Research Activity

Green spaces such as, nature reserves, parks, woods sports fields, natural meadows, wetlands, and other ecosystems, characterise an essential component of all urban ecosystems. Presence of green areas facilitate physical and mental activity and bring about relaxation among the residents. Urban green spaces also play a crucial role in providing relief from stress and anxiety. This report contains a research proposal and a critical appraisal of a systematic review, in relation to the impacts of greenery on the physical and mental wellbeing of patients.

Running head: RESEARCH ACTIVITY
Unit Reference- Number D/507/9468
Name of the Student
Name of the University
Author Note

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Executive summary
Green spaces such as, nature reserves, parks, woods sports fields, natural meadows, wetlands,
and other ecosystems, characterise an essential component of all urban ecosystems. Presence
of green areas facilitate physical and mental activity and bring about relaxation among the
residents. Urban green spaces also play a crucial role in providing relief from stress and
anxiety. This report contains a research proposal and a critical appraisal of a systematic
review, in relation to the impacts of greenery on the physical and mental wellbeing of
patients.

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Table of Contents
Task 1- Research proposal.........................................................................................................3
References..................................................................................................................................6
Task 2- Critique of a research article.........................................................................................8
Focus......................................................................................................................................8
Background............................................................................................................................9
Aim.......................................................................................................................................10
Methodological approach.....................................................................................................10
Data collection methods/tools..............................................................................................11
Data analysis and presentation.............................................................................................12
Sample..................................................................................................................................13
Ethical considerations..........................................................................................................13
Main Findings......................................................................................................................14
Conclusions and recommendations......................................................................................15
Strengths and limitations......................................................................................................16
Application to practice.........................................................................................................16
References................................................................................................................................17

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Task 1- Research proposal
Introduction- There is mounting evidence for the fact that visual exposure to greenery
assists in the recovery of dementia patients, from stress (de Keijzer et al. 2016). Furthermore,
exposure to gardens have also been correlated with reduced levels of anxiety among patients
in residential care unit (Beyer et al. 2014). This report will contain a research proposal that
will focus on determining the behavioural and physiological effects of visual exposure to
greenery.
Problem statement- Mental health conditions that encompass abnormal behavioural and
physiological manifestation, often comprise of anxiety and major depressive disorders, and
are of chief public health concern (Ekkel and de Vries 2017). Several research investigations
have drawn the conclusion that exposure to nature does provide relief from anxiety and
stress, besides increasing social interaction, encouraging physical exercise, and soothing
mental illness (Astell-Burt, Mitchell and Hartig 2014). Furthermore, it has been proved that
exposure to nature and green spaces boosts mental health and also increases happiness.
Greenery and green spaces refer to maintained and unmaintained environmental zones that
comprise of urban parks, wilderness, and nature reserves. Recent studies suggest that global
urbanisation have resulted in a decrease in engagement with and access to green-spaces,
despite the mounting evidence of existence of a positive relationship between wellbeing and
green spaces (Wolch, Byrne and Newell 2014). Furthermore, people also report the presence
of improved cortisol profiles while residing in urban zones with greater greenery, in
comparison to those with reduced green-space (Kardan et al. 2015). However, there exists a
gap in literature with regards to the effects that visual exposure to greenery creates on the
physiological wellbeing of people.

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Research question- Does visual exposure to greenery has positive physiological and
behavioural impact?
Research aim- What are the impacts of visual exposure to greenery on behavioural and
physiological wellbeing of people.
Research objectives-
 To explore the impact of greenery exposure on physiological wellbeing
 To explore the impact of greenery exposure on behavioural wellbeing
Study design- The research will focus on a systematic review where comprehensive
search strategies shall be formulated for collecting data from already published scholarly
pieces of evidences. The primary reason for adoption of this research design is to obtain an
exhaustive summary of best available evidences, pertinent to the research question (Harris et
al. 2014).
Study population and sampling- Electronic databases and search engines such as,
Proquest, MEDLINE, and CINAHL will be searched with the input of appropriate key terms,
combined with boolean operators (McGowan et al. 2016). Some key terms to be used will be
‘greenery’, ‘green-space’, ‘visual’, ‘exposure’, ‘contact’, ‘behavioural’, ‘physiological’,
‘impact’, ‘effect’, ‘wellbeing’.
Data collection- Articles that have been published in English language, on or after
2014, with the necessary key terms, will be extracted by utilising the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses (PRISMA) format, following which they
will be critically appraised (Moher et al. 2015).

