To use a mixed methods approach to investigate the patient waiting experience for a medically underserved population at an outpatient surgical clinic.We used lean methodology to perform 96 time-tracked observations of the patient journey in clinic, documenting the duration of activities from arrival to departure. We also used human-centered design (HCD) to perform and analyze 43 semi-structured interviews to understand patients’ unmet needs.Patients spent an average of 68.5% of their total clinic visit waiting to be seen. While the average visit was 95.8 minutes, over a quarter of visits (27%) were over 2 hours. Patients waited an average of 24.4 minutes in the waiting room and 41.2 minutes in the exam room; and only spent 19.7% of their visit with an attending provider and 11.8% with a medical assistant. Interviews revealed that patients arrive to their visit already frustrated due to difficulties related to scheduling and attending their appointment. This is exacerbated during the visit due to long wait times, perceived information opacity, and an uncomfortable waiting room, resulting in frustration and anxiety.While time tracking demonstrated that patients spend a majority of their visit waiting to be seen, HCD revealed that patient frustrations span the waiting experience from accessing the appointment to visit completion. These combined findings are crucial for intervention design and implementation for medically underserved populations to improve the quality and experience with healthcare and also address system inefficiencies such as long wait times. Patient wait times are an important indicator of healthcare service delivery, as long wait times have been shown to negatively impact access to care and patient satisfaction –7. In paWhile the consequences of long wait times are well-described, patient perceptions of their waiting experience are poorly understood . SeveralThe goal of this study was therefore to apply a mixed methods approach to investigate the waiting experience for medically underserved patients at an urban safety-net hospital. By combining human-centered design (HCD)  and the This study follows a prospective observational study design using a mixed methods approach Fig. . Mixed mThis study was conducted at the Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG), an urban safety-net hospital and level 1 trauma center in the city of San Francisco. ZSFG is an academic teaching hospital in the University of California, San Francisco (UCSF) network. The hospital treats medically underserved patients, including those who are indigent, un-insured or underinsured, are racial and ethnic minorities, and disenfranchised. The U.S. Department of Health and Human Services has defined such populations to be communities with members who have experienced health disparities, including refugees, religious minorities, and those identifying as African American . As of 2All study activities occurred at the general surgery outpatient clinic, which shares the same space with other surgical clinics, including podiatry, colorectal surgery, breast surgery, plastic surgery, and vascular surgery. At any given time, up to three services share the same clinical and waiting space. At the time of this study, the general surgery clinic was staffed by an attending general surgeon, a nurse practitioner (NP) and two medical assistants (MEAs). As an academic teaching hospital, medical students attend the clinic irregularly, depending on didactic and inpatient clinical activities. There are no residents staffed in the clinic because their rotation at ZSFG is in trauma surgery, rather than general surgery. Morning clinics were held Monday through Friday between 9 am and 12 pm, and afternoon clinics were held between 1 pm and 4 pm. There were 4 scheduled attending-led clinics per week (3 morning and 1 afternoon) and 1 scheduled NP-led clinic per week (afternoon.) This study was approved and informed consent was granted by the UCSF Institutional Review Board.Patient age, gender, ethnicity, race, primary home language, family size, and income source were collected and analyzed in February 2018 via chart review on patients who had a scheduled patient visit at the general surgery outpatient clinic from Jan 1, 2008 to Jan 1, 2018. We conducted this analysis to understand the sociodemographic distribution of our patients.Using the lean methodology, three quantitative researchers tracked patients throughout a clinic visit, documenting times for the following activities: patient entered the waiting room; patient entered the exam room; MEA entry and exit from the exam room; attending surgeon or NP entry and exit from the exam room; patient exited the exam room; patient exited clinic. Researchers observed 11 general surgery clinics between February 2018 and May 2018 and tracked all patients who attended their appointment during these clinics.Data were collected in a custom-built Microsoft Excel 2011 tool that used a circular formula to timestamp the start and end of each activity to track duration and frequency. Quantitative researchers were trained in the use of this tool and educated on how to identify and code each activity. Data were analyzed using basic frequency and descriptive statistics for the following activities: time patient spent waiting (in the waiting room and exam room); time spent with the provider (surgeon and/or NP); and time with staff .We used HCD to conduct and analyze semi-structured interviews with patients about their experience in clinic. HCD provides a unique approach for homing in on problems and finding solutions for them. As such, during the interview process and when analyzing the interviews, we focus on understanding the challenges and unmet needs of each stakeholder. This differs from traditional qualitative interview techniques, which focus on observing a culture, understanding an experience, and developing a theory .Three qualitative researchers trained in HCD interview methods conducted “intercept” interviews with a convenience sample of patients during two time periods: April to June 2018, and June to July 2019. Intercept interviews are conducted while