Urban Forestry & Urban Greening 65 (2021) 127340
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Urban Forestry & Urban Greening
journal homepage: www.elsevier.com/locate/ufug
Original article
Addressing psychosocial issues caused by the COVID-19 lockdown: Can
urban greeneries help?
Keeren Sundara Rajoo a,*, Daljit Singh Karam b, Arifin Abdu c, Zamri Rosli a,
Geoffery James Gerusu a,d
a Department of Forestry Science, Faculty of Agricultural Science and Forestry, Universiti Putra Malaysia, Nyabau Road, 97008, Bintulu, Sarawak, Malaysia
b Department of Land Management, Faculty of Agriculture, Universiti Putra Malaysia, 43400, Serdang, Selangor, Malaysia
c Department of Forestry Science and Biodiversity, Faculty of Forestry and Environment, Universiti Putra Malaysia, 43400, Serdang, Selangor, Malaysia
d Institut Ekosains Borneo, Universiti Putra Malaysia Bintulu Campus, Nyabau Road, 97008, Bintulu, Sarawak, Malaysia
ARTICLE INFO
Handling Editor: W Wendy McWilliam
Keywords:
COVID-19
Depression
Anxiety
Stress
Nature therapy
Preventive medicine
DASS-21
Exercise
ABSTRACT
The Coronavirus disease-2019 (COVID-19) pandemic has affected over 200 countries, forcing governments to
impose lockdowns to contain the spread of the disease. Although effective in reducing infection rates, the
lockdowns have also resulted in a severe negative impact on mental health throughout the world; Setting the
foundation for mental illnesses to become the next “silent” pandemic. This study attempts to determine a self-
care method of ensuring mental health during the COVID-19 pandemic, especially for those living under lock
down. We evaluated the potential of physical exercise (in a nature setting) and nature therapy in improving
mental wellbeing, among young adults with either stress, anxiety or depression symptoms. The study involved
thirty subjects, who were equally divided into a nature-exercise group and a nature therapy group. The par
ticipants were briefed on the activities that they were to perform on a daily basis, and both groups performed
their assigned activities concurrently for one week (27th April 2020 to 3rd May 2020) at urban greeneries
accessible to them (rooftop parks, neighbourhood parks, home gardens). We used the depression, anxiety and
stress scale – 21 items (DASS-21) to evaluate the mental health status of participants, once before beginning the
study (baseline readings) and once at the end of the study (after a week of nature-exercise/nature therapy). There
was a statistically significant reduction in stress, anxiety and depression symptoms for both the nature-exercise
and nature therapy groups. However, when evaluating the effectiveness of exercise and nature therapy in
treating stress, anxiety and depression symptoms on a case-by-case basis, it was discovered that nature therapy
was more effective in treating mental health issues. Hence, nature therapy has the potential to be a form of
preventive medicine, namely in preserving mental health during the COVID-19 crisis.
1. Introduction
The severe acute respiratory syndrome coronavirus 2 (COVID-19)
outbreak occurred at Wuhan, China in December 2019 (Santarpia et al.,
2020), and has now become a global pandemic (Wang et al., 2020). The
total number of cases and deaths has far exceeded those of SARS, and as
of September 2021, COVID-19 has killed more than 4.5 million people
worldwide. Thus, it is no surprise that the World Health Organization
(WHO) has declared the COVID-19 outbreak as “the highest level of
emergency of international concern” (Cao et al., 2020).
1.1. Mental health during the COVID-19 outbreak
Pandemic outbreaks can have a negative impact on mental health,
causing psychosis, anxiety, trauma, suicidal tendencies, chronic stress
and panic (World Health Organization (WHO), 2020). Several studies
have reaffirmed this with the COVID-19 pandemic (Kelly, 2020; Mog
hanibashi-Mansourieh, 2020; Rajkumar, 2020; Wang et al., 2020; Zhai
and Du, 2020). The impact appears to be worse in regions under lock
down (Jankowicz, 2020), . The increased stress and anxiety levels
caused by the outbreak have also been linked to an increase in domestic
* Corresponding author.
