What is the potential of Norwegian Outdoor Life Tradition

(Friluftsliv) in the Maintenance phase (III phase) of Cardiac

Rehabilitation?

A literature review with emphasize on selected theories and empirical

studies.

Supervisor: Prof. Yngvar Ommundsen Norwegian School of Sport Sciences

Gunnar Gunnarsson European Master in Health and Physical Activity Norwegian School of Sport Sciences 2008

2

ABSTRACT:

Background: In Norway, as in the rest of the world there is a high

prevalence of cardiovascular diseases (CVD). The main risk group of CVD

is elderly people, and their proportion in the society is growing. Due to

increased knowledge and new technology, there is an increasing survival

rate after cardiac events, creating a growing need for Cardiac Rehabilitation.

However, due to economical and organizational reasons, the rehabilitation

period at hospital and rehabilitation clinics is shortening. This diminishes

the chances that patients adapt to a new lifestyle during rehabilitation, and

they are therefore in danger of abandoning the active lifestyle when

returning back to their home.

Norway has a tradition for outdoor life, called “Friluftsliv”, which is highly

valued and is a popular form of recreational activity. Friluftsliv (Norwegian

outdoor life tradition) consists of dwelling and being physical active in

natural environment. Friluftsliv has developed through the years in a blend

with the Norwegian culture and identity. Together with its pedagogic and

mentoring tradition, Friluftsliv seem to represent an interesting context of

experience and activity in terms of cardiac rehabilitation.

Aim: The main aim of this literature review is to examine the health effects

of participating in Friluftsliv. To this end I search out for the health potential

of Friluftsliv for patients who return back home from rehabilitation clinics,

e.g. during the Maintenance phase of Cardiac Rehabilitation in Norway.

3

Method: There is a lack of studies in Friluftsliv focusing on the health

effects. Hence, it was necessary to also build upon relevant literature from

the fields of Physical Activity and Health in general, and upon Agriculture

and Landscape Architecture (“Nature and Health”), when examine the

health potential of Friluftsliv. The literature review is focused on published

evidence based research identified in PubMed and Cochrane, plus

publications and reports from The Swedish Agricultural University, and

from the European Cooperation in the field of Scientific and Technical

Research (COST).

Conclusion: Friluftsliv seems able to not only support involved patients’

physical and psychological development, but also their social development.

With its own tradition of pedagogy, mentoring and its cultural heritage,

Friluftsliv can be a good alternative in Cardiac Rehabilitation in Norway.

Theoretical and empirical insight from the fields of Physical Activity and

Health and from “Nature and Health” adds validity to this conclusion.

Keywords: Friluftsliv, outdoor life, leisure time activities, outdoor

recreation, cardiac rehabilitation, occupational therapy, horticulture therapy,

Ecopsychology, public health intervention, community-based rehabilitation.

4

TABLE OF CONTENTS:

1 INTRODUCTION: ................................................................................7

2 THEORETICAL AND EMPIRIC BACKGROUND .........................10

2:1 CARDIOVASCULAR DISEASES:...........................................................10

2:1:1 Mental health: ..........................................................................13

2:1:2 Cardiac Rehabilitation: .............................................................14

2:1:3 Cardiac Rehabilitation and Physical activity: ............................14

2:1:3:1 Development of Cardiac Rehabilitation: ............................17

2:1:3:2 Rehabilitation duration and adherence: ..............................18

2:1:3:3 Social support and community settings: .............................20

2:2 NORWEGIAN OUTDOOR LIFE TRADITION (FRILUFTSLIV): ..................21

2:2:1 Development of Friluftsliv and its role in personal and social

development......................................................................................23

2:2:2 Friluftsliv – instrumental approach: ..........................................25

2:2:3 How people relate to Friluftsliv: ...............................................27

2:2:4 Mentoring pedagogy in Friluftsliv: ...........................................28

2:2:5 Friluftsliv phenomenology: ......................................................31

2:2:6 The potential of Friluftsliv in a rehabilitation setting: ...............33

2:2:6:1 Physical Activity and Health: ............................................33

2:2:6:2 ” Nature and Health”: ........................................................35

2:2:6:2:1 Ecopsychology: ..........................................................36

2:2:6:2:2 Horticulture therapy (HT): ..........................................37

3 AIMS OF THESIS:..............................................................................38

5

4 METHOD:............................................................................................41

4:1 SEARCH METHOD: ............................................................................41

4:1:1 Inclusion and exclusion criteria: ...............................................42

4:2 LIMITATION: ....................................................................................42

5 THE POTENTIAL OF FRILUFTSLIV IN CARDIAC

REHABILITATION:..............................................................................44

5:1 THE BENEFITS OF FRILUFTSLIV: ........................................................44

5:1:1 Physical benefits of Friluftsliv: .................................................45

5:1:2 Psychological benefit of Friluftsliv: ..........................................46

5:1:3 Friluftsliv in a rehabilitation setting: .........................................47

5:2 PHYSICAL ACTIVITY AND HEALTH:...................................................48

5:3 “NATURE AND HEALTH”: .................................................................50

5:3:1 Ecopsychology: ........................................................................51

5:3:2 Horticultural Therapy ...............................................................54

5:3:2:2 Viewing natural scenes: .....................................................57

5:3:2:3 Being in natural environments: ..........................................58

5:3:3 The use of nature in rehabilitation: ...........................................59

6 SUMMARY..........................................................................................61

6:1 “NATURE AND HEALTH”: .................................................................62

6:1:1 Therapeutic work in “Nature and Health”: ................................63

6:2 FRILUFTSLIV AND HEALTH EFFECTS: .................................................64

6:2:1 The use of Friluftsliv in rehabilitation setting: ..........................65

6

6:3 WHAT IS THE POTENTIAL OF FRILUFTSLIV IN CARDIAC

REHABILITATION?..................................................................................66

6:4 THE LIMITATIONS OF THIS THESIS: ....................................................69

6:5 FURTHER RESEARCH: .......................................................................70

7 CONCLUSION ....................................................................................72

REFERENCE LIST................................................................................73

LIST OF TABLES:.................................................................................83

LIST OF FIGURES:...............................................................................84

7

1 Introduction:

In Norway as in the rest of the world there is a high prevalence of

cardiovascular diseases (CVD) and is the number one reason for early death.

The main risk group of CVD is elderly people and their proportion in the

society is growing. Reports are also showing increasing incidences of CVD

at adulthood. For both groups the main risk factors are inactivity and

overweight, and studies show that these two risk factors are on the increase

in modern society. This result in a growing need for Cardiac Rehabilitation

(CR). Due to economical and organizational reasons the rehabilitation

period at hospital and rehabilitation clinics is shortening. This diminishes

the chances that patients adapt to a new lifestyle during rehabilitation, and

they are therefore in danger of abandoning the active lifestyle when

returning back home. Also, the long distances to rehabilitation clinics in

Norway makes this even more likely to happen.

The Norwegian Outdoor Life Tradition, or Friluftsliv is highly valued and is

a popular form of recreational activity in Norway. Friluftsliv consist of

dwelling and being physical active in natural or near natural environment.

Friluftsliv has developed through the years in a blend with the Norwegian

culture and identity. Together with it’s pedagogic and mentoring tradition

makes Friluftsliv interesting in terms of rehabilitation. The aim of this thesis

is to do a literature review in order to get a closer look at the potential of

Friluftsliv when patients return back home from rehabilitation clinics e.g.

the Maintenance phase or phase III of Cardiac Rehabilitation in Norway.

8

Friluftsliv is included in health’s “White papers” of the Norwegian state and

is also popular as a method in rehabilitation clinics. Most of the studies in

Friluftsliv focus on pedagogic, cultural heritage and tourism, but there are

only few Friluftsliv studies focusing on the health effects of dwelling, or

being physically active in nature. Therefore by including literature of other

related professions, like the field of Physical Activity and Health and the

field of Agriculture and Landscape architecture, it seems warranted to

examine the potential of Friluftsliv.

This field of Agriculture and Landscape Architecture, which focus on the

health effects of nature, have I chosen to call “Nature and Health”. The main

contribution comes from Ecopsychology, with the active and holistic view

of the human-nature relationship. Ecopsychology emphasizes direct

experience of nature by being bodily active in contact with nature. The

studies focuses on the practical work in Ecopsychology, and examines the

health effects of working at farms and out in the countryside. The most

common therapeutic form of Ecopsychology is Horticultural Therapy (HT),

which ranges from the cultivation of plants to the appreciation of landscape.

In a rehabilitation setting, the results from HT studies are helpful when

working with people in need for rehabilitation, people with different

physiological and psychological disabilities, mental illness and mental

fatigue. The vast majority of the Friluftsliv activities, as in HT concern

direct contact between humans and natural environment. Therefore HT is of

9

interest when examining the potential of Friluftsliv in a rehabilitation

setting.

Figure 1 includes the fields that are examined in this thesis to illustrate the

potential of Friluftsliv in Cardiac Rehabilitation in Norway. Chapter 2 will

focus on the status of Friluftsliv and Cardiac Rehabilitation and chapter 5

will examine empirical studies focusing on the health effects when

participating in Friluftsliv, both in leisure time and in a rehabilitation

setting. Supplemented by theory and empirical studies from the fields of

Physical Activity and Health and “Nature and Health”

Figure 1: a “bird’s eye view” of the topics of this thesis, which will be examined to enlighten the potential of Friluftsliv in Cardiac Rehabilitation

Ecopsychology

Horticultural Therapy

Physical ActivityAnd Health

Cardiac Rehabilitation in the Maintenance

phase (Norway)

The potential of Friluftsliv in rehabilitation setting

Friluftsliv: with pedagogy and cultural heritage

“Nature And Health”

10

2 Theoretical and empiric background

2:1 Cardiovascular diseases:

The definition for health by WHO is the following: “A state of complete

physical, mental and social wellbeing, and not merely the absence of disease

or infirmity” (World Health Organization, 1946, p. 303). It emphasize that

it is not enough to cure diseases, but it is important to take into account the

person as a whole. The increasing prevalence of lifestyle diseases (Stene-

Larsen, 2006) will be a burden for both the patient himself and, will also

have a impact on his activity level, mental health, social life, work and

family (Satterfield, Volansky, Caspersen, & Engelgau, 2003). This is taken

into account in the International Classification of Function, Disability and

Health (ICF). The classification system does not only focus on the illness,

but also the patients surroundings, like family, work, leisure activities and

how the patient can manage to function in his own environment.

Worldwide there is an increasing prevalence of chronic diseases, as for

example Type II diabetes, overweight, cardio vascular diseases (CVD).

