Healthy Cities

This paper was presented to the International Healthy Cities Conference held in Belfast in late 2003 and is a summary of Green Gym focusing on Northern Ireland.

1. Summary

Green Gym is a proven approach to creating healthy people and healthy places. While the benefits of physical activity are well known, gyms and sports centres do not appeal to everyone. 'Working out' in the open air by doing practical work in the local environment, is an alternative way for people of all ages, levels of fitness and abilities to keep physically fit. However, Green Gym offers much wider benefits to both participants, in terms of physical health and mental well-being, and the wider community who enjoy a better quality of life through the environmental improvements.

Green Gym in Northern Ireland has focused on tailored programmes of work for people with minor mental and physical difficulties. Green Gyms currently operate across Northern Ireland in partnership with local Health Trusts who view this activity as an innovative and exciting approach to reintegrate participants into the wider community. Adherence rates are extremely high demonstrating the durability and sustainability of the approach and reflecting the enjoyment derived by participants, their carers and staff from the Health Trusts and Conservation Volunteers Northern Ireland (CVNI).

This paper describes how the Green Gym has been developed in Northern Ireland over the past four years, drawing on research from England into the Green Gym and comparing with findings here. It also discusses briefly the possible future developments for Green Gym in Northern Ireland and suggests that conservation volunteering in general has a greater role to play in improving people’s health.

2. Introduction

Dr William Bird, a general practitioner and BTCV (of which CVNI is a part) developed the Green Gym in 1997. This was a natural progression from using the countryside as a health resource for the local community through ‘Health Walks’ (Reynolds, 2000). Green Gym was first piloted at Sonning Common, Oxfordshire, as a way to encourage sedentary people to become more active by taking part in conservation activities. This innovative approach recognised that being healthy is not just about being ‘fit’ but also stressed the importance of the triadic relationship between the health of the local community, the local environment and the individuals within that community/environment (Bird, 1997). Green Gyms now operate throughout the UK. The success of the Green Gym has led to the name being registered by BTCV.

Green Gym has been evaluated by Reynolds (2002, 1999) at Oxford Brookes University, Centre for Health Care Research & Development using a range of broadly accepted tools to measure health including the SF-36 (Jenkinson et al 1996) and Medical Outcomes Trust Short Form (SF-12) questionnaires and the EQ-5D (EuroQol) among others. This has highlighted a number of important physiological and mental health benefits that are gained from participation in Green Gym.

3. Green Gym in Northern Ireland

Conservation Volunteers Northern Ireland has developed the Green Gym in Northern Ireland in close partnership with local Health and Social Services Trusts. To date these have included the Causeway, Foyle, South & East Belfast, Sperrin-Lakeland, Ulster Community Hospitals and Armagh and Dungannon. These have been funded through the Community Fund, Investing for Healthier Communities and the South & East Belfast Trust.

3.1 Strategic links

The foundation for this partnership has been laid down through strategic linkages between CVNI (2000) and the Department of Health, Social Services and Public Safety (DHSSPS) (1997, 2000, 2002). Green Gym addresses targets in 'Investing for Health' which states that a healthy environment is an important determinant of health and well-being. ‘Investing for Health’ outlines a framework for action to improve health and wellbeing and to reduce health inequalities. For example, Green Gym increases levels of physical activity in a country where 25% of the population is sedentary and therefore at increased risk of a long list of physical and mental problems including coronary heart disease, Type 2 diabetes, obesity and high blood pressure, (DHSSPS, 2002).

There are also links to more local strategies, for example, the South & East Belfast Health & Social Services Trust’s Community Development Strategy (1997) and Positive Health Development Strategy (1999).

Conservation Volunteers Northern Ireland's strategy is to expand the boundaries of conservation volunteering; to provide practical conservation work for people who have not traditionally taken up or had access to such opportunities. Green Gym involves many people who do not take part in any other volunteering activity. In an evaluation of a Green Gym in East Sussex 24 out of 28 (86%) participants had never before taken part in conservation work (Reynolds, 2002).