E-mail addresses: keeren.rajoo@upm.edu.my, keeren.rajoo@gmail.com (K. Sundara Rajoo).
https://doi.org/10.1016/j.ufug.2021.127340
Received 29 July 2020; Received in revised form 21 July 2021; Accepted 6 September 2021
Available online 8 September 2021
1618-8667/© 2021 Elsevier GmbH. All rights reserved.
K. Sundara Rajoo et al.
violence and child abuse worldwide (Taub, 2020). Therefore, there is a
need for people to not only take precautions in avoiding COVID-19 in
fections, but to also take necessary measures in preserving mental health
(Grover et al., 2020).
Malaysia is no exception when it comes to the negative impacts of
lockdowns (NST, 2020a). Lockdowns and movement control orders have
been largely successful in flattening the curve, however there has been
several other setbacks (NST, 2020b). Malaysia is on the verge of expe
riencing its worse economic recession in history (Khalid, 2020), massive
unemployment (Lim, 2020) and a growth in mental deterioration
(Hassandarvish, 2020). Even before the pandemic, mental health issues
in Malaysia had tripled in the past two decades, attributed largely due to
a lack of awareness on mental health and also societal stigma pertaining
to mental illnesses (Chua, 2020). With the pandemic outbreak and
lockdowns in place, mental illnesses are set to become a “silent”
pandemic in Malaysia (Hassandarvish, 2020).
Thus, there is an obvious need for a self-care method that will improve
mental health during this pandemic, especially those living under lock
downs. The World Health Organization (World Health Organization
(WHO), 2020) has listed several actions/activities that can be taken to
preserve mental wellbeing during this pandemic, for example maintaining
a daily routine, exercising, maintaining a healthy diet and keeping in
regular contact with loved ones (via telephone, social media, etc.).
1.2. Nature therapy
Research has found that nature has the ability to improve mental
wellbeing, in a process known as “nature therapy”. Nature therapy,
sometimes referred to as ecotherapy, is a technique or treatment
employed to improve an individual’s physical or mental health using
natural surroundings. Nature therapy can be performed in any natural
setting, including forests, oceans or even home gardens (Chevalier,
2012). There are mainly two forms of nature therapy. The first does not
include certified professionals such as therapists and psychologists, but
simply uses nature itself as a form of therapy (Bielinis et al., 2018; Fur
uyashiki et al., 2019). The second is an evidence-based practice that uses
certified therapists or health specialists to improve physical and mental
health by incorporating nature (Berger and Tiry, 2012; Sonntag-O¨ stro¨m
et al., 2015; Dolling et al., 2017), and is often referred to as “forest
therapy” (Rajoo et al., 2019). For this paper, we will refer to the first type
as “nature therapy”, and the second type as “forest therapy”.
Despite numerous studies affirming the benefits of nature therapy in
terms of improving general well-being (Rajoo et al., 2020), yet the exact
mechanisms that allow for these benefits is still not fully understood
(Franco et al., 2017). The general consensus is that urban settings
overload human sensory with “polluted” senses, thus experiencing
natural environments provide a calming and restorative effect (Ulrich
et al., 1991). Therefore, the various activities performed in nature
therapy focuses on experiencing nature through each of our senses
(Franco et al., 2017).
For instance, nature therapy activities that focused on viewing natural
landscapes have been found to have a calming effect (Franco et al., 2017;
Rajoo et al., 2019), even reducing blood pressure of elderly hypertensive
men (Song et al., 2017b). Nature sounds like birdsongs have also been
used in nature therapy to relieve stress (Franco et al., 2017). Breathing
exercises are commonly performed to encourage the participants to
indulge in the “smell” of natural environments (Song et al., 2016). Elderly
patients with chronic pulmonary diseases gained more health benefit
from breathing exercises when performed in forests (Bing et a., 2016).
This can be attributed to breathing in phytoncides, which are antimi
crobial volatile organic compounds derived from trees, which improves
immunity (Ohtsuka et al., 1998; Li et al., 2006). It has also been reported
that psychiatric treatment for children was more effective when paired
with nature therapy at a beach (Berger and Tiry, 2012). Activities per
formed in this study focused on “touch” sensory, whereby children
played with sand and seawater while undergoing psychiatric therapy.
