluntarily agreed to individual, semi-structured interviews lasting 30 minutes each (Table 2), which were conducted after program completion. The time and place of the interview were determined at the participant's convenience. The interview contents were audio recorded with participant permission and transcribed into text.

Semi-Structured Interview Guide

Table 2:

Semi-Structured Interview Guide

Data Analysis

Data analysis involved two datasets (quantitative and qualitative), and the general guidelines for analyzing concurrent mixed methods data proposed by Creswell and Clark (2011) were followed. Both datasets were analyzed separately and then merged so that the interpretation and discussion could be made based on the overall results.

The nonparametric Wilcoxon signed rank test was used to compare the effects before and after the intervention. Effect size (r) was calculated for the non-parametric data (Field, 2013), where r = 0.1 indicates small effect size, r = 0.3 indicates moderate effect size, and r = 0.5 indicates large effect size. SPSS for Windows version 22.0 was used for all data analysis, and statistical significance was set at p = 0.05.

The collected qualitative data were analyzed using qualitative content analysis (Elo & Kyngäs, 2008). This method analyzes the meaning of collected data based on the main research questions. The specific analytical procedure is as follows. Written materials were read to understand the essentials of the overall flow and data. The headings were identified through open coding to obtain meaningful units. The extracted headings were reduced to the general and meaningful categories, and the categories were named based on meaning and relevance. The content analysis process was conducted individually by two researchers (M.K.S., S.K.), and several meetings were held to review and agree on the data collection, analysis process, and analysis results.

Results

Quantitative Results

Eight children (four boys and four girls) with a mean age of 12.13 (SD = 1.25 years) who reside in group homes participated in the study. Demographic characteristics and outcome variables of participants are shown in Table 3.

Participants' Demographic Characteristics and Outcome Variables from the Pretest (N = 8)

Table 3:

Participants' Demographic Characteristics and Outcome Variables from the Pretest (N = 8)

Results of the Wilcoxon signed rank test examining the perceived and psychological health differences before (pretest) and after (posttest) the urban forest-based health promotion program are presented in Table 4. Participant restoration significantly increased in the posttest (Z = 2.24, p = 0.025), indicating that the program was partly effective in improving children's psychological health. Perceived stress decreased from 17.50 before the intervention to 16.50 after the intervention; however, this change was not statistically significant. Subjective health, self-esteem, depression, behavior problems, and connectedness to nature also showed no statistically significant differences.

Effects of the Urban Forest-Based Health Promotion Program on Outcome Variables (N = 8)

Table 4:

Effects of the Urban Forest-Based Health Promotion Program on Outcome Variables (N = 8)

Qualitative Results

The interview data were analyzed to explore participants' experiences and the effects of the program, including the parts not measured by the quantitative research design. In the qualitative data analysis of participants' experiences, the following six themes were identified: Feel the Refreshing Beauty of a Forest; Learn the Value of and Appreciate Nature; Think About Health Through Activities in the Forest; Stress is Relieved, and the Mind is Relaxed; Enjoy Activities; and Develop an Understanding and Considerate Attitude Toward Others.

Theme 1: Feel the Refreshing Beauty of a Forest. Participants expressed that through experiencing the program, they felt freshness and beauty in the everyday life of the city or in the forest that they did not feel when they visited the forest in the past. As they walked in the forest and sat in the woods, they experienced “the clean air of the forest,” “a natural landscape that cannot be seen in the city,” and “the beauty of the forest.” The following statement demonstrates how one participant felt refreshed and beautiful through the program:

...I have never felt refreshed in a forest. But when I was sitting in the middle of mountains...no...trees, the air felt surprisingly good. So, I think I felt like it [was refreshing]. I think I felt good. (Participant 1)

Theme 2: Learn the Value of and Appreciate Nature. Through this program, participants perceived that nature, such as trees and forests, is “alive.” They felt “happy” and “warm,” and recognized by engaging in forest activities that nature is “precious.” Participants had the opportunity to learn the value of and appreciate nature while experiencing various activities away from their daily urban lives. The program brought attention to the natural environment and sparked participants' curiosity.

…It felt valuable...how should I say this...you know, when you see insects, you try to kill them and when you see ants, you step on them. But these days, when ants are crossing like this, I kind of look behind me to check if I haven't stepped on them and try to go around them so I don't kill them. (Participant 1)

I am grateful for this nature. I'm grateful that we can see the nature and that I have legs to walk in this nature. (Participant 9)

Theme 3: Think About Health Through Activities in the Forest. Participants experienced improvement in their physical and psychological health, such as “feeling free” and “having more muscles in the legs,” and they had time to reflect on plans for healthy living. Participants mentioned activities for improving their health, including exercise (e.g., jump rope, baseball, basketball), play, and visits to the forest. This theme is illustrated by the following statements.

