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Abstract
Objectives There is burgeoning evidence for the potential of nature-based interventions to improve wellbeing. However, the role of nature in enhancing maternal mental health, child development and early relationships remains relatively unexplored. This study aimed to develop a co-designed nature-based intervention to improve postnatal mothers’ and infants’ wellbeing.
Design, setting and participants Person-based and co-design approaches informed the planning and design of the postnatal nature-based intervention. In stage 1, a multidisciplinary team was formed to agree research questions and appropriate methodology, and a scoping review was conducted. Six qualitative focus groups were then held with 30 mothers and 15 professional stakeholders. In stage 2, intervention guiding principles and a logic model were developed, and a stakeholder consensus meeting was convened to finalise the prototype intervention. The research was conducted in Bristol, UK, across voluntary, educational and community-based healthcare settings.
Results Stakeholder consultation indicated significant enthusiasm for a postnatal nature-based intervention. A scoping review identified little existing research in this area. Focus group data are reported according to four broad themes: (1) perceived benefits of a group postnatal nature-based intervention, (2) potential drawbacks and barriers to access, (3) supporting attendance and implementation, and (4) ideas for intervention content. The developed intervention was tailored for mothers experiencing, or at risk of, postnatal mental health difficulties. It was identified that the intervention should facilitate engagement with the natural world through the senses, while taking into account a broad range of postnatal-specific practical and psychological needs.
Conclusions To our knowledge, this is the first reported use of person-based and co-design approaches to develop a postnatal nature-based intervention. The resulting intervention was perceived by target users to address their needs and preferences. Further research is needed to determine the feasibility, clinical and cost-effectiveness of this approach.
- health equity
- postpartum women
- postpartum period
- psychiatry
- qualitative research
Data availability statement
Data are available on reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
Our systematic approach to intervention development foregrounds the importance of patient and public involvement and qualitative research in the early planning and design stages of a complex health intervention.
A diverse range of mothers was sampled, to develop an inclusive and accessible intervention, including for populations who often experience barriers to postnatal care and to accessing nature.
Person-based and co-design approaches enabled the development of a complex postnatal intervention that was perceived by target users to address their needs and preferences.
While we took care to welcome all views and sought a balanced perspective about the intervention, some participants may have chosen to take part in this study because of a pre-existing interest in nature, which may have influenced their responses.
Introduction
Nature-based interventions show promise as inclusive approaches to promoting postnatal mental health and treating postnatal mental illness.1 The prevalence of postnatal mental health difficulties is consistently high across different cultures (around 15%–20% for postnatal depression,2 and around 10% for postnatal anxiety3 4). They cause suffering to families, threaten the development of the mother–infant relationship, and represent a huge economic burden to society.5 Preventing and treating these problems provides an opportunity to reduce the short- and long-term impact on the mother, infant and wider family, to optimise maternal–infant attachment, and to limit the propagation of transgenerational suffering.6 Despite evidence for the use of both pharmacological and psychotherapeutic treatment approaches in the postnatal period, very few women receive treatment.7 8 Reasons include fear of medication side effects for themselves or their infant via breastmilk, lack of access to psychological therapies, and a lack of identification with Western and biomedical constructs of postnatal mental health difficulties and their treatment paradigms.7
There is a growing concern that traditional health service models are unlikely to meet rising mental health demands. Alternatives include innovative, community asset-based approaches, such as group nature-based interventions.9 10 The therapeutic benefits of such interventions may be particularly useful for mothers and their infants.1 Benefits include enhancing nature connectedness (which correlates positively both to overall wellbeing11 12 and pro-environmental behaviours13), an enriched sensory diet, increasing exposure to natural light,14 increasing physical activity,10 15 providing opportunities for shared attention and enjoyment, and enhancing parental self-efficacy.16 Therefore, nature-based interventions may represent an engaging, sustainable, inclusive and scalable approach to supporting the mother–infant dyad in the postnatal period. They may be especially important given their potential to reduce health inequalities17–19 and enhance well-being at a relatively low economic cost. However, there is very little research about the development, acceptability, feasibility and effectiveness of such interventions for this population.
