Background
Care farming (also called social farming) is the therapeutic use of agricultural and farming practices. Service users and communities supported through care farming include people with learning disabilities, people with mental and physical health problems, people with substance misuse problems, adult offenders, disaffected youth, socially isolated older people and the long‐term unemployed. Care farming is a highly complex intervention that can involve different farming activities (horticulture, forestry or livestock farming) or other activities (gardening, conservation or woodwork), with different levels of support provided according to the needs of the individual service users. Likewise the service users can contribute to farming production or the farm itself may focus on the provision of care services. Care farming sits within a broader framework of similar nature based supportive interventions collectively terms green care that also includes wilderness therapy, social and therapeutic horticulture, environmental conservation and green exercise. There are around 1,100 CFs in The Netherlands, 900 in France, 675 in Italy and 669 in Belgium. In the UK and Ireland (both the Republic and the North) numbers are fewer with around 230 and 100, respectively. With increasing pressure on the health and social care sector, commissioners are turning to green care interventions as an alternative approach. Although a number of overviews and one systematic review of care farming exists there is a need for a review that captures the full range of published and grey literature, and to explore in depth the mechanisms that explain how care farming works for different service user groups.
Objectives
The primary objective was to systematically review the available evidence of the effects of CFs on quality of life, health and social well‐being on service users. Within this, we aimed to explore the size of the effect that CFs have on the health, well‐being and social outcomes of different population groups. With available material we also aimed to explore the relationship between contextual data (the activities and characteristics of the farm and the nature of the service user groups) and the impact on outcomes. Finally, we aimed to understand the mechanisms of change for different population groups with a view to constructing a logic model to describe the ways in which care farming might work.
Search methods
In 2015, we searched 22 health, education, environmental, criminal justice and social science electronic databases. We also searched databases of grey literature, and various websites, including care farming websites across a number of European countries. Reference lists of included studies and identified systematic reviews were scanned, and citations of key papers were tracked using Google Scholar and Web of Science Citation Indices. This was supplemented by hand searching the Wageningen Journal of Life Sciences from 2000 onwards and by contacting academic and care farming networks to identify any other reports. Our search terms were deliberately broad to capture all rehabilitative interventions occurring on farm and farm type settings. The search of electronic databases as repeated in 2017, due to limited resources the grey literature search was not repeated in 2017.
Selection criteria
We included a broad range of study designs: RCTs and quasi‐RCTs; interrupted time series and nonrandomised controlled observational studies; uncontrolled before and after studies and qualitative studies. We excluded single subject designs, reviews, overviews, surveys, commentaries and editorials. Study participants were those that typically receive support at a CF, including but not restricted to people with mental health problems, learning difficulties, health problems, substance misuse problems, and offenders and disaffected youth. Only those attending for a single day as a visitor were excluded. Studies conducted in a setting that met the accepted definition of a CF were included, but farming interventions that were carried out in a hospital or prison setting were excluded. For the purposes of developing the logic model, we retained papers that described any theories to explain how and for whom care farming might work. These papers are not formally included in the review.
