TMU
Owner
Tarbiat Modares University (TMU) is the owner of HEHP.
0.8
Cite Score 2025
Volume 14, Issue 1 (2026)
Health Educ Health Promot 2026, 14(1): 53-59 |
Back to browse issues page
Article Type:
History
Received: 2026/01/5 | Accepted: 2026/02/16 | Published: 2026/01/29
Received: 2026/01/5 | Accepted: 2026/02/16 | Published: 2026/01/29
How to cite this article
Karazhian E, Davoudi Hasanabad N, Ebrahimi S, Nazemi S, Mazlom S. Effects of Nature-Based Educational Therapy on Treatment Adherence and Exercise Capacity in Ischemic Heart Disease Patients. Health Educ Health Promot 2026; 14 (1) :53-59
URL: http://hehp.daneshafarand.org/article-4-83091-en.html
URL: http://hehp.daneshafarand.org/article-4-83091-en.html
Download citation:
BibTeX | RIS | EndNote | Medlars | ProCite | Reference Manager | RefWorks
Send citation to:
Rights and permissions
BibTeX | RIS | EndNote | Medlars | ProCite | Reference Manager | RefWorks
Send citation to:
1- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Mashhad University of MedicalSciences, Mashhad, Iran
Abstract (578 Views)
Aims: This study evaluated the effect of nature-based therapy on treatment adherence and exercise capacity in patients with ischemic heart disease.
Materials & Methods: This randomized controlled clinical trial was conducted on 58 patients who were randomly assigned to the intervention and control group (n=29 per group). The intervention group participated in a structured nature-based educational program that included guided walking, group discussions, relaxation techniques, and exercise sessions conducted in a natural environment. The control group received routine face-to-face education. Treatment adherence was assessed using the eight-item Morisky Medication Adherence Scale, and exercise capacity was evaluated using the six-minute walk test before and after the intervention. Secondary physiological outcomes, including blood pressure, heart rate, respiratory rate, and oxygen saturation, were also measured. Analysis of covariance was used to compare post-intervention outcomes between groups while adjusting for baseline values.
Findings: After adjusting for covariates, treatment adherence was significantly higher in the intervention group than in the control group (p<0.01). Exercise capacity was also significantly greater in the intervention group than in the control group (p<0.001). Furthermore, the intervention group showed significant improvements in physiological parameters, including lower systolic and diastolic blood pressure, reduced heart rate, and improved oxygen saturation compared with the control group (p<0.05).
Conclusion: Nature-based therapy significantly improves treatment adherence, exercise capacity, and physiological outcomes in patients with ischemic heart disease in the short term.
Keywords:
| | Full-Text (HTML) (30 Views)
References
1. Nedkoff L, Briffa T, Zemedikun D, Herrington S, Wright FL. Global trends in atherosclerotic cardiovascular disease. Clin Ther. 2023;45(11):1087-91. [Link] [DOI:10.1016/j.clinthera.2023.09.020]
2. Sarrafzadegan N, Mohammmadifard N. Cardiovascular disease in Iran in the last 40 years: Prevalence, mortality, morbidity, challenges and strategies for cardiovascular prevention. Arch Iran Med. 2019;22(4):204-10. [Link]
3. Jensen RV, Hjortbak MV, Bøtker HE. Ischemic heart disease: An update. Semin Nucl Med. 2020;50(3):195-207. [Link] [DOI:10.1053/j.semnuclmed.2020.02.007]
4. Shi H, Xia Y, Cheng Y, Liang P, Cheng M, Zhang B, et al. Global burden of ischaemic heart disease from 2022 to 2050: projections of incidence, prevalence, deaths, and disability-adjusted life years. Eur Heart J Qual Care Clin Outcomes. 2025;11(4):355-66. [Link] [DOI:10.1093/ehjqcco/qcae049]
5. Ambrose-Oji B. Mindfulness practice in woods and forests: An evidence review. Warrington: The Mersey Forest; 2013. [Link]
6. Religioni U, Barrios-Rodríguez R, Requena P, Borowska M, Ostrowski J. Enhancing therapy adherence: Impact on clinical outcomes, healthcare costs, and patient quality of life. Medicina. 2025;61(1):153. [Link] [DOI:10.3390/medicina61010153]