the participant is still on site and engaged with the experience or product in question. They are commonly used in consumer research where potential participants are difficult to reach and engagement with the experience or product is key to the interview , 29. TheTwo of the qualitative researchers independently performed inductive analysis in order to identify initial themes, in accordance with the HCD method for qualitative analysis . They me17,632 patients scheduled 65,211 visits with the general surgery outpatient clinic from 2008 to 2018. Their sociodemographic characteristics are described in Table n = 26, 27%) were over 2 hours long. On average, patients spent 68.5% of their visit waiting to be seen by a provider or staff member. While a majority of their waiting period was spent alone in their exam room (43.0%), the remainder was spent in the clinic waiting room (25.5%). Patients spent 19.7% of their visit with the attending physician or a nurse practitioner, and 11.8% of their visit with a staff member. Of the time spent with a staff member, 5.4% of the visit was spent performing vitals and 6.6% of the visit was spent on additional visits with an MEA  expressed it as feeling like the doctors were playing with her health. Patients felt that they needed to “fight” (AN) and “sue” (BH) to be seen and taken care of by their providers. In addition to emotional distress felt by patients, patients also reported that difficulties in scheduling their appointment resulted in delays of care. For instance, it took AN “1.5 years” to get their surgery done. Finally, it was not an infrequent occurrence for patients to learn that their appointment was canceled or rescheduled only after they arrived in clinic. This exacerbated their sense of frustration and mistrust as they reported having already made the difficult rearrangements to attend their appointment.Patients struggle to find the support necessary to attend their appointment, leading to frequent non-attendance and increased socioeconomic stressors.Description:The clinic operates during standard work hours, which conflicts with primary work responsibilities for many patients. Patients are low-income and have jobs and responsibilities for which they are unable to miss without significant consequences. As such, the opportunity cost of attending clinic appointments is high – it may mean reduced pay or leaving loved ones unattended. Many patients reported missing their appointments for these reasons. For instance, AY is a care provider and lives with her client “24/7”. Her goal in life “is to keep clients alive and out of the hospital”. Finding a time to make it to the appointment while also ensuring that her client is taken care of in her absence is difficult and rare.Description:Patients lack affordable and accessible transportation options that fit within their medical and socioeconomic constraints, leading to increased stress and missed appointments.Transportation was a common barrier to attendance. Patients reported using the following forms of transportation: driving their own cars, having other people give them a ride, taking a taxi or rideshare, and taking public transportation. Each had limitations; there was no ideal option. Due to the high cost of living within the Bay Area and in San Francisco, many of our patients live over 20 miles away from the hospital. This resulted in patients making significant rearrangements to make it to the clinic on time. “I drove starting at 3AM to get here today” (AL), was a typical experience echoed by many patients. For those that were late to their appointment or not able to make their appointment, patients were labeled as “no-show” and had their appointment canceled. This resulted in delays in care and poor patient experience.For those who drove their own cars, many cited parking as a source of stress. At the time of our interviews, there was a 1-hour limit enforced on street parking surrounding the hospital. With the average visit lasting over an hour, and many lasting more than 2 hours, parking is a nontrivial matter. Deciding whether to step out of clinic to move their car or to stay and risk getting a hefty fine, added a significant amount of stress for patients. As BO stated: “Once I had to wait for 45 minutes in a room, and got a $75 dollar parking ticket.” Patients worried that they would miss their turn getting called for their visit if they left clinic, thereby increasing their waiting time to see their provider.Patients without personal transportation either sacrifice time or money. For patients who relied on friends or family to drive them to their appointment, they had to sacrifice some of their own time to make the appointment. For instance, BP had to work around his son’s schedule, resulting in him being “dropped off early in the morning before [his] son goes to work and waiting for him to pick [BP] up.” Those who took taxis or ride shares found the cost prohibitive. As BD stated: “I missed some appointments...I try to make this a priority but every time I have to take a taxi over here, it’s expensive.” Those who took public transport sometimes got lost or were late to their appointments because the transportation was not reliable. As AV stated, “I got lost from the bus stop, it’s a long walk, I had no idea where [the clinic] was.”Even once they reached the hospital, patients faced difficulty getting to the clinic. Many patients used a wheelchair or crutches or had other mobility issues; the clinic is on the third floor and is not close to the elevator. On top of that, patients frequently got lost in the hospital while looking for the clinic. As BJ, who used crutches, said: “[the clinic is] on the third floor. Even the check in place was pretty far from the elevator. All the way to this waiting room is not the shortest walk that I’ve done.”Patients spend most of their visit in the clinic waiting to be seen by a provider, leading to anxiety and frustration.Description:Patients reported wanting to spend a meaningful amount of time with their care team, and for the time spent waiting to be outweighed by the benefits of being seen by a provider. However, many expressed