Previous research has largely attempted to explore breast screening experiences of South Asian women by combining opinions from Pakistani, Bangladeshi, and Indian women. This research often fails to reach the most underserved sub-groups of this population, with socioeconomic status not routinely reported, and English fluency being a participation requirement. With uptake low amongst British-Pakistani women, this study explores the experiences these women encounter when accessing the NHS Breast Screening Programme.19 one-to-one semi-structured interviews were carried out with British-Pakistani women from East Lancashire, UK. 14 interviews were conducted via an interpreter.‘Absence of autonomy in screening and healthcare access’ describes how currently the screening service does not facilitate confidentiality or independence. Access requires third-party intervention, with language barriers preventing self-expression. ‘Appraisal of information sources’ makes distinctions between community and NHS communication. Whereas community communication was invaluable, NHS materials were deemed inaccessible due to translation incongruences and incomprehensible terminology. ‘Personal suppositions of breast screening’ explores the subjective issues associated with disengagement, including, the cultural misalignment of the service, and perceiving screening as a symptomatic service.Data were analysed using thematic analysis. Three themes were identified: British-Pakistani women face some unique challenges when accessing breast screening. To promote uptake, the service needs to address the translation of screening materials and optimize upon community networks to disseminate knowledge, including knowledge of the screening environment within the context of culture to promote informed choice about attendance. However, over a 10-year period, uptake to the NHSBSP has fallen.6 With breast cancer risk factors (i.e. being overweight or obese) increasing in the current screening age population, this persistent decline in uptake is concerning.7The number of South Asian women diagnosed with breast cancer in the UK is comparatively lower than figures recorded for the white population.712 Insufficient knowledge and a lack of awareness about breast cancer and screening have been identified as significant barriers to uptake in South Asian communities.1316 Emotional barriers and the anxiety of a diagnosis are also major deterrents.5,13,16,17 With modesty and respect highly valued amongst South Asian communities, screening and the discussion of breast health is often viewed as dishonourable, contributing to screening disengagement and a lack of family and community dialogue about breast cancer.5,15,16,18South Asian women in particular have lower screening attendance rates than host country women, and other minority ethnic communities.18 With regards to verbal communication, healthcare professionals surveyed in 95 UK breast screening sites rated their ability to communicate verbally with South Asian woman as difficult and poor.19 These findings are consistent with data from UK Black and Minority Ethnic cancer patients (including South Asian women), who described themselves as unable to effectively access healthcare services due to a lack of confidence in healthcare professionals, as well as significant knowledge and communication barriers.20To aid accessibility and informed choice, NHS screening programmes provide information in various languages. Despite this, verbatim translations can produce inaccuracies, causing a reduction in the amount of information disseminated, and lacking the desired impact apparent in the original English.2123 Survey data suggest that uptake is particularly poor amongst British-Pakistani women.10,24 The British-Pakistani population are the second largest minority ethnic group in England , and the largest minority group in North West England.25 Compared with other South Asian populations settled in England (i.e. Bangladeshi and Indian), 30.9% of British-Pakistanis live in the 10% most deprived neighbourhoods, 19% of whom live in health deprived areas.26 According to the 2011 census, 185,925 British-Pakistanis in England have fair to very bad health. The proportion of British-Pakistanis described as having very bad health is higher than that recorded for other South Asian communities in England.27 Therefore, compared with other UK South Asian populations, British-Pakistani communities are of particular importance to health research, due to their level of health deprivation and poorer health outcomes.The ethnicity of women attending breast screening is not routinely recorded by the NHS, resulting in a significant gap in knowledge regarding the disparities in screening uptake amongst minority ethnic communities.either not reported or the most underserved populations are not reached.13,14,17,18 Furthermore, with some studies requiring fluency in English,14,17,18 an exploration into the screening experiences encountered by the most vulnerable and underserved sub-groups of this population is lacking. With changes being proposed to the programme regarding the introduction of breast cancer risk estimation,28 it is increasingly important to address and explore, in-depth, the current engagement barriers these women encounter before substantial service level changes are implemented. The aim of this study was specifically to explore the views and experiences that British-Pakistani women have of the NHSBSP.Most research exploring the links between ethnicity and breast screening engagement has typically treated South Asian women as a homogenous group, generalizing findings from women of Pakistani, Bangladeshi, and Indian origins. Moreover, a scoping review of the literature has also revealed that the socioeconomic backgrounds of these women are This study adopted a qualitative cross-sectional design. Semi-structured interviews, conducted in English or via an interpreter, explored women’s views and experiences of the NHSBSP. Semi-structured interviews were chosen to obtain in-depth and nuanced insights from an underserved population, who have previously received little research attention in this area. Open-ended questions were used flexibly to enable participants to answer freely and to explore areas of personal meaning and interest.Participants were eligible to take part if they were British-Pakistani, and from a low socioeconomic background. Demographic details (i.e. ethnicity and postcode) were collected to ensure that women were from the identified population. Women were excluded if they were not born biologically female. Women with breast cancer or previous breast cancers were also excluded. Women approaching screening age were eligible to take part, although the researchers aimed to interview women of screening age. The rationale for including women approaching screening age was to gain their views on breast screening, their intentions to attend, and the challenges they could face prior to their attendance. Additionally, in some areas of England, an age-extension trial is taking place, so some women are invited for breast screening at age 47. Finally, women were not excluded based on their English language skills, as interpreters were to be employed if women requested their assistance.To devise an optimal recruitment strategy for engaging women who are often described as ‘hard to reach’, Patient and Public Involvement meetings were set up prior to the study commencing. In these meetings, the study team were advised that direct contact via community networks would help to raise awareness of the research. Traditional methods of sending study information to women’s homes would prove ineffective, as many would be unlikely to access the information due to language barriers. Liaising with women via community networks was described as an effective way to establish trust. Additional advice was also provided on how to present the study to women. For example, it was suggested that describing the study as ‘research’, and wearing official NHS uniforms or University/NHS lanyards could be intimidating.With this advice, participants were recruited from the East Lancashire area via a breast cancer community event, and community contacts. A member of the research team  provided contact details for outreach workers in the East Lancashire area to facilitate recruitment. The breast cancer community event was designed as a get together for women in the local area to learn more about breast screening. Culturally appropriate information materials were made available, and women were able to ask questions about breast cancer and screening. Casual discussions about the study were conducted, and information about participation was distributed. NHS-approved interpreters who were employed across the East Lancashire area were also present. Contact information was exchanged with the interpreters for future bookings for the study. As well as the community event, community contacts disseminated information about the study to women in the area. The research team were provided with the contact details and language preferences of women interested in taking part. When arranging a suitable time and date to be interviewed, a telephone interpreter was arranged for women who were not fluent in English.25 a high proportion of neighbourhoods in the 10% most deprived in the UK,29 and uptake to breast screening is below the targeted 70%.30The East Lancashire area was the chosen recruitment site as there is a large British-Pakistani community,Nineteen women born in Pakistan who moved to the UK with their husbands and families were interviewed. All were living in high deprivation areas according to the Indices of Multiple Deprivation Index. Twelve women were of breast screening age (50+), five were aged under 50, and two did not disclose their ages. All women known to be of screening age reported previously attending for breast screening.In one-to-one, semi-structured interviews lasting 1–2 hours, women were asked about their perceptions, knowledge, and experiences (if appropriate) of breast screening. For 14 women, an interpreter was employed. For the remaining women, an interpreter was declined, due to their fluency in English. The interviewer spoke directly to the interviewee, and the interpreter translated in third person. On one occasion the interviewee’s daughter interpreted for her mother, in addition to the employed interpreter. At the interviewee’s request, one interview was not recorded, and notes were taken instead. Data from this interview were synthesized into the larger dataset, to assess parity across accounts. The remaining interviews were recorded and transcribed verbatim. Personal details were anonymized, and participants were allocated pseudonyms.31 Primary data analysis was conducted by VGW with collaborative input from LSD, HR, and FU. Analysis began through familiarization, with researchers (VGW and LSD) reading each transcript in turn, after which coding began (conducted by VGW). To avoid the influence of pre-existing theory and literature, a manifest-inductive approach was adopted. As a realist epistemology was applied to this thematic analysis, data analysis was driven by the assumption that there is an apparent reality of the participant’s experiences inherent in the dataset.31 Coding was iterative; as new data were analysed, codes became more refined and initial themes were established. Data sufficiency for addressing the research aims was achieved, and recruitment stopped, when there appeared to be no new content being discussed in the final two interviews. Codes and themes were continually refined and assessed by VGW, LSD, HR, and FU to establish their representativeness across the dataset.Analysis was conducted in NVivo Version 11 using thematic analysis. For this thematic analysis a realist approach was adopted, with the researchers accepting that participants' accounts represented their experiences and realities.This project was approved by London-City and East NHS Research Ethics Committee (ref: 17/LO/1275) and received HRA approval. The study was conducted in accordance with Good Clinical Practice guidelines and the Declaration of Helsinki. The study and consent form was explained fully by the interpreter and all participants gave written informed consent. Written informed consent was obtained from participants to use anonymized extracts from interviews in publications and presentations.Data were grouped into three themes: (i) absence of autonomy in screening and healthcare access, (ii) appraisal of information sources, and (iii) personal