This article details the research activities undertaken as part of ‘The Mother Nature Project’, to plan and design a nature-based intervention to promote postnatal mental health using a person-based and co-design approach. We highlight the value of using robust methodologies, emphasising the importance of stakeholder involvement and adequately acknowledging the contribution of women’s lived experiences to the overall shape and feel of the intervention.
Methods
Approach to intervention planning and design
Evidence-based, theory-based, person-based and co-design approaches informed the planning (stage 1) and design (stage 2) of the intervention. Health intervention research suggests that the development of new interventions should be grounded in an in-depth understanding of the preferences and needs of the target population.20 21 The person-based approach (PBA) to intervention planning and development aims to situate intervention design in the perspectives and psychosocial context of the people who will use it. This is achieved by in-depth qualitative exploration of the key issues, needs and challenges that must be addressed. In addition, guiding principles are formulated, which outline the key design objectives that then inform the intervention’s key features.22 23 Our approach, in line with the PBA, is also informed by co-design through patient and public involvement (PPI). This has been described as doing research ‘with’ rather than ‘to’ individuals, thereby aiming to produce interventions that have greater relevance to the people who will use them.24 25 The PBA and co-design ethos also require greater transparency and detailed reporting of methodology.21 For rigour of reporting, we have used the Guidelines for the Reporting of Intervention Development Checklist (GUIDED)26 and the Guidance for Reporting Involvement of Patients and the Public27 (see online supplemental material 1).
Supplemental material
Following a conceptual analysis (reported elsewhere1), intervention planning (stage 1) included several components:
Formation of a multidisciplinary team, with continuous stakeholder consultation, and searching the relevant literature including a scoping review.
A qualitative focus group study, to explore women’s perceptions, perceived need, barriers and facilitators pertinent to planning the intervention.
In line with a person-based and co-design approach, the results from stage 1 were brought together in stage 2 to create iterative ‘guiding principles’ that outline the intervention design objectives and key intervention features. We developed a logic model and convened a stakeholder consensus meeting to agree upon the prototype intervention to be evaluated.
Stage 1: intervention planning
Stakeholder group formation
A steering group was formed, comprising multidisciplinary team members with expertise including: psychiatry (KH, JE, RB and RR), perinatal psychiatry research (JE), parental self-efficacy and nature connectedness research (CB), complex intervention development and qualitative methodology (KMT), environmental humanities, nature-based practice (LD), perinatal mental health charity project management (MW), community researchers in migrant and refugee rights and disability advocacy, and mothers with lived experience of perinatal mental health difficulties. Ten multidisciplinary team meetings were held during the planning and design phase, between November 2021 and August 2022. These were attended by the core authorship team and interested community stakeholders who became involved through word-of-mouth.
Scoping review
We undertook a scoping review exploring the existence of any nature-based interventions for postnatal mothers and their experiences of such interventions. A PRISMA Extension for Scoping Reviews (PRISMA-ScR) checklist is included in online supplemental materials 2A. Our objective was to include both quantitative and qualitative research, to gain an overview of current evidence and identify knowledge gaps. This broad topic, in which many different study designs might be applicable, lent itself well to scoping review methodology.28 As such, our inclusion criteria were broad. Arksey and O’Malley’s five-stage framework was used.28 We used Medical Subject Headings (MeSH) terms and free-text terms to design a search strategy around the following key concepts: mothers, the postnatal period, or postnatal depression, and nature-based interventions or nature connectedness. NICE HDAS (Healthcare Databases Advanced Search) was used to search PsycINFO, PubMed, MEDLINE, CINAHL, EMBASE and AMED in March 2022. No date, language, document type or publication status limitations were applied to the search. Full search strategies for all databases are provided in online supplemental materials 2C. Additional literature was sought through expert consultation and searching article reference lists. Titles and abstracts were screened by KH and RR. Where relevant, data on authors, intervention type and key findings were extracted. Findings are reported in the ‘Results’ section.