doubts that this was the case, and wondered aloud if their visit justified the hardships they faced in accessing their appointment and the experience of waiting to be seen by their provider. As BN put it: “The procedure is not even five minutes but sometimes I have to sit in the room waiting for 45 minutes. I can’t do anything while I’m waiting.” Another patient (AU) put it this way: “I’m here because it’s either be here or be in pain…I wouldn’t come if I had to wait this long, and my leg didn’t hurt”.Patients managed their frustration and anxiety with extended wait times in different ways. Some patients, like BE and AU, developed workarounds in attempt to decrease their waiting time, such as coming in earlier or later than their appointment time. Others felt resigned to waiting; they felt that it was a part of life or that things could be worse, so they chose not to complain about it. As AG stated, “wait time is long, but I can’t complain, there’s a reason why, but I’ve heard horror stories.”Information opacity makes patients feel disrespected and incapable of managing their medical conditions, leading to frustration and disempowerment.Description:Patients wanted information that allowed them to participate in their care and sought information at two points in time: before their clinic appointment and during their visit. Unfortunately, there was information opacity at both points. For the former, the questions centered around logistics. As noted in insights 1 and 3, patients often did not receive enough information about their appointment or where the clinic was located. For the latter, patients wanted updated waiting time estimates and to learn how to manage their medical conditions. While patients were dissatisfied with the long wait times, they were especially frustrated that they did not know when they would be called – especially after their original appointment time had passed. In addition, some patients stated they experienced disease progression and complications because they did not receive adequate patient instruction on how to take care of themselves and their health conditions. As AK explained: “I followed all the directions, but I still ended up injuring myself post-surgery. I’m not happy with this, it was not explained, I wasn’t given adequate instruction to protect myself.”Patients responded to this information opacity in a variety of ways. Most expressed feelings of frustration and disrespect. Some expressed resignation and felt that complaining wouldn’t lead to their desired outcome; all they could do was practice patience and endure. For instance, BH was waiting to be seen and was frustrated that her hernia repair had been delayed. Even though she had been waiting in the waiting room for a long time and was angry at the providers and hospital to the point of breaking down and crying during our interview, she decided to not “go off on no body which I feel like doing...I have more patience...that’s all I can do. What else can you do?”An uncomfortable physical environment in clinic exacerbates patients’ anxieties related to waiting for their appointment, adversely impacting their mental and emotional states.Description:The environment of the waiting room was an important aspect of the waiting experience for many patients as it helped determine how calm or anxious the patients felt. Cleanliness was one factor that patients used to assess a waiting room. For many, it was the only factor they considered; if the room was clean, they were satisfied. As AQ put it: “As long as it’s clean here, I’m fine with it.” Some patients associated cleanliness with the people occupying the same space. As AH elucidated: “[the waiting room is] not clean, there are so many types of people”; and as BM put it (referring to another patient), “when that man stands up, his seat will be wet”. Since many patients prioritized their health and often saw their fellow patients as “dirty, filthy” (BL), personal space was highly valued. Patients preferred larger waiting rooms so that they could have more space and have more choices on where to sit.Patients also wanted a waiting experience that was calming, with minimal noise. Many patients, such as BJ and AN, noted that the TV audio was bothersome and would prefer it to be off.Patients also preferred waiting experiences that had distracting activities to calm them down. Suggestions included adding refreshments  and things to do , followed by improving the existing environment . When asked what benefit these would serve, they responded that such interventions would “help [them] calm down” (BL), “not stuff that’s rousing of emotion” (AN).Our study used a mixed methods approach to understand the waiting experience for a medically underserved population. Quantitative analysis found that 74% of their time was spent waiting to see a provider or staff while in the waiting room or in the exam room. This corresponded with previous research that demonstrated that patients who were uninsured or had Medicaid experienced long wait times in comparison to the time spent with their provider , 9. QualUsing a mixed methods approach allowed us to use qualitative data to augment, add meaning to, and confirm findings from the quantitative data. For instance, our quantitative findings showed that patients spend the majority of their time waiting to be seen; our qualitative findings demonstrated that patients perceived this time as sources of anxiety and frustration and wondered whether the cost of waiting was justified. Most notably, qualitative analysis revealed that the ‘pre-visit’ waiting experience significantly impacts perceived satisfaction. Interventions based on quantitative data alone would have aimed at decreasing wait times and improving the experience of waiting in clinic, and thus would have fall short of meeting patients’ core needs. By using the lean methodology to assess the extent to which patients wait, and HCD to capture an in-depth view of patient frustrations and unmet needs, we can design patient-centered solutions that improve efficiency and experience.This study had limitations. First, all interviews were conducted in one