suppositions of breast screening.Mum does prefer in Urdu ‘cause she wouldn’t like to basically worry the kids ‘cause it affects their studies and stuff like that, so she’d rather keep that information to herself’ (Fareeda via interpreter). Some women acknowledged that relying on others to translate resulted in feelings of shame, due to their lack of English skills. To mitigate this, women suggested providing invitation/result letters in languages in which they are literate, to afford them privacy and independence: ‘But, if they could do it in a language, they don’t have to rely on anybody […] it’s nice to be independent, rather than saying, you know what, I’ve got this poor quality inside me, which there’s nothing I can do about’ (Sadia via interpreter). It was acknowledged, however, that some members of the British-Pakistani community, especially older generations, cannot read or write, and so providing information in their spoken language would not necessarily mitigate this barrier to privacy.It was discussed by the women that a large majority of British-Pakistani women of breast screening age have limited/no literacy in English. Thus inviting women to breast screening via letter can be problematic. Some explained that they rely on family members, or women in their community, to explain the letter. For some, asking others to translate caused them to feel burdensome, and also concerned as to what effect translating private letters (which may contain results) could have on their translators, especially when the majority of those translating for them are their daughters, ‘Six years she really struggled. She couldn’t explain anything to her doctor, and just felt really bad […] there was no way that she could explain to him what was wrong with her, and he couldn’t understand her either. There weren’t any interpreters, that she was aware of, that could help her’ (Roshanah via interpreter). To compensate for this, women attend appointments with a family member who is able to translate and ‘speak for them’. Using family members as translators has the drawback of putting them in an uncomfortable position, resulting in them being selective in what they are willing to ask on the woman’s behalf, ‘Yeah, she thinks that we get embarrassed […] Like we go to the doctor with her and she’ll say, ask him this, and sometimes we won’t. We’ll be like, no, I don’t want to ask that’ (Fareeda via her daughter acting as interpreter). Unaware that interpretation services exist, women expressed that a professional interpreter should be employed across all NHS services, so that women could be afforded the opportunity to express themselves without restrictions.Some women explained that, during medical appointments, including breast screening, they are often unable to communicate with their healthcare professional due to limited fluency in English. In one account, a woman who had moved to the UK from Pakistan recalled the struggles she encountered when attending GP appointments, ‘Her sister in law, she went for breast screening, so she’s kind of explained to her, what happened, and how it’s done (Bushra via interpreter). ‘So, how does it make you feel, knowing that extra information before you are due to go?’ (Interviewer). ‘It’s helpful, awareness about our body changes and diseases, so it can help us also, when I know what it is, and what to expect’ (Bushra via interpreter). Women expressed that breast screening and breast health should be regularly talked about amongst women in the community. Specifically, knowledge should be filtered through generations, enabling young women to become informed about the importance of screening, ‘ … knowledge needs to be passed on, should be talked regular, especially to your daughters, that this is very important, a vital part of your life…’ (Sadia via interpreter). Women described using their experiences to encourage and support others when making their decisions to attend. However, not all women in their communities, especially older generations, were comfortable in discussing private appointments, potentially resulting in insufficient knowledge transfer.It was highlighted that for this group of women, family and community dialogue is invaluable for sharing knowledge about breast screening. Women emphasized that by talking to others who had attended screening, they gained valuable information about the procedure, ‘She didn’t have any knowledge about it, no, how it’s going to happen or anything, until she actually went there. It was kind of an eye-opener for her…’ (Ushna via interpreter). For these women, their limited literacy in English often resulted in valuable information being ignored, missed, or thrown away, rendering the information provided in this format as inaccessible and useless, ‘…because everything was in English I only read first few line and then I chuck it in the bin, the leaflet…’ (Tahmina). Instead, holding regular community events, in venues of familiarity such as GP surgeries, schools, and Muslim community centres, where women could come together to learn about breast screening was seen as a more effective way of disseminating crucial information, ‘…invite them to an awareness day where you would disseminate the information at that venue […] As in the fact that well look, it’s just screening. And this is how it’s going to benefit you and this is the process then. And then that way they’ve had it orally’ (Fatima via interpreter). Yet, women explained that leaflets are still valuable resources, but would be more likely to be read if they were distributed in a variety of languages.Only two women out of those who said they had attended screening recalled being able to access information about the NHSBSP when invited and understand what was going to happen at their appointment. The majority described having no prior knowledge, and attended their appointments naïve about what it would entail, ‘Cause breast screening, again, when that’s put together, when someone’s reading that […] it’s like an alien kind of a word, like screening what is it?’ (Roshanah via interpreter). It was explained that in the common languages spoken by the British-Pakistani community (i.e. Urdu), clear and direct translations of screening terminology is lacking. The uncertainty over what these terms denote caused some women to speculate about what would happen during their appointments, often resulting in inaccurate suppositions, ‘What is breast screening? Is it a screen that you go through, or is it like a room, is it like a shower room, what is it?’ (Sadia via interpreter). Women suggested that a glossary of screening terminology could be provided, or more common terminology (e.g. ‘X-ray’ or ‘scan’) could be used to reduce conjecture and facilitate understanding.The terminology used to describe breast screening including ‘screening’ and ‘mammogram’ are difficult to comprehend, ‘ … she’s just saying, her religion, says the same, her culture, if you’re a daughter, you can’t be uncovered’ (Ushna via interpreter). It was apparent that if women knew that a female radiographer would be performing the mammogram, they would be more inclined to attend. Women made a distinction that, in their culture, for routine appointments such as screening, it is more appropriate to see a female healthcare professional; however, when events become more serious, the preservation of life becomes more important than cultural customs, ‘ … other ladies, they don’t like to be, like, be naked in front of other men, so that’s why they get a bit more shy. But, in our culture, like in Islam, if you’ve got a disease or something, or if you’ve got some serious problem, and if it’s a male doctor, then there’s no problem, you can go to him … ’ (Iffat via interpreter). In particular, one woman yet to be screened expressed that if a man were to perform the procedure she would not attend, ‘Well, if it’s a man, I prefer, I don’t go’ (Namra). To avoid this uncertainty, women explained that the presence of female only radiographers should be explicitly highlighted at events and in screening materials, to reassure women with specific cultural and religious beliefs.The necessity to reveal breasts to a stranger is a major deterrent to attending breast screening for British-Pakistani women, ‘So even though the letter might come through the door a lot of women disregard it and just feel like well, it's not really important. Do I really need to go? So they brush it to one side’ (Fatima via interpreter). Women suggested that this ambivalence towards screening may, in part, be due to the knowledge that women in their community hold about the purpose of breast screening. It was suggested that many British-Pakistani women view screening as a symptomatic service, rather than an early detection measure, with one woman explaining that she saw no merit in attending her appointment, ‘First time she went, well, she was fit and healthy, and then her husband … she said to her husband, I don't really need to go [ … ] She didn't feel any kind of symptoms or anything like that, so there was no need for her to go’ (Zareen via interpreter). This was evidenced further by another woman, who identified women in her community who only actively seek breast screening or healthcare when symptoms arise, ‘ … it’s really when they get the disease and they feel it’s [the breast] hard, then they will go, before that they think they don’t need to go’ (Sara via interpreter).Despite receiving letters inviting women to screening, it was highlighted that many women view their attendance as unimportant, By exploring British-Pakistani women’s experiences and views of the NHSBSP, this study has uncovered a number of modifiable barriers that could be addressed at a service level to improve the programme for underserved populations. Specifically, language barriers were highlighted as particularly problematic, with information being missed, as well as autonomy and privacy being compromised. Women also highlighted that communication about the service could be improved, by focusing on alternative dissemination strategies, for example, providing information via community networks. Additionally, specific attention should be aimed toward making the terminology used to describe breast screening more accessible, as well as providing explicit publicity for available translation and interpretation services. Women also pointed out the challenge that screening presents to modesty, with women reluctant to attend, unless the NHS personnel are female. Incorrect knowledge regarding the purpose of screening was also described as a major contributor to low attendance.21,22,23, there was no systematic way to reliably identify disengaged women. Furthermore, minority ethnic groups are often described as ‘hard to reach’ in research.32 In this study 19 British-Pakistani women were interviewed. Although we believe that data sufficiency was achieved, interviews with women who disengage with screening could have yielded more insight, as well as specifically recruiting women who are unable to read and write. The researchers who conducted the interviews were not of the same cultural background as the women, and interpreters were therefore employed. However, an advantage of the researchers’ naivety to the participants’ cultural traditions and beliefs meant that they engaged in more in-depth enquiry, with layers of meanings explored to facilitate understanding, rather than drawing assumptions based on shared cultural knowledge.A strength of this study is it enabled women from a particular underserved population with low uptake to breast screening to express the specific personal and service level issues they encounter. Nevertheless, with ethnicity and language spoken not routinely collected by the NHSA specific challenge of communicating with women via an interpreter was that the researchers could not guarantee that verbatim translations were being obtained. To mitigate against this, interpreters were thoroughly briefed about the aims of the study prior to commencing the interview. The need for accuracy when translating for and to the women was also stressed. If time and resources had allowed, an independent interpreter could have been employed to listen to the recordings of the interviews, to assess the accuracy of the translations. Nevertheless, a major strength of employing interpreters was their shared cultural background with the participants. For example, on arrival at participants’ homes, traditional forms of welcome were exchanged. Therefore, via the interpreter, the researchers were able to build rapport, and attain