Qualitative focus group study
Focus groups were conducted to elicit the perspectives of stakeholders about the acceptability and feasibility of a postnatal nature-based intervention and to identify potential barriers, facilitators and contextual issues relevant to its design.
To ensure a diverse representation of mothers, and as advised by our PPI contributors, we conducted focus groups with mothers of young children (aged <5) from the following groups:
Focus group 1: mothers with experience of postnatal mental health difficulties.
Focus group 2: mothers from the refugee community.
Focus group 3: mothers from migrant backgrounds.
Focus group 4: mothers living with physical disabilities.
In addition, we held two focus groups with professional stakeholders:
Focus group 5: nature-based practitioners.
Focus group 6: health professionals working with mothers and infants.
Detailed methodology for focus groups 1–4 has been reported previously.29 In summary, participants for groups 1–4 were recruited via a perinatal mental health charity, a refugee centre, an ethnically diverse mother-and-baby group, and through social media channels for disabled mothers. Participants for focus group 5 were recruited through a regional forum for nature-based practitioners, and for focus group 6 via emails to teams of local National Health Service professionals working with mothers and infants. Women who expressed an interest in the study were given a participant information sheet and invited to sign a consent form following the opportunity to ask questions.
Between February and April 2022, the lead author and another member of the research team facilitated the six focus groups, with a total of 45 participants (table 1). A topic guide was used and included questions to elicit the following: (a) perceptions of the impact of nature on mothers and infants (results reported previously29); (b) the need and desirability (or lack thereof) for a postnatal nature-based intervention, and (c) factors that might help or hinder intervention implementation, including practical considerations and modes of delivery.
Focus group details
The guide was slightly tailored where appropriate, to suit the needs of the different groups.
With participant consent, focus groups were audio-recorded and fully transcribed by university-approved professional transcribers. Focus group data were reviewed for their adequacy, in terms of richness and complexity, in meeting the study’s aims, with the total number of groups being pragmatically determined.30
Inductive thematic analysis, structured according to Braun and Clarke’s six phases, was undertaken by KH, RB and RR, to identify key issues and perceptions of potential intervention features, as well as how to overcome postnatal-specific challenges. The findings were discussed and reflected on at regular authorship team meetings, as reported previously.29
Stage 2: intervention design
The knowledge collectively generated during intervention planning was mapped onto existing theory regarding the benefits of nature on mental health as well as infant development. Drawing on relevant theoretical literature, we determined that, rather than developing an entirely novel nature-based intervention, the needs of postnatal women and their infants could best be met by tailoring and hybridising existing approaches, specifically a blend of ‘forest bathing’ and the Five Pathways to Nature Connectedness. Intervention content was influenced by the theories summarised in online supplemental materials 3.
In line with the PBA,23 brief guiding principles were developed by KH and the research team, and iterated throughout the intervention development process (see online supplemental materials 4). These guiding principles outline the intervention design objectives, based on data from stage 1, which address the needs and challenges faced by target users, and key intervention features designed to achieve these objectives.
A summary of qualitative findings from stage 1 and the guiding principles were presented by the research team at a stakeholder consensus meeting. Previous project participants and third-sector partners were invited to a 2.5-hour outdoor meeting in May 2022 at a local city farm, with 40 attendees overall (table 2). Participants were invited to sample intervention content, by way of a ‘sensory meditation’ guided by a nature-based practitioner (LD). In the latter half of the meeting, participants agreed intervention guiding principles and key design features in smaller groups, each facilitated by a member of the research team.
Participants attending the stakeholder consensus meeting
In line with the UK Medical Research Council (MRC)/National Institute for Health and Care Research (NIHR) guidance for developing and evaluating complex interventions,31 a logic model was created by RR, RB and KH, with input from the research team. The model combines findings from the intervention planning and development process, including our primary qualitative work, to hypothesise as to underlying mechanisms of action connecting intervention components and expected outcomes.