Data collection and analysis
Each screening stage involved two independent reviewers. Studies that were potentially eligible after title and abstract screening underwent full paper screening. Disagreements were discussed and resolved by consensus at each stage. Papers describing theories in relation to care farming were separately retained even if they did not meet the inclusion criteria for the purposes of constructing a theoretical framework to inform the logic models. The Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) was used to state the process of study selection. We stored all references in Endnote (VX7) and recorded extracted data and the outcomes of full paper screening in EPPI‐Reviewer 4 (V.4.5.0.1). The data extraction form was based on the CPHG Data Extraction and Assessment Template with subsections for contextual information, and qualitative and quantitative data. We used a sequential exploratory approach to the review involving four stages: (a) developing a theoretical framework; (b) identifying the intervention components, mechanisms of change, and proximal outcomes from existing theories and qualitative data; (c) mapping the mechanisms of change and proximal outcomes to the theories to develop the logic models and (d) testing the logic models against the quantitative data. We used an adapted version of the COREQ tool to assess the quality of the qualitative studies, and the EPOC and EPHPP tools to assess the risk of bias in quantitative studies. No studies were excluded based on quality. The nature of the studies meant that we were unable to assess treatment effect and reporting biases.2.6 ResultsIn 2015, our search methods identified 1,659 articles, of which 14 qualitative studies, 13 quantitative studies and one mixed methods study met the inclusion criteria. In addition, we identified 15 theories that had been quoted in connection with care farming. The rerun of the search of publish literature in July 2017 identified a further 391 articles, of which three qualitative studies met the inclusion criteria. The total studies in this review are 18 qualitative studies and 13 quantitative studies, one of which was a mixed‐methods study. We created four logical models to explain how care farming might work: an overall one for all service user groups; one for people with either mental health problems or substance misuse problems, one for disaffected youth and one for people with learning disabilities. These models comprised five key theoretical concepts derived from identified theories (restorative effects of nature, being socially connected, personal growth, physical well‐being and mental well‐being), five categories of intervention components (being in a group, the farmer, the work, the animals and the setting) and 15 categories of mechanisms derived from included qualitative studies (achievement and satisfaction, belonging and nonjudgement, creating a new identity, distraction, feeling valued and respected, feeling safe, learning skills, meaningfulness, nurturing, physical well‐being, reflection, social relationships, stimulation, structure, and understanding the self). In addition, from the theories and qualitative studies, we identified 12 different outcomes, both proximal (secondary) and primary, that we expected to find when testing the logic models against the quantitative studies. One key theoretical concept “restorative effects of nature” was underrepresented in the intervention components and mechanisms reported within the qualitative studies. The types of mechanisms appeared to differ according to different service user groups, suggesting that care farming may work in different ways according to different needs. Across the 13 quantitative studies (including the mixed methods study), 24 different outcome measures were reported. Eight studies (both qualitative and quantitative) reported results for mixed client groups. Only the logic model for mental illness and substance misuse was tested, due to a lack of quantitative evaluations for the other service user groups. We found a lack of evidence to indicate that CFs improve quality of life, and limited evidence that they might improve depression and anxiety. There was some evidence to suggest that CFs can improve self‐efficacy, self‐esteem and mood, with inconsistent evidence of benefit for social outcomes. All of the studies had a high risk of bias so the results should be treated with caution.
Authors’ conclusions
There is a lack of evidence available to determine whether or not care farming is effective in improving quality of life, depression and anxiety. More evidence is available for those with mental ill‐health, but firm conclusions cannot be drawn. Small study sizes of poor design, evaluations involving mixed service user groups, the use of multiple and sometimes unvalidated outcome measures, short follow‐ups, and the absence of key outcomes that fit with theory have all hampered the development of a more robust evidence base. However, we now have a set of theory‐based logic models that offer a framework for research evaluations. With recommendations in place to address the current research inadequacies there is an opportunity to vastly improve the evidence base for care farming.Despite the current lack of robust evidence to support the effectiveness of care farming, there are strong arguments to support a more integrated approach to care farming as a viable alternative or adjunct to mainstream approaches for mental health problems. Lack of choice, gender inequalities and over‐burdened statutory services indicate the need for a credible alternative treatment option. A concerted effort to increase awareness among commissioners of health care, frontline service providers, and potential service users about care farming, how, and for whom, it might work is needed. Models across Europe that offer a more integrated approach between green care and statutory services could provide valuable learning. The evidence for care farming for other service user groups is not as well developed as it is for those with mental health problems, but that is not to say there is not a need. Disaffected youth, adult offenders and people with dementia represent significantly large vulnerable population groups where current service provisions struggles to meet demand. The need to continue to improve and provide high quality research in these areas is, therefore, pressing.
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