surgical waiting room at one hospital with a medically underserved population. As such, our results have limited generalizability for patients who might seek care at private hospitals. Second, interviews were conducted in the waiting room, which is a public space, rather than a private room, so that we could capture as many perspectives as possible. This meant that other patients could hear the conversation, which may have led to some response bias. For instance, while patients expressed anxiety that they would get sicker if they came into contact with other patients, many were hesitant to elaborate more about these fears within earshot of their fellow patients. Third, intercept interviews, by their nature, use convenient sampling. Eligible patients were those who were in the waiting room at the same time as when the researchers were conducting interviews. Also, given the nature of our study design, patient-specific sociodemographic information on the patients we observed and interviewed are not available. These may limit generalizability and internal validity, due to the possibility of sampling error and lack of representation of certain populations. As such, the exact insights and opportunities generated from this research are not directly generalizable to other contexts. However, the HCD and time tracking methodologies themselves are repeatable.The surgical clinic where our study took place is at a safety-net hospital that treats patients who have a historically and/or personally poor relationship with the health system. A striking finding was that when interviewed, many patients felt hesitant to “complain” about their problems . Rather, they felt that their role was to be “patient”  and wait quietly for their turn. For instance, for AJ, waiting several months to be seen was the standard of healthcare delivery that he had experienced and so understood to be the norm: “There’s a wait time, sometimes 10-12 weeks, I understand, you just have to be patient, that’s what you expect at a hospital”. Another patient BH had already waited about 1 hour by the time we interviewed her. She was getting impatient since she had four young children under 10 years of age waiting at home, but didn’t think it was appropriate to ask to be seen. BH and others saw complaining as a character flaw; i.e., giving constructive feedback (something positive) had been internalized into something negative (complaining). By interpreting qualitative interviews through this lens, and realizing that some areas for improvement may go unrecognized and that others may be delivered in muted language and tone by our patients, we can help amplify their concerns and improve the care that they receive.Our study must be considered within the broader context of racism and the inequities that it has brought and continues to bring into healthcare, especially in the U.S., and how those inequities impact our patients before they even enter the waiting room. Racism is a system of policies, practices, and norms that affects how people interact with the world based on their outer appearance. Historic policies, such as redlining, disproportionately affected and continue to affect people of color, placing them at higher risk for being poor, falling sick, and dying –36. SuchBy using a mixed methods approach consisting of HCD in combination with lean methodology, we gained an in-depth understanding of the waiting experience in a general surgery outpatient clinic from the patient and system’s perspective. This dual approach, which places the patient at the center, will contribute to the development and implementation of patient-focused interventions that prioritize patients’ unmet needs.


The largest effect size was found for nature connection. Interviews revealed that before the session, participants had a mixed understanding and expectations of the intervention. Conclusions: After the session, the participants expressed enjoying the social aspects of being part of a group and being present in the moment by noticing nature. They expressed the effects of this as immediately calming and relaxing. Urban forest bathing improved nature connection and wellbeing in adolescents and could be implemented and/or signposted by schools and youth charities.Background: Research suggests that an early connection with nature can benefit wellbeing into adulthood. However, there is less research assessing whether adolescents benefit from formal nature connection interventions such as forest bathing . This research aimed to assess whether an urban nature connection intervention  could improve adolescents’ nature connection and wellbeing. Method: In an experimental repeated measures design, 44 adolescents sampled opportunistically from Scouts groups, completed surveys and interviews before and after experiencing an urban nature connection intervention. Results: Paired-samples  An estimated 20% of adolescents struggle with poor mental health , with raThere are a wealth of correlational studies showing that mere access  to nature is beneficial for adolescents’ wellbeing. A review by McCormick  found thBeyond correlational studies exploring the benefits of merely accessing nature, there have been some experimental studies assessing interventions that aim to improve adolescents’ nature connection  and wellbeing ,20,21,22Whilst brief nature connection interventions  have beNature connection interventions have also been shown to be helpful for adolescents with challenging behaviours. For example, Jeon et al.  found thThese formal nature connection intervention studies provide promising evidence for the potential to improve adolescent nature connection and wellbeing. However, most previous studies have assessed mere access to nature, relying on correlational survey data, and have not used experimental designs that involve assessing outcomes before and after delivering a more active nature connection intervention. The current study is therefore unique in using a mixed methods experimental design, collecting survey and interview data before and after a formal nature connection intervention. In this study, forest bathing was delivered to adolescents, and