Patient and public involvement
Patients and the public were involved in the design, conduct, reporting and dissemination plans of this research. Four patient advisory group meetings were held during the planning and design phase. These provided lived-experience perspectives on important research questions and study design, to help identify and resolve potential issues with acceptability and feasibility, and to advise on appropriate and inclusive recruitment and dissemination strategies. The meetings comprised between 6 and 10 mothers with lived experience of perinatal mental health difficulties recruited through partner charities. These meetings indicated significant enthusiasm for an inclusive group nature-based intervention to enhance postnatal mental health.
Results
Scoping review findings
1659 electronic records were identified, of which 131 duplicates were removed. A flow diagram can be found in online supplemental materials 2C. Four full texts were obtained for full screening, but three were excluded due to the age of children studied falling outside the postnatal period.
The one remaining study fulfilled our search criteria: a pilot randomised controlled trial of a 4-week intervention (a ‘nature coach’ and digital ‘nudges’) aiming to increase postpartum women’s time spent in nearby nature (n=36 postpartum women from a low-income USA neighbourhood).32 The study found that, compared to controls, the intervention group made three times the number of visits to greenspaces and spent four times as long there overall. The study was too small to detect significant differences between the two arms of the trial, in relation to scores on the Edinburgh Postnatal Depression Scale (from low baseline scores in both groups). Reported barriers to accessing nature included physical and mental health symptoms and a lack of social support.
The scoping review indicated there to be little research into postnatal nature-based interventions, in keeping with the research gap reported during expert consultation. Therefore, primary qualitative work was undertaken, the findings of which are reported below.
Qualitative focus group study findings
We identified four themes pertinent to the design of the intervention: perceived benefits, potential drawbacks and barriers to access, supporting attendance and implementation, and ideas for intervention content.
Perceived benefits of a group postnatal nature-based intervention
Both mothers and practitioners expressed enthusiasm for a postnatal nature-based intervention.
If you can create something like that, that would be so important for us. [FG-2: mother from refugee background]
Healthcare professionals identified that many women in need do not meet the threshold for accessing secondary mental healthcare services, and suggested that the proposed intervention might help to fill this gap. They also felt that many mothers already in secondary care may not yet be ready for traditional, individualised psychological therapies, but may benefit from a group nature-based intervention.
Many of them are having therapy and are having to sit and talk about their trauma again and again and again, and perhaps the really, really vulnerable mums are not ready for that part of it. [FG-6: health professional]
Various benefits of the group-based format of the intervention were identified by mothers and practitioners, in particular the sense of connection that this may foster.
Participants felt that sharing caregiving tasks amongst mothers and facilitators would increase the chances of mothers feeling able to engage with the natural surroundings.
Potential drawbacks and barriers to access
Some mothers and health professionals noted that the group-based format could be a source of anxiety, particularly if participants felt that their mothering skills were being scrutinised. Some women also reported having previously felt singled out in mother-and-baby groups because of their age or marital status.
Whether alone or in a group setting, mothers’ accounts of the challenges of accessing natural spaces with their infants, reported previously,29 were highly relevant to intervention design. These included issues around logistics (such as wet weather), and mental or physical health barriers, which frequently intersected in ways specific to the postnatal period.
I don’t have the confidence, because of my agility, to get on a bus with her pushchair. [FG-4: disabled mother]
Health professionals also encouraged consideration of specific physical needs arising related to birth and the postnatal period, so as not to cause additional stress.
I guess we have to be mindful of mode of delivery and if they have any physical trauma from their birth […] that would compound their distress if we’re then asking them to do something that they can’t do from the birth. [FG-6: health professional]
Participants reported potential barriers to gaining a referral to this type of intervention from a health professional. Reasons included mistrust towards healthcare professionals, a lack of identification with or knowledge of Western medical constructs of postnatal mental health disorders, or cultural expectations that having a baby is an inherently joyful time.
A lot of people don’t go to the doctors, especially from our cultures. [FG-3: mother from migrant background]
Some health professionals described the difficulties of promoting less traditional interventions to some patients who might hold them in lower esteem than traditional medical treatments, particularly in the time-pressured primary care setting.