cultural sensitivity.33 To facilitate this, translation and interpretation services are widely available across NHS trusts, but this study has shown a lack of awareness of these services. Access to these services need to be more widely advertised, especially via screening invitations, to enable women to receive unfiltered health messages and to attend appointments unaccompanied.A recurring issue underpinning these interviews was the incongruence between languages and the challenge women face in communicating with healthcare professionals, maintaining privacy, and understanding the importance of screening materials and health messages. Central to the NHS constitution is the right to privacy, confidentiality, and the provision of information to enable informed choice.34 However, with ‘language spoken’ not being formally collected by NHS services,2123 there is currently no pro-active way to distribute tailored and translated materials to service users. This policy therefore only partly addresses the problems of inequalities and facilitating informed choice amongst underserved communities. The health service and screening services should begin to collect data on service users’ preferred communication, to promote understanding, preserve autonomy and privacy, and enable informed choice.22 Asking patients at the point of GP registration to specify their preferred method of communication and language may enable this change to be implemented. For example, for those who have limited or no literacy skills in English or their spoken language, a telephone call, via an interpreter, may be the most effective form of communication when being invited for appointments such as breast screening.Our results show that information about breast screening provided in English is largely ignored, resulting in misunderstandings and speculations about the screening procedure. Via NHS England’s Accessible Information and Communication Policy, information materials are made available online in different languages.18 Furthermore, women explained that screening in their community is often seen and described as a symptomatic service, rather than a service for the prevention and early detection of breast cancer. The incomprehensible and inaccessible terminology used to describe screening could partly account for this misunderstanding. Small changes to screening materials could be made to facilitate understanding, and thereby to reduce conjecture. Direct involvement with women from underserved populations in the creation of screening materials would produce more accurate linguistic translations, providing consistent and accessible health messages across languages.This study highlighted the problem that the terminology used to describe screening is not directly translatable or understandable. This reinforces research which suggests that translations are not always reliable.18 In this study local schools were suggested as potential locations, as women do not have to make unscheduled trips to attend. To facilitate communication between healthcare professionals and women at these events, multilingual lay health workers should be used in an attempt to improve knowledge and screening uptake.35The value of community dialogue was clear in this population of women. It was suggested that community-based education events would provide a comfortable and safe environment for women to come together to learn about breast screening. Here, procedural information and the purpose of screening could be disseminated to facilitate understanding, especially amongst those who are unable to access screening materials (i.e. those illiterate in English or their spoken language). Indeed it has been suggested in this study and previous literature, that holding educational events in locations of familiarity would be advantagious.5,15,16,18 There is an opportunity for screening materials to address cultural sensitivities, and to reassure women whose values are incongruent with Western medical practices.15 In the UK, radiographers performing mammograms are female, but this was not common knowledge. There is further opportunity to address this, by reassuring women that breast screening is a female only environment. Where cervical screening may be performed by a male healthcare professional, South Asian women have expressed their discomfort.36,37 Without explicit information, we argue that women are given no reason to believe that breast screening will not be performed by a male radiographer. Information which directly communicates breast screening as a female only environment would probably reduce this concern, not only for British-Pakistani women, but for all women wishing to access the service.The necessity to show intimate body parts has been recognized as a difficult obstacle to overcome, as modesty and respect are highly valued in this community.This research has shown that inequity in access continues to be challenging for British-Pakistani women. To mitigate the challenges presented by language difficulties, the breast screening service should provide explicit information signposting women to the NHS Translation and Interpretation Service, and should, in addition, involve women in the creation of screening materials. Positive changes to engagement could be made by utilizing family and community networks, via health awareness events hosted in facilities across the community. At these events, specific attention should be given to explaining the screening environment and purpose of screening. The NHSBSP and, more broadly, the health service should begin to routinely record the service user’s preferred form of communication, to enable underserved populations to receive tailored health materials. Should this be implemented, further research should aim to identify non-attenders to breast screening across different underserved populations, to gain different perspectives on disengagement. Doing so would add nuanced insight into screening disengagement and contribute positively to the fundamental changes needed to make breast screening accessible to underserved populations.


Under a warming climate and urban heat island effects, cooling behaviours are increasingly important for city dwellers. Cooling actions, especially air conditioning, receive increasing scrutiny in social science, as does engagement and communication on behaviours spanning adaptation and mitigation. In response, this paper evaluates the relation between residents’ adaptation and mitigation behaviours around cooling in Fukuoka, Japan, and draws lessons for communication on encouraging adaptation and mitigation actions. A survey distributed to residents in six areas of Fukuoka, Japan, assessed perceptions of global warming and urban heat island effects, frequency of mitigation and adaptation behaviours, use of air conditioning, electricity bills and evaluation of green spaces. We observe a difference between respondents using air conditioning with an energy-saving (i.e. mitigation) focus, versus those using air conditioning with an adaptation (i.e. cooling) focus. We also note residents emphasising mitigation behaviours may use shade in parks or cooling centres as alternative cooling strategies, but that awareness of effective air conditioning use may be lacking. Our findings build on existing literature by reinforcing – in a subtropical context – the need to reconsider practices around air conditioner use; and illustrate the value of a breadth of messages to promote joint mitigation and adaptation actions. Yet whilst there is a large body of research on urban heat islands and their effects on people for temperate climates, scholarship on urban thermal environments for lower latitudes is still emerging  and has Under a warming urban environment, air conditioning has both benefits and drawbacks. On one hand, air conditioning is an important cooling and adaptation strategy for city dwellers, and can especially reduce risks from excess heat for vulnerable groups such as the elderly or those with pre-existing medical conditions . Yet theMoreover, whilst research has shown that low-income households may be more concerned about health risks from heat and climate change, low-income households in the US were less likely to have air conditioning at home . Lack ofPartly in response to this increasing concern with air conditioning in cities, there has been recent engagement with the social and cultural contexts governing people’s relationships with cooling technologies and cooling behaviours. There is hence a body of extant research into how air conditioning is embedded within individuals’ behaviours, actions, and lifestyles. However, much of this work comes from temperate climate contexts such as the United Kingdom and parts of the USA, and has an emphasis on trying to understand people’s practices as a means of stopping the ‘spread’ of air conditioning and hence mitigating climate change. By contrast, in tropical and subtropical city contexts, air conditioning is already widespread and may – if used sensitively – form part of a suite of adaptation measures for climate changes that cities are already locked into e.g. . In thisOur work is guided by the emergent body of research into the interface between mitigation and adaptation actions, specifically research into the kinds of communication and messaging strategies that may help citizens engage in not only mitigation behaviours but also appropriate adaptation actions. At the city-wide level, there has been interest in linking mitigation and adaptation approaches , especiaMoreover, Our study therefore takes this question of how citizens understand cooling behaviours in relation to mitigation and adaptation, and uses it to contribute not only to conceptual understandings of cooling practices in a context where air conditioning is also prevalent, but also to make an empirical contribution to understandings of messaging, communication and engagement at the mitigation-adaptation interface. To do so, we evaluate citizen behaviours in the subtropical city context of Fukuoka, Japan.22.1This study focused on Fukuoka City, which is located in the Kyushu area in Japan . FukuokaA questionnaire survey on global warming and the urban heat island effect was carried out with Fukuoka residents in January 2018. The survey included respondents’ perception of the problem, evaluation of measures, and mitigation and adaptation behaviours. As respondents use public transport, parks/green spaces, and materials for greening their home, their behaviour is influenced by geographical conditions and housing situation. Six areas were surveyed to reflect three key areas of enquiry: use of public transportation, proximity to greenspace, and type of housing. As the use of public transport as a mitigation option and the use of greenspace as a cooling strategy were areas of enquiry in the survey, sampled areas were selected to give one area near to and one area far from a subway station, and one area near to and one area far from greenspace. Moreover, as behaviours such as greening may differ between apartments and detached houses, one area with many apartments (in the city centre) was surveyed, and one area with many detached houses (in the suburbs) was surveyed see . A total2.2mitigation behaviours as those where the primary intention is to reduce the extent of climate change or urban heat island effects in the near-term and long-term future by taking actions that reduce the amount of electricity consumed and hence the emissions produced. Conversely, we classified adaptation behaviours as those where the primary intention is to reduce the impacts of rising temperatures that are already happening.The questionnaire covered five areas: 1. Perception of global warming and the urban heat island effect; 2. Current mitigation and adaptation behaviours being carried out; 3. Evaluation of green spaces, 4. Length of time per a day and number of months over which air conditioner is used during summer, and 5. Electricity bill for August as the hottest month of the year. It is of course true that mitigation and adaptation are not entirely separate, and that some actions may contribute to both mitigation and adaptation. We thus adopted the IPCC definitions of mitigation (“An anthropogenic intervention to reduce the sources or enhance the sinks of greenhouse gases” : 750) anThe number of returned valid questionnaires was 246 . In terms of gender, respondents were 53.4 per cent male and 46.6 per cent female. As for age, respondents under 30 accounted for 2 per cent, respondents in their 30 s to 50 s represented 37 per