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Data analysis- Specific patterns and information from the extracted articles will be
examined, pinpointed, and recorded in the form of themes, for describing the phenomenon
under investigation (Braun et al. 2019).
Ethical considerations- Duplicate and redundant publications shall be avoided.
Efforts will also be taken to refrain from plagiarising the words, data and original creations of
the authors, whose published articles will be selected. Articles that have conflicts of interest
between the researchers will not be selected for the review.

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References
Astell-Burt, T., Mitchell, R. and Hartig, T., 2014. The association between green space and
mental health varies across the lifecourse. A longitudinal study. J Epidemiol Community
Health, 68(6), pp.578-583.
Beyer, K., Kaltenbach, A., Szabo, A., Bogar, S., Nieto, F. and Malecki, K., 2014. Exposure to
neighborhood green space and mental health: evidence from the survey of the health of
Wisconsin. International journal of environmental research and public health, 11(3),
pp.3453-3472.
Braun, V., Clarke, V., Hayfield, N. and Terry, G., 2019. Thematic analysis. Handbook of
Research Methods in Health Social Sciences, pp.843-860.
de Keijzer, C., Gascon, M., Nieuwenhuijsen, M.J. and Dadvand, P., 2016. Long-term green
space exposure and cognition across the life course: a systematic review. Current
environmental health reports, 3(4), pp.468-477.
Ekkel, E.D. and de Vries, S., 2017. Nearby green space and human health: Evaluating
accessibility metrics. Landscape and urban planning, 157, pp.214-220.
Harris, J.D., Quatman, C.E., Manring, M.M., Siston, R.A. and Flanigan, D.C., 2014. How to
write a systematic review. The American journal of sports medicine, 42(11), pp.2761-2768.
Kardan, O., Gozdyra, P., Misic, B., Moola, F., Palmer, L.J., Paus, T. and Berman, M.G.,
2015. Neighborhood greenspace and health in a large urban center. Scientific reports, 5,
p.11610.
McGowan, J., Sampson, M., Salzwedel, D.M., Cogo, E., Foerster, V. and Lefebvre, C., 2016.
PRESS peer review of electronic search strategies: 2015 guideline statement. Journal of
clinical epidemiology, 75, pp.40-46.

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Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., Shekelle, P. and
Stewart, L.A., 2015. Preferred reporting items for systematic review and meta-analysis
protocols (PRISMA-P) 2015 statement. Systematic reviews, 4(1), p.1.
Wolch, J.R., Byrne, J. and Newell, J.P., 2014. Urban green space, public health, and
environmental justice: The challenge of making cities ‘just green enough’. Landscape and
urban planning, 125, pp.234-244.

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Task 2- Critique of a research article
Whear, R., Coon, J.T., Bethel, A., Abbott, R., Stein, K. and Garside, R., 2014. What is the
impact of using outdoor spaces such as gardens on the physical and mental well-being of
those with dementia? A systematic review of quantitative and qualitative evidence. Journal
of the American Medical Directors Association, 15(10), pp.697-705.
Focus
Research focus forms a crucial aspect of any investigation owing to the fact that it
encompasses the question that needs to be explored in the formal research. The focus of this
particular research was on dementia patients and the impact of outdoor spaces having gardens
on their mental and physical wellbeing. The researchers were correct in addressing a well-
focused issues in their investigation, which in turn can be accredited to the fact that dementia
encompasses a group of symptoms that are related with a decline in the thinking ability and
memory power of older individuals (Hendriks et al. 2014).
The researchers stated that the primary focus of the study was to explore the different
non-pharmacological interventions that can be implemented in healthcare settings, with the
aim of improving signs and symptoms of dementia, thereby enhancing the overall wellbeing
and quality of life of the patients. This can be cited as a correct approach since the
interference of the illness with behaviour and thinking of the patients, decreases their ability
to perform the activities of daily living, besides impeding their normal working and social life
(Vernooij-Dassen and Jeon 2016). Furthermore, research evidences have also stated that
providing suitable surroundings to dementia patients allows them to lead satisfying and
productive lives for several years, after being diagnosed of the illness (Digby and Bloomer
2014).

