Nature versus urban hiking for Veterans with post-traumatic stress disorder: a pilot randomised trial conducted in the Pacific Northwest USA

Alyson J Littman, Gregory N Bratman, Keren Lehavot, Charles C Engel, John C Fortney, Alexander Peterson, Alex Jones, Carolyn Klassen, Joshua Brandon, Howard Frumkin, Alyson J Littman, Gregory N Bratman, Keren Lehavot, Charles C Engel, John C Fortney, Alexander Peterson, Alex Jones, Carolyn Klassen, Joshua Brandon, Howard Frumkin

Abstract

Objectives: To evaluate feasibility and acceptability of a group-based nature recreation intervention (nature hiking) and control condition (urban hiking) for military Veterans with post-traumatic stress disorder (PTSD).

Design and setting: A pilot randomised controlled trial conducted in the US Pacific Northwest.

Participants: Veterans with PTSD due to any cause.

Interventions: Twenty-six participants were randomised to a 12-week intervention involving either six nature hikes (n=13) or six urban hikes (n=13).

Primary and secondary outcome measures: Feasibility was assessed based on recruitment, retention and attendance. Questionnaires and postintervention qualitative interviews were conducted to explore intervention acceptability. Questionnaires assessing acceptability and outcomes planned for the future trial (eg, PTSD symptoms) were collected at baseline, 6 weeks, 12 weeks (immediately after the final hike) and 24 weeks follow-up.

Results: Of 415 people assessed for eligibility/interest, 97 were interested and passed preliminary eligibility screening, and 26 were randomised. Mean completion of all questionnaires was 91% among those in the nature hiking group and 68% in those in the urban hiking group. Over the course of the intervention, participants in the nature and urban groups attended an average of 56% and 58%, respectively, of scheduled hikes. Acceptability of both urban and nature hikes was high; over 70% reported a positive rating (ie, good/excellent) for the study communication, as well as hike locations, distance and pace. Median PTSD symptom scores (PTSD Checklist-5) improved more at 12 weeks and 24 weeks among those in the nature versus urban hiking group.

Conclusions: This pilot study largely confirmed the feasibility and acceptability of nature hiking as a potential treatment for Veterans with PTSD. Adaptations will be needed to improve recruitment and increase hike attendance for a future randomised controlled trial to effectively test and isolate the ways in which nature contact, physical activity and social support conferred by the group impact outcomes.

Trial registration number: NCT03997344.

Keywords: adult psychiatry; complementary medicine; public health; trauma management.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Conceptual model.
Figure 2
Figure 2
Depiction of study design and assessments. PTSD, post-traumatic stress disorder.
Figure 3
Figure 3
CONSORT diagram. CONSORT, Consolidated Standards of Reporting Trials.

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