Even when I was kind of annoyed, I felt more lighthearted after I went to the mountains. I think like sweating and all makes my body kind of better. (Participant 8)

I want to exercise a lot to live a healthy life. (Participant 2)

Theme 4: Stress is Relieved, and the Mind is Relaxed. As children participated in the forest activities, they experienced that negative emotions, such as “anger” or “irritation,” were resolved, and that the activities “relieved stress” and “relaxed and enriched the mind.” It was found that forest activities had the effect of relieving stress and tension. The following participant's statement reveals the comfort felt when interacting with nature.

I think my mind is kind of enriched like the mountains. I am angry at something and am annoyed when going up, but all this irritation is emptied when I come down. (Participant 9)

Theme 5: Enjoy Activities. Before children participated in the program, they thought that hiking or mountain climbing were the only activities one could do in the forest. However, through physical and art activities in the forest, they experienced “enjoyment,” “fun,” and “happiness.” In particular, children expressed pleasure and satisfaction with activities in which they had previously expressed a desire to participate.

It was way better than I had thought. When I thought of the mountains, I only thought of hiking, but I feel that you can do a lot of other activities in the mountains. (Participant 8)

Knotting was amazing, and hanging ropes was kind of fun. (Participant 9)

My heart felt better. It was fun and enjoyable. The free time was the most memorable. (Participant 7)

I had fun and was happy because I did what I wanted to do the most [cycling]. (Participant 5)

Theme 6: Develop an Understanding and Considerate Attitude Toward Others. Children had the experience of “understanding” another person and knowing their “mind or emotions.” Understanding other people makes children think positively, apologize to others first, laugh with them when they are happy, and give them consideration when they are sad. The following statements show that by participating in the program, these children gained an understanding of others that has changed their relationships.

I was kind of able to understand why Rob [pseudonym] does those things. I always thought of Kathy [pseudonym] as bad…negatively, but I think I was able to find the good side of him/her a little bit. (Participant 1)

I want to understand how others feel…so that I can laugh with them when they are happy and be considerate when they are sad. Being able to learn others' feelings…like in which situations they feel like this and when they feel happy…knowing each other's feelings made our relationship better. (Participant 2)

Participant Satisfaction

Overall, participants were satisfied with the program; six were “very satisfied,” one was “mostly satisfied,” and one was “average.” Seven of eight participants said they would like to participate again if they had the opportunity, and seven of eight said they would recommend it to another friend. Participants were interviewed and surveyed for satisfaction and reported that the duration of the program was too short and that they were sorry that they had not been able to visit more forests.

Discussion

The current study was designed to develop a health promotion program using urban forests for children living in group homes, and a concurrent mixed methods design was used to evaluate the effects on subjective and psychological health. Previous research on forest interventions targeted general elementary and middle school students. However, the current study was expected to promote health by applying forest activities to more vulnerable individuals. Based on the quantitative and qualitative results, the program contributed to positive changes in the children's emotional and social health and attitudes toward nature.

The ROS score of the children participating in the program significantly increased, which is consistent with previous research that found contact with nature leads to restorative experiences (Chawla, 2015; Collado & Corraliza, 2015). In particular, the results of restoration with the attributes of vitality and relaxation can be linked to the forest characteristics mentioned in Cha and Kim's (2009) study on how the forest experience affects individuals with alcohol use disorder. Vitality can be understood as “a lively living being in the forest” with hope and desire for life, and relaxation can be understood in a context similar to “placidity and tranquility,” in which the feeling of pressure is alleviated (Cha & Kim, 2009, pp. 341–342). The results of the qualitative analysis also reported that angry or annoyed minds were calmed and became comfortable and enriched.

Forest activities have been reported to have a positive effect on stress reduction in adults as well as children (Hansen et al., 2017; Hohashi & Kobayashi, 2013). In the current study, participants' perceived stress scores decreased after the intervention and approached significance (p = 0.057). In the qualitative analysis, participants were expected to be able to relieve stress through forest activities and reported that they were relieved and relaxed. Children living in group homes are under high stress due to separation from their original family and adaptation to unfamiliar environments (Dubois-Comtois et al., 2015; Hambrick et al., 2016); therefore, it may be helpful to use urban forests to relieve stress.