3.2 Methods of delivery

In Northern Ireland Green Gym has mainly involved disadvantaged people who attend Day Care Centres or Learning Resource Centres. Participants typically have, for example, learning difficulties, depression or physical disabilities. They take part in regular physical conservation volunteering activity including access work, developing and maintaining community gardens, creating outdoor art features, tree planting and nursery work. Green Gym training and practical conservation activities are carefully tailored to the participant’s ability based on factors such as mental health and wellbeing, physical fitness and disability. Staff from Health Trusts and CVNI attend Green Gym sessions working with participants who volunteer and whose carers are in agreement. An average of 10 people attends each Green Gym for a day a week. In many cases participants would otherwise be indoors at Centres every day of the week.

The first Green Gym in Northern Ireland began in September 1997 at Victoria Day Care Centre, South & East Belfast Health Trust. It is still ‘going strong’. Of the original 10 participants eight are still attending six years later. Since then a further 11 Green Gyms have been initiated of which 9 are still running. Two short (three month) pilot Green Gyms, one with staff from the Industrial Development Board (now Invest Northern Ireland) and one with clients from Armagh and Dungannon Health Trust, did not continue. Green Gyms are operated essentially using ‘A practical guide to setting up a Green Gym’ produced by BTCV (Trchalik, 1999). CVNI staff received training to deliver warm-up and cool-down exercises and first aid. Health Trusts deliver additional support training to CVNI staff relevant to the participating groups. Additionally, staff are trained in health & safety and although only a small part of the safe management of this work staff are checked using Northern Ireland’s Pre-employment Consultancy Service. In some cases, where Health Trusts feel it appropriate, this is extended to other volunteers.

All participants play a role in selecting the practical activities carried out by their group following initial assessment by the Centre Managers of each activity’s suitability. CVNI provide transport, training in all practical activities, tools and protective equipment for each Green Gym. Green Gym often links in to other projects that can then supply all the necessary materials.

3.3 Monitoring and feedback

Feedback is regularly sought from groups through informal discussion. Formal feedback is gathered using a standard questionnaire agreed with the Health Trusts and adapted from the SF12. The initial baseline questionnaire (Appendix 1) differs slightly from that used at subsequent time intervals (Appendix 2), usually every 15 weeks. Additional feedback is gathered from carers (Appendix 3) and Health Trust staff supervising Green Gym groups (Appendix 4). CVNI have recently drawn together the results of this feedback in an internal report by Keys (2003).

4. Results

Green Gym activities have major social, physical and psychological impacts in addition to the environmental ones as demonstrated by research evaluations in England by Reynolds (2002, 1999) at Oxford Brookes University, Centre for Health Care Research & Development. A body of evidence to support these findings is now being generated in Northern Ireland, through regular use of an adapted SF12 questionnaire, agreed with Health Trusts.

4.1 Social benefits

Factors found to motivate continued participation in Green Gym included the social aspect of working with a group, increased awareness of conservation issues and doing something worthwhile (Reynolds, 2002). Green Gym has, in part, been successful because of its multiple motivators. This, and a complex interaction of the many benefits conferred upon participants, has helped attract and retain people who would not otherwise have ‘stuck at it’ for so long. In Northern Ireland Green Gym has successfully reached disadvantaged people who are often stigmatised through their disability. It has allowed people to reintegrate into society reducing social isolation which is itself a risk factor for disease (Sarason et al, 1983).

Participants in Green Gym carry out practical work on a wide range of sites, many of which are open to the public or are also worked on by other groups of volunteers. This is an important element of the work given that the most important motivating factor for attending the Green Gym is doing something worthwhile (Keys, 2003). This is reflected in individual participants positive comments about “mixing with other people” and “doing something worthwhile for other people” (CVNI, 2003).