There are risk factors of these diseases, which are connected to people’s

lifestyle. CVD is globally the number one reason for early death, and two of

the main risk factors for developing CVD are inactivity and obesity. There

is a high level of physical inactivity reported in most industrialized countries

(Pratt, Macera, & Blanton, 1999), including Norway (Søgaard, Bø,

Klungland, & Jacobsen, 2000). In the case of obesity, a recent review

11

reported that the proportion of obese (BMI >30kg/m2) Norwegian adults

has doubled over the last two decades and the situation is described as an

epidemic (Ulset, Rut, & Malterud, 2007).

In Norway, as in the rest of the Western countries, there has been a

reduction in mortality caused by CVD since the 80`. But still in 2004

Cardiovascular Disease was the main cause of death (Figure 1) and Heart

Attack and Stroke were the leading cause of mortality (38%) in Norway

(Nasjonalt Folkehelseinstitutt, 2006)

Cause of death 2004

0 4000 8000 12000 16000

Cardiovascular diseases

Unknown or undefined reason

Cancer

External reason

Pulmonary diseases

Mental illness

Dis

ease

s

Mortality

Mortality

Figure 2: In 2004 Cardiovascular diseases were the main cause of death in Norway (Statistics Norway, 2006)

New statistics from 2006 show that since 2000 there has been 14,6%

increase in hospitalizing caused by CVD. Especially Heart Attack is

increasing (60%). There may be two reasons for this. First, a change was

made in the diagnostic system in 2000, which may have lead to an increase

in registered heart attacks. The other reason is probably reflecting an

12

increase of the group at risk or those who have passed the age of 60. In the

case of Heart Attack, 3 out of 4 hospitalizations where patients older than 60

year old, and 2 out of 3 were men (Statistics Norway, 2007).

In many industrialized countries, the percentage of the population that is

elderly is rising; more people are surviving with conditions that in the past

were fatal, and the prevalence of obesity and a sedentary lifestyle are still

increasing. Due to increasing obesity and sedentary lifestyle, CVD is no

longer a disease only among the elderly but also among the younger

generations. As a result, the number of people living with a chronic illness is

rising rapidly. In Norway there is no registration of how many live with

morbidity as a result of CVD, but in the UK the proportion of people living

with a chronic condition has risen from 21% in 1972 to 35% in 2002. And

17% of those with a chronic condition, have a cardiovascular illness or

hypertension, and approximately 25% have three or more chronic health

problems (Pattenden & Lewin, 2007). This means that more people are in

need of care.

Atherosclerotic cardiovascular diseases are the major cause of death in

middle-aged and older-adults in most western countries, including Europe.

In addition, atherosclerotic diseases, of which coronary artery disease is the

most common, result in substantial disability, a loss of productivity, and

contribute considerably to the escalating costs of health care, especially in

regard to an ageing population. For those patients already identified as

having cardiovascular diseases, the prevention of subsequent cardiovascular

13

events while maintaining adequate physical functioning and independence,

and a good quality of life, are thus major challenges. The results of

EUROSPIRE II (EUROASPIRE II Study Group, 2001) study show that too

many patients are not receiving appropriate therapeutic interventions

(cardiac rehabilitation) or health behaviour advice.

2:1:1 Mental health:

Acute cardiovascular events strongly affect people’s psychological

condition. After a myocardial infarction, about 70% of patients report

fatigue or lack of energy and are concerned about issues like physical

health, return to work, sex life, the possibility of engaging in physical

activities, and of living an enjoyable life in all aspects (Doerfler, Pbert, &

DeCosimo, 1997). Around 15-20% of patients develop signs of depression,

which increases the risk of future cardiac events (Carney et al., 1987; Welin,

Lappas, & Wilhelmsen, 2000), and this is especially the case if there is also

lack of social support (Horsten, Mittleman, & Wamala, 2000). But it has

been shown is several studies that patients, who participate in cardiac

rehabilitation programs, report improvement in well-being, health, and

physical abilities. They also consume less tranquillisers and are less

depressed compared to patients not enrolled in cardiac rehabilitation (Lavie

& Milani, 1997; Milani, Lavie, & Cassidy, 1996).

14

2:1:2 Cardiac Rehabilitation:

The Rehabilitation of cardiac patients, is the sum of activities required to

influence favourably the underlying cause of the disease, as well as to gain

the best possible physical, mental and social conditions, so that they may by

their own efforts, preserve or resume when lost, as normal a place as

possible in community (World Health Organization Expert Committee,

1993).

Cardiac Rehabilitation is by WHO been divided into 3 phases (ibid):

(I) The Acute phases

(II) The Reconditioning phase

(III) The Maintenance phase.

The aims of Cardiac Rehabilitation phase I-III is to facilitate recovery

(Cardiac Rehabilitation) and to prevent future cardiac illness (“secondary

prevention”) (Vanhees, McGee H, Dugmore, Schepers, & Van Daele P,

2002)

2:1:3 Cardiac Rehabilitation and Physical activity:

Therapeutic exercise training is an accepted adjunct to medical therapy in

the management of many chronic diseases. There is evidence that exercise

training leads to potential central (cardiac) and peripheral (skeletal muscle)

beneficial adaptation and can give significant improvements in exercise

tolerance and symptoms in cardiac patients (Belardinelli, Georgiou, Cianci,

15

& Purcaro, 1999). A Cochrane review, confirmed a 27% reduction in all

cause mortality with exercise based cardiac rehabilitation (Jolliffe et al.,

2008) Moreover, systematic physical activity may reduce anxiety and

enhance well-being, and quality of life in these patients (Belardinelli et al.,

1999; Willenheimer, Erhardt, Cline, Rydberg, & Iraelsson, 1998).

In a literature review evaluating the evidence-base of exercise therapy the

authors estimated that physical training has strong or moderate positive

effect on disease pathogenesis in 50% of chronic diseases included in their

review (9 of 18). They documented that physical fitness or strength can be

increased in most diagnoses (strong or moderate evidence in all 18

diagnosis). This shows that good fitness level often means less symptoms

and less disability in daily activities (Pedersen & Saltin, 2006). Also during

maintenance phase (phase III) in Cardiac Rehabilitation, physical training is

favourable because it leads to reinforcement of physical condition and

healthy lifestyle(Vanhees et al., 2002).

Studies in CR show that exercise training of lower intensity can produce

improvements in functional capacity comparable to those produced by

higher-intensity exercise. The lower-intensity exercise is characterized by

greater safety, which is particularly important if exercise sessions are

unsupervised; it causes less discomfort and is more enjoyable, and thus

makes adherence to the recommended exercise regime more likely. Also the

largest benefit in terms of mortality (30-40% reduction), does appear to

accrue though engaging in moderate activity levels. That means activity

16

performed at an intensity of 3-6 MET’s, or like brisk walking for most

adults (Paffenbarger, Hyde, & Wing, 1994). But maybe the most important

is that for each 1 MET improvement in exercise capacity, which is

achievable for most people, is associated with large (10-25%) improvement

in survival (Myers, 2007). And among patients who can safely perform

modest levels of dynamic exercise, the relative safety and substantial value

of low-intensity isometric or resistive (strength training) exercise, have also

been identified (Mathes, 2007). An increasing amount of recent research has

demonstrated that resistance training not only improves both muscular

strength and cardiovascular endurance, but it also has positive influence on

existing conditions such as hypertension, hyperlipidemia, obesity, and

diabetes (Graves & Franklin, 2001).

There are studies showing that exercise-based CR not only increases

exercise tolerance, as maximum oxygen consumption, but also health-

related quality’s of life (HRQoL) (Friedman, Thoresen, & Gill, 1986; Rees,

Bennett, West, Davey, & Elbrahim, 2004). But the patient’s own perception

of health status does also have an influence on clinical outcomes; for

example, the perceived ability to exercise correlates better with the

resumption of work than the objective measurements of exercise capacity

during formal testing. And there is substantial correlation between

perception of health status and returning to usual family and community

activities, and recreational and occupational pursuits. And most importantly,

this perception can be favourably altered by education and counselling

(Friedman et al., 1986)

17

2:1:3:1 Development of Cardiac Rehabilitation:

Initially physical activity in Cardiac Rehabilitation was done outdoors and

the intension was to improve symptoms and physical capacity. For more

than 200 years ago, Herberden observed the beneficial effects in a patient

being advised to saw wood for 30 minutes daily over a 6-month period.

And the first person to introduce exercise systematically into the therapy of

cardiovascular disease was M. Oertel in 1875 (Oertel, 1891). He

successfully treated a patient with overweight and shortness of breath with

an increasing number of steps in a hilly terrain, the “Terrain-Kur”, which

became popular in the ensuing years. In Europe the rehabilitation clinics

were build in rural surroundings, but the tendency now a days is that when

the economy is lagging, the number of rehabilitation centers decline, and are

being replaced by ambulatory programs for outpatients (Mathes &

Halhuber, 1982).

The use of home-based rehabilitation programs is now also more frequently

used after hospital discharge and sometimes even after an ambulatory

program. The disadvantage of home-based rehabilitation is the lack of

contact with other people. That is why specialized sports clubs or

specifically designed heart groups may be better to facilitate long-term

secondary/preventive lifestyle (Vanhees et al., 2002). But the use of home-

based exercise training is safe, and studies even demonstrate higher

symptomatic benefit after combined home- and hospital-based training

18

programs, than in the hospital-based only programs (Piepoli, Flather, &

Coats, 1998).

The exercise training programs for cardiac patients have different level of

supervision, depending on the time after the cardiac event and the risk for

developing cardiac complications during exercise. For patients who are

evaluated at low-risk at 12 weeks after the cardiac event, there is no

supervision needed. The use of electrocardiographic monitoring may be

appropriate during the first 6 to 12 sessions, but being gradually reduced to

once a week or once a month. For patients, which are evaluated at low-risk

12 weeks after index may enter a gymnasium- or community-based program

that offer controlled exercise in an enjoyable environment. This is the ideal

setting to promote self-confidence and risk factor control. Patients have the

opportunity to exchange experiences with each other, and group activities

help them to increase exercise adherence. For low-risk patients, home

exercise rehabilitation is an alternative to supervised group programs

(Moraes & Ribeiro, 2006).