It can be a bit like marmite… some people might feel that you’re fobbing them off or feel that it [for example mindfulness] doesn’t seem like a proper medical intervention. [FG-6: health professional]
This corresponded with the experiences of some nature-based practitioners of the need to spend time building relationships with some individuals prior to engaging them in a nature-based intervention.
Supporting attendance and implementation
The discussion around the potential benefits and drawbacks of the proposed intervention was closely connected to suggestions for successful implementation.
Importance of preparation
Mothers felt that they could overcome most barriers with the right preparation, either on their own or with the help of facilitators. Suggestions included receiving adequate information prior to joining the group, having clear directions to the site, and receiving weather updates prior to sessions. There was consensus across all groups as to necessary practical provisions, including the need for a toilet, consideration of baby changing requirements, pram accessibility, and provision of a sheltered area, refreshments, and spare equipment such as waterproof clothing.
Psychologically safe, private, welcoming and non-judgemental space
These practical considerations were felt by mothers to contribute to the sense of the intervention as providing ‘a safe space’ for mothers and babies. There was also a crucial psychological dimension to achieving this sense of safety: for example, the need for a private setting, not to feel judged, to be responded to appropriately by skilled facilitators, and for the use of appropriately sensitive language.
Amongst mothers, there was near-unanimous preference for female-only participants and facilitators; one mother voiced that she would not mind a male facilitator or the presence of partners, and another highlighted the need not to exclude transgender parents.
A dad could be a dad for many years, but a mum can recognise a mum’s emotions more I think, ‘cause you can see the look in their eyes at the end of the day, you can recognise “I can see that, I’ve felt like that before.”’ [FG-1: mother with lived experience]
All groups expressed that the sense of psychological safety would be enhanced if they knew that other participants (and perhaps also a facilitator) had lived experience of postnatal mental health difficulties.
Location considerations
Competing priorities for ideal locations included public transport links, parking availability, privacy, availability of amenities, and quality or ‘wildness’ [FG-5] of the natural site. There was consensus on the importance of reimbursing transport costs.
Session timing, length and number
Participants emphasised the need to cater for diverse needs depending on mothers’ individual situations, for example, by considering how session timing would affect accessibility.
I think you’ve got to really think about—is that mum more worried about getting back on that bus for three o’clock pick up, you know, if you’ve got another child at school? [FG-5: nature-based practitioner]
There was diversity of opinion among nature-based practitioners regarding optimal session length, with suggestions ranging from 1 hour to over 3 hours. Competing priorities included providing enough time for participants to settle in and ‘let go’ [FG-5], and, on the other hand, mothers’ and infants’ practical and emotional capacity for a longer session. Mothers and practitioners agreed that a weekly programme of five or six sessions would be short enough not to be intimidating, but long enough to reduce the impact of a missed session.
Ideas for intervention content
Flexible, responsive, non-directive content and delivery
Mothers suggested a flexible approach to participation to account for diverse physical, mental health and cultural needs, such as limited mobility, sensory impairment, social anxiety, and time for prayer. Nature-based practitioners agreed that allowing flexibility in how participants respond facilitates autonomy, curiosity and creativity.
[Regarding forest bathing] It’s very much feeling the way, and it’s very open. They’re invitations, they’re not activities. [FG-5: nature-based practitioner]
Mothers valued a mix of familiar structure with unstructured opportunities for free-flowing discussion, which correlated with how nature-based practitioners described their approaches to facilitation and session design. Nature-based practitioners emphasised the value of a slow pace and simple session structure. Mothers and practitioners alike felt that babies would naturally be included in the session content, given their innate fascination with the outdoor environment and tendency to remain close to their caregiver.
We don’t really need to do too much, because we’ve recognised that children know how to be with nature, so they will naturally be fascinated. [FG-5: nature-based practitioner]
Intervention prototype
The output of the intervention development process is reported using Michie et al’s guidance on reporting complex interventions,21 shown in box 1.
Pilot intervention prototype
Characteristics of those delivering the intervention
Co-facilitation by one forest bathing/nature-based accredited practitioner and one peer-support worker from a local perinatal mental health charity.