4.2 Physical benefits

A major factor motivating people to take part in Green Gym was keeping fit. Green Gym confers demonstrable improvements for participants in cardiovascular fitness and muscular strength (Reynolds, 1999). Other research suggests that regular exercise can significantly reduce the incidence of heart disease, strokes, insulin dependent diabetes, hip fractures in the elderly and certain cancers (DHSSPS, 2002). MacAuley’s (1999) research supports the notion that it is not just vigorous exercise that brings cardiovascular health benefits. Moderate or even low intensity exercise, performed regularly, is beneficial. In fact some Green Gym activities, such as tree planting, utilise more calories per minute than walking or aerobics (Reynolds, 1999).

However, in Northern Ireland it is accepted that participation in a Green Gym one day per week is in itself inadequate to confer significant health gains. Fortunately, the impact of Green Gym on participants lives goes beyond the weekly Green Gym event itself. Over 90% of participants indicate that they have become more aware of the importance of physical activity on their health (Keys, 2003). Due to a combination of factors such as medication and the lack of physical activity opportunities within Day Care Centres a number of participants are conscious of their weight.

Participation in the Green Gym has led to many volunteers incorporating some of the activities, in particular the stretching exercises, into their everyday lives (Reynolds, 1999). In Northern Ireland nearly 80% of participants report an increase in energy levels resulting in an increase in the amount of exercise they undertake each week. Examples include:

A small but growing number of participants that now volunteer with CVNI outside of the regular Green Gym programme and without their carers or Health Trust staff,
Participants that walk more and
Participants that do more gardening in their own time (Keys, 2003).

Carers and Health Trust staff have observed that after regular involvement in Green Gym participants walk further, at a faster pace and with less need for encouragement than before their involvement. CVNI staff have noticed increases in the amount of work groups are able to complete before requiring rest (Keys, 2003).

Green Gym has helped change participants behaviour so that they become more active on a regular basis thus increasing their chances of securing the personal health gains mentioned above. That the majority of participants stay involved in Green Gym over the long-term makes this fact all the more important. Over four years after the first pilot Green Gym was set up 80% of the original participants still regularly attend (O’Riley 2003). Between April 2002 and March 2003 the overall adherence rates for the nine ongoing Northern Ireland Green gyms was 90% (Keys, 2003). In England, where Green Gyms rely heavily on referral from GPs adherence rates are lower and more variable, but still encouraging. In East Sussex 48% of participants remained involved for at least six months (Reynolds, 2002) while in the Sonning Common Green Gym the figure was 72% (Reynolds, 1999). The Northern Ireland figures compare very favourably with those from fitness suites and other exercise programmes where drop out rates are up to 50% in the first six months (Reynolds, 2002). Thus Green Gym is a useful tool to engage people who lead inactive lifestyles including those who experience physical and social isolation and have mental or physical health difficulties.

4.3 Psychological benefits

Physical activity lowers levels of stress and anxiety (Biddle et al, 2000). In general sedentary people are twice as likely to have symptoms of depression as more active people are. Physical activity improves self-esteem, mood and perceived ability to perform daily tasks (Rejeski et al, 1996). Participants viewed Green Gym as being beneficial to their mental health and wellbeing (Reynolds, 2002).

An evaluation of the original Northern Ireland Green Gym by staff at Victoria Day Care Centre looked at changes in participants perceptions over time. There was a perceived improved quality of life for participants with concomitant benefits for their health workers and carers who reported that participants are calmer, happier and more contented when returning from Green Gym, resulting in a more rewarding and enjoyable experience for all (Boylen, 2000).

Completing practical tasks carries intrinsic benefits such as a sense of achievement; of having done something worthwhile. These sources of job satisfaction increase confidence and can have an important part to play in motivating people to remain in their Green Gym.

4.4 Environmental benefits

Green Gym delivers long-term environmental enhancements improving the quality of life for local people, whether or not they have been directly involved in Green Gym. In some cases, where Green Gym groups have worked on publicly accessible sites, this impacts on significant numbers of people. Much of CVNI’s work takes place in areas of social need as defined by the Noble Index where environmental improvements can have the greatest impact on quality of life (BTCV/BEN, 2002).