2:1:3:2 Rehabilitation duration and adherence:

Despite the knowledge of beneficial effects of cardiac rehabilitation is there

low adherence to cardiac rehabilitation programmes; in USA it is only 10-

20%, and in UK 14-23%. A study done among patients from one of the

private cardiac hospitals in Norway, Feiringkliniken (n=398) reported

similar percentage. Only 20% of patients after ACB or PCI did participate in

19

cardiac rehabilitation (Grimsmo & Vold, 2005). Further, in addition to this,

in 2006 there was a 16% reduction in rehabilitation capacity in Norway

(Norsk Pasientregister, 2006). This fact together with other difficulties, such

as lack of motivation, financial problems, the need for speedy job

resumption or timetable conflicts also prevent patients from participating in

a CR program - the first step in a lifetime intervention. Moreover, the Health

care systems, insurance companies and financial restrictions have lowered

the payment and reimbursement for CR in the last decades. Consequently,

interventions have shortened from the typical 3-6 months to some weeks, a

time period insufficient to promote long-lasting behaviour change. This was

supported by the EUROASPIRE II study conducted in 15 European

countries. Results showed that there was a large potential and need for

secondary implementation, because many patients have not adopted

appropriate lifestyle or are even not taking the medications as recommended

(EUROASPIRE II Study Group, 2001). By being a long-lasting intervention

with significant financial and personal costs, the maintenance phase (III

phase) carries a significant risk of being quickly abandoned. Patients may be

frequently asymptomatic, previously sedentary and not wishing to do any

lifestyle changes (Ockens, Hayman, & Pasternak, 2002). This often results

in progressive decay in program compliance by the patients. In a study by

Dorn and coworkers, only 13% of the participants were still exercising 3

years after the program started (Dorn, Naughton, & Imamura, 2001). By

being aware of the typical drop-out factors (Ockens et al., 2002) and at the

same time organize the programmes in cooperation with the patients,

20

enhanced compliance can be ensured. Performing the exercise in groups

might be preferred for the maintenance phase as the patient will benefit

from psychosocial support within the group (Donovan & Blake, 1992).

2:1:3:3 Social support and community settings:

There is a good deal of evidence to support the use of peer mentors with at-

risk patients. Peer Mentors can provide social support to decrease heart

disease-related depression, encourage healthy recovery, and decrease

hospital readmission rate (Cashen, Dykes, & Gerber, 2004). And peer

support groups for people 12 months after a cardiac event, led to an increase

in physical activity and smoking cessation (Hildingh & Fridlund, 2003).

Not only do studies show positive results for the patient but also for the peer

mentor/advisor (Whittemore, Rankin, & Callahan, 2000).

Rehabilitation intervention are often implemented at a hospital or

rehabilitation clinic (inpatient/outpatient) but emerging evidence support the

safety and effectiveness of rehabilitation in other settings, such as

community centres and homes (Marchonni et al., 2003). Three decades ago

the World Health Organisation (WHO) introduced the community-based

rehabilitation (CBR) strategy, and in a modern health care system

encouraging cost-effective methods, CBR is becoming an attractive method

because of the low cost profile (Sharma, 2007). The primary aim of CBR is

to provide primary care and rehabilitative assistance to persons with

disabilities, by using human and other resources already available in their

21

communities. In most countries CBR has been connected to the health care

system but most of the success histories comes from where CBR is

connected to private institutions or organisations (Ingstad, 2001). In

Scandinavia it is especially private organisations that has used CBR in their

organisations, adapting the CBR to the ideology of Scandinavian

rehabilitation of normalisation, integration and equal opportunities for

everybody (Ingstad & Eide, 2007).

2:2 Norwegian Outdoor Life Tradition (Friluftsliv):

In this thesis the focus is on rehabilitation and secondary prevention. Hence,

the spectrum of Friluftsliv will be limited to daily activities in local outdoors

environments, or tours varying no more than one day (Norwegian: Nærmiljø

Friluftsliv).

The definition for Friluftsliv used in this thesis is: “Friluftsliv includes both

dwelling and being physically active in the outdoors in leisure time, to

achieve a change of environment and to experience nature”(my translation)

(White Paper no 39 (2000/2001), 2001, p. 11)

This is a vast and open definition, which includes almost every form of

recreation in leisure time but the emphasis is on experiencing nature. The

main issue is to regard Friluftsliv as a simple and ecologically responsible

way of spending time outdoors. It should be practised in an

environmentally responsible way, where ecological diversity is cared for.

The emphasis is also on non-competitive activities and use of non-motorised

22

and simple equipment. The essence is the good balance between man and

nature, as well as the social fellowship between people when spending time

outdoors (Westersjø, 2007).

Norway has a population of 4.6 million people and Friluftsliv has enormous

popularity and is highly valued by the nation. For example, more than 80%

of the Norwegian population practice some kind of outdoor activity at least

10 times a year (Vaage, 2007). And the strongest reason for why people like

to be active in Friluftsliv is experiencing nature and silence, and

contemplation (MMI/FRIFO, 1993). But also the excitement of mastering

Friluftsliv activities, playing and having fun, the social aspect and the

feeling of responsibility when participating in Friluftsliv (Vorkinn M.,

Vittersø, & Riese, 2000). When asked about what is necessary for living a

good and healthy life and what is important for the individual identity, 19

out of 20 Norwegian mentioned “nature”(White Paper no 39 (2000/2001),

2001).

In White Paper nr. 39, the Norwegian government has stated that Friluftsliv

may be the road to a better quality of life (White Paper no 39 (2000/2001),

2001). Also the white paper called “Prescription for a healthier Norway”, an

official document on Norwegian Health Policy, includes Friluftsliv in the

chapter called “To choose a healthier lifestyle” (White Paper no 16

(2002/2003), 2003) Given this common acceptance and statements from the

state of Norway, Friluftsliv is often used as a part of rehabilitation

interventions(Bischoff, Marcussen, & Reiten, 2007). This seems the case

23

despite of the shortage of evidence based studies evaluating the health

effects of Friluftsliv and supporting the use of it in rehabilitation settings.

2:2:1 Development of Friluftsliv and its role in personal and

social development.

Friluftsliv is heavily influenced by the Norwegian culture of harvesting by

Norwegian small –holders but also by English mountaineers, the explorer

Fridtjof Nansen and the Deep Ecology movement of the 1970s. The

Norwegian outdoor tradition is reputed for its holistic approach to living

close to nature. The industrialisation came late to Norway and same with the

urbanisation. There were few landowners and a negligible aristocracy.

Hence huge tracts of common land were accessible to the Norwegian

people. Furthermore, the judiciary which “advanced the land user rather that

the landowner’s right” supported liberal land ownership, which encouraged

people to journeying and harvesting in the woods, mountains and coastal

waters (Tordsson, as cited in (Westphal, 2006, p. 134)). Due to this easy

access to land, gathering berries, fishing and hunting for food this became

one of the main strands of Friluftsliv. And in 1957 the Parliament ensured

by the law: “Friluftsloven” (Outdoor Recreation Act), that Norwegians

could continue travelling through both uncultivated and cultivated land

when accessing recreational areas. This right is called: “Allemannsretten”

(Mytting & Bischoff, 2001). In this way nature became a resource, and

together with Friluftsliv became a part of the Norwegian identity. The

explorer and scientist, Fridtjof Nansen (1861-1930) was one of the most

24

important figures for Norwegian Friluftsliv. Nansen said in a speech to

students in 1921: “In the wilderness, in the loneliness of the forest, with a

view towards the mountains and a distance from glamour and confusion –

this is where personalities are formed.” (Reed & Rothenberg, as cited in

(Westphal, 2006, p. 144)). And in the years after World War I Friluftsliv

was gradually perceived as means of smoothing or even solving society’s

problems such as the moral and physical decay, which was prevalent at that

time. Also, The Norwegian Trekking Association (DNT) started in 1932 to

organize group tours into the mountains, which was increasingly

acknowledged as an effective tool for personal and social development

(Westphal, 2006).

In the 1970s and 1980s came a massive protest against western societies and

its excessive exploitation of natural resources (Breivik, as cited in

(Westphal, 2006)). The modern society was believed to be on a collision

course with nature. Friluftsliv acted as an antidote to this development and

at the same time the “Deep Ecology” emerged. This branch of Ecological

philosophy considers mankind as an integral part of its environment and

gets its inspiration from the philosophical works of Spinoza, Buddhism and

Gandhi (Næss, as cited in (Westphal, 2006)). It was acknowledged that

Deep-Ecological Friluftsliv could offer its followers the opportunity to

acquire life-skills that would “tackle life as such” and transfer systemic

symbolic experience such as “the seasonal rhythm of the year, the rhythm

with landscapes and waves” into holistic skills needed to support the work-

25

life balance of daily routines (Myksvold, as cited in (Westphal, 2006, p.

151)).

In the years after World War II Norway had enormous increase in wealth,

resulting in massive demographic change. For instance in pre-war Norway

only 30% of Norwegian lived in urban or populated areas, whereas this

figure rose to more than 70% by the end of the century. As a result, the

harvesting tradition in rural areas became less important and Friluftsliv

became an outdoor activity for the “urbanized well-to do people from the

cities” in their leisure time (Pedersen, as cited in (Westphal, 2006, p. 155)).

Gradually Friluftsliv lost its political force to improve society (Tordsson, as

cited in (Westphal, 2006)) at the same time the emphasis on deep-ecological

Friluftsliv waned and the strands of Friluftsliv assumed a character of

diversity.

2:2:2 Friluftsliv – instrumental approach:

One of the new dimensions of friluftsliv that grew up was an instrumental

approach, where Friluftsliv was used as an instrument or a pedagogic

method to gain a goal. The working areas were therapeutic groups,

management training, integration of ethnic groups, and personal

development where teamwork (Bischoff & Odden, as cited in (Westphal,

2006)). At the same time Scandinavians (Norway, Denmark and Sweden)

became introduced to the Anglo-American approach of using outdoor life to

personal and social development (Sjong, as cited in (Westphal, 2006)). And

26

some innovative rehabilitation clinics, like Beitostølen Helsesportsenter,

Valnesfjord Helsesportsenter and Atføringssentret i Rauland embraced a

Friluftsliv-inspired therapeutic approach to learning, and they demonstrated

their faith and commitment to Friluftsliv as a worthy educational tool

(Bischoff et al., 2007). But despite its apparently growing acceptance in

Norwegian practice, the instrumental strands of Friluftsliv holds less sway

as a solidly anchored concept compared to traditional Friluftsliv (Westphal,

2006). The Anglo-American personal and social development approach in

outdoor life is far more consolidated and explicit in its practice than the

Norwegian Friluftsliv, which favour the implicit nature of personal social

development-related learning in the context of Friluftsliv (Norwegian: “Det

kommer av seg selv” My translation: It will emerge by itself) (Sjong, as

cited in (Westphal, 2006)). The Anglo-American approach utilises the

outdoors in order to empower the individual (Wood, as cited in (Westphal,

2006)) by focusing on individual competence like `self-development`, `self-

esteem` and `self-efficacy` (Bischoff, as cited in (Westphal, 2006)).

