PROTOCOL: The impact of care farms on quality of life among different population groups: protocol for a systematic review

1.1 DESCRIPTION OF THE CONDITION

The care farming approach has been used in attempt to provide health and social support to a range of people. As such, the intervention does not target any specific conditions. The number of care farms has been growing, particularly in Europe with an estimated 1000 care farms in the Netherlands (Elings et al., 2011) and over 200 in the UK (Care-Farming, 2014), 900 in France, 300 in Belgium, 160 in Germany, 675 in Italy and 100 in Ireland (Di Lacovo and O'Connor, 2009).

In the UK, approximately 30% of service users in care farms are offenders referred from probation services. These offenders often have mental and physical health problems (Elings, 2012a, Elings, 2007, Brooker et al., 2009); drug addiction and substance misuse problems (Abracen et al., 2000); socioeconomic deprivation (Farrington, 1990), have witnessed domestic violence (Caputo et al., 1999); have a family history of criminal violence (Farrington and West, 1990); and have experienced harsh or neglectful parenting (Pederson et al., 2012). Care farms may provide an environment where offenders can be provided with opportunities and are able to build their self-esteem and hope for the future, this may in term not only improve their mental health but also increase their chances of maintaining a crime-free life.

Care farms also provide services to young people many of whom have severe conduct problems, ADHD, autistic disorders or have been excluded from school (Elings, 2012b). Evidence suggests that the numbers of young children who have conduct disorders are increasing (Robins et al., 1999, Mcewan, 2014) and a large proportion of youth who show problem behaviour at a young age go on to develop antisocial personality disorders as an adult (Rutter et al., 1997) or can experience social exclusion(Hassiotis and Hall, 2008). Conduct disorders can also increase the risk of psychoactive substance use disorders, bipolar disorder and smoking in the long-run(Biederman et al., 2008). As with offenders, many young people with conduct disorders may have had limited contact with nature or responsibility of caring for other living creatures or plants. The care farm provides this interaction which may well increase self-esteem and provide a sense of purpose for these young people. This could have direct benefits to quality of life and longer-term impacts on social and educational opportunities.

Elderly people, including those with dementia, and those with physical or learning disabilities also utilize care farms (Elings et al., 2011). Being able to be physically active in nature may help to improve both the physical and mental well-being of these groups. Levels of depression and anxiety are often higher among these groups than the general populations (Pederson et al., 2011), and findings suggest that depression can cause worse health scores when combined with chronic conditions such as arteritis, asthma or diabetes (Moussavi et al., 2007). The literature on green care indicates that people often find solace when they have contact with nature, particularly when they are engaged in activities such as farming or gardening (Sempik et al., 2010). Studies have also shown that connectedness to nature has a positive effect on people's mental, physical, and psychological well-being, and spiritual beliefs (Bragg, 2013b, Sempik et al., 2010). As a result, care farms may be beneficial for a wide range of service users.

1.2 DESCRIPTION OF THE INTERVENTION

Care farming (also called social farming) has been defined as the use of commercial farms and agricultural landscapes as a base for promoting mental and physical health through normal farming activity (Hassink et al., 2007, Hassink, 2003, Hine, 2008). A care farm utilises the whole or part of a farm to provide health, social or educational care services for different groups of people, providing a supervised, structured programme of farming-related activities rather than occasional one-off visits (Care-Farming, 2014).

Care farming is a truly complex intervention. Farms differ in the type of farming activities (e.g. horticulture and livestock farming), other activities (e.g. gardening, conservation, and woodwork) and level of support provided (e.g. health promotion, counselling, skills qualifications). There is also a wide range of clients using care farms. These include those with dementia, depression, learning disabilities, substance misuse and behavioural issues, as well as offenders. Given this complexity, the main defining feature of a care farm is the involvement in farm activities for a therapeutic purpose. It is also important to highlight the farming component of the intervention, this helps to distinguish care farms from horticultural- or animal-based therapy projects. Care farms function as a social enterprise where income gained by agricultural production is used to finance the care farm (Elings et al., 2011).

A diverse range of activities can be offered to clients at a care farm. Activities selected are primarily determined by the particular needs of the client and the type of farm. For example, at one care farm in Worcester, UK, clients such as those with substance misuse problems and offenders will attend the farm twice a week for approximately 25 sessions. The first session is focused on skills training and cognitive development; following sessions are work -based, including activities such as growing vegetables, harvesting, and retailing produce and working with the farmer to manage a large herd of beef cattle (Willowdene and RITE Social Enterprises, 2013). Another care farm in West Yorkshire has clients that include young people, those with learning disabilities and offenders. These clients take part in gardening, conservation work, bee keeping and fish farming (The ABLE Project, 2013). These are just two examples of UK care farms, and other farms will have other activities depending on the nature of the farm and the clients. Apart from engaging in different activities, some care farms offer clients the opportunity to interact with other professional caregivers to receive counselling or support to develop a healthier lifestyle. A recent survey of care farms in England found that on average, 34 participants attended a care farm per week however, this varied largely from a single participant to a maximum of 300 participants. The length and duration of the care farm intervention is determined by the need of the client and this varied from 1 to 3 times a week, continued on average for 30 weeks(Bragg, 2014a).