Some participants are carrying out additional gardening work and these lifestyle changes could lead to additional environmental projects taking place.

Certain environmental enhancements such as tree planting have been shown to affect individual’s health. For example, views of trees from a hospital room after an operation reduces the levels of painkillers required post-operation and reduces the time spent in hospital, when compared to control patients undergoing the same surgery etc whose rooms look out on the built environment (Ulrich, 1984). Other studies have shown that views of trees on the way to and from work reduce stress and improve problem solving ability (Ulrich, 2000). These spin-off benefits of Green Gym should not be underestimated.

5. Discussion

Ideally, Green Gyms work towards becoming self-sufficient. However, in Northern Ireland, where the delivery focus has been with people with disabilities this will not always be an appropriate aim. Therefore CVNI needs to establish longer-term sources of income if the Green Gym is to be sustainable. Current funding for the Green Gym ends over a 12-month period beginning in April 2004. CVNI are seeking alternative sources of funding and have already met with some success. For example, new funding streams will begin in 2004 through the New Opportunities Fund’s Palliative Care Programme to run a number of Green Gyms across the Eastern Health Board area and to develop a number of Fruit and Vegetable Gardens in partnership with the North & West Belfast Health Trust. While this is positive news CVNI aims to work closely with the Health Boards and Trusts to seek ways to mainstream the Green Gym as a vehicle to deliver physical health and mental well-being gains.

5.1 Next steps Green Gyms

Currently Green Gym requires the presence of both CVNI and Health Trust staff. One possible development in appropriate situations is to withdraw the Health Trust staff requirement. This has already been successfully tested in several locations where Day Care clients have, in addition to their Green Gym day, begun to go out with other volunteer groups being managed by CVNI. The next step could be to run the Green Gym day without Health Trust staff present. In some cases the clients are making their own way to the pick-up points rather than being collected at the Day Care Centres.

5.2 Respite for Carers

Conservation Volunteers Northern Ireland is also testing the Green Gym as a tool to provide respite for carers by taking participants on residential Green Gym activity weekends. Green Gym already offers some respite for carers through the psychological benefits (see above) gained by participating. However, Green Gym can give carers a total break from looking after loved-ones through use of CVNI’s residential facilities. Feedback from the first weekend Green Gym, based in Clandeboye Estate, has been very positive. The weekend included training workshops for 12 participants on:-

Building living willow structures
Identifying tree seed
Collecting, treating and sowing native tree seed
Making willow pegs.

The Green Gym group is now very keen to repeat this at CVNI’s Fermanagh residential facility at Castle Archdale. CVNI will be looking to develop this further with other Health Trusts.

5.3 Green Gym for employees

Conservation Volunteers Northern Ireland also believes there are opportunities to develop Green Gyms for employed people suffering stress at work. It could also be used as a stepping stone for helping people who are absent from work through stress, depression and other mental illness to get back to work. Numbers of people off sick in Northern Ireland are very high. In a reply to a written Parliamentary question in 2003 it was stated that an average of 1,933 doctors, nurses and other health care professionals off sick every day. One factor was thought to be the increasing levels of work related stress according to the British Medical Association (Gould, 2003). These areas of work need to be carefully researched to determine the health and, also importantly, the financial gains from any Green Gym programme.

6. Conclusions

Local evaluation of Green Gym demonstrates individual benefits through increased fitness and mental well-being, and forming of positive habits, respite benefits to carers and benefits to Health Trusts with happier clients and staff. Local drop out rates from Green Gym are extremely low when compared to other exercise programmes and thus health gains are sustained over the long-term.

BTCV’s experience of how Green Gym can sustainably deliver the health gains and practical outputs varies considerably from country to country. In Northern Ireland it has been found to work best as a partnership requiring support from Health Boards/Trusts to attract sufficient funds to develop it further.