Depression and lack of self-esteem that may arise due to separation from the original family are known psychological and emotional characteristics of protected children. In the current study, depression scores decreased after the intervention but were not statistically significant; there also was little change in self-esteem scores. In a systematic review of the effects of forest treatment on depression, forest therapy has been reported to be a new and effective intervention for reducing depression in adults and children (Lee, Choi, et al., 2017; Song & Bang, 2017). According to a meta-analysis of the effectiveness of forest-related programs, psychological variables showed a large effect size (0.729), and depression (1.358) and self-esteem (1.269) showed large effect sizes (Cho et al., 2015). A study of forest activity programs for at-risk children in orphanages, sheltered housing, and group homes also reported that these programs increased children's self-esteem (p < 0.001) and positively changed their interpersonal relationships (p < 0.001) and degree of depression (p < 0.001) (Lee, Hong, et al., 2017). Although the quantitative results of the current study are not statistically significant, the qualitative data indicate that participants felt interest and enjoyment through the program. Recognizing and enjoying pleasant stimuli can lead to a decrease in depression levels (Min et al., 2019); therefore, it is necessary to help children recognize and feel pleasant and positive experiences in the forest throughout the program. In the current study, mean depression score of children living in group homes was 13.38 (SD = 7.05), which did not reach the cut-off value of 19 for depression. However, for children in grades 4 to 6 not living in group homes surveyed using the same scale, mean depression score was 8.41 (SD = 6.93) (Bang, Kim, Kang, et al., 2018). The depression level of children living in group homes tends to be high, and active intervention is needed to alleviate depression.

Self-esteem results, which showed no significant change after the intervention, are consistent with previous studies (Barton et al., 2015; Wood et al., 2014). It has been reported that gender, length of stay, original family attachment, foster care caregiver attachment, and peer attachment affect children's self-esteem in group homes (Kim, Yi, et al., 2012). These characteristics may have acted as a confounding variable. In addition, in previous studies of vulnerable children, forest therapy was integrated into horticultural therapy (Choi & Koh, 2014), or forest therapy with college student mentors (Bang, Kim, Song, et al., 2018). These mentors were involved in activities to facilitate the program and promote participation of children. As the effects of natural activities, including forest healing, on the enhancement of self-esteem in children remain unclear, further research is needed.

As a result of the current study, although the minimum and maximum values of problem behaviors decreased, there were no statistical differences. On the other hand, previous studies have shown that forest activities lead to a decrease in behavioral problems, such as ADHD or general hyperactivity, distraction, and impulsivity, and in problem behaviors, such as anger and aggressiveness (Kim et al., 2015). The results of the current study may be different from those of previous research because the sample population included children with various psychosocial problems living in group homes. According to previous studies on problem behaviors in foster care children, foster care caregiver–child relationships play a significant role in reducing the child's problem behaviors and promoting childcare (Dubois-Comtois et al., 2015). Therefore, to reduce problem behaviors of children who live in group homes, stakeholders should consider adding forest activities that can be implemented by the foster care caregiver and child together.

Connectedness to nature increased after the intervention but was not statistically significant. The qualitative research revealed that participants recognized the freshness and beauty of the forest and that they developed an awareness of the importance and appreciation of nature after the program. Connectedness to nature increases with time in a natural environment; it also increases as empathy and emotional intimacy with nature increase (Hinds & Sparks, 2008). The characteristics of socioeconomically vulnerable children may cause them to be unfamiliar with the forest; thus, it is likely that more time was needed to create emotional intimacy or empathy for connectedness to nature. In addition, the current program included activities resulting in a “winner,” which tended to make the children more interested in achievement or victory than interaction with nature. Therefore, it is necessary to extend the time and duration of the program and to present in detail how to focus on and interact with nature for each child to have sufficient interactions.

The qualitative research showed that children expressed pleasure and fun through forest activities and experienced feelings of understanding and consideration toward others. Participants reported experiencing positive feelings toward forest activities, and fun was the single most frequently expressed reason. During the interviews, participants expressed that they experienced more fun and satisfaction when given the freedom to do whatever they wanted to do. Glasser (1996) described survival, power, belonging, freedom, and fun as five basic needs that must be met for physiological and psychological health. The purpose of human behavior is to satisfy these basic needs, and these basic needs must be fulfilled for physical and mental health to be optimized (Frey & Wilhite, 2005). Among other things, fun comprises enjoyment, pleasure, relaxation, laughter, and learning. Fun has also been regarded as an important element in making physical activity enjoyable and is often at the top of the agenda for children (Dismore & Bailey, 2011). Through the program, children are able to satisfy their needs for fun and express their suppressed emotions and energy. Children in foster care live in a controlled environment and are required to follow certain rules, which may limit their freedom of choice and movement. In the current study, it can be inferred that giving participants a choice and including time for free activities before the end of each session were effective in meeting their needs for freedom and forming positive experiences. Meanwhile, group-based activities are known to affect children's emotions, interaction, and socialization, and represent a way to use limited resources efficiently (Allen, 2008). The feeling of understanding and care for others, which participants mentioned experiencing, may be due not only to the effects of forests but also to the effects of playing with others.