However, this focus on individual competence does not fit so easily into the

Norwegian tradition of Friluftsliv with its value and belief system which is

historically rooted in ego suppressive and lateral thinking through its

egalitarian tradition (Westphal, 2006). In the Friluftsliv’s tradition the

potential as personal and social development instrument lies implicit in it. It

is represented as values that may contribute to human development. It is

possible to explore and utilise these values by selecting the proper

environmental context and the challenge level of the tour. This is labelled

27

“inherent pedagogy”, which is “pedagogy which builds on the ability to see

the inherent qualities, potential and leadings in situations. The pedagogue

has the job to find, pick up and clarify, structure and use situations which in

their own way to communicate the message” (Tordsson, as cited in

(Westphal, 2006, p. 209)).

2:2:3 How people relate to Friluftsliv:

There are 3 different explanation models on how people relate to

Friluftsliv:

• The biological explanation is that we as human beings belong to the

nature. When on hike we fall into a way of living, which we as

human beings are adapted to and in which simple rules of surviving

are ruling. The idea is that as a result of long evolution, we have

developed and adapted to the environment in ways, which has given

us the best possibility of surviving.

• The second explanation, Friluftsliv is a socio-cultural phenomenon,

is most commonly used one in Norwegian studies of Friluftsliv.

According to this view, Friluftsliv is important as a cultural identity

and cultivates important values in Norwegian society. Friluftsliv is

something as we as a nation has sculptured, and we are proud of it.

Friluftsliv is something that is learned, embedded in the culture and

is taught from one generation to the next generation.

28

• The third and last explanation model is more of an

phenomenological perspective in the view of Friluftsliv as a

phenomenon of its own. In this way Norwegian Friluftsliv is

explained from the inside, from how we arrange Friluftsliv in a way,

which is a contrast to our everyday living. And gives us the

possibility to experience life in another way than in our routine life.

This is where phenomenology and Merleau-Ponty enters the scene

with the aspect of studying phenomenon from the inside and

emphasize how the body and our behaviour are important for how

we experience our environment. In Friluftsliv, this can be

understood as every situation has its own possibilities, problems and

pedagogic potential: each situation communicates different message,

which we need to percept and the body will react to by adjust to the

situation (for further details see chapter 2:2.5). In this way,

Friluftsliv can give the feeling of meaningfulness where information,

both conscious and unconsciously, is creative and reflectively

processed. (Tordsson, 1999).

2:2:4 Mentoring pedagogy in Friluftsliv:

Through the years Friluftsliv has developed its own mentoring didactic,

which emphasize group development, situational and process orientated

mentoring. At the same time it focuses on experiencing the nature, both as a

goal on its own but also as a method to influence people with respect to

environmental issues. The Norwegian Friluftsliv mentoring didactic is

29

influenced by gestalt pedagogic, which emphasize experience of wholeness

and relatedness between human being and the environment. The Deep

Ecology movement, which has influenced the development of Friluftsliv,

states that it is not possible to separate nature, consciousness, ego and the

society surrounding us (Sendstad, 1992).

When participating in Friluftsliv, everyone has the change to try out new

roles as for example being a leader or having a role that includes

responsibility. This is not only meant as an individual challenge but also as

a part of a socialisation process in to the group, which they are apart of. In

that way the participants are able to experience how their decision will

affect others and try to predict consequences of their choices. The

participants need to learn from their own decision-making, and the group as

a whole, which will act as a reference on how well it worked. All group

members are considered equal and have experience, knowledge and

motivation, which is important for the group. The knowledge exchange

often happens while being active, but will also happen automatically when

sitting around the campfire. People experience situations differently and will

therefore have different perceptions, which gives the participants the chance

to learn from one another and make each other more conscious of different

angles of view. The campfire is a context that invites participants to dwell,

reflect and share experiences and knowledge. The situation is one where

culture, language and context melt together and includes everybody sitting

around the campfire.

30

One definition of mentoring in Friluftsliv is: “a special process orientated

mediation method, which focus on groups activities and direct contact with

nature” (My translation) (Tordsson, 1993) Mentoring in Friluftsliv is meant

to help people with individual problem solving, and by working in groups

find solutions to challenges. And at the same time by using the context of

Friluftsliv, participants experience joy, teamwork, satisfaction, quality of

life, responsibility for them self and nature.

The goals by mentoring in Friluftsliv have been formulated by Tellnes as:

• Mediate the experience of untouched nature, which can give the

feeling of happiness and quality of life

• Developing deeper connection to the untouched nature, which may

lead to the feeling of responsibility in environmental issues

• Develop the ability of critical analyse of the way of living in modern

society, and be aware of the consequences these may lead to.

• Inspire to change lifestyle; to more simple and “richer” life

• Mediate the individual ability to cooperate, responsibility and to

personal development (Tellnes, 1992)

Friluftsliv has developed some pedagogic principles, like “tur etter evne”

(my translation: adapted tour to ones ability). This means the abilities of the

participations should always be attuned to the demand of the tour. This is

not only meant as to secure a pleasant hike but is an important security

principle which will allow the mentor and the participants to accomplish

their tour goal. The mentor needs to be experienced to accomplish this, and

31

by doing so this will train the participant in their ability to evaluate if they

have the ability to sustain the demands of the nature. By following this

principle of “tur etter evne” (adapted tour to ones ability) there will be a

progression in the ability by the participations by every tour they do. An all

to soon progression will act as guiding and leave out the support that

enables the participant for self-help (Tordsson, 1993).

2:2:5 Friluftsliv phenomenology:

It is a common belief in Norway that Friluftsliv includes everyone who

wants to participate and gives the opportunity to explore nature, not only by

being physically active but also by dwelling and experience the nature.

Friluftsliv is a holistic physical activity, which includes people physically,

psychologically and intellectually. When in nature you need to be active, not

only with your body but also intellectually when experiencing/sensing the

natural environment. Mother Nature can be friendly and hostile, warm or

cold, beautiful or horrific and more, all at the same time. At the same time

as we explore and react to the nature, we do explore our self, how we react

both physically and psychologically. The interaction between people and

nature in Friluftsliv has been explained as:

1. In Friluftsliv we perceive the nature by its different qualities. To

experience the nature is to acknowledge these qualities and accept

them.

32

2. In Friluftsliv we belief that the nature communicates with us. Nature

approaches us as a whole person; our body with it’s capacity to

perceive intellectually and emotionally.

3. We express our understanding of nature by specific bodily action

where we interact with the nature

4. In the fundamentals of Friluftsliv lies the belief that the experiences

in nature add in a valuable way to us as human beings. Not only do

we explore the nature, but also our self in the interaction with nature,

which can give us the experience of happiness as well as contribute

to personal and social development (Tordsson, 1999).

Friluftsliv often seek to the philosophic ideas of Merlau-Ponty, because one

of the key elements of his phenomenology is that it is not possible to

separate body and mind. The one can’t work without the other. Or as

Merleau-Ponty says: “We are our bodies” and for him consciousness was

not just something that goes on in our heads. Rather, our intentional

consciousness is experienced in and through our bodies (Duesund, 1995, p.

31). We experience our body, both as subject when we are physically active

and as object when reflecting about our self. The objective body is visible

when we reflect over the body. Such visibility is not possible without the

subjective body. The body cannot be only subject or object and it is not

possible to make them independent of one another. Merleau-Ponty argued

that it is when being physically active that we come close to experience of

the subjective and objective body at the same time. We are being active

33

without thinking about what we are doing or in other words we forget our

bodies and are just active (Duesund L., 1999).

2:2:6 The potential of Friluftsliv in a rehabilitation setting:

Traditional Friluftsliv includes many different activities as hiking, canoeing,

cross-country skiing, climbing, gathering berries and mushrooms, which

require different levels and type of physical activity. In some form of

Friluftsliv, physical activity is important but in other not so important. In

traditional Friluftsliv experiencing nature has been key elements (Hegge,

1990) and from a phenomenological perspective this is only possible

through the use of body. Physical activity is a important part of Friluftsliv

and the arena is the nature, but there are only few studies of the health

benefits of physical activity and nature in participating in Friluftsliv.

Therefore, will this thesis now introduce the fields of Physical Activity and

Health and “Nature and Health”, but chapter 5 will look closer into the

research question.

2:2:6:1 Physical Activity and Health:

Physical activity is a fundamental means for improving physical and mental

health. But as the case for too many people, has the physical activity been

removed from everyday life, with dramatic effects for health and well-

being. Physical inactivity is estimated to account for nearly 600 000 deaths

per year in the WHO European Region. Tackling this leading risk factor

34

would reduce the risks of cardiovascular diseases, non-insulin- dependent

diabetes, hypertension, some forms of cancer, musculoskeletal diseases and

psychological disorders. In addition, physical activity is one of the keys to

counteracting the current epidemic of overweight and obesity that is posing

a new global challenge to public health (World Health Organization Europe,

2006). Over the past decades, knowledge has been accumulating concerning

the significance of exercise in the treatment of a number of chronic diseases.

Today, exercise is indicated in the treatment of a large number of medical

disorders. In the medical world, it is traditional to prescribe the evidence-

based treatment known to be the most effective and entailing the fewest side

effects or risks. The evidence suggests that in selected cases, exercise

therapy is just as effective as medical treatment – and in special situations

more effective – or adds to the effect (Pedersen et al., 2006).

Table 1: Summary of the health effects associated with physical activity (World Health Organization Europe, 2006)

Condition Effect

Heart disease Reduced risk

Stroke Reduced risk

Overweight and obesity Reduced risk

Type 2 diabetes Reduced risk

Colon cancer Reduced risk

Breast cancer Reduced risk

Musculoskeletal health Improvement

Psychological well-being Improvement

Depression Reduced risk

35

Physical activity has major beneficial effects on many chronic diseases

(Table 1). These benefits are not limited to preventing or limiting the

progression of disease, but include improving physical fitness, muscular

strength and the quality of life. The strongest evidence indicates that the

greatest benefit of physical activity is in the reduction of CVD risk. Inactive

people have up to twice the risk of heart disease of active people. Physical

activity also helps to prevent stroke and improves many of the risk factors

for CVD, including high blood pressure and high cholesterol (World Health

Organization Europe, 2006).

2:2:6:2 ” Nature and Health”:

One of the main issues in the Norwegian definition of Friluftsliv is

experiencing nature, and surveys conducted in Norway show that this is one

of the main reason why people join Friluftsliv. For the purpose of this paper,

nature is defined as an organic environment where the majority of

ecosystem processes are present (e.g. birth, death, reproduction,

relationships between species. This includes the spectrum of habitats from

wilderness areas to parks in urban environment.

To get closer look at the interaction between human beings and nature, and

health benefits of nature will the thesis now turn to Ecopsychology and

Horticultural Therapy. Ecopsychology is more the theoretical and the

philosophical background and Horticultural Therapy is the practical

36

application of how plants in healing garden and landscape in more natural

environment, can benefit the human health.