In addition, the intervention can vary depending on the setting where it is delivered. For example, in the Netherlands an agriculturally productive farm will offer some form of care or health promotion to their clients, where as in Germany care farms are frequently connected to a healthcare institution rather than being solely based on agricultural production (Haubenhofer et al., 2010). German care farms often function on a large scale, as government subsidies are only provided to farms with more than 300 clients (Haubenhofer et al., 2010).

The clients that utilize care farms also differ according to the setting of the intervention, for example in the Norway the clients tend to be primarily young children and psychiatric clients, where as in the United Kingdom, Belgium, the Netherlands and Italy a variety of different people use the intervention(Haubenhofer et al., 2010). Clients will engage in different activities on the farm depending on their needs and interests. For example, frail elderly clients may engage in activities that require less physical exertion such as potting plants or selling produce; young people and offenders may thrive on more physical tasks and also be involved in activities that can build their skills for future employment. The authors' initial scoping of the published and unpublished literature has not identified any details and comprehensive cross-sectional studies of care farming across Europe, the US or other high income country. If such cross-sectional studies are found during this review, this important background information will be added to the publication of the findings of the review.

While the number of care farms is growing across Europe and their services are increasingly commissioned by a range of public health and social sector organisations, commissioners face challenges in identifying evidence of their effectiveness. The complexities and multi-faceted nature of care farms means that this is not an intervention that lends itself easily to a randomised controlled study design. The observational evidence that is available is published in a wide range of journals across Europe and is not easily synthesised.

Care farming can be seen as one element within a wider discourse of ‘green care’. Green care has been defined by Sempik and Bragg (2013) as follows:

Green care utilises plants, animals and landscapes to create interventions to improve health and wellbeing; (i.e. it does not represent a casual encounter with nature) It also provides care and support to enable people to reach their true potential (i.e. although many of the approaches are termed ‘therapies’ or ‘therapeutic’, they are not necessarily directed at treating or curing conditions and diseases but, as in the case of people with learning difficulties, for example, they provide care, support, training and other opportunities to enable those individuals to develop. Such opportunities are often not available elsewhere.) (Sempik and Bragg, 2013)

An overview of green activities and their relationship with nature has been developed by Bragg (Bragg, 2014b) and distinguishes between merely experiencing the natural environment and interacting with natural elements. Care farming is seen as a subset within these broader green care approaches.

OPEN IN VIEWER

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Care Farms within the Typology of Green Care

The evidence base for the effectiveness of care farming is relatively recent (within the last 10 years). Much research originates from The Netherlands and Norway. Berget, Ekeburg and Braastad (Berget et al., 2008) conducted one of the few RCTs focusing specifically on psychiatric patients and their interaction with animals in the farm setting. They found significant improvements in self-efficacy and coping ability at 6 months follow up. Kam and Siu 2010 (Kam and Siu, 2010) conducted a small RCT among 22 participants with psychiatric illness and found improvements in anxiety and depression following horticultural sessions on the farm. Pedersen et al. conducted a small RCT of 29 people with psychiatric illness and reported significant decreases in anxiety and depression ((Pederson et al., 2012). Several cross-sectional and qualitative studies have found that many participants benefit from the relationship with the farmer (and their family and other staff); being part of a social community; engaging in meaningful activities in a green environment; and for some, the possibility for work opportunities (Berget et al., 2007, Pederson et al., 2011, Pederson et al., 2012, Elings, 2012a, Elings, 2007). The fact that the farm provides an informal, non-care context which is close to the experience of everyday life, is also valued (Hassink et al., 2007; Hassink et al., 2009; Bragg, 2013a). Qualitative studies also point to improvements in mental well-being and improvements in social interactions (Hassink et al., 2011, Leck, 2013). Positive behavioural impacts such as reduced police contact and drug use have been noted amongst young participants (Hassink et al., 2009). Reductions in anxiety and depression have been observed in people with mental health issues (Pederson et al., 2012, Berget and Grepperud, 2011, Gonzalez et al., 2009, Bragg, 2013a) and those with psychiatric and addiction problems have also experienced improved social and work skills (Elings et al., 2011, Hassink et al., 2009, Bragg, 2013a, Berget et al., 2008, Berget et al., 2007, Leck, 2013). People with learning difficulties also appear to benefit, with increased life skills and improved social interaction (Leck, 2013). Improved dietary intake has also been noted in a small controlled before and after study comparing among people with dementia attending a care farm compared to those receiving day care (De Bruin et al., 2010).