Limitations

The current study has some limitations. First, the quantitative analysis was a one-group pre-/posttest design that is vulnerable to various types of bias, because there is no random extraction procedure or control group. In addition, group homes participating in the study were selected based on accessibility and preference, which could have led to an imbalance or bias between study conditions and may have influenced the subsequent analysis. A number of potential confounders, such as demographic variables (e.g., gender, residence period), could not be accounted for in the analyses, including characteristics of the group homes or the impact of the social component of the program.

The second limitation relates to the small number of participants. Small sample size is problematic due to violations of normality and limited statistical power. In the current study, it is difficult to determine the reason for the statistically insignificant results, either because the sample size is insufficient or because changes are too small to be meaningful. Therefore, it is necessary to repeat the study using a larger number of participants. Third, there was no follow-up assessment to determine whether the changes in restoration were maintained. Finally, there is no guideline on whether a certain amount of forest activity is effective. However, the 8-week program (120 minutes per day) was not enough to find significant changes in vulnerable children, indicating the program duration may not have been long enough to improve health. Consequently, interventions with a duration >8 weeks would be necessary to confirm whether significant changes can be observed.

Nonetheless, the current study contributed to the understanding and health promotion of children living in group homes with mental, social, and behavioral problems as individuals in need of intervention. Vulnerable children, including those living in group homes, fall within the realm of social welfare in Korea. These children are reported to be vulnerable in regard to their social and economic conditions, as well as their health status, which requires continued attention. The program appeared to be associated with an improved sense of restoration, as well as more positive affective responses to nature/activities. However, a more robust investigation with a larger sample and a control group is needed to reach a better understanding of the program's impact on this population.

Implications for Practice

Adequate psychosocial mental health care is important for children separated from their parents and living in foster care systems (e.g., group homes), as these children may exhibit various behavioral problems and psychiatric problems, such as anxiety, depression, aggression, and ADHD. The current study has an important impact on mental health nursing in that it has confirmed the effectiveness of forest therapy on psychosocial problems in children living in communal situations.

Forest therapy has been studied to promote the health of children living in group homes. The results of the current study provide empirical support for the benefits of forest therapy on foster children's restoration, relaxation, stress reduction, understanding for others, and positive feelings about forests and nature. Findings also confirm the possibility of practical application.

Overall, the current research can contribute to expansion of mental health practices aimed at improving children's mental health through the development of interventions, including traditional treatments and forest therapy.

Conclusion

A health promotion program using urban forests indicated the possibility of improving restoration outcomes and relieving perceived stress of children living in group homes. The study results provide preliminary evidence that forest activities for children who live in group homes have positive effects on children's subjective and psychological health, their understanding of themselves and others, and their connectedness to nature. These findings may serve as a foundation for the implementation of programs using urban forests to promote the psychological health of children in other types of child welfare facilities.

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Program Session Themes, Objectives, and Contents

Session Theme Objectives Contents
1 Forming rapport <list-item>

Develop intimacy with nature by encountering the forest

</list-item>
<list-item>

Introduction

</list-item><list-item>

Receive permission to participate

</list-item><list-item>

Pretest: complete questionnaire

</list-item><list-item>

Forest walking

</list-item><list-item>

Make a nickname for natural objects that resemble oneself and draw them

</list-item>
2 Forming rapport and expressing emotion 1 <list-item>

Gradually feel closer to the forest by searching for natural matter

</list-item><list-item>

Express one's feelings through forest activities

</list-item>
<list-item>

Physical activities in the forest

</list-item><list-item>

Cloth volleyball, traditional play

</list-item><list-item>

Express one's feelings

</list-item>
3 Exploring and expressing emotion 2 <list-item>

Be immersed in the forest itself and open one's mind while walking in the forest

</list-item><list-item>

Come to realize the existence of various feelings in one's mind through forest activities

</list-item>
<list-item>

Play with natural materials

</list-item><list-item>

Read one's expression and mind

</list-item><list-item>

Find natural materials (treasure hunt)

</list-item>
4 Increasing self-awareness and awareness of others 1 <list-item>

Understand and embrace oneself, view one's situation through communing with nature