2:2:6:2:1 Ecopsychology:

“Human sanity requires some less-than-obvious connections to nature as

well as the necessity for food, water, energy, and air. We have hardly begun

to discover what those connections may be....” (Sherpard and McKinley, as

quoted in (Fisher, 1999, p. 2)).

Ecopsychology can be described as a synthesis between ecology and

psychology, placing human psychology in an ecological context, and

mending the divisions between mind and nature, humans and earth. A

fundamental concept for Ecopsychology is that it is psychologically

damaging for humans to live disconnected from their ecological context, as

most of us do in contemporary urban industrial cultures. Nature is not

supposed to serve humans instrumental purpose and be separated from us

human beings (Schroll, 2007). Ecopsychology emphasizes direct experience

of nature by being bodily active in contact with nature. The Ecopsychology

elevates phenomenology as a useful philosophical foundation for thinking

about the connection or disconnection between humans and their ecological

context (Fisher, 1999).

Theodore Roszak was the first one to use the term Ecopsychology and

defined it as:

37

1) The emerging synthesis of ecology and psychology.

2) The skilful application of ecological insights to the practice of

psychotherapy.

3) The discovery of our emotional bond with the planet.

4) Defining “sanity” as if the whole world mattered. (Roszak, 1992)

2:2:6:2:2 Horticulture therapy (HT):

Most of the studies concerning nature health effects, which are referred to in

this thesis is originated from Horticulture therapy. HT is defined as “a

process utilizing plants and horticultural activities to improve social,

educational, psychological and physical adjustment of persons thus

improving body, mind, and spirit of people.” (Relf, 2005, p. 3).

Traditionally has Horticulture therapy been associated with plant cultivation

as a tool of occupational therapy, but nowadays a broader definition is

recognised, ranging from plant cultivation to appreciating landscape

(Braastad & Bjørnsen, 2006). Such therapy is used in rehabilitation and

vocational centres, youth outreach programs, nursing homes and senior

centres, hospitals, hospices, war veteran centres, homeless shelters,

penitentiaries, mental health facilities, schools, community gardens, and

botanic gardens. In cases when non-professional therapists lead these

activities, they are considered as activities with a therapeutic value.

38

3 Aims of thesis:

There is a high prevalence of cardiovascular diseases (CVD), not only in

Norway but also in the rest of the world. The main risk group of CVD is

elderly people and their proportion in the society is growing, which means

increased incidence of CVD. Reports are also showing increasing

incidences of CVD at adulthood. For both groups, the main risk factors are

inactivity and overweight, and studies show these two risk factors are on the

increase in modern society. And together with higher survival rate, results in

a growing need for Cardiac Rehabilitation (CR). Due to economical and

organizational reasons, the rehabilitation period at hospital and

rehabilitation clinics is shortening. This diminishes the chances that patients

adapt to a new lifestyle during rehabilitation, and they are therefore in

danger of abandoning the active lifestyle when returning back to home.

The distance from south to north in Norway is the same as the distance from

Oslo, the capital of Norway, to Rome in Italy. And due to long distances to

hospitals and rehabilitation clinics there is a need for activity-

form/method/intervention in the home community of the patient. Since

Friluftsliv is a widespread form of physical activity in Norway and is highly

valued both by the state and the population of Norway it might have an

unrealised potential when it comes to be included in cardiac rehabilitation in

Norway. Hence, the aim of this thesis is to conduct a literature review to

examine the potential of Friluftsliv to be used as a method in Cardiac

rehabilitation. To get a closer look at the potential of Friluftsliv, studies

39

focusing on health benefits of Friluftsliv will be included, supplemented

with studies from the fields of Physical Activity and Health and “Nature and

Health” (figure 3).

Given that the short in-hospital period is beneficial for the patient but does

not give the patient enough time to adapt new lifestyle. Moreover, it is hard

for the patient after in-clinic rehabilitation to keep on exercising on his or

her own. That is why this thesis will focus on the Maintenance phase (Phase

III) in rehabilitation and try to discover if Friluftsliv can play a role in this

phase of the rehabilitation after Cardiovascular Diseases.

Figure 3: studies focusing on the health benefits of nature and physical activity are included to enlighten the potential of Friluftsliv in Cardiac Rehabilitation

Ecopsychology

Horticultural Therapy

Physical ActivityAnd Health

Cardiac Rehabilitation in the Maintenance

phase (Norway)

The potential of Friluftsliv in rehabilitation setting

Friluftsliv: with pedagogy and cultural heritage

“Nature And Health”

40

The research question is:

What is the potential of Norwegian Outdoor Life Tradition (Friluftsliv)

in the Maintenance phase (III phase) of Cardiac Rehabilitation?

41

4 Method:

4:1 Search method:

This thesis is based on literature review of studies related to cardiac

rehabilitation, Friluftsliv, Ecopsychology and Horticultural Therapy. My

interest is on how Friluftsliv can been used in the health care sector. There is

almost non-existing literature or studies on the health effects of participating

in friluftliv1. Therefore I found it necessary to search for evidence-based

research from Agricultural and Landscape Architecture studies. Both in

Friluftsliv and Agricultural studies, the nature is as an arena and there are

published high quality studies in Horticulture therapy. I have searched for

published literature on Pubmed and Cochrane but it has also been useful to

search for work on www.google.com and http://scholar.google.no/. In

search for literature on databases I used the following search words:

Friluftsliv, outdoor life, leisure time activities, outdoor recreation, cardiac

rehabilitation, comprehensive cardiac rehabilitation, horticulture therapy,

ecotherapy, Ecopsychology, rehabilitation intervention, community-based

rehabilitation and health promotion in community setting. I have also

searched for thesis publications from the universities of most relevance. In

this case for Friluftsliv, it has been Norwegian, Swedish and Danish

universities of sports. In the case of Ecopsychology and Horticultural

1 In order to get a closer look at the area of this thesis I participated in workshops focusing

on Cardiac Rehabilitation (www.feiringklinikken.no) and Friluftlsiv and Mental health

(www.nakuhel.no)

42

Therapy, has publications and reports from The Swedish Agricultural

University, and the European Union project COST Action 866: Green Care

in Agriculture, been a helpful source.

4:1:1 Inclusion and exclusion criteria:

Inclusion criteria:

• Published literature in scientific journals

• Thesis published by universities in the area of Physical Activity and

Health, Ecopsychology and Horticulture Therapy.

• Studies with adult participants

• Studies focusing on rehabilitation or secondary prevention after

cardiovascular diseases or their risk factors.

Exclusion criteria:

• Theoretical and empirical studies conducted on Wilderness therapy

and Adventure therapy, as these therapy forms of outdoor life

usually are a trip done over 2-4 days or more. The focus in this thesis

is on daily activities in nearby natural or near natural environment.

4:2 Limitation:

This thesis search for theories and empirical studies from 4 different areas:

physical activities and health, Friluftsliv (Norwegian Outdoor Life

Tradition), Ecopsychology and Horticulture. Comparing and using studies

from different technical perspective is a challenging task. I have tried to be

43

true to both the aims of this thesis and of each of these areas, while at the

same time be open for new evidence based research, which might add to the

knowledge of Friluftsliv in Cardiac Rehabilitation.

44

5 The potential of Friluftsliv in Cardiac Rehabilitation:

More than 80% of the Norwegian population practice some kind of outdoor

activity at least 10 times a year (Vaage, 2007). The government has stated in

a White Paper nr. 39 that Friluftsliv may be the road to a better quality of

life (White Paper no 39 (2000/2001), 2001). And Friluftsliv is regarded as a

popular method in rehabilitation clinics and as a tool to promote physical

activity in public health interventions. This is a paradox, because little

research evidence exists supporting directly that Friluftsliv promote better

health.

5:1 The benefits of Friluftsliv:

In traditional Friluftsliv, nature is considered as a partner and not just as a

background for one’s recreational activities. The arena is commonly remote

wide-open nature, but with increased urbanisation there is increasing

utilisation of nearby nature areas for recreational purpose. The strongest

reason for why people like to be active in Friluftliv is experiencing nature,

experiencing silence, excitement, mastering, play and having fun,

responsibility, social aspects (Vorkinn M. et al., 2000) and contemplation

and peace (MMI/FRIFO, 1993). Participating in Friluftsliv has not only a

physical component but also involves the possibility of improving

psychological and social wellbeing (Table 2).

45

Table 2: The benefits of Friluftsliv on physical, psychological and social well-being (White Paper no 39 2000/2001, 2001)

Category of health Benefits of Friluftsliv

Physical well-being

• Physiological improvement (endurance, strength, motor skills)

• Loss of weight • Prevention of illnesses and injuries

Psychological wellbeing

• Experience of nature and culture • Reaching or overcoming ones individual boundaries • Silence, (self-) reflection, room for philosophy

Social wellbeing • Experience • Interacting and sharing with others

5:1:1 Physical benefits of Friluftsliv:

There are only few studies, which have focused on the physiological

benefits of Friluftsliv, but two are worth mentioning. Both of them deal

with participants, which were tested both pre- and post-hunting season. The

first study concluded, after comparing result based on interviews and tests

of pulse and cholesterol from the test group (n=22) and the control group

(n=16), the increased activity level during preparing for and under hunting

season, had positive effect on the physiological health of the participations

(Okstad, 1994). The other study showed that the participants (n=22) had a

significant increase in VO2 max, or 46,81 ml/kg pr. min. from pre-hunting

season compared to post-hunting season, 48,21 ml/kg pr. min. (Kleiven &

Bekkevold, 1994).

Given that physical activity is a part of the definition of Friluftsliv, it is

natural to look at research studies on the health benefit of physical activity.

And evidence based research show that physical activity has diverse

46

beneficial physiological effects to the muscle- and skeleton system,

cardiovascular system and energy metabolism(Pedersen et al., 2006). I will

come back to this in 5:2.

5:1:2 Psychological benefit of Friluftsliv:

It is well known that moderate physical activity improves mental health like

the feeling of being calm, relaxed and improved cognitive functions

(Martinsen, 2004) (Moe, Retterstøl, & Sørensen, 1998). When speaking of

psychological benefits of Friluftsliv, this has not been studied in great detail.

However, there are some studies which point to psychological benefits of

Friluftsliv. A study conducted back in 1994 indicated that the everyday level

of mental distress was a lot higher for inactive people in comparison to

active participants in Friluftsliv (Ingebrigtsen, 1994). Further, in a study

published in 2002, only 30% of the participants who did exercise training

reported positive psychological health effects of their participation

compared to 60% of those who where active in Friluftsliv (Myrvang, 2002).