7. Özlek B, Başaran Ö. Statin discontinuation: Global challenge in secondary prevention. Am J Cardiol. 2024;212:40. [Link] [DOI:10.1016/j.amjcard.2023.11.051]
8. Leslie KH, McCowan C, Pell JP. Adherence to cardiovascular medication: A review of systematic reviews. J Public Health. 2018;41(1):e84-94. [Link] [DOI:10.1093/pubmed/fdy088]
9. Malachias MVB, Kaiser SE, Albuquerque DCd, Brandão AA, Sposito AC, Moura LZ, et al. Risk of adverse health outcomes in patients with poor adherence to cardiovascular medication treatment: A systematic review. Arq Bras Cardiol. 2024;121(10):e20240469. [Link] [DOI:10.36660/abc.20240469]
10. Gomes-Neto M, Durães AR, Conceição LSR, Silva CM, Martinez BP, Carvalho VO. High-intensity interval training versus moderate-intensity continuous training on exercise capacity and health-related quality of life in patients with coronary artery disease: An updated systematic review and meta-analysis. Braz J Phys Ther. 2025;29(1):101137. [Link] [DOI:10.1016/j.bjpt.2024.101137]
11. Pagnoni G, Vicenzi A, Darroudi S, Maini A, Sbarra F, Marangi F, et al. Adherence to exercise and functional rehabilitation programs in patients with cardiovascular diseases: Barriers and strategies. J Cardiovasc Dev Dis. 2026;13(1):8. [Link] [DOI:10.3390/jcdd13010008]
12. Ruano-Ravina A, Pena-Gil C, Abu-Assi E, Raposeiras S, Van't Hof A, Meindersma E, et al. Participation and adherence to cardiac rehabilitation programs. A systematic review. Int J Cardiol. 2016;223:436-43. [Link] [DOI:10.1016/j.ijcard.2016.08.120]
13. Struthers NA, Guluzade NA, Zecevic AA, Walton DM, Gunz A. Nature-based interventions for physical health conditions: A systematic review and meta-analysis. Environ Res. 2024;258:119421. [Link] [DOI:10.1016/j.envres.2024.119421]
14. Coventry PA, Brown JE, Pervin J, Brabyn S, Pateman R, Breedvelt J, et al. Nature-based outdoor activities for mental and physical health: Systematic review and meta-analysis. SSM Popul Health. 2021;16:100934. [Link] [DOI:10.1016/j.ssmph.2021.100934]
15. Laezza L, Vacondio M, Fornasiero A, Pellegrini B, Pasini M, Brondino M, et al. Evaluating the benefits of green exercise: A randomized controlled trial in natural and built environments assessed for their restorative properties. Psychol Sport Exerc. 2025;80:102883. [Link] [DOI:10.1016/j.psychsport.2025.102883]
16. Harrison L, Coventry P, Armitt H, Chew-Graham C, Churchill R, Darcy P, et al. Nature-based interventions for health and wellbeing: What works. York: University of York; 2023. [Link]
17. Tilgner N, Nehls D, Lichtmess C, Kober A, Küsel C, Radloff L, et al. Adherence to exercise and fitness following exercise-based outpatient cardiac rehabilitation: A cross-sectional survey for Germany. BMC Sports Sci Med Rehabil. 2022;14(1):191. [Link] [DOI:10.1186/s13102-022-00585-0]
18. Morisky DE, Ang A, Krousel‐Wood M, Ward HJ. Retracted: Predictive validity of a medication adherence measure in an outpatient setting. J Clin Hypertens. 2008;10(5):348-54. [Link] [DOI:10.1111/j.1751-7176.2008.07572.x]
19. Bellet RN, Adams L, Morris NR. The 6-minute walk test in outpatient cardiac rehabilitation: Validity, reliability and responsiveness-a systematic review. Physiotherapy. 2012;98(4):277-86. [Link] [DOI:10.1016/j.physio.2011.11.003]
20. ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: Guidelines for the six-minute walk test. Am J Respir Crit Care Med. 2002;166(1):111-7. [Link] [DOI:10.1164/ajrccm.166.1.at1102]
21. Hamilton DM, Haennel R. Validity and reliability of the 6-minute walk test in a cardiac rehabilitation population. J Cardiopulm Rehabil. 2000;20(3):156-64. [Link] [DOI:10.1097/00008483-200005000-00003]
22. Summers JK, Vivian DN. Ecotherapy-A forgotten ecosystem service: A review. Front Psychol. 2018;9:1389. [Link] [DOI:10.3389/fpsyg.2018.01389]
23. Chalquist C. Ecotherapy: Healing with nature in mind. Berkeley: Counterpoint; 2009. [Link]