cent, respondents in their 60 s accounted for 29 per cent, those in their 70 s made up 24 per cent of the sample and those over 80 accounted for 8 percent . As for According to the 2019 Fukuoka City Statistics Handbook, for Fukuoka City as a whole, the population is 47.2 per cent male and 52.8 per cent female; 31% under 30, 41% in their 30 s to 50 s, 11% in their 60 s, 10% in their 70 s, and 7% in 80 s and up. Whilst available data does not provide a split between apartment blocks and detached houses, 50% of households live in privately rented accommodation, and a further 12% live in public, housing authority or company housing which are likely to be apartment-style ’, ‘Adjust the heat with clothes (4.48)’, ‘use air conditioners and fans to reduse room temperature (4.40)’, and ‘use hat or parasol under sunshine (4.36)’.3.2As there were many kinds of mitigation and adaptation behaviours, synthesis variables were created by means of factor analysis . We perfThe first factor in mitigation behaviours was made up of variables that lower environmental load by using nature, such as increasing vegetation and creating shade; this factor was named ‘use of natural elements’. The second factor was made up of variables related to energy-saving when using air conditioning, such as temperature setting, ‘cool share’, shutting off of sunlight, and having better ventilation; this factor was named ‘energy-saving use of air conditioning’. The third factor was made up of everyday energy-saving behaviours, such as the use of curtains, purchase of energy-saving electrical appliances, and plugging off; this factor was named ‘energy-saving through habitual actions’. The fourth factor was named ‘purchase of energy-saving goods’ because it was made up of the purchase of thermal-insulated windows and LEDs, and the installation of grilles or shutters in the bedroom. The fifth factor was made up of one variable; it was named ‘public transport’.The first factor in adaptation behaviour was named ‘use of air conditioning and cooling approaches’ as it was made up predominately of air conditioning and cooling-related behaviours: ‘lowering the temperature with an appropriate use of air conditioning’, ‘adjusting to the temperature using appropriate clothing’, and ‘the use of air conditioning while sleeping’ . The second factor was named ‘fluid/salt intake and rest’ and consisted of factors to preserve physical energy: ‘frequent intake of fluid/salt’ and ‘taking frequent rest’. The third factor was named ‘shade preference’ as it was made up of ‘using a hat or parasol’, ‘staying under the shade of trees’ and ‘avoid going out’.3.3Regarding the use of air conditioning, there is a contrast between mitigation and adaptation behaviour. Using air conditioning with a ‘mitigation’ motivation encourages restriction of the use to save energy, whereas using air conditioning with an ‘adaptation’ motivation promotes use to maintain health and comfort against rising temperatures. Consequently, a correlation analysis was conducted among each factor of mitigation/adaptation behaviour, the length and period of use of air conditioning in early summer and mid-summer, and the electricity bill for August . For thep < 0.05), periods of use of air conditioning , and electricity bill for August . There is negative correlation between ‘energy-saving by habitual actions’  and ‘shade preference’  and electricity bill for August. In short and perhaps unsurprisingly, these results suggest that those practicing energy-saving uses of air conditioning are likely to use air conditioning for less time, and to see lower electricity bills in summer.As p < 0.01), sleeping at the beginning of June (early summer) , per day at the beginning of August (mid-summer) , and while sleeping at the beginning of August (mid-summer) . In other words, those using air conditioning with ‘adaptation’ motivations were likely to use air conditioning for more time each day, and over a longer number of months during summer.Except for the electricity bill for August, ‘use of air conditioning and cooling approaches’ was positively correlated with the length of use per day at the beginning of June (early summer) . As for ‘setting the room temperature at 28 °C’’, the average August bill of respondents who carried and did not carry this out on an everyday basis was JPY 10,541 and JPY 13,560, respectively. There was a difference of about JPY 3,000 between the two. As for ‘using curtains and blinds when using air conditioning’, the average August bill for those who carried and did not carry this out was JPY 11,033 and JPY 16,000, or a difference of about JPY 5,000.As for how air conditioning use and electricity bill varied between households living in apartments and those in detached homes, people livubf in detached houses use air conditioning one hour more than those in apartments during daytime in summer in average. The average electricity bill for detached houses was JPY 14,047 per month, compared to JPY 10,015 for apartments. As the main component of the electricity bill in summer in Japan is the use of air conditioning , we can 3.5The previous sections show that there are different approaches to using air conditioning. One is to focus on using air conditioning in a way that reduces energy consumption and thus mitigates climate change; and the other is to use air conditioning primarily to adapt to increasing temperatures. Consequently, to identify factors influencing behaviour, a multiple regression analysis, with ‘an energy-saving use of air conditioning’ and ‘the use of air conditioning’ as criterion variables and perception and situations as explanatory variables, was conducted.Multiple regression analysis of the statement ‘Reduce use of air conditioner’  showed t‘The use of air conditioning’ were significantly correlated with ‘it is difficult to use air conditioning appropriately’ and ‘I use air conditioning more frequently’ . The var3.6There was a negative correlation between ‘shade preference’ and the electricity bill for August. Its constituent variables, ‘using a hat and parasol’ and ‘not going out when it is hot’, had a non-significant negative coefficient, whereas ‘staying under the shade of trees’ had a significant negative coefficient. This suggests that when one stays in the shade, one is not at home and, therefore, consumption of electricity for air conditioning and other household appliances is reduced.homes were far. ‘Staying in the shade of trees’ scored 3.23 among respondents whose homes were near parks/green spaces and 3.17 among those whose homes were far. These differences were not, however, found to be significant in the t-test.44.1It was notable in our findings that those using air conditioning in an energy saving manner also engaged with a number of other cooling practices outside the home. These included staying in shade, using ‘cool share’ and other public facilities, and going out often. It is notable that some respondents, at least those with green spaces near their homes, still valued the shade of trees as a cooling strategy in spite of the high prevalence of air conditioning in Japan. Building on recent research into practices in more temperate climates where air conditioning and associated cooling behaviours are a relatively new phenomenon, our findings thus remind us of two points. The first is that in the tropics, understandings of cooling practices may already be well established. These may encompass not only a wider basket of individual and household actions extending beyond the use of air conditioning identified in our factor analysis such as shading, fluid intakes and daily rhythms ; but alsAs such, our findings reflect the calls of 4.2Our findings on the different motivations for and practices of using air conditioning are broadly consistent with existing research. In our results, those who actively use air conditioning in an energy-saving manner  tended to be more aware of environmental issues and engage with a wider range of pro-environmental behaviours. Separately but related, those engaging in energy-saving uses of air conditioning also saw lower electricity bills during the summer period. There are here links to findings from other research e.g.  indicatinot ‘do not use air conditioning’, but rather ‘use air conditioning appropriately’ accompanied by technical and practical guidance on doing so.Nonetheless, our findings also indicate that even in cases where people acknowledge the need for energy saving, there may be confusion over how to use cooling technologies ‘efficiently’ Section . This fiGreen Curtain, Flower City Fukuoka and Flower and Green Urban Placemaking initiatives led by Fukuoka City Government may be useful starting points for the city in this regard.Finally, our findings also hint at the benefits of promoting greening practices at the household or neighbourhood level. Our results show that for respondents to be able to benefit from the shade of trees as a cooling strategy, the trees need to be located near to the respondent’s home, and also that satisfaction with the city’s green spaces is higher among those living near green spaces Section . On the 4.3Our survey focused on adaptation behaviours in relation to heat and cooling, partly because this is an issue where the interface between mitigation and adaptation behaviours is most apparent due the role of air conditioning, and partly because this is a significant climate risk for Fukuoka. Further research, similar to that of Moreover, whilst our study solicited responses across a range of demographics and socio-economic groups, we did not explicitly consider those who may be most vulnerable to extreme heat. With a number of studies in North America and Australasia advocating specific attention to the adaptation actions of the most vulnerable , further5In this paper, we assessed citizens’ adaptation and mitigation behaviours – especially cooling practices – in response to the urban heat island effect in Fukuoka, Japan. In doing so, we sought to bring a Japanese subtropical city perspectice to existing research on the societal dimensions of cooling practices, and to offer insights into communication and messaging strategies at the mitigation-adaptation interface. Our findings revealed a contrasting tendency between people focusing on mitigation in their cooling practices (those emphasising energy-saving) and people focusing on adaptation in their cooling practices (those using air conditioning to regulate temperature). Our survey also found there is a lack of knowledge on to how to use air conditioning appropriately in a manner that is also saves energy, and that those engaging in energy-saving behaviours may be more likely to combine air conditioning use with other practices such as staying in shade or visiting cool-sharing facilities. Accordingly, we propose that communication measures to demonstrate more effective uses of air conditioning – for instance, setting appropriate room temperatures and combining with use of shading – may help to reduce the heat island and climate impacts of those focusing on adaptation behaviours. Moreover, communicating the economic benefits of appropriate air conditioning use on electricity bills may help to engage less aware citizens. Finally, however, we note that taking advantage of shade from green spaces may only be possible for those living close to green spaces, hence we suggest the promotion of household or neighbourhood-level greening as a means of enabling a breadth of mitigation and adaptation behaviours.Conceptually, our findings reinforce and build on emergent thought on the relation between individuals’ cooling practices and the wider social and cultural context, but question the extent to which extant social and cultural practices of cooling may be able to cope with the pace and extent of climate change. In practical terms, our results tend to support what is already known about mitigation behaviours being more engaging to those with high environmental awareness or concern, versus adaptation behaviours and/or wider rationales being more effective with those with lower awareness or concern. We thus argue that a breadth of rationales for actions bringing joint mitigation and adaptation benefits – and the provision of practical information to help citizens modify existing practices – may help to maintain the adaptation benefits of air conditioning in subtropical contexts whilst reducing negative climate change and urban heat island effects.The authors declare no conflicts of interest associated with this manuscript.The authors report no declarations of interest.