Urban Forestry & Urban Greening 65 (2021) 127340
1.3. Study objective
This study attempts to determine a self-care method of ensuring
mental health during the COVID-19 pandemic, using urban greeneries.
We evaluated the potential of nature therapy and physical exercise in
improving mental wellbeing, among young adults with either stress,
anxiety or depression symptoms. This study aims to serve as a pilot study
for future widescale research projects that can provide governmental
agencies, mental health professionals and the general public an effective
tool in safeguarding the mental wellbeing of society as a whole, in the
face of the COVID-19 pandemic.
2. Material and methods
2.1. Study design, setting and participants
This study was approved by the University’s Ethic Committee for
Research Involving Human Subjects. This research was considered to be a
low risk research, whereby the Ethic Committee only raised anonymity as
being a cause for concern. The study utilized anonymous online surveys,
in all thirteen states and three federal territories of Malaysia. The survey
was propagated using social media and their anonymity were ensured, by
only using all data provided by the participants solely for this study. Any
personal identifiers such as contact details were only used for direct
communication pertaining to this study, and were deleted once the study
was concluded. Other personal details that could reveal the identity of
the participants were deleted at the conclusion of the study.
To obtain a homogenous group of participants, we focused on young
adults (18–40 years old) that believed they were suffering from mental
health issues as a direct result of the COVID-19 pandemic or the MCO.
The initial survey was conducted on 19th April 2020 to 23rd April 2020,
receiving 853 respondents, and we evaluated their mental health status.
We used the depression, anxiety and stress scale – 21 items (DASS-21),
which is a widely validated tool in evaluating the status of depression,
anxiety and stress of subjects (Lovibond and Lovibond, 1995; Lee et al.,
2020). Each parameter (depression, anxiety and stress) is evaluated
separately in the questionnaire (seven items for each parameter), along
with different scoring weightages for each parameter; Stress symptoms
requires a score of ≥15, for anxiety symptom ≥ 8, and for depression
symptom ≥ 10 (Lovibond and Lovibond, 1995).
Besides evaluating their mental health, the respondents were also
asked demographic questions and also how often they followed-up on
COVID-19 news. They were also asked the “zone level” at their place of
residence. The Ministry of Health of Malaysia categorizes the severity of
COVID-19 infection rates by zones; Green zones (no Covid-19 cases),
yellow zones (1–20 cases), orange zones (21–40 cases), and red zones
(41 cases and above). Red zones have more MCO restrictions in place,
while green zones have more leeway.
Only 42 of the initial 853 respondents exhibited either stress, anxiety
or depression symptoms. These 42 respondents also responded “none” to
the statement “What steps do you take to maintain your mental health?”,
indicating that they did not take any active measures to manage their
mental health.
An invitation was extended to these 42 respondents to participate in
this study on 24th April. Several subjects had to drop out of the study as
they didn’t have access to urban greeneries or due to other personal
issues that were not specified. The respondents were allowed to opt-out
of the study without providing justification, in line with the university’s
ethical committee’s guideline. Additionally, three more participants
didn’t comply with the study protocols and were removed from the
study. Thus, a total of thirty participants were recruited for this study.
The thirty participants were split and assigned to their respective
groups randomly; nature-exercise group and nature therapy group.
Both the groups performed their preassigned activities at urban
greeneries that were accessible to them; Rooftop parks, neighbourhood
parks, home gardens.
2
K. Sundara Rajoo et al.
Table 1
Descriptive statistics of baseline DASS-21 scores of participants, before the
intervention study was conducted.