</list-item>
<list-item>

Meditation

</list-item><list-item>

Look for a tree that resembles oneself

</list-item>
5 Increasing self-awareness and awareness of others 2 <list-item>

Focus on oneself, feel soothed and open through communing with nature

</list-item><list-item>

Acknowledge negative desires and resolve them by placing the desire on the forest

</list-item>
<list-item>

Gaze up at the sky above the forest

</list-item><list-item>

Gather stones for every current worry

</list-item>
6 Improving interpersonal relationships 1 <list-item>

Come to one another through forest activities

</list-item><list-item>

Bring emotion back and be reminded of loved ones

</list-item>
<list-item>

Guide a friend wearing an eye patch

</list-item><list-item>

Describe precious people as natural objects

</list-item>
7 Improving interpersonal relationships 2 <list-item>

Recover one's confidence through forest activities

</list-item><list-item>

Embrace other people and start to consider and collaborate with others

</list-item><list-item>

Awaken feelings toward art through experiencing natural art

</list-item>
<list-item>

Forest day camp

</list-item>
8 Wrap-up <list-item>

Hold a positive emotion and mindset while settled in the forest activities

</list-item>
<list-item>

Write a letter in the forest

</list-item><list-item>

Posttest: complete questionnaire

</list-item><list-item>

Closing

</list-item>

Semi-Structured Interview Guide

Introductory Question
  Please talk about the health promotion program using forests that you participated in for 8 weeks.
Transition Questions
  Why did you participate in the health promotion program using forests?
  Before joining the study, what did you expect from this program?
Key Questions
  What was the status of your body and mind before and after the program?
  Did you have any special experience during the program?
  Has anything changed since you participated in the program? If so, what has changed?
  What do you want to do for a healthy life in the future?
  What did you like/dislike about the program?
Ending Questions
  Have we missed anything important?
  Is there anything else you would like to tell me?

Participants' Demographic Characteristics and Outcome Variables from the Pretest (N = 8)

Characteristic/Variable n (%)
Gender
  Boy 4 (50)
  Girl 4 (50)
Grade
  5th 4 (50)
  6th 1 (12.5)
  7th 1 (12.5)
  8th 2 (25)
Mean (SD) (Range)
Age (years) 12.13 (1.25) (11 to 14)
Perceived health statusa 3.88 (0.84) (3 to 5)
Self-esteemb 29.75 (4.59) (20 to 33)
Depressionc 13.38 (7.05) (4 to 25)
Perceived stressd 18.63 (4.90) (12 to 26)
Behavior problemse 70.75 (26.11) (36 to 107)
Restorationf 39.13 (10.25) (20 to 51)
Connectedness to natureg 17.13 (4.26) (11 to 24)

Effects of the Urban Forest-Based Health Promotion Program on Outcome Variables (N = 8)

Variable Median (IQR) Z p Value Effect Size (r)
Pretest Posttest
Perceived health status 4.00 (3.00 to 4.75) 4.50 (3.00 to 5.00) 0.82 0.414 0.29
Self-esteem 32.00 (27.25 to 33.00) 31.00 (24.25 to 34.50) 0.51 0.609 0.18
Depression 11.50 (8.25 to 19.50) 9.50 (6.00 to 17.75) −0.70 0.483 −0.25
Perceived stress 17.50 (15.00 to 23.50) 16.50 (10.50 to 20.00) −1.90 0.057 −0.67
Behavior problems 74.50 (45.50 to 95.50) 77.00 (37.75 to 93.00) −1.05 0.292 −0.37
Restoration 40.00 (32.75 to 47.75) 55.00 (39.25 to 62.50) 2.24 0.025 0.79
Connectedness to nature 16.00 (14.25 to 20.75) 20.50 (14.50 to 27.50) 1.36 0.176 0.48
Authors

Dr. Song is Assistant Professor, Department of Nursing, University of Ulsan, Ulsan, Dr. Bang is Professor and Dr. Kim is Professor, College of Nursing, The Research Institute of Nursing Science, Seoul National University, Seoul, and Ms. Lee is PhD Candidate and Ms. Jeong is PhD Candidate, College of Nursing, Seoul National University, Seoul, Republic of Korea.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This work was supported by the National Research Foundation of Korea grant funded by the Korean government (NRF-2016R1A2B4007767).

Address correspondence to Kyung-Sook Bang, PhD, RN, College of Nursing, Seoul National University, 103, Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea; email: ksbang@snu.ac.kr.

Received: October 22, 2019
Accepted: January 23, 2020
Posted Online: April 14, 2020

10.3928/02793695-20200406-01

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