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Background
Research background typically comprises of a brief outline of the most significant
investigations that have been steered so far, with respect to the phenomenon being
investigated. The background for this piece of scholarly article was not comprehensive and
contained limited information on the facts that formed the foundation for the investigation.
The researchers recognised dementia as a matter of public health priority and elaborated on
the fact that an estimated 7.7 million new dementia cases are identified every year. This can
be supported by the fact that approximately 50 million people suffer from dementia on a
global basis, which is much higher than the population of Spain (Dementiastatistics.org
2018). Reports from the WHO (2017) also affirms the widespread prevalence of the problem
by stating that dementia has been recognised as a major reason for dependency and disability
among older adults and expects the total affected population to reach an estimated 82 million
and 152 million in 2030 and 2050, respectively.
The researchers also stated that nearly half of the aging population, dwelling in
residential care facilities have dementia, which upsurges to additional three-quarters alone in
nursing homes. This is congruent with the global estimates of roughly 5.2% people aged
above 60 years, being affected with this illness (Dementiastatistics.org 2018). The research
background also illustrated the fact that detailed attention must be given to the physical
situation where individuals with dementia live, counting in the plan of and entree to gardens,
thus being representative of the fact that gardens are a robust component of future dementia
care. This has already been proved by Gonzalez and Kirkevold (2014) that non-
pharmacological interventions that encompass exposure of dementia patients to sensory
gardens, and their participation in horticultural activities, reduces the manifestation of
disruptive behaviour amid them, and enhances their wellbeing as well. Visits to therapy
gardens have also been associated with promotion of physical movement, and increased

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social participation among dementia patients, thus justifying the research background (Spring
2016).
Aim
The research aim focused on determining the therapeutic effect of outdoor spaces or
gardens for individuals diagnosed with dementia, who reside in care homes. The research aim
was appropriate since it attempted to increase understanding on a domain that was previously
not known by others.
Methodological approach
Research methodology forms a crucial component of any scholarly evidence and
encompasses the precise techniques and procedures that are used for identifying, selecting,
processing, and analysing information on particular research phenomenon. The researchers
had adopted the methodology of a systematic review, in accordance with standard guidelines.
Conducting a systematic review was suitable for this topic since it encompasses collection of
secondary data that are critically appraised, followed by synthesis of the quantitative and
qualitative findings (Kumar 2019). This methodological approach has the potential advantage
of being an exhaustive summary of contemporary evidences, significant to the research
question. Another likely benefit of systematic review is that, it acts as the key to evidence
based practice. Systematic reviews have also been identified as a strong type of medical
evidence, with adequate reliability (Boland, Cherry and Dickson 2017).
It should also be taken into consideration that showing compliance to CRD’s guidance
for formulating the research methodology, facilitated the search and selection of articles that
reduced bias, thereby increasing the likelihood of the researchers of arriving at accurate and
reliable conclusions. Summarising qualitative and quantitative information based on impact
of outdoor spaces and gardens on wellbeing of dementia patients, and the views of the carers

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and home staff, made it easier for the end user to understand the information. The review also
facilitated establishing whether a particular intervention (non-pharmacological intervention of
exposure to outdoor spaces and greenery in this case), works properly, is safe, and effective
(Kallio et al. 2016). The researchers developed a searched strategy that comprised of expert
consultation, and usage of a combination of free text and MeSH terms for extracting relevant
articles from 14 electronic databases.
Search strategy has been identified imperative for any systematic review owing to the
fact that they provide an organised structure for retrieving articles from databases. The
appropriateness of the research article can also be accredited to the fact that systematic
reviews provide a detailed idea of how well the research results can be applied to everyday
practice (Colquhoun et al. 2014). The review also facilitates identification of knowledge gaps
that recognise the need of conducting further research, with the aim of exploring the
therapeutic effects of outdoor spaces or gardens on dementia patients.
Data collection methods/tools
Apart from retrieving articles from the 14 databases, the researchers also contacted 38
relevant organizations, over e-mail or telephone, for the identification of unpublished reports
that were pertinent to the research question. The fact that the researchers used both
quantitative and qualitative articles for the review, was advantageous. According to
Berthiaume et al. (2014) use of quantitative research evidences helped them in collecting
relevant statistics, facts and numerical data for determining the impacts of gardens on the
dementia patient’s wellbeing. Additionally, inclusion of quantitative articles also facilitated
easy measurement of the health outcomes, by representing the results of research in the form
of objective data. On the other hand, the fact that qualitative articles were also extracted from
the databases and the aforementioned organisations, helped the researchers gain a deeper
understanding of the impacts of the intervention, by taking into account the feelings,