Total (N =
30)
Mean SD
Symptoms
Skewness Kurtosis
Yes
No
Stress
Anxiety
Depression
12.63 4.52 0.58
6.87 3.25 0.26
8.23 4.43 0.04
0.49
9 (30 %) 21 (70 %)
0.82
17 (56.67 13 (43.33
%)
%)
1.23
15 (50 %) 15 (50 %)
Exercise group (N = 15)
Stress
13.13 3.96 1.1
Anxiety
Depression
6.8
3.63 0.46
8.67 4.53 0.11
1.33
5 (33.33 10 (66.67
%)
%)
1.23
9 (60 %) 6 (40 %)
1.26
8 (53.33 7 (46.67
%)
%)
Nature therapy group (N = 15)
Stress
12.13 5.11 0.51
Anxiety
6.93 2.94 0.11
Depression
7.8
4.44 0.01
0.21
4 (26.67 11 (73.33
%)
%)
0.12
8 (53.33 7 (46.67
%)
%)
1.19
7 (46.67 8 (53.33
%)
%)
Urban Forestry & Urban Greening 65 (2021) 127340
Table 2
Relationship between baseline DASS-21 scores with COVID-19 variables, before
the intervention study was conducted.
Stress
Anxiety
Depression
COVID-19 Zone level
Following-up on
COVID-19 news
Red
Orange
Yellow
Green
Chi-Squared
test
Very often
Somewhat
often
Not very often
Never
Chi-Squared
test
21.75 ±
3.14
17.24 ±
2.75
14.4 ±
3.74
8.96 ±
6.32
0.03*
12.81 ±
4.23
11.6 ±
2.34
11.82 ±
4.74
–
0.21
7.13 ±
5.28
7.25 ±
3.41
6.5 ±
1.83
6.58 ±
2.74
0.39
7.14 ±
4.85
6.61 ±
1.7
5.21 ±
2.69
–
0.57
8.5 ± 2.2
8.63 ± 3.5
7.2 ± 4.8
4.84 ±
5.85
0.36
7.5 ± 2.5
8.6 ± 1.96
7.63 ± 1.7
–
0.37
N = 30, M ± SD, *p < 0.05.
Participants were briefed on their respective activities via a PDF file
attached to Google Docs, and were encouraged to ask questions
regarding their responsibilities either via email or WhatsApp. Both
groups performed their assigned activities daily and concurrently for
one week (27th April 2020 to 3rd May 2020) for approximately twenty
minutes. On 4th May, the participants’ mental health status was eval
uated once again, using the DASS-21.
For the nature-exercise group, we used a clinically proven exercise
program that was especially designed for beginners to perform without
any gym equipment (Kilka and Jordan, 2013). Each exercise in the circuit
is performed for 30 s, with 10 s transition time between. Total time for
entire circuit workout is approximately seven minutes. The twelve ex
ercise were jumping jacks, wall sit, knee push-up (regular push-up for
those who are able to), abdominal crunch, step-up onto chair, squat,
triceps dip on chair, plank, running in place, lunge, knee push-up
(push-up and rotation for those who are able to) and side plank. Partic
ipants either used YouTube or the Home Workout exercise app to guide
them throughout the exercise program. Participants also did appropriate
warm-up before exercising, and were reminded to not exert themselves.
For the nature therapy group, the participants performed three
common nature therapy activities; Sensory enjoyment, stretching exer
cises and meditation (Song et al., 2016). These activities were selected as
they had been found to be effective in a previous Malaysian forest
therapy study (Rajoo et al., 2019). Sensory enjoyment consisted of
engaging the senses with different natural aspects. This included visual
stimuli performed by observing the natural environment in detail, smell
by taking in deep breaths, sound by listening to natural sounds like
birdsongs, and touch by feeling the soil and flora. For stretching exer
cises, participants performed basic stretches incorporating the neck,
arms, lower back and legs. Participants were informed to not overdo the
stretches beyond their physical limit. Meditation either involved deep
breathing or reciting religious/spiritual mantras, which was performed
according the participant’s personal preferences. Each activity was
performed for five to seven minutes. The participants were briefed in
detail on how to practice each activity, and were instructed to conduct
the nature therapy program every morning, before the afternoon heat.
2.2. Data analysis method
The data were analysed using SPSS software version 25, for descrip
tive statistics and inferential statistics (chi-squared and dependent t-test).
Besides statically analysing the results, we also compared the data based
on a case-by-case basis, that is whether the week-long exercise or nature
therapy program was able alleviate the individuals’ stress, anxiety or
depression symptoms.