1.3 HOW THE INTERVENTIONS MIGHT WORK

Sempik, Hine and Wilcox (2010) have collated theoretical frameworks that may explain how care farms are beneficial to health, well-being and social functioning among different population groups. In particular, they identify the following dimensions which are all present within care farming and the theoretical explanations for the effectiveness of these dimensions:

Looking at nature: Attention restoration theory (Kaplan and Kaplan, 1989) highlights how the view or experience of nature is inherently interesting or stimulating, requires no particular effort but plays an important role in recovery from mental fatigue. Similarly, the biophilia hypothesis put forward by (Wilson, 1984) emphasises our inherent connection to nature, and our need to be in nature to achieve individual meaning and personal fulfilment (Kellert and Wilson, 1993).

In addition to these theories, Hassink et al. (2009) highlight that the sense of community is the most valued aspect of the care farm. Participants find that they develop friendships and feel that they belong to the larger community at the care farm. Hassink et al. (2011) also finds that the role of the farmer is an important aspect of the care farm. Farmers were perceived as a role model with a strong sense of identity, who were proud of their business. Especially for youth, the farmer and the family functioned as an important role model. In addition clients with mental illnesses appreciated that they were treated with respect and without prejudice and valued the farmer as an informal caregiver.

Given the range of client groups that utilise care farms, the mechanisms influencing effectiveness are likely to vary with the needs of the participant. For example, dissonance theory may offer further insights into why care farms might be particularly effective for offenders. Key elements of dissonance theory are the recognition that the interventions that are most successful in reducing recidivism are those that can be individualised, when there are opportunities for building human relationships, opportunities or hooks for change and opportunities to reflect on past experiences and behaviour (Farrall and Bowling, 1999, Weaver and McNeill, 2007), when the offender can develop their self-efficacy (Maruna, 2001, McCulloch, 2005, McNeill, 2006), social capital by learning and applying new skills, develop a new more positive identity, (Farrell, 2004, Giordano et al., 2002, Laub and Samson, 1993, Maruna, 2001, McNeill and Maruna, 2007) and being more hopeful by focusing on the possibilities rather than limitations. It may be that care farms offer opportunities in all these areas. In this review we will identify, particularly through qualitative studies, mechanisms that may explain the effects of care farms for other key population groups. In addition, we also would explore how these mechanisms would relate to existing theories and conceptual frameworks.

1.4 WHY IT IS IMPORTANT TO DO THIS REVIEW

Finding interventions that can improve the health and well-being of different population groups is an important public health goal. If successful interventions can be found they may have a role to play in reducing inequalities. Improving the lives of the most disadvantaged can have far-reaching societal benefits, for example through enhancing social cohesion, reducing use of health and social care service usage and reducing crime (Wilkinson and Pickett, 2009). Care farming is one intervention that can potentially offer these benefits to a wide range of people.

In recognition of this, commissioners and policy makers are beginning to turn to care farms as a potentially effective intervention. Farmers across Europe are increasingly looking for ways to diversify the use of their land, and care farming may be an increasingly attractive option. As such there is great potential for the increase in the use of care farms as an intervention to bring beneficial outcomes to a range of different population groups. However there is little evidence on effectiveness (in relation to context and client groups) that can guide decision making about resource allocation.

We have identified two previous reviews on care farms. Hine et al (2008a) documented the extent and range of care farming initiatives and summarised evidence for benefits to mental health. Elings (2012a) reviewed the literature on therapeutic benefits across a number of vulnerable client groups. These reviews have helped shape the current proposal but there is a need for a systematic review to capture the full range of both published and grey literature, and to synthesise the evidence in a way that can garner current knowledge on what aspects of care farming may work, when, and for whom.

From its early establishment in Scandinavia, the Care Farming movement is expanding across Europe. In parallel with this, there are a growing number of evaluations of care farms for particular client groups. Due to the diverse nature of the client groups and the geographical locations of care farms, this evidence is rarely brought together. This review aims to synthesise this evidence, drawing out key lessons for policy makers and practitioners on the effectiveness of care farms in improving health and well-being for a wide range of clients.