accordingly, was adapted to suit the needs of younger people by encompassing more playful and creative sensory activities, such as creating artwork from natural materials and interviewing a tree about its life (more details can be found in the methods section). Whilst most previous intervention studies conducted forest bathing interventions in wilderness or rural settings, young people might be limited in their access to such wilderness or rural settings due to their lack of autonomy, availability of transport, and parental permission . The curThis research aimed to assess whether an urban nature connection activity  could improve adolescents’ nature connection and wellbeing, by evaluating their experiences before and after the intervention through surveys and interviews. We hypothesise that nature connection and wellbeing survey scores will improve following a formal nature connection activity that is based on forest bathing.The evaluation used a mixed methods repeated measures design, where participants provided survey and interview data before and after a 1.5 h session of urban forest Bathing. Through the repeated measures design, participants acted as their own controls, and their baseline and post-intervention data were matched through a participant-generated ID code.Survey and interview data were collected immediately before and after a 1.5 h urban forest bathing session . Transcripts from interviews were thematically analysed to capture adolescents’ more in-depth experience of ParkBathe, using this feedback to improve future sessions and make it accessible to a wider audience.N = 4), and felt that the data could not be considered generalisable.The study was approved by the College of Health, Psychology and Social Care, University of Derby Research Ethics Committee, and was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki. The intervention was delivered during the COVID-19 pandemic and aimed to improve mental wellbeing and social connection in adolescents who had been unable to attend school or meet with friends. Adolescents were sampled opportunistically from Scouts groups. The authors contacted Scout leaders local to the intervention site and asked them to invite their Scout groups and obtain parental permissions and consent. Scout leaders attended the sessions with their Scout groups to provide a sense of safeness through familiarity, and to comply with safeguarding requirements. Seventy-seven adolescents were registered by their parents to attend the session; of these, 63 adolescents completed baseline surveys, 51 completed post-intervention surveys, and 44 adolescents were matched according to their ID code. Hence, after an initial loss of complete data following registration (43% loss), the final sample completing the pre–post assessments was 44 adolescents , 19 males (49%), and 3 other or prefer not to say (8%); age 13.05 ± 1.65, range 9–17 years). There were 30 white participants (77%), 4 of mixed ethnicity (10%), 3 Asian participants (8%), and 2 ‘others’ (5%). Nineteen adolescents took part in field-based interviews immediately before and after the ParkBathe session. The researchers did attempt to collect follow-up data at 3 months but had a low response rate (N = 5), they could still engage in ParkBathe.The practitioners approached Scout and Youth group leaders who were local to the intervention site of Crystal Palace Park, London, and invited them to book their groups of adolescents onto a ParkBathe session. The group leaders distributed the information sheet and consent form via email to the adolescents’ parents to complete on their child’s behalf. If adolescents were aged 16–18 years old, they completed their own consent forms. On arrival at their session, the participants were asked to complete an online or paper-based survey and were interviewed. They began the ParkBathe session, which comprised a 1.5 h guided walk led by two qualified forest bathing guides around an urban park . If participants did not wish to consent to the evaluation , six items scored 1–5 ), ruminahttps://podcasts.apple.com/gb/podcast/mother-nature-connecting-children-to-nature/id1543205446?i=1000548655401 (accessed 23 August 2022).Adolescents were asked the following questions before their ParkBathe session: Have you ever done something like forest bathing before? What do you think this is about? How are you feeling about it? How do you think it will make you feel? How is school at the moment? The following questions were asked after ParkBathe: How did you find that? Was it what you were expecting? How do you feel now? Did you have a favourite exercise? Do you think you might come and use the park to relax more? Adolescents were interviewed and audio was recorded using a mobile phone with plug-in microphone. Audio was transcribed and then thematically analysed by an independent researcher , and the analysis was second-coded, discussed, and agreed with a second independent researcher . Independent researchers conducted the transcription and analysis because the research team wanted to avoid potential bias that might arise from team members who delivered the intervention conducting the transcription and analysis. Soundbites from adolescent interviews and further discussions about the adolescent sessions can be found on the ParkBathe podcast The free 1.5 h forest bathing sessions were led by two qualified practitioners trained by The Forest Bathing Institute , and involved the guided discovery and mindful appreciation of an urban park . Forest bathing group sizes ranged from 6–15 participants. The practitioners originally tried to deliver a similar forest bathing session to the type that adults would receive . They quickly realised from observations that the adolescents were too active and talkative for this to be enjoyable for them, and so sessions were iteratively improved using adolescents’ feedback. The sessions therefore resembled forest school, but with a more sensory forest bathing focus. The session started with an introduction in which the history and purpose of forest bathing was explained. Participants engaged in visual activities which included (i) visually inspecting a tree from roots to canopy, and noticing the shape and character; (ii) searching for leaves and other fallen objects to create a natural colour palette (perhaps colours they would like to paint their bedroom); and (iii) inspired by images of art produced by Andy Goldsworthy, to create their own natural artwork on the forest floor. In a listening activity, adolescents were invited to cup their ears to determine what sounds they could hear. In a smell activity, adolescents were invited to smell leaf litter and soil from the woodland floor; however, this activity was observed to make them uncomfortable and self-conscious, and was therefore omitted from future sessions. In a touch activity, they were invited to partner-up, and one person guided the other (who had their eyes closed) to a tree and encouraged them to get to know their tree through touch alone, they then brought their partner back to the centre and asked them to find their tree. Finally, in an empathy activity, adolescents interviewed a tree in pairs, with one person pretending to be the tree whilst another interviewed the tree about their life. Adolescents also engaged in two sharing circles throughout the session, where they were invited to feedback on their experience. The intention of sharing circles is peer learning and benefiting from the experience of others . For exaThree difference scores in anxiety (POMS), one in rumination, and two in scepticism between pre-intervention and post-intervention sessions were identified as outliers by the outlier labelling rule , and wert-tests were conducted for all outcome variables where complete data was provided between baseline and post-intervention (N = 44). There were statistically significant improvements in nature connection and social connection, which both increased significantly, and improvements in anxiety (POMS), rumination, scepticism, and excitement (three circle model), which reduced significantly (d = 0.95 [Paired-samples ficantly . The effd = 0.95 ). p > 0.05) and covariances . For gender , significant interaction effects were identified in anxiety (POMS) and scepticism  = 4.83, p = 0.04, partial η2 = 0.12).Subgroup analyses were conducted to examine whether there was a significant interaction effect between subgroups from baseline to post-intervention: gender , nature connection, scepticism, and anxiety at baseline . Two-way mixed ANOVAs were conducted. There was homogeneity of variances  = 5.61, p = 0.02, partial η2 = 0.14).Likewise, as shown in F = 20.84, p < 0.001, partial η2 = 0.36). As shown in p8 ‘Never heard of it until now, it’s a new thing’, implying that they thought it was a contemporary form of practice. Other participants related it to more established wellbeing practices such as mediation, yoga, and mindfulness. However, most of the participants recognised that it was about being in nature. For example, one participant stated, p2 ‘It’s about the nature around us that seems to be doing something to you’, another stated, p5 ‘Immersion in nature’. This indicates that there was a collective understanding that a key element of this approach involved the therapeutic factors of being in the natural world. The qualitative findings support these survey results. Firstly, there was a mix of understanding and expectations from the adolescents. There were participants who did not have any understanding of forest bathing at all. For example, one participant stated, p1 ‘I’m quite relaxed’ but another stated p7 ‘The only way to be calm is if anger was not an emotion’. There were some expectations that it would improve their mental health. For example, p6 ‘It’s an opportunity to relax without having to think’. However, a parent of a child admitted ‘He didn’t come voluntarily but I know he’ll enjoy it when he gets going’. This implies that this parent recognised that their child was reluctant but believed that taking part would be beneficial. Five participants commented on their current mood before taking part; again, this ranged from feeling relaxed to stressed. For example, one participant stated, p4 ‘It was fun, creative’ and another p9 ‘To explore, do activities, enjoy being here’. One participant stated, p12 ‘Everyone here is much younger, and I just got to be a kid again’. This indicates that this young person was able to be childlike and carefree. Secondly, the social aspect of the activities was also something some participants particularly noticed. For example, one participant stated, p6 ‘It took trust to actually listen to people’. This implies that there was a sense in building confidence as a collective to connect with one another. Another participant suggested they were surprised there was a focus on group interaction p13 ‘I thought it would be more about nature and me, but it was less about that and more about the connection with activities we did’.The qualitative findings following the intervention indicate that for most of the participants the experience was seen as positive, and this was expressed in several ways. Firstly, there was a strong sense of enjoyment. For example, one participant said, p14 ‘Making yourself stop, take stock and take time to listen is great’. Other participants expressed what they had noticed whilst doing the activities. For example, p10 ‘(The tree bark) Smells like fresh bread, the doughiness of the bread’ and p3 ‘Trees grow in very peculiar ways, none of them are ever the same’. Other participants conveyed learning from the experience. For example, p7 ‘I never realised how brittle these trees are. You think they’ll be hard because they’ve been here so long, but you touch it and the bark flakes off. Imagine how long these trees have been here and how much knowledge they’ve got; they’ve seen so much.’ and p1 ‘Having a conversation with a tree was enlightening’. This connection to nature was described further by another participant who stated, p6 ‘When I feel the tree, you have a connection with the tree, how it’s feeling (not like human emotions), like the health of the tree. It’s like I’m looking for a heartbeat, and as you move your fingers down the tree, it’s almost like you can feel