3. Results
3.1. Research participants’ demographic and baseline mental health
status
As mentioned previously, a total of 30 participants were involved in
this study, who were split evenly and assigned to their respective groups
randomly; nature-exercise group (N = 15) and nature therapy group (N
= 15). The participants were 26.2 ± 4.14 years old (20 males and 10
females). Table 1 shows the baseline mental health status of the re
spondents, that is their mental health status before the study was con
ducted. Of the thirty participants in this research, 30 % showed
symptoms of stress, 56.67 % had symptoms of anxiety while 50 % had
symptoms of depression. For the nature-exercise group, the majority
exhibited symptoms of anxiety (N = 9) and depression (N = 8). While for
the nature therapy group, a majority of the participants exhibited
symptoms of anxiety (N = 7), seven participants had symptoms of
depression while four had symptoms of stress.
3.2. Association between COVID-19 variable with mental health status
Table 2 shows the relationship between COVID-19 variables with
mental health status of the participants, before conducting the study. Of
the 30 study participants, four lived in red zones, five resided in orange
zones, nine lived in yellow zones while the remaining twelve lived in
green zones. More than 66 % of the participants followed COVID-19
related news very often (N = 11) or somewhat often (N = 9), while 33
% followed the news not very often (N = 10). None of the participants
said that they never followed the news at all. Pearson Chi-Square anal
ysis found no association between COVID-19 zone level with anxiety (X2
(1, N = 30) = 37.64, p = 0.39), and depression (X2 (1, N = 30) = 45.07, p
= 0.36). Pearson Chi-Square analysis also found no association between
following-up on COVID-19 news with stress (X2 (1, N = 30) = 45.81, p =
0.21), anxiety (X2 (1, N = 30) = 22.23, p = 0.57) and depression (X2 (1,
N = 30) = 29.94, p = 0.37). However, Pearson Chi-Square analysis
found an association between zone with stress (X2 (1, N = 30) = 40.74, p
= 0.03), whereby participants in red zones recorded higher stress.
3
K. Sundara Rajoo et al.
Table 3
Summarized effects of the nature-exercise program on DASS-21 scores of
participants.
Baseline
After
t-test
Stress
Anxiety
Depression
13.13 ± 3.96
6.8 ± 3.63
8.67 ± 4.53
11.27 ± 4.41
5.27 ± 3.6
7.2 ± 7.2
0.00*
0.02*
0.01*
N = 15, M ± SD, *p < 0.05.
Urban Forestry & Urban Greening 65 (2021) 127340
The depression baseline readings before the program (M = 8.67, SD =
±4.53) significantly reduced after the nature-exercise program (M =
7.2, SD = ±7.2), (t(14) = 3.0, p < 0.01). However, the results weren’t as
promising when the effects of exercise were evaluated on a case-by-case
basis (Table 4). Of the five subjects that exhibited stress symptoms, only
one individual (Subject-E4) ceased to show stress symptoms after one-
week of exercise. Nine participants had anxiety symptoms, but only
four participants (Subject-E2, Subject-E5, Subject E-6 and Subject E-11)
stopped showing anxiety symptoms, while out of the eight participants
Table 4
Effects of the nature-exercise program on DASS-21 scores, by subject.