This systematic review is part of a feasibility and pilot study, funded by NIHR's Public Health Research Programme, which is the start of a planned programme of work to identify the cost-effectiveness of care farm in improving the quality of life of offenders and reducing recidivism (see: http://medhealth.leeds.ac.uk/info/561/research/1045/understanding_the_impacts_of_care_farms_on_health_and_wellbeing). Through this pilot project, human and financial resources are available to undertake this systematic review and to disseminate findings to key stakeholders including commissioners, academics and care farmers.

3.1 TYPES OF STUDIES

We do not expect to find many randomised controlled trials of the effectiveness of care farms. Due to the possible paucity of such evidence, we are keen to include observational and qualitative studies. These studies will also be valuable in identifying possible mechanisms of action to inform our logic model.

The study designs to be included in the review are:

Randomised controlled trials (RCTs) with randomisation at individual or cluster level.

In addition to the study designs mentioned above, we will consider including before and after studies that do not have a control group as we expect to find some studies utilizing this method. We will synthesise the results of single group pre-post designs separately from other study designs. The findings may provide useful information on the nature and context of care farms and the mechanisms that may support effectiveness.

Single-subject designs will be excluded.

3.2 TYPES OF PARTICIPANTS

Relevant studies of clients attending care farms of any age will be included in the review. The list below presents the likely population groups. We acknowledge, however, the possibility of identifying other relevant client groups during the execution of the review.

Offenders serving community orders or similar sentences in the community rather than in prison; offenders ‘on-licence’ (i.e. recently leaving prison to re-enter the community).

3.3 TYPES OF INTERVENTIONS

All care farms have some degree of ‘farming’ (crops, livestock, woodland etc.) and of ‘care’ (including health care, social rehabilitation, education or training), but the balance of these elements differs from care farm to care farm. Many care farms offer therapeutic contact with farm livestock or with crop plants, but some also provide specific therapies and interventions such as Animal Assisted Therapy (AAT) and Horticultural Therapy (HT).

The extent of the ‘caring’ element also differs from farm to farm. It may be that some clients particularly benefit from the noticeable absence of a ‘care’ or ‘institutional’ element and the presence of a working, commercial farm. Yet the situation at other care farms may be far more ‘care’ and ‘carer’ oriented with the farming element present primarily to produce benefits for clients rather than for agricultural production.

It is possible to consider a scale which has at one end a care farm with farming production as its primary focus and at the other a care farm with its main focus on provision of care services. Between these two extremes lies a potential myriad of different approaches (i.e. care farms with slightly different foci, depending on the needs of participants, motivations and goals of the project and the type of farming enterprise). Care farming is taken in this review to be an inclusive term, including all these different types of farm and their variation in motivation and type of application be that social, therapeutic or vocational.

The review will not include interventions that are purely categorised as ‘therapy’ whether in relation to animals or other natural elements; examples include pet therapy and donkey/equine therapy, where these activities are not part of a working farm. The review will also exclude petting farms and farms used for ‘one off’ educational activities. Interventions provided in hospital or in prisons will also be excluded.

Comparison conditions: An initial literature search found no trials and only a couple of small European studies which have used a comparator group. However, any studies identified during this systematic review that compare care farms to a suitable comparator will be included. Comparators will be specific to the population group studied, for example offenders serving their community order on a care farm could be compared to those serving their order by providing another community service such as cleaning public areas or for those with addiction problems, another drug rehabilitation programme.

3.4 LENGTH OF FOLLOW UP

The review will include any length of follow up of participants subsequent to their attendance at the care farm. Where possible, outcomes will be grouped as short term (under 6 months), medium term (up to 5 years) and long term (over 5 years).

3.5 TYPES OF OUTCOME MEASURES

Primary outcome: Quality of life as measured by a validated quality of life measure such as the EQ5D (Szende et al., 2014), SF36 (Ware et al., 2007.), CORE-OM (Gray and Mellor-Clark, 2007), WEMWBS (Tennant et al., 2007).

Secondary outcomes: While our primary outcome is quality of life, we will include any outcomes that use a recognised measure of health, wellbeing or behaviour, assessed using self-report or objective measures. This review will cover a broad range of secondary outcomes. We aim to use this review and evidence from our primary research to identify pathways to change for different population groups and develop a logic model to explain these relationships. Being too restrictive in the secondary outcomes for the review would limit our understanding of these potential mechanisms. The secondary outcomes will therefore include, but not be restricted to:

Measures relevant to mechanisms known to be determinants of health:

physical activity

To be included in the meta-analysis the primary outcome (quality of life) needs to be measured using a validated instrument.). We will include studies using self-reported, objectively measured or routinely collected data (e.g. police or school data). We will not exclude any outcome measure falling within the broad definition of health, well-being and social functioning. The outcomes studied will be recorded and will help in understanding the potentially wide range of benefits of care farms.

Search strategy for identification of relevant studies