it’. Here the participant associated the tree as a living entity they could relate to. Another participant’s feeling of connection was described as rooted historically, p12 ‘Trees are beautiful, they keep us alive, they do so much for us, we can misjudge nature but when you have that connection with nature it is like that instant bond. Nature, it is almost like part of who we are and our ancestors and things and connecting to deeper history’.There was strong indication from the participants that they were able to be present within the moment by noticing the natural world around them. For example, one participant stated, p18 ‘Much more relaxed and rested’, p8 ‘Found activities calming’, p2 ‘Relaxing experience’ and p4 ‘Very chill’. Another participant expanded on this, p9 ‘Much happier. I’ve had a lot of stress this week. Exams coming up, but I’m not even thinking about that right now, I’ve got chronic fatigue so my fight/flight is all over the place, next time I’ll spend more time in the woods, just listening and jumping about.’ One participant expressed a deeper value in the activity they experienced, p7 ‘I found this experience to be incredibly indulgent and an eye-opening journey I truly hope this reaches other kids as I believe it helps and can bring enlightenment to those without’. For this participant, taking part led to an immediate revelation and insight into how this type of practice can be beneficial. Therefore, in summary, these findings indicate an immediate effect on connecting adolescents with people, nature, and themselves.Lastly, there was an overall recognition that the activities had a positive impact on their mental health. Participants described feeling When interpreting the below findings, it is worth considering the context that the intervention was delivered during the COVID-19 pandemic, and aimed to improve mental wellbeing and social connection in adolescents who had been unable to attend school or meet with friends. There were statistically significant improvements in nature connection and social connection, which both increased significantly, and significant improvements in anxiety (POMS), rumination, scepticism, and excitement (three circle model), which all reduced significantly. The effect size was largest for nature connection.Subgroup analyses revealed that female adolescents’ anxiety and scepticism scores decreased substantially compared with male’s scores, which showed a subtle increase. This is consistent with Barton et al. , who fouThese survey results showing improved scores in nature connection, anxiety, and social connection, are consistent with previous research, which found that nature-based interventions improved nature connection ,21,27,39The qualitative findings indicate that, although there was a mixed degree of understanding and expectations from adolescents, the majority recognised that the key element involved being with nature. They reported an assortment of mental states before the intervention commenced, in particular, anxiety about completing schoolwork. However, following the intervention, most of the participants experiences were expressed as positive in several ways. These included being able to enjoy the activities and the social aspects of being part of a group. The participants were enabled to learn, trust, and build confidence for sharing thoughts and experiences with each other. There was also a strong indication that they were able to be present in the moment by noticing the natural world around them. They found the effects of this intervention immediately calming and relaxing.The themes of enjoying the social aspects of being part of a group, being present in the moment by noticing the natural world, and finding the experience calming and relaxing, show some consistency with previous qualitative studies that have examined the benefits of nature for young people. For example, Birch et al.  found thThrough focus groups ,43 and pThe recruitment strategy for the study was opportunistic sampling from Scout groups in the local area. Opportunistic sampling has limitations in the respect that adolescents in a specific localised area may not be demographically or socio-economically representative of the wider population. One strength, however, is that because this was a pre-established group, a more pragmatic sample was obtained, which included adolescents who would not normally choose to engage in more mindful and creative nature connection activities. This is likely to have provided a more balanced view of how acceptable and effective the intervention was. Future studies should aim to recruit more diverse populations, and to base the sample size on a power calculation.Gathering survey or diary data from adolescents can pose challenges, such as problems of validity and reliability, associated with inaccurate assessment, recall bias, and social desirability bias . Some adThe researchers observed that some adolescents appeared self-conscious about providing interview responses. In a paper outlining recommendations for interviewing young people, Ponizovsky-Bergelson et al.  suggest This study did attempt to collect heart rate variability (HRV) data. However, adolescents were too mobile and continuously adjusted their HRV devices (Polar H10), meaning that devices frequently failed to provide a signal. Hence, data were only successfully gathered for seven participants, and we do not report this data here as the sample size is too small to be generalisable. Finally, there is great variability in delivering nature-based programmes, and this makes it a challenge to objectively compare the current intervention with interventions assessed in previous studies . Future There is a wealth of evidence showing that mere access to nature can benefit adolescents’ wellbeing. However, nature connection interventions that actively seek to develop a connection with nature can have an even greater impact on adolescent wellbeing, and are currently less researched. The current study assessed an active nature connection intervention, and found that following urban forest bathing, significant improvements were found in anxiety, rumination, scepticism, nature connection, and social connection. The largest effect size (improvement) was found for nature connection. Interview data complemented the survey data, and provided convergent validity. Interviews revealed that participants enjoyed the social aspects of being part of a group, being mindfully present in the moment by noticing the natural world around them, and feeling immediately calmed and relaxed. Previous nature connection intervention studies have assessed interventions taking place in wilderness or rural settings. However, some researchers suggest that young people might be limited in their access to such settings due to their lack of autonomy, transport, and parental permission . The cur