In Sweden, where Friluftsliv has similar status and popularity as in Norway,

a study with 10.000 participant was conducted on how leisure time

activities, work, place of residence, economy and their social network

influenced their quality of life (Norling, 2001). Results from the study

showed that involvement in leisure time activities correlated strongly with

subjective evaluation of quality of life. And participants placed Friluftsliv as

second most important leisure time activity (60%). In Norway, several

47

projects has been conducted in which Friluftsliv have been used as a method

with the objectives of increased physical and psychological health. These

projects have been argued to be successful, but studies with evaluation of

the outcome has not been conducted (Bischoff et al., 2007).

5:1:3 Friluftsliv in a rehabilitation setting:

As mentioned earlier Friluftsliv is often used at rehabilitation clinics as a

method in a comprehensive rehabilitation in the case of as obesity,

orthopaedic and amputation, rheumatism, mental disorder and

cardiovascular diseases (Bischoff et al., 2007). Further, the fruitfulness of

using Friluftsliv has been supported by showing that Friluftsliv activities in

a rehabilitation setting, help patients with Rheumatism mastering their

perception of pain (Hobbelstad, 2004). Studies also indicate that Friluftsliv

may be a good alternative when working with patients dealing with

challenges of modern society (Bjørnå, 2005) or overweight (Marcussen,

2006). Further, for patients with mental disorders has outdoor life as

walking/ light tour been shown to be a good alternative to exercise training

in particular, because it results in lower drop out rate compared to jogging

(Martinsen, 2000) and increases social capacity (Eikenes, Gude, Hoffart,

Strumse, & Aarø, 1999).

48

5:2 Physical Activity and Health:

Physical activity is an important part of Friluftsliv and studies show that

physical activity has beneficial effects on both physical and psychosocial

health. Regular physical activity increases the exercise capacity and the

degree of change depends primarily on the initial stage of fitness and

intensity of training. The training increases exercise capacity by increasing

both maximal cardiac output and the ability to extract oxygen from the

blood. And these physiological benefits of a training program can be

classified as morphologic, hemodynamic, and metabolic (Table 3).

Table 3: Physiological adaptations to physical training in human (Perk J et al., 2007)

• Hemodynamic adaptations: Increased cardiac output

Increased blood volume

Increased en-diastolic volume

Increased stroke volume

Reduced heart rate for any submaximal workload

• Metabolic adaptations: Increased mitochondrial volume and number

Greater muscle glycogen stores

Enhanced fat utilitzation

Enhanced lactate removal

Increased enzymes for aerobic metabolism

Increased maximal oxygen uptake

• Morphologic adaptations Myocardial hypertrophy (likely only in younger

individuals)

49

For patients with heart disease, the most important physiological benefit of

training occur in the skeletal muscle. That is the metabolic capacity of the

skeletal muscle is enhanced through increases in mitochondria volume and

number, capillary density, and oxidative enzyme content. These adaptations

all together, enhance perfusion and the efficiency of oxygen extraction. In

addition, exercise training has positive influence on the cardiovascular risk

profile (Table 4) and a improvement in both insulin sensitivity and

endothelium function. Recent studies also suggest that programs of regular

exercise have favourable effects on plasma concentrations of inflammatory

risk markers like C-reactive protein and homocysteine (Myers, 2007).

Table 4: Changes in risk factors influenced by exercise training (Perk J et al., 2007)

Empirical studies show that exercise-training result in both lower morbidity

and mortality, but there are also other benefits of exercise training. Those

who get exercise cardiac rehabilitation, have higher event-free survival rate

and a lower hospital readmission rate compared to the controlled

• Decrease in blook pressure

• Increase in high-density lipoprotein cholesterol

level

• Reduction in plasma inflammatory risk markers

(C-reactive protein, homocysteine)

• Augmented weight reduction efforts

• Psychological effects:

Less depression

Reduced anxiety

• Improved glucose tolerance

• Improved fitness level

50

group(Belardinelli et al., 2001). But for more empirical studies on the

outcome of exercise training in cardiac rehabilitation go to chapter 2:1:2.

5:3 “Nature and health”:

As stated in the Norwegian definition of Friluftsliv, nature is an important

part of Friluftsliv: “Friluftsliv includes both dwelling and being physically

active in outdoors environment in leisure time, to achieve a change of

environment and to experience nature”(my translation) (White Paper no 39

(2000/2001), 2001, p. 11). Here the words “outdoors environment” and

“experiencing nature” have the connection to nature. For the purpose of this

paper, nature is defined as an organic environment including both

wilderness areas and parks in urban environments. Most of the studies in

this field focuses on the benefits of contact with nature in park environments

for urban-dwelling individuals, and explores the potential of contact with

nature for promotion of health. In 1986 WHO published the Ottawa Charter,

which identifies the importance of environments supportive of health. The

charter also states that the inextricable links between people and their

environment represents the basis for a socio-ecological approach to health.

The Charter advocates for protection of natural and built environments, and

conservation of natural resources as essential in any health promotion

strategy. And the central theme has been promotion of health by

maximizing the health value of everyday settings, which includes places

where people live, work and play (World Health Organization, 1986). This

51

includes how people in urban, rural and more out in the countryside areas

relate to their environment.

The idea that contact with nature is good for human health and wellbeing,

has been the subject of research in diverse disciplines such as psychology,

environmental health, psychiatry, biology, ecology, landscape preferences,

horticulture, leisure and recreation, wilderness, and public health policy and

medicine. The central notion is that as well as being totally dependent on

nature for material needs (food, water, shelter, etc.) is the interacting with

nature beneficial, perhaps even essential, to human health and wellbeing

(Maller, Townsend, Brown, & Leger, 2002; Wilson, 1984)

5:3:1 Ecopsychology:

Ecopsychology integrates ecology and psychology. Among its contributions

are the application of psychological principles and practices to

environmental education and action. By also bringing ecological thinking

and the values of the natural world to psychotherapy and personal growth, it

would seem easier to aim for fostering lifestyles that are both ecologically

and psychologically healthy. Most of its practitioners and theorists are based

in the USA, with a growing movement in Australia, South Africa and the

UK. Ecopsychology suggests that there is a synergistic relation between

planetary and personal wellbeing. Although only relatively recently adopted

in modern western society, Ecopsychology is essentially modern

52

interpretation of ancient views of humans and nature held by many

indigenous peoples. Ecopsychologists believe that disconnection from

nature has a heavy cost in impaired health and increased stress (Schroll,

2007).

In Ecopsychology there are 3 different models, which explain the positive

health effects nature has on people:

• The “evolutionary theory” states that, visual patterns of the natural

environment are easiest to interpret, because people use their

involuntary attention (Kaplan & Kaplan, 1989). This form of

attention is preferable and may release negative stress. This

assumption is explained by the brain’s pre-programmed

preparedness to sort out different stimuli in a natural environment,

where man was originally meant to live. The opposite is directed

attention, which occurs when humans are bombarded by information

from the urban, artificial, environment, which has to be sorted out.

This attention requires much energy leading to overloading and

negative stress, i.e. easy distraction, difficulties in planning and

implementing and to feeling of impatience and irritability (Jernberg,

2001).

• The “cultural learning theory”; individuals adapt to the natural

environment where grown up, leading to a preference for familiar

trees and flowers (Relf, 1992). This statement contributed to the

53

formulation of the theory of “the living environment” (Grahn, as

cited in (Söderback, Söderström, & Schälander, 2004, p. 249). This

theory prompted the suggestion that environments should be created

to facilitate memories of competence and experience among people

with dementia.

• The “psycho-evolutionary theory” states that, humans have long

adapted positively to nature for survival, and therefore react with

positive emotional physiological responses when in natural or

nature-related environments (Ulrich, Simons, & Losito, 1991b). This

theory has been proved acceptable through several studies (Ulrich et

al., 1991b; Ulrich, 1981; Ulrich, 2000; Ulrich, 1984).

Many Eco-psychologists have turned to the phenomenology of Merlau-

Ponty as a philosophical source for Ecopsychology. One perspective is that

Merleau-Ponty’s phenomenology can be used to make people aware of their

direct, embodied being in the world. As such, we may well discover more

emotional and/or spiritual experiences of the natural world around us (de

Jonge, 2002). The American Eco-psychologist, Andy Fisher, emphasizes on

being present in our experiences, “…pay attention both to our experience of

nature and to the nature in our experience;…)(Fisher, 1999, p. iv). Fisher

states that modern society “… lack the contexts necessary to bear our pain

and suffering, and so to stay above the healing threshold.”(ibid, p. 299) In

his work he refer to the nature as the context, which can enable healing.

“Bearing pain is always a matter of placing it in a larger context so that it

54

both loses its overwhelming power and is given the space it needs to

move.”(ibid, p. 303).

5:3:2 Horticultural Therapy

Eco-psychologists use different types of practical methods when working

with patients. The most used method is Horticultural therapy, but other

forms comprise Wilderness therapy, Nature-guided therapy and Animal

assisted therapy (Schroll, 2007). The most studied method is Horticultural

therapy. Therefore, studies originating from Horticultural Therapy are

considered here.

Studies from Horticultural Therapy have showed that the experience of

nature affects people differently and is largely depending on their life

situation (Ottosson & Grahn, 1998a). Figure 4 shows that a person in a life

crises is in need for peaceful and non-demanding environments when

processing fundamental questions about his life. At the bottom of the

pyramid is the directed inwards involvement level where mental power is

very weak. The type of physical activity that can be undertaken tends to be

private, like walking, picking berries, or collecting wood a short distance

into the forest, and disturbances are disliked (Ottosson, 2001).

55

Figure 4: The x-axel shows the human need for nature and the y-axel shows humans mental state (Stigsdotter & Grahn, 2002)

Studies done at the Swedish Agriculture university in Alnarp, show that

those green-marked areas who have number of spatial qualities or basic

characteristics (table 5) are generally more popular, more appreciated and is

visited more often than a green-marked area with only one or few of the

basic characteristics (Berggren-Bärring & Grahn, 1995). And the most

valuable and health beneficial for stressed and vulnerable people, is if the

living environments has the basic character of serene, space, wild, rich in

species (plants, trees and animals) and in some cases essence of culture

(Grahn, 2005).

56

Table 5: The eight basic characteristics, which influences the popularity of green areas (Grahn, 1991a)

The eight basic characteristics

Character of the garden room Sketches showing what the garden rooms might look like

1. Serene Peace, silence and care. Sounds of wind, water, birds and insects. No rubbish, no weeds, no disturbing people.

2. Wild Fascination with wild nature. Plants seem self-sown. Lichen- and moss-grown rocks, old paths.

3. Rich in Species A room offering a variety of species of animals and plants.

4. Space A room offering a restful feeling

of “entering another world”, a coherent whole, like a beech forest.