Characteristics of the recipients
Between 5 and 9 mother–baby dyads (mothers self-identifying with some form of postnatal mental health difficulty or stress, and babies under the age of either 1 or 2 years, depending on how the postnatal period is defined and local needs).
Setting
Outdoors, in an accessible location, with optional shelter.
Practitioners will complete a risk assessment of the site and check walking routes before the sessions.
Mode of delivery
Face-to-face, group-based programme.
Intensity and duration
Five/six, once weekly sessions, each lasting 2 hours.
Adherence/fidelity to delivery protocols
After piloting, facilitation strategies such as the development of a manual will be used to standardise implementation and increase fidelity.
Session content and structure
Half-hour welcome and checking in period, with refreshments provided.
Introduction by co-facilitators
Mothers will be encouraged to involve their babies and to respond to any of their infant’s needs throughout the sessions.
The nature-based practitioner will invite participants to partake in a series of three ‘invitations’:
Seated mindfulness exercise.
Slow, guided walk, noticing natural surroundings.
A different nature-based activity each week, themed according to the pathways to nature connectedness.
Each invitation is designed to facilitate mindful immersion in the natural environment and aid mothers to engage their senses, noticing colours and patterns, sounds, smells, and textures of the natural environment.
Following each invitation, participants will be invited, but not required, to share their experiences in a ‘sharing circle’, which facilitates peer learning and benefiting from the experiences of others.34
Any ‘think-aloud’ insights arising about the experience of the intervention by participants will be documented in order to contribute to iterative development of the intervention in accordance with the needs of mothers and their infants.23
Discussion
We have described the research activities undertaken to plan and design a nature-based intervention to promote mental health for mothers experiencing, or at risk of experiencing, postnatal mental health difficulties, and to promote infant wellbeing, using a person-based and co-design approach. To our knowledge, no other study has been published reporting the development of a nature-based intervention for this target population. We found that the needs of our target population could best be met by adapting existing interventions aimed at enhancing nature connectedness. Undertaking primary qualitative work in this understudied area, and engaging patients and the public throughout the lifecycle of the project thus far, ensured that the intervention was planned and designed with the needs and preferences of target users in mind. We found that engagement with the intervention may be influenced by implementation issues including method of delivery, facilitator stance, characteristics of the group and mode of referral.
We consulted a diverse range of participants in the co-design process, intending to develop an inclusive intervention and reducing the risk of inadvertently perpetuating health inequalities. We found that small adaptations could render the intervention highly inclusive and able to meet the needs of under-served communities. A 2020 survey by the Government Advisor, Natural England, found that people from areas of high deprivation and those from minority ethnic backgrounds are less likely to visit natural spaces.33 This highlights the need for any nature-based programme to ensure accessibility for these populations and to avoid situations in which those most likely to benefit are the least likely to access the intervention.
During the design phase, we used qualitative findings and existing nature connectedness theory to determine the intervention’s key content, features and guiding principles. In doing so, we identified that many of the needs of postnatal women were aligned with what forest bathing theory can offer, which we were able to adapt accordingly. Specifically, the focus on noticing nature through the senses and on connecting with nature at a deeper level resonated with mothers and professionals.
Strengths and limitations
To our knowledge, this study represents the first adaptation of a forest bathing-informed nature-based intervention for mother–infant dyads. Mothers sampled were culturally and socioeconomically diverse, and their views were complemented by those of experienced professionals and practitioners. The use of person-based and co-design methodologies allowed a robust and methodical approach to planning, designing and creating the intervention. The lead author was present at all focus groups, co-design meetings and patient and public advisory meetings, allowing an overview of information being gathered. However, this may have introduced a social desirability bias, with potentially more favourable opinions being expressed to support the researcher. To mitigate this insofar as possible, we took care to welcome all views, whether in support of or against the proposed intervention. There was also the potential for self-selection bias, with those already predisposed to nature-based approaches being more likely to participate in focus groups. We conducted some focus groups with existing members of established groups unrelated to nature, in an attempt to minimise this.