Southeastern Appalachian Ohio has more than double the national average of diabetes and a critical shortage of healthcare providers. Paradoxically, there is limited research focused on primary care providers’ experiences treating people with diabetes in this region. This study explored providers’ perceived barriers to and facilitators for treating patients with diabetes in southeastern Appalachian Ohio.We conducted in-depth interviews with healthcare providers who treat people with diabetes in rural southeastern Ohio. Interviews were transcribed, coded, and analyzed via content and thematic analyses using NVivo 12 software .Qualitative analysis revealed four themes: (1) patients’ diabetes fatalism and helplessness: providers recounted story after story of patients believing that their diabetes was inevitable and that they were helpless to prevent or delay diabetes complications. (2) Comorbid psychosocial issues: providers described high rates of depression, anxiety, incest, abuse, and post-traumatic stress disorder among people with diabetes in this region. (3) Inter-connected social determinants interfering with diabetes care: providers identified major barriers including lack of access to providers, lack of access to transportation, food insecurity, housing insecurity, and financial insecurity. (4) Providers’ cultural understanding and recommendations: providers emphasized the importance of understanding of the values central to Appalachian culture and gave culturally attuned clinical suggestions for how to use these values when working with this population.Evidence-based interventions tailored to Appalachian culture and training designed to increase the cultural competency and cultural humility of primary care providers may be effective approaches to reduce barriers to diabetes care in Appalachian Ohio. Focused ethnography is a means to access beliefs and practices in the context in which they occur, thereby improving our understanding of factors surrounding health and disease , asking participants’ broad, open-ended questions about barriers unique to treating diabetes in Appalachia. Further, participants were asked how Appalachian culture might influence diabetes self-care behaviors and beliefs toward diabetes. The interviewer used directive probes to elicit additional information and clarify questions  performed content analysis by independently marking and categorizing key words, phrases, and texts to identify themes , we employed investigator triangulation with experts from different disciplines. Utilizing multiple analyst triangulation to review our findings provided a check on potential selective perceptions as well as a means to identify cognitive biases in the analysis  identified as primary care providers, 66.7% (n = 28) identified as female, and 95.2% (n = 40) self-reported as white. The mean number of years in clinical practice was 17.7 ± 11.5, with an estimated diabetes caseload of 46.8 ± 29.6%  reported patients’ perceptions of diabetes fatalism as a major barrier to treating diabetes in the region. Providers recounted story after story of patients believing that their diabetes was inevitable because everyone in their family had it and that they were helpless to prevent or delay diabetes complications:The fatalistic attitude is because they see so many people around them, and everybody they talk to today either has diabetes or has a family member or neighbor or knows somebody with diabetes, so it’s a given. Everybody’s got diabetes, that’s what you hear today. Nearly, all of the providers I feel like I’m pushing the 5,000-ton boulder all the time in the sense that it could be better, that you can change this. I do not feel like that message is out there. They are not destined to have diabetes. They could make lifestyle changes to improve their health and either have very mild or well-controlled diabetes or reverse it completely. That is probably my hugest barrier because I feel more hopeful for them than they do. Further, providers described patients feeling resigned to a life with diabetes where they felt powerless to affect the onslaught of inevitable complications and eventual death. Providers commented that these fatalistic attitudes made treating diabetes more challenging because their patients felt less hopeful about the disease than they did:I think that they see it as a problem, but they have sort of a fatalistic approach that, ‘Well, there’s not too much I can do about it. You know, I can’t afford to eat the right foods. My hills are uneven, so I can’t go out and walk for exercise.’ In the providers’ words, patients did not know or understand that they could perform self-care behaviors to prevent or delay the onset of diabetes or diabetes complications. Further, they explained that even if patients did understand that diabetes was associated with self-care behaviors, many could not afford to purchase healthier foods or access safe spaces to exercise:n = 32 out of 42; no differences observed between in-person and telephone interviews, χ2 = 3.521, P = 0.061) reported high rates of comorbid mental illness in the region. They understood that psychosocial issues affected a larger proportion of people with diabetes compared to the general population. Specifically, they noted high rates of depression and anxiety in people with diabetes:A lot of my patients have mental health issues; [in] my diabetes population probably about 50 percent of them do. Depression and anxiety, I just see that through and through, over and over, everyday. Providers Providers also talked about how treating diabetes with comorbid psychosocial issues was difficult given that southeastern Ohio was a health professional shortage area for mental health providers. With a lack of mental health professionals, providers could not refer their patients for proper treatment. Providers observed that patients with untreated mental health issues were less likely to engage in self-care behaviors and more likely to have blood glucose levels above target:There was one day when I first started here, and I was scheduled eight patients in the afternoon. They were all new to me. Five of them had been sexually abused, and one of them was a man who had been abused by his father. Another woman, who I think because of her sexual abuse, now has serious psychological problems. She became schizophrenic. Has had multiple suicide attempts, IV drug abuse, endocarditis. And there is no pill that fixes these things. There is no pill that fixes it. Several providers also discussed the pervasiveness of incest, abuse, and post-traumatic stress disorder (PTSD) in the region. Treating these issues appeared to induce a sense of helplessness and to take an emotional toll on these providers as they described their patients’ traumatic experiences. They spoke about the difficult task of trying to treat patients with diabetes who had experienced these horrific traumas:We have three clinics in Meigs County. We have no hospitals. If they are in need of any long-term care, you have to travel at least 50 miles roundtrip to get to a facility where you get a lot of testing, and maybe education, and things like that. A lot of people say I can’t get there, so I’m not going to do anything about it… Transportation is one of the biggest barriers here. All 42 providers stressed how high-risk social determinants of health interfered with their ability to treat diabetes effectively. Major barriers included lack of access to providers, lack of access to transportation, food insecurity, housing insecurity, and financial insecurity. All of the providers agreed that one social determinant of health often contributed to another social determinant of health. For example, when describing access to providers, transportation barriers were mentioned simultaneously:I think there are limited options for food. So driving the ambulance around the county, I can see that there’s food deserts, where there is no grocery store. The nearest grocery store is 40 minutes away. There are a lot of gas stations where people will get their meals from. There’s a lot of fast food options in Meigs County. Similarly, when discussing transportation barriers, providers referred to problems with food insecurity. Providers talked about limited options for food and the high prevalence of food deserts in southeastern Ohio:Housing is another thing. I mean if you’ve got a homeless person they really have a hard time taking care of themselves. Their self-management is going to be really poor because they’re more worried about not having shelter, not having food, that kind of thing. The [low-income] housing is almost nonexistent here. Providers identified housing insecurity as a significant issue complicating diabetes management. As providers explained, if their patients are trying to find a place to stay, they most likely are trying to find food and employment. Therefore, everything is a barrier for their diabetes. They have to prioritize where they are going to sleep ahead of engaging in diabetes self-care behaviors:Affordable medications, that’s a huge barrier. There’s patient assistance programs, but not everyone qualifies. And then if they don’t qualify, they still can’t afford their insulins, and I think that is a huge barrier. Because they need their insulin to survive, and they still can’t afford it. Finally, providers cited the cost of diabetes supplies, in particular diabetes medications, as insurmountable. Even with state pharmaceutical assistance programs, the majority of these providers’ patients could not afford their diabetes medications:n = 14 out of 42) demonstrated a clear understanding of the values central to Appalachian culture: kinship, loyalty, generosity, and caregiving One-third of the providers Show them that you really care. When their mom dies, go down to viewing hours and say, ‘I heard about your mom dying. I thought I’d come down and pay my respects’ and suddenly they may start listening to you when they think that you really care about what matters to them. It’s meaningful to the people that love them. So I go, and I pay my respects, and I talk to the family and say ‘You know, I really liked Joe’ or ‘I really liked Mary. She was a lovely lady. She always treated me really well.’ It’s sincere…It’s part of the culture to have a family reunion when someone dies. Importantly, these providers recognized that trust was crucial in the delivery of primary care to patients in Appalachia. Trust facilitated their patients’ healthcare-seeking behaviors, open dialog, and engagement in self-care. On the other hand, providers also understood that trust had to be earned by showing respect to the community and its cultural traditions. Providers suggested relationship-building behaviors, including practicing nonjudgmental communication and participating in meaningful activities of the community, as strategies to help build trust with their patients:People don’t want to ask for handouts in Appalachia either. They want to be able to help other people; they want to be able to give, but they don’t want to ever have to ask for help or ask for handouts, and that’s part of the culture. I think it’s really hard for them to feel that they need somebody else, or need to depend on somebody. Finally, providers recognized that Appalachians take great pride in helping others in their community. The people of Appalachia are very independent and hardworking, so it may be difficult for them to accept assistance from others:I think the best thing that could happen for diabetes care is that the diabetes people who are really dedicated to it find a way to get out of that facility, get buy-in into a separate place that is within the community that people go to where they don’t have to go to the hospital, but they can come in and they’re treated by other Appalachians, maybe their cousin or their aunt or somebody, and they say ‘Okay, this is for us and by us. We manage it in a way that makes sense for us.’ And that the people researching them really understand and take the time to understand the culture of Appalachia. Therefore, finding a way to involve community members in diabetes care may be one solution to increase patients’ engagement in self-care and reduce barriers to diabetes treatment:This qualitative study explored providers’ perspectives for treating diabetes in southeastern Appalachian Ohio. All of the providers emphasized the frequency and seriousness of social determinants of health and how they negatively affected diabetes management. Further complicating efforts to treat diabetes were patients’ widespread fatalistic attitudes and sense of helplessness toward diabetes. The majority of providers noted that patients felt predestined to develop diabetes because everyone in their family had it. They explained that their patients did not know or understand that they could perform behaviors to reduce the risk of developing diabetes or to prevent or delay diabetes complications. High rates of comorbid psychosocial issues, particularly depression, anxiety, and PTSD posed additional challenges and feelings of helplessness for both patients and providers. This region is a health professional shortage area for mental health providers; therefore, many patients did not receive the care that they needed. Further, individuals with untreated psychosocial issues were less likely to engage in self-care behaviors and have high blood glucose levels. To address the barriers identified by the providers, many stressed the importance of understanding Appalachian culture. These providers recognized that earning the trust of Appalachians and showing loyalty to the community were essential to developing an effective patient–provider relationship.et al., et al.’s  and nine interviews for a total sample size of 45 participants with diabetes. Currently, we are analyzing the data to identify themes that occurred multiple times, both within and across, the focus groups and interviews. Preliminary findings revealed that people with diabetes identified numerous social determinants of health  and mental health as significant barriers to their diabetes care (Ruhil et al., et al., 1c, psychosocial issues, and social determinants of health.Study limitations include homogeneity of the study sample with regards to race/ethnicity, small sample size, participant self-selection, and self-reported data. The predominantly white study sample is reflective of the racial and ethnic distribution in southeastern Ohio (95.0%; Race and Ethnicity in Ohio, et al., et al., et al., et al., et al., et al., In conclusion, recognition and understanding of providers’ challenges is an important first step in developing culturally appropriate interventions for people with diabetes in Appalachian Ohio. Culturally appropriate interventions when delivered with community support have been shown to improve diabetes self-care behaviors in other cultural groups, including Hispanic adults with diabetes (Babamoto


Several studies have confirmed that the natural environment has psychophysiological healing effects. However, few studies have investigated the healing process involved in the effect of the natural environment. To date, no theoretical model on the nature-based therapy process has been clearly established. Thus, the aim of this study was to develop a theoretical model of the nature-based therapy process by analyzing individual empirical data. Research materials were 180 self-reported essays on “Forest Therapy Experiences” submitted to the Korea Forest Service. This study was conducted based on grounded theory. Data were analyzed through open coding. A total of 82 concepts, 21 subcategories, and six categories were derived. Results revealed that the nature-based therapy process contained six categories: Stimulation, acceptance, purification, insight, recharging, and change. When in the natural environment, participants first experienced positive emotional change, followed by cognitive and behavioral changes. Based on these results, a nature-based therapy process model was derived. This study revealed that the nature-based therapy process did not consist of just a single element or step, but involved an integrated way of healing with emotional and cognitive changes. This study is significant in that it derives a theoretical model of the nature-based therapy process with comprehensive mechanisms. Further research is needed to establish more systematic theoretical model. Modern people are exposed to various problems and diseases due to rapid social and lifestyle changes. In particular, stress is a major threat to the quality of life and health. It is strongly associated with psychological and physical diseases . Stress When the body is exposed to external stimuli, the brain recognizes them as threats and activates the autonomic nervous system inducing a “flight-or-fight” response . Stress Responses to stress and coping strategies vary from person to person . FailureRelieving stress has emerged as an important issue to improve health and quality of life. Interest in nature-based therapy is increasing because having contact with nature can relieve stress with a positive psychophysiological effect. Many studies have reported the positive effect of natural environments. There are several major theories related to nature-based therapy. Ulrich’s psycho-evolution theory (PET)  and KaplThese two theories are related to Wilson’s ‘biophilia’ hypothesis . ‘BiophiMany studies support these nature recovery theories in various ways. Ulrich  comparedHartig et al.  conducteValidation studies about the physiological effect of forest baths have been actively conducted in Japan. Park et al.  assignedStudies on stress and cognitive recovery in natural environments have also been performed in various ways. Tryvainen et al.  surveyedThese findings confirmed that a green environment could promote health and recovery in humans. In addition, activities in a natural environment can significantly improve self-esteem and reduce overall negative feelings . Kuo & SIt has also been reported that green environments have positive effects on cognitive abilities of children. Wells  investigIn addition, forests can affect spiritual aspects and enhance well-being . PreviouPrevious studies ,24,25,26These results suggest that the natural environment has positive effects on public health, indicating that nature-based therapy can be utilized as a strategy to prevent diseases. Despite these positive effects of the natural environment, it is currently unclear why and how recovery occurs in nature. Previous studies were mostly effect-oriented. Only a few studies have determined how physiological, mental, and social changes proceed in natural environments. To date, there is no theoretical model to explain the nature-based therapy process. For nature-based therapy to be recognized and further developed for use in the field of public health, it is necessary to develop theoretical models of nature-based therapy processes and mechanisms. Thus, the aim of this study was to develop a theoretical model of the nature-based therapy process by analyzing empirical data.Data collected for this study were 180 self-reported essays entitled “forest therapy experiences” that were submitted to the Korea Forest Service from 2014 to 2015. The Korea Forest Service has hosted an annual public essay contest on forest therapy experiences in order to promote and draw public attention to the importance of forests and natural recovery effects. Topics of essays used in this study were all related to forest therapy, such as overcoming diseases , recovering from various addictions, and resolving family problems. Those without an experience of natural recovery effects were excluded. The text format was free prose which was about 3–4 A4 sheets in length. The Korea Forest Service stated that “all submitted essays will not be returned and may be used for public interest.” Among these works submitted, excellent ones were selected and published in a book. Data used for this study were not raw data. They were edited and compiled. The 180 essays collected were reconstructed with all personal information  removed and assigned serial numbers. Therefore, data of this study did not include any information disclosing personal identity. Essays cited were taken from those already published in a book from 2014 to 2015. This study did not directly observe or interview individuals. Their essays used in this research were open to the public. All personal information was removed during the editing process. In principle, the use of materials that are open to the public does not require Institutional Review Board (IRB) review. Therefore, this study was not reviewed by the Institutional Review Board (IRB).Study data were composed of stories of experience of individuals who visited the natural environment on their own and experienced a recovery. Participants described their own natural recovery experience in a free format. Data included information about what participants felt and how they were moved when they first visited the natural environment, where they visited, main symptoms, causes of stress, changes in body and mind, and the healing process. In addition, these essays specifically described motives for changing one’s perspectives and thoughts while subjects were in the natural environment, the state of psychological change, and changes in life and values after the recovery. This study identified some patterns and common phenomena in the healing process. These patterns and phenomena were then developed into concepts that could infer the nature-based therapy process.Because nature-based therapy proceeds through a very complex mechanism, existing quantitative research methodologies alone are limited in developing a theory encompassing multiple aspects of the nature-based therapy process. To develop a theory on the nature-based therapy process, there should be sufficient investigations on nature-based therapy phenomena. Therefore, qualitative studies are needed to complement quantitative