5. The Common A green, open place providing vistas and inviting you to stay.

6. The Pleasure Garden

An enclosed, safe and secluded place, where you can relax and be yourself and also experiment and play.

7. Festive A meeting place for festivity and pleasure

8. Culture A historical place offering

fascination with the course of time

People with access to nearby natural settings have been found to be

healthier overall than other individuals. The long-term, indirect impacts of

nearby nature also include increased levels of satisfaction with one’s home,

one’s job and with life in general (Kaplan et al., 1989). Access to nearby

natural setting means to be in interaction with nature on a daily bases, ether

by viewing or by being in natural environments.

57

5:3:2:2 Viewing natural scenes:

The healing effects of a natural view is increasingly being understood in

stressful situations or environments such as workplaces, hospitals and

nursing homes (Lewis, 1996). In these environments, as well as for people

who work in windowless offices, studies show that seeing nature is

important to people and is an effective means of relieving stress and

improving well-being (Lewis, 1996; Kaplan, 1992a). A study examining

recovery rates of patients who underwent gall bladder surgery found that

those with a natural view recovered faster, spent less time in hospital, had

better evaluation form nurses, required fewer painkillers and had less

postoperative complications compared with those that viewed an urban

scene (Ulrich, 1984). In another study by Ulrich colleagues they compared

physiological effects of different natural and urban scenes on subjects who

had just watched a stressful film. The physiological data measured in this

study, suggests that natural settings elicit a response that includes a

component of the parasympathetic nervous system associated with the

restoration of physical energy (Ulrich, Dimberg, & Driver, 1991a).

Evidence has also been presented to show that even by only watching

nature, results in psychological responses like the feeling of pleasure,

sustained attention or interest, and diminution of negative emotions, such as

anger and anxiety (Rohde & Kendle, 1994).

58

5:3:2:3 Being in natural environments:

Early research found that in the act of contemplating in nature, the brain is

relieved of “excess” circulation (or activity) and the nervous system activity

is reduced (Yogendra, 1958). Experiencing nature can help strengthen the

activities of the right hemisphere of the brain, and restore harmony to the

functions of the brain as a whole (Furnass, 1979).

Kaplan and Kaplan described restorative environments as those settings that

foster recovery from mental fatigue (Kaplan, 1992b). According to their

findings and other studies, restorative environments require four elements:

• Fascination (an involuntary form of attention requiring effortless

interest, or curiosity)

• A sense of being away (temporary escape from one’s usual setting or

situation)

• Extant or scope (a sense of being part of a larger whole)

• And compatibility with an individual’s inclinations (opportunities

provided by the setting and whether they satisfy the individual’s

purpose) (Kaplan et al., 1989; Hartig, Mang, & Evang, 1991).

Empirical, theoretical and anecdotal evidence demonstrates that contact with

nature positively impacts blood pressure, cholesterol, outlook on life and

stress reduction (Kaplan et al., 1989; Ulrich et al., 1991b; Lewis, 1996;

Kaplan, 1992a; Rohde et al., 1994; Hartig et al., 1991; Leather, Pyrgas, &

Lawrence, 1998; Parsons, Tassinary, Ulrich, Hebl, & Grossman-Alexander,

1998). A study from Norway showed that walking in natural environment

59

increased the parasympathetic activation, resulting in lower heart rate and

lower blood pressure. But this was not the case after similar activity in an

urban environment (Laumann, 2004). These outcomes have particular

relevance in areas of mental health and cardiovascular disease, categories

that are set to be the two biggest contributors to disease worldwide by the

year 2020 (Murray & Lopez, 1996).

5:3:3 The use of nature in rehabilitation:

There are many examples that natural environments/green areas are used in

therapeutic activities. The participants are often elderly, people with

different physiological and psychological disabilities, mental illness, mental

fatigue or people in need of rehabilitation. Horticultural therapy is a therapy

form which includes interventions mediated by nature-oriented views and

spaces, such as gardens and everything associated with them, the plants and

material related to them, garden tools and garden occupations performed

among disabled people for healing and for restoring or improving health and

wellbeing or for rehabilitation (Parr, 2005). An outdoor recreation provides

an opportunity to increase quality of life and heighten social interaction, and

thus helps to enhance community spirit and foster a more socially inclusive

society (Scottish Natural Heritage, as cited in (Morris, 2003)). Ryan (1997

as cited in (Morris, 2003)) describes the impact of incorporating therapeutic

gardening into reminiscence work for people with dementia, regaining

mobility, dexterity and co-ordination after a stroke, to regain confidence and

self-esteem.

60

Studies show that interaction with plants and earth enables sensory

stimulation, provides an opportunity to keep warm through activity, and

exposes the body to fresh air. It can also help people gain basic and social

skills, obtain qualifications, rebuild their lives, and maintain or improve

quality of life. It provides something to talk about, a chance for enthusiasts

to impart knowledge, it 'humanises' institutions, provides motivation,

induces aesthetic satisfaction, status and self-esteem (Ryan, as cited in

(Morris, 2003)).

Studies have further shown that recreation in parks, healing gardens and in

natural environments positively influence health. Moreover, it seems that

particularly those with poor general health, benefits the most (Ottosson &

Grahn, 1998b). A study composed on effects of Horticulture Therapy on

mood and heart rate in patients participating in an inpatient

cardiopulmonary rehabilitation program, showed significant lower heart rate

and improved mood state after intervention. The study compared patient

educational classes supplemented with Horticulture Therapy, and a group

given only educational classes. They concluded that given that stress

contributes to coronary heart diseases, findings support the role of

Horticulture therapy as an effective component of cardiac rehabilitation

(Wichrowski, Whiteson, Haas, Mola, & Rey, 2005)

61

6 Summary

The objective of this thesis is to study the potential of Friluftsliv as a

method in Cardiac Rehabilitation. The starting point is the high prevalence

of cardiovascular diseases (CVD) not only in Norway but also in the rest of

the world. The main risk group of CVD are elderly people and their

proportion in the society is growing, which means increased incidence of

CVD. Reports are also showing increasing incidences of CVD at adulthood.

For both groups, the main risk factors are inactivity and overweight, and

studies show these two risk factors are on the increase in modern society.

And together with higher survival rate, results in a growing need for Cardiac

Rehabilitation (CR). Due to economical and organizational reasons, the

rehabilitation period at hospital and rehabilitation clinics is shortening. This

diminishes the chances that patients adapt to a new lifestyle during

rehabilitation, and they are therefore in danger of abandoning the active

lifestyle when returning back home. Also, the long distances to

rehabilitation clinics in Norway, makes this even more likely to happen.

Friluftsliv has developed through the years in a blend with the Norwegian

culture and identity. Also the inherent pedagogic and mentoring didactical

potential of Friluftsliv mixed with deep ecology, makes Friluftsliv

potentially unique in terms of rehabilitation. Friluftsliv is an activity form

and is practised in natural or a near natural environment. Friluftsliv is highly

valued and is a popular form of recreational activity in Norway. Hence, it

seems interesting to look closer at the potential of Friluftliv in CR when

patients return back home, from rehabilitation clinics e.g. the Maintenance

62

phase or phase III of CR. The literature review reveals some Norwegian

Friluftliv studies, showing the potential physiological and psychological

health benefits of practising Friluftsliv. There is however, a lack of good

studies, in particular on the potentially physiological effects of practising

Friluftsliv and on the physiological and psychological benefits of dwelling

in nature. Therefore in including literature of other related professions like

the field of Physical Activity and Health and “Nature and Health” (Figure

3), seem warranted to examine the potential of Friluftsliv.

6:1 “Nature and Health”:

In a attempt to examine the field of “Nature and Health” has this thesis

looked closely into Ecopsychology and empirical studies conducted on

Horticultural Therapy. The main contribution from Ecopsychology in the

scheme of this thesis is the active and holistic view of the human-nature

relationship. The Ecopsychology states, that it is psychologically damaging

for humans to live disconnected from their ecological context. But

Ecopsychology also emphasizes direct experience of nature by being bodily

active in contact with nature. Ecopsychology turns to Phenomenology in

search for a philosophical foundation, and in order to explain the value of

human interacting with their environment (Fisher, 1999). Similar statements

can be found in Friluftsliv, which focus on the interaction between people

and nature. That nature communicates with us, and the experience in nature

has something valuable to give to us human beings (Tordsson, 1999).

63

6:1:1 Therapeutic work in “Nature and Health”:

The studies focusing on the practical work in Ecopsychology examine the

health effects of working at farms and out in the countryside, and on how

animals, plants, and the landscape can be used in recreational or work-

related activities for different patient groups. These studies include

participants such as psychiatric patients, mentally disabled persons, people

with learning disabilities, with burnout problems, people with drug

problems, young people, elderly people, and clients of social services. The

most common therapeutic form is Horticultural Therapy, which ranges from

cultivating plants to appreciation of landscape. Horticultural Therapy (HT)

is the most studied therapeutic form within the context of Ecopsychology.

Although Friluftsliv includes activities with animals, like horse riding, is the

vast majority of the Friluftsliv activities as in HT, concerns direct contact

between humans and natural environment. Therefore HT is of interest when

examining the potential of Friluftsliv in a rehabilitation setting.

Studies on Horticultural Therapy or therapeutic horticultural activities,

reveal that it is possible to relieve stress, improve well-being (Kaplan,

1992b; Lewis, 1996) and elicit restoring physical energy (Ulrich et al.,

1991a) only by viewing natural scenes. Also studies have shown that by

experiencing nature, this can have positive effects on brain function

(Furnass, 1979), cholesterol level, and people’s outlook on life (Hartig et al.,

1991; Kaplan et al., 1989; Kaplan, 1992b; Lewis, 1996; Parsons et al., 1998)

plus lowering heart rate and blood pressure (Laumann, 2004). In the case of

64

rehabilitation after cardiovascular diseases, HT has been helpful in

regaining mobility, dexterity and co-ordination after a stroke. And in order

to help lowering heart rate and to improve mental state in cardiopulmonary

patients (Wichrowski et al., 2005). These results indicate that the natural

environment may have various beneficial effects on cardiac patients.

Peoples need for nature and social activities is different, and is largely

affected by peoples life situation (Ottosson et al., 1998b; Stigsdotter &

Grahn, 2002). In the case of life crises, people need peaceful and non-

demanding environments when processing fundamental questions about

their life. And this can be supported by the Ecopsychologist Andy Fisher

who states that the nature is a good place to start with, in time of a life crises

because: “Bearing pain is always a matter of placing it in a larger context, so

that it both loses its overwhelming power and is given the space it needs to

move.” (Fisher, 1999, p. 303).