Future research
Evidence-based, theory-based, person-based, and co-design approaches will continue to inform the next stages of development and evaluation of the prototype intervention. We plan for this to undergo feasibility testing using a mixed-methods approach, and ultimately evaluation of effectiveness and cost-effectiveness. Further research into similar nature-based interventions for fathers or co-parents may potentially increase access for all parents in the future.
Conclusions
Many women facing postnatal mental health difficulties are currently under-supported, including those from minority ethnic groups or those facing additional socioeconomic challenges and health inequalities. New and inclusive approaches to supporting the mother–infant dyad and wider family are, therefore, required. These approaches should be developed using systematic methods, which prioritise the needs and preferences of the intended users. This article provides an example of how in-depth qualitative research and co-design processes can be applied to plan and design a nature-based intervention for mothers and infants, to promote postnatal mental health. Our research activities determined that the needs of our population were optimally met by tailoring existing nature-based interventions. Mothers from under-served groups, many of whom have less access to nature than other demographic groups, have shaped the resulting intervention, which is ready for further evaluation.
Data availability statement
Data are available on reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
Ethical approval was granted by the University of Bristol Faculty of Health Science Research Ethics Committee (ref: 10105) in January 2022. All methods were carried out in accordance with relevant guidelines and regulations. A participant information sheet was provided to all participants, detailing the aims for the study and what taking part would entail. They had at least 24 hours to consider the information and ask questions. Participants were made aware of their right to withdraw from the study at any time without providing a reason. Those who wished to take part signed a consent form prior to the focus group starting. After each focus group, participants were reminded of the sources of support listed on a ‘debrief sheet’. They were thanked for their participation and offered a £10 voucher as a token of appreciation.
Acknowledgments
We sincerely thank the numerous individuals, including many mothers of young babies with lived experience of perinatal stresses, who contributed their time and energy so generously to this research. We also wish to thank the nature-based practitioners and healthcare practitioners for sharing their wisdom during the co-design process, and the charity providers and organisations who supported our recruitment activities. Warm thanks to our wider research team, including Lucinda Stanton, Rissa Mohabir, Ruth Nortey, Sherien Elsheik, and Rachel Hobbs, for their help with recruitment (LS, RM, RN and SE), co-facilitation of focus groups (RM and RN), and perspectives on analysis. We also thank Dr Alan Kellas for his generous guidance and support, David Woodley for his invaluable advice on Patient and Public Involvement, and Lucy Jones and Dr Samantha Walton for their thought-provoking perspectives on the work.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @DrChrisBarnes
Contributors KH conceived the idea for the research and designed the study in collaboration with JE, CB, KMT, LD and MW and the wider research team above. KH and RB identified and recruited participants, alongside members of the research team acknowledged above. KH organised and guided the focus groups, with RR, RB, MW and LD as co-facilitators, as well as members of the research team acknowledged above. KH, RB and RR conducted the initial data analysis and analysed the codes to develop themes. This was overseen by KMT, CB and JE. KH drafted the manuscript with initial input from RR, RB and CB. All authors participated in the editing of this manuscript and approved the final version for publication. KH is the guarantor.
Funding This work was supported by an NIHR Academic Clinical Fellowship for KEH (award reference ACF-2020-25-015) and Avon and Wiltshire Partnership NHS Trust NIHR Research Capability Funding awarded to KH (award reference RCF 21-22-015).
Competing interests LD co-founded ‘The Human Nature Project’, which offers free forest bathing sessions to people in Bristol to support wellbeing. It is Big Lottery funded with a Reaching Communities grant. The running and evaluation of this project provided important insights which aided the development of the intervention reported in this study. MW is a project manager of Bluebell Care Trust. Following the co-design of the intervention described in this study, Green Social Prescribing funding was awarded to Bluebell Care Trust to pilot the prototype intervention. LD and MW were not involved in data analysis beyond sharing perpectives on the findings afterwards. The other authors declare no competing interests.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.