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attitudes, and behaviour of the research participants (Bernard 2017). Additionally, since
qualitative articles encourage research participants to expand on their replies, new avenues
that had not been initially considered by previous researchers were included in this review.
The researchers had utilised a modified, piloted data extraction form that was
thoroughly checked and reviewed, followed by resolving all kinds of discrepancies. Use of a
data extraction form helped in assessing the quality of the research articles that were included
in the review (Brannen 2017). Additionally, evaluating the risk of bias of the included articles
with the use of Effective Public Health Practice Project tool and the Wallace criteria for
quantitative and qualitative studies was another suitable step for data collection. This can be
validated by the fact that both the tools reliably measure the quality of methodological
research (Davies and Hughes 2014). Hence, the research methodology was correct for the
phenomenon.
Data analysis and presentation
The process of data analysis is imperative in research since it involves inspection,
cleansing, transformation, and modelling of data, with the primary objective of unravelling
valuable information, thus drawing conclusions and arriving at decision-making. The
researchers adopted an approach of narrative analysis for summarising and tabulating the
results of the included quantitative studies. Use of a narrative approach facilitated placing an
emphasis on results that had been reported by the researchers (Syed and Nelson 2015).
Hence, the researchers relied on representing the statistical or numerical representation of
research results, which in turn helped them to quantify the impacts of gardens or outdoor
spaces on the health and wellbeing of the participants. Descriptive data collected from the
qualitative studies were organised in the form of thematic analysis.

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Performing a thematic analysis was accurate since it is one of the most common types
of analysis that is employed for qualitative research. This approach allowed the researchers to
pinpoint, examine, and record specific themes or patterns within the data (Clarke and Braun
2014). Furthermore, one major advantage of this analysis procedure can be accredited to the
fact that presence of specific data set within research articles help in identification of raw
data, followed by their coding into detailed headings, commonly referred to as themes.
Typically the essential concepts obtained from qualitative research are encoded, prior to their
interpretation, which helps in comparing between the theme frequencies, recognising the co-
occurrence of similar facts, and graphically displaying the correlation between the different
identified concepts. The researchers participated in reading and re-reading the results,
followed by organisation of the concepts into third-orders.
Sample
Sample in research encompasses a group of objects, items or people that are obtained
from a larger population, with the aim of measurement (Faber and Fonseca 2014). Hence, it is
imperative for all research sample to be adequately representative of the wider population
that is pertinent to the research phenomenon. Conducting an electronic search in the 14
databases helped in the extraction of 1295 articles, of which the researchers retrieved 85,
depending on their full-text eligibility. Following analysis of the articles based on specific
inclusion and exclusion criteria, 17 were considered prospective for the review. Hence, it can
be stated that the sample size was adequate for the systematic review.
Ethical considerations
In the words of Neuman and Robson (2014) while conducting a systematic review,
efforts must be taken to ensure that no ethical issues arise, with respect to the research
methodology, data collection, and extraction. The researchers stated that they could not
determine if the research findings or the design of the articles that were included in the