Stress Symptoms
Subject
Subject-E1
Subject-E2
Subject-E3
Subject-E4
Subject-E5
Subject-E6
Subject-E7
Subject-E8
Subject-E9
Subject-E10
Subject-E11
Subject-E12
Subject-E13
Subject-E14
Subject-E15
Gender/Age
Male, 21
Female, 27
Female, 32
Male, 26
Male, 20
Male, 39
Male, 27
Female, 27
Female, 23
Male, 27
Male, 28
Male, 19
Female, 27
Female, 28
Male, 30
Baseline
23 (Yes)
18 (Yes)
16 (Yes)
16 (Yes)
14 (No)
11 (No)
11 (No)
10 (No)
9 (No)
12 (No)
10 (No)
11 (No)
13 (No)
8 (No)
15 (Yes)
After
19 (Yes)
18 (Yes)
15 (Yes)
12 (No)
11 (No)
9 (No)
12 (No)
9 (No)
5 (No)
14 (No)
7 (No)
9 (No)
8 (No)
5 (No)
16 (Yes)
Improvement
No
No
No
Yes
–
–
–
–
–
–
–
–
–
–
No
Anxiety Symptoms
Baseline
11 (Yes)
9 (Yes)
12 (Yes)
7 (No)
8 (Yes)
9 (Yes)
4 (No)
2 (No)
2 (No)
10 (Yes)
8 (Yes)
1 (No)
2 (No)
9 (Yes)
8 (Yes)
After
8 (Yes)
7 (No)
11 (Yes)
5 (No)
5 (No)
4 (No)
2 (No)
1 (No)
1 (No)
8 (Yes)
5 (No)
1 (No)
1 (No)
10 (Yes)
10 (Yes)
Improvement
No
Yes
No
–
Yes
Yes
–
–
–
No
Yes
–
–
No
No
Depression Symptoms
Baseline
11 (Yes)
6 (No)
9 (No)
4 (No)
4 (No)
2 (No)
16 (Yes)
10 (Yes)
13 (Yes)
11 (Yes)
5 (No)
14 (Yes)
13 (Yes)
2 (No)
10 (Yes)
After
10 (Yes)
5 (No)
5 (No)
4 (No)
3 (No)
3 (No)
15 (Yes)
8 (No)
13 (Yes)
10 (Yes)
2 (No)
8 (No)
10 (Yes)
1 (No)
11 (Yes)
Improvement
No
–
–
–
–
–
No
Yes
No
No
–
Yes
No
–
No
Table 5
Summarized effects of nature therapy on DASS-21 scores of participants.
Baseline
After
t-test
Stress
Anxiety
Depression
12.13 ± 5.11
6.93 ± 2.94
7.8 ± 4.44
7.67 ± 3.48
4.8 ± 2.46
4.53 ± 2.85
0.00*
0.00*
0.00*
N = 15, M ± SD, *p < 0.05.
3.3. Effects of nature-exercise on mental health
Table 3 shows that there was a significant reduction in stress, anxiety
and depression symptoms after the nature-exercise program. The stress
levels of the participants reduced significantly after the nature-exercise
program (M = 11.27, SD = ±4.41) when compared to the baseline
readings before the nature-exercise program (M = 13.13, SD = ±3.96),
(t(14) = 3.2, p < 0.001). Similarly, the anxiety baseline readings before
the program (M = 6.8, SD = ±3.63) significantly reduced after the
nature-exercise program (M = 5.27, SD = ±3.6), (t(14) = 3.1, p < 0.02).
that had depression symptoms, only two (Subject-E8 and Subject-E12)
stopped showing depression symptoms.
3.4. Effects of nature therapy on mental health
Similar to the nature-exercise group, there was a significant reduc
tion in stress, anxiety and depression symptoms after a week-long nature
therapy program (Table 5). The stress levels of the participants reduced
significantly after the nature therapy program (M = 7.67, SD = ±3.48)
when compared to the baseline readings before the nature therapy
program (M = 12.13, SD = ±5.11), (t(14) = 7.9, p < 0.001). Similarly,
the anxiety baseline readings before the program (M = 6.3, SD = ±2.94)
significantly reduced after the nature therapy program (M = 4.8, SD =
±2.46), (t(14) = 3.1, p < 0.001). The depression baseline readings
before the program (M = 7.8, SD = ±4.44) significantly reduced after
the nature therapy program (M = 4.53, SD = ±2.85), (t(14) = 5.2, p <
0.001). Moreover, unlike the nature-exercise group, the effects on an
individual basis were also promising (Table 6). After nature therapy, all
Table 6
Effects of nature therapy on DASS-21 scores, by subject.