studies. The research method was based on the grounded theory of Strauss & Corbin , a qualiThe sequence of analysis was as follows. First, the overall feeling and perceptions of healing experiences were derived by repeatedly reading the data. Second, using line-by-line analysis, each sentence was read line-by-line. In each case, all sentences containing words or contents related to mental, physiological, social, and relational recovery were coded. Third, focusing on recurring themes of recovery, concepts were derived by grouping similar themes. “Theme” was found according to contents of recovery. “Concepts” were obtained by extracting and combining common themes from experiences related to recovery. Fourth, by continuous comparing, concepts, subcategories, and categories were derived. These concepts, subcategories, and categories derived from open coding were restructured according to the flow and order of time.As a result of analysis, ages of those who experienced nature-based therapy ranged from teenagers to the elderly in their 80s. There were 77 men, 83 women, and 20 miscellaneous cases in which the gender was not identified or classified as other. These participants had various mental, physiological, and social symptoms . Among these symptoms, depression and stress coexisted the most (102 cases).Forests and parks near the place of residence were the most commonly experienced place (67.6%), followed by recreational forests, arboretums, close mountains, and remote mountain life. In this study, the park was a wooded forest and the arboretum was a national forest designed for forest healing. Remote mountain life meant that participants with diseases lived in deep mountains to recover. The duration of the recovery experience in the natural environment differed by disease and individual. In some cases, participants experienced a healing effect with just one visit. In others, participants experienced recovery with multiple visits over a long term.It was difficult to accurately analyze the number and the duration of the visit to the natural environment. Data on the frequency of visits included daily visits, two to three times a week, irregular visits, and regular visits for more than 20 years. Experiences in the natural environment included walking, staying in a quiet place and resting, forest bathing, talking with trees, observing trees, hiking, observing animals and plants, and contemplation and meditation. As for the motivation for the visit, individuals with cancer or atopic dermatitis mentioned that they actively visit forests for the purpose of a cure. However, most people visited natural environments by chance or simply visited forests and parks just because they were near their homes. Once they had a positive experience, they visited the natural environment more actively. In particular, those who lived close to forests visited forests more frequently  and continuously. Results indicate that frequent trips to parks or forests near one’s home are more effective for health promotion than occasional trips to distant mountains.Through open coding, 82 concepts, 21 subcategories, and six categories were derived .The nature-based therapy process is a systematic connection of healing phenomena in the natural environment. In this study, the nature-based therapy process was developed by analyzing the progress of healing according to time among the content described by people who experienced nature-based therapy. It was found that the nature-based therapy process was composed of six categories: Stimulation, acceptance, purification, insight, recharging, and change. Based on these results, a comprehensive six-step model of the nature-based therapy process was developed .“Seeing the green trees, listening to the sounds of all kinds of birds and insects in my ears, and falling into the imagination as if I was in heaven when faced with the cool wind blowing from the forest.”“I climbed the mountain and walked through the forest, and I liked the sounds of the wind blowing. In particular, the sounds of the leaves striking and the sunlight shining between the green forest felt so fresh and beautiful.”“First, my ears were cleared by the birdsong. The bird sang deep enough to penetrate my lungs through my ears and stimulate my mood. ”“When I went to the forest, various fragrances, birdsongs, trees, and small pretty grass made me happy. Fresh air enters my whole body and clears my mind ... At home, it was difficult to breathe because of cancer cells, but in the forests, it was like magic because I could breathe comfortably like using an oxygen respirator.”On visiting the forest, participants felt better and refreshed by five sensory effects of the forest. They also experienced emotions such as happiness, fascination, curiosity, and joy. Their senses and sensibilities were recovered. Participants who had experienced such positive stimulation tended to visit natural environments more actively and frequently. Therefore, the experience of positive stimulation in the natural environment is an important starting point for healing and change. In the stimulus stage, words related to positive emotions such as mood, beauty, refreshment, pleasure, joy, and fascination appeared.“As I walked along the forest, I felt as if I was at a party invited to happiness, and I felt precious and special. ”“Walking through the forest, I feel like I’m in my mother’s arms. The forest comforts the tired and exhausted me and accepts my everything.”“I told the forest of my troubles, greed, and many heartfelt stories. The forest listened to me silently. The forest was my mother, my friend, my mentor, and myself.”“The oxygen and phytoncide of the forest became my friend and touched my tired and painful body and mind ... Sometimes like a friend, sometimes as a mother who accepts everything, it comforted me, saying, ‘okay, okay’.”“Holding a pine tree, which was my friend, seemed to make me lean and listen to my heart. The forest seemed to comfort me every time I visited.”In this stage, participants experienced receptive feelings in the forest, including the sense of consolation and comportment. The forest is a place where participants could rest and relax at any time. Participants felt that the forest accepted everything about them. They felt consolation and comfort in the forest as if they were in their mother’s arms. Their tiring and exhausting lives were relieved when they communicated emotionally with the nature. Their minds were opened. In the acceptance stage, words such as friends, mother, comfort, relax, and hug gave emotional stability and consolation appeared.“My mind was generous when I came down from the mountain and everything was forgiven”“When I climbed a steep mountain road … all my worries disappeared and I felt refreshed. When I climbed the mountain, my thoughts were cleared up and my head felt lighter.”“I have told the forest my worries, greed, and inner feelings … I drop the manager’s title and the dream of promotion; I started emptying everything one-by-one ... and after a year and a half, I started to feel comfortable.”“As I visited the forest every day, my mind began to empty. Greed, hatred, and resentment in my heart disappeared ... As I walked through the forest, my resentment for the doctor disappeared and was forgiven.”“Drinking the clear night air in the forest, my body was feeling completely clean. Surprisingly, it seemed that the disease of heart that weighed me heavily was disappearing in the forest. The forest fairies seemed to blow the stress away. When I was in the forest, I forgot my anxiety, my worries disappeared, and my stress disappeared.”In the purification stage, participants overcame and dissolved their negative feelings. They vented and released their negative energy in a quiet forest. Their minds and emotions were then lightened and cleansed. This led them to experience relief from stress. Their pain and anger then disappeared. They also forget worries while they walked through the forest. They could honestly recognize their own feelings of avoidance in the tranquil forest alone. They confided stories from their heart that they usually could not tell others. They communicated with nature, emptying and washing away their mind and emotions. They became relaxed and generous so they could afford to look back and reflect on themselves. Purification is an important mediator that can lead to insight. Words used frequently at this stage were release, dissolve, tear, disappear, and forget.“It was alcohol that destroyed my family, and it was alcohol that was dropped me in depression and despair. I started to think about how to live well. If I had to give up and go as I expected, my remaining life was so pitiful and unfair.”“While walking through the forest, I could talk to myself … I thought my life was the way I had to climb up myself ... Rather than waiting for someone to change me, I thought I had to change myself. While those thoughts filled my mind, I wanted to study. It’s still a difficult family environment, but in the end I felt that I had to change. I wanted to achieve the results myself.”“Communicating with the forest, I realized that all my conflicts and worries came from vain greed ... The forest was a mentor to me.”“I enjoyed thinking naturally as I walked through the forest. As a result, I began to realize precious things. It was my family and the dream of my youth.”“The old trees, the stones worn out over time, the grass that knows when they were bloomed became my teacher ... I realized that the mind should be healed first, not the body. I gained wisdom from many of the teachers in the forest.”Insight is the most important and meaningful stage in the nature-based therapy process. Participants experienced awakening through self-reflection and meditation in nature. They then communicated with themselves and talked with their inner self. They knew what they really wanted. They found a new way of life. They regained their identity. They also discovered the meaning and purpose of their life and reinterpreted the meaning of their pain. The most important phenomenon at this stage was “change of thought”. “Change of thought” is a core phenomenon of nature-based therapy. Participants could make a choice for new life through “change of thought.” Factors that could promote insight in nature are survival methods of animals and plants, strong vitality, and the order of nature. Frequently used words at this stage were thinking, reflection, enlightening, finding a dream, and understanding.“Before that, I struggled with guilt for my family, I was filled with the courage and willingness to start again”“The time to stay in the mountains has increased. As I grew in strength, I grew a confident and gradually began to think positively. The mountain gave me a good energy … I certainly felt as I was going up the mountain and my lack was filling up and my mind was refreshing … The good feelings and positive energy I felt as I climbed the mountain changed me.”