The Green Gym’s versatility has helped it meet the needs of groups with very different disabilities. The type of work, location, frequency and duration can all be tailored to best meet the needs of individuals within a group. This flexibility will allow Green Gym to be equally successful in developing methodologies to work with employees suffering from stress at work or off work through stress.

Significantly, all CVNI's programmes of practical conservation work, whether through weekday volunteering or working at the tree and wildflower nurseries, are likely to deliver similar health benefits. Although this work is not currently 'packaged' under Green Gym in future CVNI should consider the personal health gains from these activities and how this might impact on health targets. Health gains are likely to at least equal those of Green Gym given that in most cases volunteers attend far more regularly than on Green Gym.

7. References

Gould, N. (2003) Revealed: Ulster’s ‘sick’ health service. Belfast Telegraph p1. 11th August 2003.

Biddle, S., Fox, K.R. and Boutcher, S.H. (2000) Physical activity and psychological well-being. Routledge. London.

Bird, W. (1997) Health Walks: A step by step guide, Sonning Common Health Centre.

Boylen, S. (2000) The Green Gym in Belfast. Healthy Living and Trees Conference Proceedings. Conservation Volunteers Northern Ireland. p18-20.

BTCV/BEN (2002) Environments for All: Baseline review of BTCV’s work with disadvantaged communities. BTCV.

Conservation Volunteers Northern Ireland (2003) Green Gym video. Red Box Media.

Conservation Volunteers Northern Ireland (2000) Strategic Plan: Expanding the boundaries of conservation volunteering. BTCV.16pp.

DHSSPS (2002) Investing for Health. Department of Health, Social Services and Public Safety.

DHSS (1997) Well into 2000: A positive agenda for health and wellbeing. Department of Health and Social Services.

DHSS (1996) Health & Wellbeing: Into the next Millennium. Regional Strategy for Health and Social Wellbeing 1997-2002. Department of Health and Social Services.

Jenkinson, C., Layte, R., Wright, L. and Coulter, A. (1996) The UK SF-36: An analysis and interpretation manual. Health Services Research unit, University of Oxford.

Keys, D. (2003) An evaluation of Green Gym in Northern Ireland: 2002–2003. Conservation Volunteers Northern Ireland. Internal Report.

MacAuley, D. (1999) The benefits and hazards of exercise. British Medical Journal Press.

O’Riley, B. (2003) Victoria Day Care Centre Manager. Pers. Comm.

Reynolds, V. (2002) Well-being comes naturally: An evaluation of the BTCV Green Gym at Portslade, East Sussex. Oxford Brookes University, Oxford Centre for Health Care Research & Development. ISBN 1 902606 15 9.

Reynolds, V. (2000) The Green Gym. Voluntary Action, 2 (2): 15-25.

Reynolds, V. (1999) The Green Gym: An evaluation of a pilot project in Sonning Common, Oxfordshire. Oxford Brookes University, Oxford Centre for Health Care Research & Development. ISBN 1 902606 05 1.

Rejeski, W., Brawley, L., Schumaker, S. (1996) Physical activity and health-related quality of life. Exercise and Sports Science Reviews, 24: 71-108.

Sarason, L., Levine, H., Basham, R., et al (1983) Assessing social support: The social support questionnaire. Journal of Personal Social Psychology, 44: 127-139.

SEBT (1999) Positive Health Development Strategy. South & East Belfast Health & Social Services Trust.

SEBT (1997) Community Development Strategy. South & East Belfast Health & Social Services Trust.

Trchalik, Y. (1999) A practical guide to setting up a Green Gym. BTCV. 48pp. ISBN 0 946752 21 4.

Ulrich, R. (1984) View through a window may influence recovery from surgery. Science, 24: 420-421.

Ulrich, R. (2000) Trees and Stress. Healthy Living and Trees Conference Proceedings. Conservation Volunteers Northern Ireland. p6-11.

CVNI : Green Gym : Evaluation : Healthy Cities