Stress Symptoms
Subject
Gender/Age
Baseline
After
Subject-N1
Subject-N2
Subject-N3
Subject-N4
Subject-N5
Subject-N6
Subject-N7
Subject-N8
Subject-N9
Subject-N10
Subject-N11
Subject-N12
Subject-N13
Subject-N14
Subject-N15
Male, 33
Male, 31
Male, 19
Male, 24
Female, 24
Female, 25
Male, 28
Male, 23
Male, 27
Female, 30
Female, 28
Male, 21
Male, 19
Male, 33
Male, 30
18 (Yes)
19 (Yes)
23 (Yes)
14 (No)
12 (No)
13 (No)
9 (No)
15 (Yes)
11 (No)
10 (No)
11 (No)
9 (No)
4 (No)
9 (No)
5 (No)
12 (No)
12 (No)
14 (No)
9 (No)
8 (No)
9 (No)
5 (No)
11 (No)
8 (No)
6 (No)
4 (No)
5 (No)
2 (No)
5 (No)
5 (No)
Improvement
Yes
Yes
Yes
–
–
–
–
Yes
–
–
–
–
–
–
–
Anxiety Symptoms
Baseline
After
8 (Yes)
10 (Yes)
13 (Yes)
4 (No)
3 (No)
9 (Yes)
2 (No)
8 (Yes)
6 (No)
8 (Yes)
9 (Yes)
4 (No)
5 (No)
7 (No)
8 (Yes)
6 (No)
7 (No)
8 (Yes)
2 (No)
1 (No)
7 (No)
0 (No)
5 (No)
6 (No)
4 (No)
8 (Yes)
4 (No)
3 (No)
5 (No)
6 (No)
Improvement
Yes
Yes
No
–
–
Yes
–
Yes
–
Yes
No
–
–
–
Yes
Depression Symptoms
Baseline
After
3 (No)
7 (No)
5 (No)
11 (Yes)
10 (Yes)
2 (No)
10 (Yes)
6 (No)
7 (No)
3 (No)
15 (Yes)
12 (Yes)
14 (Yes)
11 (Yes)
1 (No)
1 (No)
4 (No)
2 (No)
8 (No)
5 (No)
2 (No)
7 (No)
3 (No)
4 (No)
1 (No)
7 (No)
4 (No)
10 (Yes)
8 (No)
2 (No)
Improvement
–
–
–
Yes
Yes
–
Yes
–
–
–
Yes
Yes
No
Yes
–
4
K. Sundara Rajoo et al.
four participants (Subject-N1, Subject-N2, Subject-N3 and Subject-N8)
that had stress symptoms, showed no symptoms after nature therapy.
Out of the eight participants that had anxiety symptoms, six participants
(Subject-N1, Subject-N2, Subject-N6, Subject-N8, Subject-N10 and
Subject N-15) ceased showing symptoms. Six out of the seven partici
pants that had depression symptoms, stopped showing symptoms after
nature therapy (Subject-N4, Subject-N5, Subject-N7, Subject-N11, Sub
ject-N12 and Subject-N14).
4. Discussion
The purpose of this study was to determine a self-care method of
ensuring mental health during the COVID-19 pandemic, using urban
greeneries. We evaluated the potential of nature therapy and physical
exercise (in a nature setting) in improving mental wellbeing, among
young adults with either stress, anxiety or depression symptoms. Sta
tistical analysis found an association between zone and stress, where
residents of red zones were more likely to experience stress symptoms.
Which is understandable since residents of red zones have more re
strictions in place compared to other zones. Red zone inhabitants have
their movement severely restricted via police roadblocks (they can only
travel within 10 km for essential goods and services), have increased law
enforcement surveillance and in some extreme cases, they are not even
allowed to leave their homes for essential goods (food supplies are
delivered directly to them). Thus, individuals under severe quarantine
conditions are more at risk of mental health deterioration (Moghani
bashi-Mansourieh, 2020).
There was a significant reduction in stress, anxiety and depression
symptoms for both the nature-exercise and nature therapy groups.