24. Isham A, Jefferies L, Blackburn J, Fisher Z, Kemp A. Green healing: Ecotherapy as a transformative model of health and social care. Curr Opin Psychol. 2025;62:102005. [Link] [DOI:10.1016/j.copsyc.2025.102005]
25. Field T, Field T. Ecotherapy research: A narrative review. J Clin Psychol Neurol. 2024;2(4):1-12. [Link] [DOI:10.61440/JCPN.2024.v2.32]
26. Tüner H, Polat F, Alıç E, Kaya AN, Çakmak Ç B, Coşkun F, et al. Effectiveness of cardiac rehabilitation in enhancing adherence and improving clinical outcomes post-acute coronary syndrome: A randomized controlled trial. Clin Cardiol. 2025;48(6):e70160. [Link] [DOI:10.1002/clc.70160]
27. Aharon KB, Gershfeld-Litvin A, Amir O, Nabutovsky I, Klempfner R. Improving cardiac rehabilitation patient adherence via personalized interventions. PLoS One. 2022;17(8):e0273815. [Link] [DOI:10.1371/journal.pone.0273815]
28. Santiago De Araújo Pio C, Chaves GS, Davies P, Taylor RS, Grace SL. Interventions to promote patient utilisation of cardiac rehabilitation. Cochrane Database Syst Rev. 2019;2(2):Cd007131. [Link] [DOI:10.1002/14651858.CD007131.pub4]
29. Matata BM, Williamson SA. A review of interventions to improve enrolment and adherence to cardiac rehabilitation among patients aged 65 years or above. Curr Cardiol Rev. 2017;13(4):252-62. [Link] [DOI:10.2174/1574884712666170710094842]
30. Yang Z, Jia H, Wang A. Predictors of home-based cardiac rehabilitation exercise adherence among patients with chronic heart failure: A theory-driven cross-sectional study. BMC Nurs. 2023;22(1):415. [Link] [DOI:10.1186/s12912-023-01566-5]
31. Busk H, Ahler J, Bricca A, Mikal Holm P, Varning Poulsen D, Skou ST, et al. Exercise-based rehabilitation in and with nature: A scoping review mapping available interventions. Ann Med. 2023;55(2):2267083. [Link] [DOI:10.1080/07853890.2023.2267083]
32. Huber D, Mayr M, Hartl A, Sittenthaler S, Traut-Mattausch E, Weisböck-Erdheim R, et al. Sustainability of hiking in combination with coaching in cardiorespiratory fitness and quality of life. Int J Environ Res Public Health. 2022;19(7):3848. [Link] [DOI:10.3390/ijerph19073848]
33. Fortin É, Langelier MÈ, Léonard G, Da Silva RA. The impact of nature-based interventions on physical, psychosocial, and physiological functioning for physical chronic diseases: A systematic review. J Ageing Longev. 2025;5(3):35. [Link] [DOI:10.3390/jal5030035]
34. Sheng SP, Feinberg JL, Bostrom JA, Tang Y, Sweeney G, Pierre A, et al. Adherence and exercise capacity improvements of patients with adult congenital heart disease participating in cardiac rehabilitation. J Am Heart Assoc. 2022;11(16):e023896. [Link] [DOI:10.1161/JAHA.121.023896]
35. Lahart I, Darcy P, Gidlow C, Calogiuri G. The effects of green exercise on physical and mental wellbeing: A systematic review. Int J Environ Res Public Health. 2019;16(8):1352. [Link] [DOI:10.3390/ijerph16081352]
36. Simpattanawong D, Li Q, McEwan K. A controlled trial comparing the impact of guided forest bathing or a mindful urban walk on heart rate, blood pressure, and mood in young Thai adults. People Nat. 2024;6(6):2577-86. [Link] [DOI:10.1002/pan3.10744]
37. Brooks D, Solway S, Weinacht K, Wang D, Thomas S. Comparison between an indoor and an outdoor 6-minute walk test among individuals with chronic obstructive pulmonary disease. Arch Phys Med Rehabil. 2003;84(6):873-6. [Link] [DOI:10.1016/S0003-9993(03)00011-X]
38. Torng CS, Lin PC. Impacts of ecotherapy on physiological and psychological benefits. AIP Conf Proc. 2023;2685:060008. [Link] [DOI:10.1063/5.0116597]
39. Ideno Y, Hayashi K, Abe Y, Ueda K, Iso H, Noda M, et al. Blood pressure-lowering effect of Shinrin-yoku (forest bathing): A systematic review and meta-analysis. BMC Complement Altern Med. 2017;17(1):409. [Link] [DOI:10.1186/s12906-017-1912-z]
40. Twohig-Bennett C, Jones A. The health benefits of the great outdoors: A systematic review and meta-analysis of greenspace exposure and health outcomes. Environ Res. 2018;166:628-37. [Link] [DOI:10.1016/j.envres.2018.06.030]
Send email to the article author