“As I started to go to the mountains, many negative thoughts disappeared and positive thoughts were filled. I felt good thoughts springing up like fountains.”“I didn’t want to do anything and it was painful ... As this thought diminished, I began to desire to do something ... When I come to the mountain, my desire for life springs up.”The fifth stage is recharging. It fills participants with positive energy such as hope, courage, and confidence. Recharging involves both psychological and physiological aspects. In the natural environment, participants developed the will and desire for life. Hope, courage, confidence, and positive thoughts became energy that could overcome difficulty and create a new life. Recharged with positive energy, participants could go back into the world they were once afraid of and avoided. Words often used at this stage were power, hope, energy, courage confidence, positive, vigor, and vitality.“Since then, I have not drunken alcohol at all. Of course, there are days when I want to drink alcohol depending on my mood, but I did not even go to the supermarket to escape the temptation. For me, the best prescription was to go to a mountain where cool oxygen is emitted.”“And time went by and I took a second SAT. I just want to achieve what I want to do. There was only one thing and I passed one of the colleges I wanted. At the end of the challenge I started to get out of the dark tunnel, I achieved what I wanted to do. My personality has become much more cheerful since then, and I have the courage and mental power to boldly challenge and overcome hard work. And I’m walking hard on my way to my dream. It was unimaginable before.”“For me, forests have given me psychological stability, peace of mind, and health that I can’t get anywhere else in the world. Forests gave me a great life affordability and happiness that I can’t get or feel in gold.”“My depression and popular avoidance were cured by 90%. Even without the psychiatric treatment ... 3–4 days in the mountains are so happy that the rest of the day has no time to depress.”“Now I am happy every day. The ordinary daily life is special, and every day is coming up anew.”“I became more humble. I am generous with people and things and feel grateful for the little things.”The last stage is change. In this stage, participants recovered and changes occurred mentally and physically. Participants could now live a life with changes such as relationship restoration, re-employment, advancement, new challenges, and accomplishments. In addition, the value of life could be changed. They described having a more positive attitude, leading to a satisfying life. These changes ultimately led to self-realization. They described this life as rebirth, reproduction, and rejuvenation. Words that appeared frequently at this stage were improvement, happiness, health, healing, treatment, recovery, love, lightening, and positive.This study found that nature-based therapy process had six categories: Stimulation, acceptance, purification, insight, recharging, and change. These six steps of nature-based therapy could be categorized into three aspects: Emotional change, cognitive change, and behavioral change .In the psycho-evolution theory (PET), Ulrich et al.  have empThe first change that participants experienced in the natural environment was a shift from negative to positive emotions. Negative emotions such as tension, anxiety, and anger were reduced while positive emotions were increased. These findings are consistent with studies showing that positive emotion is the first to appear when humans encounter a natural environment . They arNext, participants’ experiences in the natural environment evolved into cognitive changes. Participants changed into having positive emotions in the natural environment. Then, they began to reflect on themselves in a more relaxed and stable state. They changed their perspectives about themselves and their problems while they were in the nature. They moved on to the next stage of planning and preparing for the future.The reason for cognitive changes in the natural environment is related to positive emotions. Positive emotions can help individuals relax psychologically and restore resources depleted by stress . PositivSonntag-Öström  has repoThe third change that participants experienced in the natural environment was their behavioral change. Those who had experienced emotional and cognitive changes were found to be healthier in body and mind than they were before. They lived healthy and happy lives with positive attitudes and behaviors. In other words, positive emotional experiences in the natural environment promoted changes in thinking and cognitive systems. Cognitive changes then brought about changes in behavior. Most participants had stress along with various mental and physical diseases. Their emotional and cognitive changes caused their body and mind to interact with each other, resulting in recovery and leading to restorations of interpersonal relationships and social life.Psychological mechanisms that cause emotional and cognitive changes in the nature-based therapy process are as follows. Sense of beauty, wonder, and freshness in the natural environment could provide psychological and emotional stimulation, evoking positive emotions and awe. Participants were immersed in various charms of the nature. They built emotional rapport with various creatures of nature. As they experienced a sense of unity with nature, their negative emotions such as rage and anxiety disappeared. When they were deeply immersed in nature, they went one step further and had a chance to reflect on themselves. Deep communication with nature took participants deeper into themselves. At this time, they could fully focus on themselves and look into their feelings and thoughts . By communicating with themselves, participants could realize the cause of their problem and decide to change. Such experience occurred mainly through reflection in silence when they were alone in the nature.Factors triggering emotional changes in their interactions with nature were found to result from stimulation of five main senses coming from forest, such as pleasant smell, landscape, beauty, and fresh air. Factors that could promote cognitive changes were various elements of the nature, such as the natural order, the survival and robustness of animals and plants, and plants rooting and surviving in a harsh environment. Participants reflected on themselves as they observed animals, plants, and insects that exerted their utmost in a given environment, seeing trees grow their leaves, watching flowers blooming according to the time and season, and observing grass and trees surviving the cold. In addition, they develop a new perception of the situation and themselves, away from negative perspectives of their reality.Another important element in this reflection process was that participants could discover the meaning and purpose of their life through their observations of the nature. Many participants, unable to find meaning in their hopeless lives, had the feeling of frustration and depression, addiction, and suicide attempts. However, they found their new meanings for life in the natural environment. Participants began to accept their negative and destroyed situations and self-image through their observations of trees managing to grow in a harsh environment. They saw creatures conforming to the order of nature and accepted their own painful reality. Seeing various creatures in nature finding their own ways of survival and living, people came to accept their own values. Their self-esteem was recovered. Their helpless body and mind were recovered through their changes of perspectives even in difficult circumstances. Psychological changes led to physical changes because body, mind, and emotion acted as an one system. Improved body and mind brought hope and confidence for new life, leading to better mental and physical improvements. As a result, participants who had experienced natural recovery effects described in their essays that they were living healthier and happier than before.At this time, the initiator and driver of such changes were oneself, indicating that their mind and body were recovered through reflection on their own. In this regard, the natural environment can be a place that provides a transcendence to overcome difficulties of reality and a place of “self-therapy” that promotes finding the cause of the problem and resolving the issue by oneself.A comprehensive finding of this study was that the nature-based therapy process proceeded with a very complex and multidimensional mechanism, in which the body, mind, and emotional cognitive behaviors interacted with the nature . ResultsThe nature-based therapy process consisted of six categories.The six-step process proceeded through emotional, cognitive, and behavioral changes.The psychological mechanism for nature-based therapy consisted of “communication with nature”, “communication with oneself”, and “communication with the world”. In other words, “communication with nature” could promote participants’ changes into positive emotions while “communication with oneself” could trigger cognitive changes. Participants who had experienced emotional and cognitive changes in the natural environment changed to lead a life with more intensive and healthy “communication with the world” in terms of daily activities, social lives, and interpersonal relationships.The results of this study are consistent with Wilson’s “biophilia” hypothesis . In addiThe nature-based therapy process is composed of six stages: Stimulation stage, acceptance stage, purification stage, insight stage, recharging stage, and change stage. The nature-based therapy process does not comprise a single element or step. Instead, it is an integrated way of healing through emotional and cognitive changes. In other words, in the nature-based therapy process, self-healing progresses as the mind and body interact with various elements of the nature. Natural environments are not only healing places where physical symptoms and psychological problems are healed, but also healing places where holistic healing, including oneself and others as well as social and relational recovery, can take place. In addition, natural environment, such as a forest, can serve as a place that provides a transcendence to overcome difficulties of reality and a place of “self-therapy” that can help one find the cause of the problem and resolve the issue by oneself.This study was significant in that it derived a theoretical model of the nature-based therapy process and mechanisms. It was also meaningful in that it explored changed lives and long-term effects of participants after experiencing natural recovery. However, it has limitations in generalization since this study is based on self-reported “forest therapy experiences”. Further research is needed to establish a more systematic theoretical model through the development of nature-based therapy programs based on results of this study and structured interviews.