However, everyone reacts differently to stressful situations, thus the key
to effective mental health management is to ensure that the resources
are appropriate to their needs (Reinhard, 2000; Arya, 2020). When
evaluating the effectiveness of nature-exercise and nature therapy in
treating stress, anxiety and depression symptoms on a case-by-case
basis, it is apparent that nature therapy is more effective than exercise
in treating mental health issues. As mentioned previously, studies have
proven that nature therapy has a positive effect on human health, from
both physiological and psychosocial perspectives. Moreover, nature
therapy has also been found to be able to alleviate depression (Fur
uyashiki et al., 2019), manage stress for highly-stressed individuals
(Dolling et al., 2017), and in treating patients with severe exhaustion
disorders (Sonntag-O¨ stro¨m et al., 2015). Thus, in line with the findings
of this study, nature therapy could be an effective tool in mental health
management during the COVID-19 pandemic.
There has been much debate on why natural environments have a
positive effect on mental and physical health (Rajoo et al., 2021). Some
researchers believe that it is the activities performed in nature that
brings benefit, and not nature itself. Therapeutic activities and light
exercises like stretching exercises have been found to have a positive
effect on the immune system (Smyth et al., 2002), blood glucose levels
(Ohtsuka et al., 1998) and chronic stress reduction (Dolling et al., 2017).
However, several studies that examined the effects of urban environ
ments and natural environments on human health, discovered that the
positive effects of relaxing activities and light exercises could only be
experienced by participants in forest settings (Bing et al., 2016; Song
et al., 2017b). Ulrich et al. (1991) proposed that living in
structure-dominant environments would increase the stress levels of
urbanites, causing them to be more susceptible to mental and physical
illnesses. The Stress Reduction Theory (SRT) developed by Ulrich et al.
(1991) explains the need for urbanites to experience natural elements at
times. SRT states that by observing natural sceneries, such as greeneries
and lakes, it creates positive feelings and emotions that enables a
restorative effect. This theory isn’t new. In ancient Rome, it was com
mon for people to periodically take refuge in forested areas to deal with
urban congestion (Glacken, 1967). Some researchers believe the healing
powers of nature is primarily due to phytoncides, a volatile substance
Urban Forestry & Urban Greening 65 (2021) 127340
emitted by plants Li et al. (2006). Song et al. (2016) discovered that
indoor exposure to forest derived phytoncides could increase NK cell
activity and improve overall immunity function. Hence, it is safe to
conclude that the health benefits derived from nature therapy is due to a
combination of relaxing activities, light exercises and the natural ther
apeutic atmosphere.
5. Conclusion
The core objective of this study was to serve as a pilot study for future
widescale research projects that can provide key stakeholders and the
general public an effective method to manage mental health, especially
during the COVID-19 pandemic. This study found that both exercise and
nature therapy when performed at urban greeneries, has the potential to
be a form of preventive medicine, namely in preserving mental health
during the COVID-19 crisis. In this regard, mental health professionals
should advise the general public on the actions/activities that they can
take to prevent mental health issues, especially for those under quar
antine or lockdowns. For individuals with access to natural sceneries
such as home gardens, nature therapy should be one of the activities
performed on a daily basis.
This study has several limitations. Namely, the lack of a control
group. This meant that other factors, such as time, could have improved
mental health instead of the interventions. Other factors such as gender,
age and type of greenery were also variables that can affect the outcome
of the study, but could not be statistically analysed due to a small sample
size. Thus, this pilot study is best used as a foundation for future research
in this area. Future studies should involve a larger sample size, and use
other evaluation tools besides DASS-21, including direct psychiatric
evaluation. The potential for nature therapy to serve as a preventive
medicine for individuals experiencing mental fatigue and work stress
should also be evaluated. Appropriate governmental agencies should
develop effective self-care nature therapy programs for the general
public, allowing for the preservation and improvement of the mental
wellbeing of society.
Author statement
Keeren Sundara Rajoo contributed to the conceptualization, method
ology, interpretation of results and writing. Daljit Singh Karam contrib
uted to the data acquisition, interpretation of results and writing. Arifin
Abdu contributed to interpretation of results and writing. Zamri Rosli and
Geoffery James Gerusu contributed to the writing (Review & Editing).
Financial disclosure
None.
Declaration of Competing Interest
None.
Acknowledgement
The authors would like to thank all respondents that participated in
this study. We would also like to thank the anonymous reviewers for
their invaluable feedback that help improve this article.
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