6:2 Friluftsliv and health effects:

There are many ongoing Friluftsliv projects both in rehabilitation clinics and

in community settings in Norway (Bischoff et al., 2007). When focusing on

physiological effects of Friluftsliv there are two Norwegian studies where

the participants, showed improvement in pulse, cholesterol level (Okstad,

1994) and VO2 max (Kleiven et al., 1994) post-hunting season as

compared to pre-season.

65

Concerning psychological effects of participating in Friluftsliv, there are

studies showing lower everyday stress level (Ingebrigtsen, 1994) when

participating in Friluftsliv. Also does higher percentage of participants in

Friluftsliv (60 %) rapport positive psychological effects as compared to

those doing exercise training (30 %) (Myrvang, 2002).

Because of the insufficient evidence based research in the field of

Friluftsliv, it is necessary to supplement this discussion of health effects in

Friluftsliv, by seeking knowledge from the field of Physical Activity and

Health. The field of Physical Activity and Health, has reliable studies

showing both psychological and physiological benefits of physical activity

(Pedersen et al., 2006). It is not the aim of this thesis however, to select

which form of activity in these studies aligns to the activity forms of

Friluftsliv. Rather the aim is to acknowledge the impact that physical

activity has on health and quality of life.

6:2:1 The use of Friluftsliv in rehabilitation setting:

Friluftsliv is used in rehabilitation clinics as a method in the case of obesity,

orthopaedic and amputation, rheumatism, mental disorder and

cardiovascular diseases (Bischoff et al., 2007). It helps rheumatism patients

to master their perception of pain (Hobbelstad, 2004), it helps patients to

deal with their mental illness (Bjørnå, 2005) and overweight (Marcussen,

2006). But maybe the most important in the context of this thesis, is that

there is greater adherence to Friluftsliv activities compared to exercise

66

training when patients return back home (Martinsen, 2000), and it helps

people to socialise (Eikenes et al., 1999). This is very important in the III

phase of Cardiac Rehabilitation because patients often stop being physical

active (Dorn et al., 2001) and isolate themselves when returning back from

rehabilitation clinics (Cashen et al., 2004; Claesson, Burell, Birgander,

Lindahl, & Asplund, 2003).

6:3 What is the potential of Friluftsliv in Cardiac Rehabilitation?

The origin to systematic exercise training in Cardiac Rehabilitation was a

outdoor activity done in a hilly terrain (Oertel, 1891). In those days the aim

was to improve symptoms and physical activity, but through the years the

original form of physical activity in Cardiac Rehabilitation, became

forgotten. But in the demanding modern society and in the aim of cardiac

rehabilitation, there might be a place for Friluftsliv not only due to the

physical activity factor, but also due to it’s values and qualities (Tordsson,

2003).

The development of CR shows that in Norway there was a 16% reduction in

available cardiac rehabilitation services in 2006 (Norsk Pasientregister,

2006), and the general development in Europe is that the Health care system

and insurance companies are lowering their payments to CR. Therefore

there is a large potential and need for secondary implementation, plus the

fact that the short period in hospital stay, results in patients finding it

difficult to adopt to an appropriate lifestyle (EUROASPIRE II Study Group,

67

2001). Patient may be frequently asymptomatic or previously sedentary, and

may not wish to change lifestyle (Ockens et al., 2002). Hence, they are

expected to fall back to previous habits when entering the maintenance

phase of CR on the return to their home community. It is necessary to

support these cardiac patients, especially if the patient is in lack of social

support (Horsten et al., 2000) because about 70% of those who experience

myocardial infarction, report fatigue or lack of energy (Doerfler et al., 1997)

and 15-20% of cardiac patient develop signs of depression (Carney et al.,

1987). This can be counteracted by using human and other forms of

resources already available in the patients community, or by organising

Community Based Rehabilitation (Ingstad, 2001). In the Norwegian

settings with long distances and the highly valued outdoor activity form

(Vaage, 2007), Friluftsliv represents a potential resource in cardiac

rehabilitation.

12 weeks after index event, cardiac patients can enter community-based

programs or even do home-based exercise rehabilitation, if they are found to

be at low risk of developing cardiac complications during exercising. But it

is preferable with group setting, because it is ideal to promote self-

confidence and risk factor control. And also, the patients have the

opportunity to exchange experiences with each other (Moraes et al., 2006).

And here Friluftsliv may play a role because an experienced Friluftsliv

leader can selectively use the inherent pedagogy (Tordsson, 2003) of

Friluftsliv together with the principle of “tur etter evne” (my translation:

adapted tour to one’s ability). Together with a wisely chosen hiking tour,

68

which for example may include making campfire, Friluftsliv can act as

instruments in an ongoing process, of not only physical but also personal

and social development (Sjong, as cited in (Westphal, 2006)) of the cardiac

patient (Friedman et al., 1986).

Most of the traditional activities in Friluftsliv are endurance activities, like

hiking, harvesting and hunting, and this thesis has focused on local and

short duration Friluftsliv activities (Norwegian: Nærmiljø Friluftsliv). This

excludes long hiking tours with heavy backpacking, which are probably too

demanding for cardiac patients. By selecting a suitable environment and

following the principle of “tur etter evne” (adapted tour to one’s ability), the

activity’s intensity can be controlled so as to be light to moderate in

intensity. That implies an intensity of 3-6 MET, which can improve exercise

capacity of a cardiac patient comparable to those produced by higher-

intensity exercise. But activity forms at lower intensity are more favourable

because of greater safety, less discomfort, and they are more enjoyable for

the participants (Paffenbarger et al., 1994). A variation in terrain, like in

Terrain-Kurz (Oertel, 1891), the first systematic cardiac exercise program,

will give variation in resistance for the muscles. Studies show that both

dynamic and low-intensity isometric resistive exercises not only improves

muscular strength and cardiovascular endurance, but also has beneficial

influence on hypertension, hyperlipidemia, obesity and diabetes (Graves et

al., 2001; Mathes, 2007).

69

6:4 The limitations of this thesis:

There are always some limitations to every study and this one is no

exception. Most of the studies done in the field of Friluftsliv are

concentrated around pedagogic, cultural heritage and tourism, and only few

studies focus on the health effects of Friluftsliv. Also includes Friluftsliv a

wide variety of activities, and there is a possibility that some of them are not

suitable for use in a rehabilitation setting. Therefore much work needs to be

done on definitions, and discussing the role of Friluftsliv in public health

interventions and rehabilitation.

Another limiting factor is a lack of studies focusing on the health effects of

Friluftsliv. Hence, it was necessary to include studies from other research

areas to be used as part of the framework of this thesis. But including

studies from Ecopsychology, Horticultural Therapy, and from the field of

Physical Activity and Health together with Friluftsliv studies, is a

demanding task. Hence, one runs the danger of mixing together theories and

knowledge with fundamental differences. It is only by critical review and

further studying of this new direction of Friluftsliv, it is possible to examine

synergetic effects of these different research areas.

I have tried to be true to the philosophy of Friluftsliv and use the studies of

Friluftsliv to work on this thesis. But when reviewing Friluftsliv studies it

has to be kept in mind that most of these studies are conducted with few

participants, and have therefore low statistical power.

70

6:5 Further research:

There is a need to expand existing knowledge and seek out new information

and relationships that may increase our understanding of the potential of

Friluftsliv in the field of Cardiac Rehabilitation.

• Work needs to be done on definitions and the objectives of

Friluftsliv when used in a rehabilitation setting

• Research teams within Friluftsliv and in the field of Physical

Activity and Health, need to cooperate and explore further the

physiological and psychological health effects of Friluftsliv

• It would be beneficial for the field of Friluftsliv to cooperate with

agricultural universities to explore more the field of Ecopsychology

and Horticultural Therapy. Friluftsliv has some of its roots in Deep

Ecology, which is related to Ecopsychology and might therefore be

valuable when studying the health effects of Friluftsliv.

• There are already many ongoing Friluftsliv projects both at

rehabilitation clinics and in community settings. But since there is a

lack of qualified research studies in the field of Friluftsliv it is

valuable to coordinate and structure these projects to make it

possible to do evaluation studies with the required quality.

71

• And last but not least there is need for studies that compare the

effects of indoor exercise training and Friluftsliv in Cardiac

Rehabilitation. It is important not only to look at physiological

effects but also on mental health and quality of life.

72

7 Conclusion

In the view of higher survival rate after cardiac events and the increasing

incidence of obesity and inactivity, together with increasing proportion of

elderly in the population, there is a growing need for Cardiac Rehabilitation.

Together with tighter economical framework in the health care system, long

distances in Norway and low adherence to CR, there is a need in the health

care system for new solutions. Hence, to identify new methods and ways on

how to utilise both the human and other available resources in the

communities of Norway, and to include them in the Cardiac Rehabilitation

work, should be regarded important tasks. Therefore, this thesis has taken a

closer look at the potential of Friluftsliv in Cardiac Rehabilitation in

Norway. This potential lays in including activity forms embracing the

inherent qualities and values of Friluftsliv. Participating in Friluftsliv

includes active interaction between human being and the natural

environment, and this may support the physical, psychological and social

development of involving cardiac patients. Friluftsliv can, with its own

tradition of pedagogy, mentoring and its cultural heritage, supplemented by

knowledge from the fields of Physical Activity and Health and of “Nature

and Health”, be a good alternative in Cardiac Rehabilitation in Norway.

73

Reference list

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Belardinelli, R., Paolini, I., Cianci, G., Piva, R., Georgiou, D., & Purcaro, A. (2001). Exercise training intervention after coronary angioplasty: the ETICA trial. J Am Coll Cardiol, 37,pp. 1891-1900.

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List of Tables:

Table 1: Summary of the health effects associated with physical activity

(World Health Organization Europe, 2006) .......................................34

Table 2: The benefits of Friluftsliv on physical, psychological and social

well-being (White Paper no 39 2000/2001, 2001)..............................45

Table 3: Physiological adaptations to physical training in human (Perk J et

al., 2007)...........................................................................................48

Table 4: Changes in risk factors influenced by exercise training (Perk J et

al., 2007)...........................................................................................49

Table 5: The eight basic characteristics, which influences the popularity of

green areas (Grahn, 1991a)……………………………………………….. 56

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List of Figures:

Figure 1: a “bird’s eye view” of the topics of this thesis, which will be

examined to enlighten the potential of Friluftsliv in Cardiac

Rehabilitation......................................................................................9

Figure 2: In 2004 Cardiovascular diseases were the main cause of death in

Norway (Statistics Norway, 2006).....................................................11

Figure 3: studies focusing on the health benefits of nature and physical

activity are included to enlighten the potential of Friluftsliv in Cardiac

Rehabilitation....................................................................................39

Figure 4: The x-axel shows the human need for nature and the y-axel shows

humans mental state (Stigsdotter & Grahn, 2002)..............................55