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review had any possible ethical concerns, or recruited an adequate sample as participants.
Hence, it cannot be clearly stated that all ethical considerations were addressed in the review.
There is no clear evidence as to whether the researchers had avoided plagiarism while
reporting the ideas, data and words from the extracted articles. There also lies uncertainty
regarding the transparency of the research funding and associated competing interests.
Nonetheless, it can be stated that the researchers tried to avoid using duplicate or redundant
publications in the systematic review since manifold publication of scientific trials have the
likelihood of skewing the results of the systematic review. Additionally, there might also be a
chance that recurrent publication of positive results and suppressing the negative results
might create understated psychological impacts on the researchers, thereby making them
misplace their confidence on the particular non-pharmacological intervention, thus preventing
them from clearly stating the negative impacts of outdoor spaces with gardens on the
dementia patients (if any).
Main Findings
Of the 17 studies that were included in the review, 9 were quantitative, 7 were
qualitative, and 1 was a mixed method study. It was found from the narrative analysis that the
quantitative studies did not have high quality evidences. The researchers were successful in
identifying a high risk of bias in the quantitative studies, which in turn was accredited to the
absence of blinding of the participants and the investigators. However, this bias was also
correlated with the fact that the researchers of the quantitative articles were unable to mask
the activities of “going to the garden” in the form of an intervention. However, an analysis of
the data reported in the quantitative articles suggested that garden and outdoor space use were
significantly associated with a reduction in the levels of agitation among dementia patients.
There was lack of interpretation and clarity in two of the quantitative articles, which in turn

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resulted in failure of the researchers in clearly drawing any descriptive conclusions from
them.
This was in clear contrast to the qualitative articles that were used for thematic
analysis. All of the included qualitative articles were based on well formulated research
question and had employed study designs that were accurate to the phenomenon under
investigation. Additionally, inclusion of the qualitative articles helped the researchers in the
fact that these scholarly pieces of evidences contained an exhaustive description of the data
collection procedures, and suggested reasonable claims about the result generalizability. An
analysis of responses of most of the qualitative studies suggested that outdoor environments
were primarily therapeutic in nature, and were beneficial in providing an occasion for
multisensory encouragement through social interaction, reminiscence, enhancing cognitive
and physical competence, enhancing self-esteem, and bringing about relaxation. The
researchers were able to draw conclusions from the experiences and views of garden, in
relation to its usage, nature of relations, and mechanisms by which it created an impact on the
dementia patients. Moreover, the articles included in the review suggested that garden usage
was able to reduce several behaviours such as, trespassing, pacing, and exit seeking amid the
patients. No significant effects of the intervention were observed on emotional outcomes such
as, anxiety, sadness, interest, pleasure, anger, and contentment. Mixed results were obtained
in terms of the impact on physical activity and sleep.
Conclusions and recommendations
The systematic review was able to explore both qualitative and quantitative evidence
on the effects of garden and outdoor spaces for individuals with dementia, who were in
residential care. Findings from the quantitative evidences suggested that decreased agitation
was significantly correlated with exposure to garden. Nonetheless, there was inadequate
evidence for allowing generalizability of the results on different facets of physical and mental

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wellbeing. Qualitative study findings helped in identification of themes, which were based on
experiences and opinions of garden usage from the staff, residents, and perspectives of the
family members. Hence, the researchers concluded that there exist promising influences on
stages of agitation amid care home residents, who have been diagnosed with dementia and
spend considerable time in gardens. They recommended that future research would largely
profit by placing a due focus on crucial outcomes that are measured in analogous ways, with
a distinct emphasis on what underpins the restricted accessibility of patients to gardens,
within the setting of residential care homes.
Strengths and limitations
This was the first systematic review that explored both qualitative and quantitative
evidence on the influence of gardens for individuals diagnosed with dementia, in residential
care homes. Inclusion of both types of research articles helped in summarising a wider
evidence, thereby facilitating the researchers in drawing definite conclusions. Poor reporting
of the included studies and the potential risks of bias in the results were a major limitation of
the systematic review.
Application to practice
Although more research must be done, prior to implementing this intervention for
enhancing the wellbeing and health of dementia patients, accessibility of the gardens by the
patients is another matter of concern that must be taken into consideration in future.

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References
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Faber, J. and Fonseca, L.M., 2014. How sample size influences research outcomes. Dental
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Whear, R., Coon, J.T., Bethel, A., Abbott, R., Stein, K. and Garside, R., 2014. What is the
impact of using outdoor spaces such as gardens on the physical and mental well-being of

19RESEARCH ACTIVITY
those with dementia? A systematic review of quantitative and qualitative evidence. Journal
of the American Medical Directors Association, 15(10), pp.697-705.
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