John Fitzgerald Kennedy (JFK), the 35th President of the USA, had chronic low back pain deemed to be centralized pain. Reportedly, attention‐deficit/hyperactivity disorder (ADHD) could associate with centralized pain. Based on his biographies, JFK could have had ADHD, a plausible cause of pain that afflicted him. Patients who tend to be hyperactive, like JFK, have centralized pain, such as chronic low back pain, and may also have comorbid ADHD. Clinicians should screen for ADHD because chronic centralized pain can improve with ADHD medications. JFK's biographies are filled with tales of the President's inattention and hyperactivity. In recent years, ADHD has been associated with centralized pain and chronic LBP.2John Fitzgerald Kennedy was depicted as a lively man, full of energy; he forced himself to act this way. In reality, he suffered from poor health; the details of his ailments remained a secret until 2001 (at the request of the Kennedy family), when the medical archives of the Kennedy library were opened for public scrutiny.The Impact of Illness on World Leaders,Kennedy's biographer Robert Dallek chose Dr. Jeffrey Kelman, a specialist in internal medicine and physiology, to accompany him, along with Dr. Bert E Park, a neurosurgeon and the author of James MacGregor Burns was a Democratic nominee in Massachusetts's first congressional district who published a biography of JFK in 1959 to determine whether JFK had the qualifications of a president.3According to the diagnostic criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM‐5),3.1Several factors indicate that JFK experienced problems with attention, including inattention related to work‐related activities (DSM‐5 inattention criterion a), difficulty in sustaining attention to tasks (criterion b), being dreamy or preoccupied (criterion c), not following through on instructions in the workplace (criterion d), having difficulty keeping belongings in order and poor time management (criterion e), avoiding tasks requiring sustained mental effort (criterion f), often losing things (criterion g), and frequent forgetfulness (criterion i). Several examples can be quoted as follows: JFK's thesis had “many typographical errors and was English diction defective” (a).Other descriptions indicate that he also had characteristics of hyperactivity and impulsivity, including often fidgeting with his hands (a), often leaving his place or seeking fast‐paced activity (b), often running about or feeling restless (c), always “on the go” acting as if “driven by a motor” (e), and difficulty in waiting patiently (h). Specifically, as he talked with visitors in his office, Kennedy would fidget with a pencil.Considering the above descriptions of JFK (some of which indicate his mannerisms even before 12 years of age), we believe that JFK met several diagnostic criteria for ADHD outlined in the DSM‐5; these included 8/9 items  from the subcategory “Inattention” and 5/9 items  from the subcategory “Hyperactivity/impulsivity” in item A of the ADHD section in DSM‐5. This could be considered ADHD of the combined type.4To the best of our knowledge, this study is the first report to investigate the possibility of JFK's diagnosis of ADHD in line with valid diagnostic criteria. However, ADHD did not prevent JFK from achieving success because he was able to surround himself with competent, detail‐oriented people , and he was willing to delegate to them both responsibility and authority.Thus, adult ADHD is less likely to manifest functional impairment when occupational and social demands are met by internal resources, such as intellectual ability and self‐control, and external resources, such as support from family members.As JFK was also called a dynamo, his “overactivity”, “action‐proneness”, and “ergomania”, which have been described as typical behavioral traits of patients with chronic pain in the previous literature,Pinals et al.In addition to pain disorders, conditions such as fibromyalgia, IBS, celiac disease, insomnia, malabsorption, hypothyroidism, and allergies, which were present in JFK, are all physical disorders associated with ADHD.Although the concept of ADHD had not existed during his lifetime, JFK preferred the central stimulant amphetamine for pain management,Additionally, Kennedy's son was diagnosed with ADHD,Furthermore, behind JFK's success, his continued anxiety and fear of rejection from his father, who forced him to become a politician like a surrogate doll, was one of the main conflicts in JFK's life.The limitation of this study is that the ADHD diagnosis of JFK is a hypothetical diagnosis based on the description in the published literature, as the authors did not directly examine JFK.The President's Panel on Mental Retardation,SK and KM conceived the study. SK and NS collected and organized the literature information. SK wrote the manuscript. S‐IN assisted in writing the manuscript. All authors have approved the final manuscript for submission.This study was funded by the Japan Society for the Promotion of Science KAKENHI (Grant Number: JP20K07755). The sponsor has no role other than funding.The authors declare that there is no conflict of interest.None.Informed consent for patient information to be published in this article was not obtained because we have dealt with only already published historical data in this case report. There is nothing in this paper that would harm the human rights of the patient.