Nature-based Therapy Research Articles

How outdoor and indoor green spaces affect human health: a literature review.

The analysis of the complex interactions between outdoor or indoor greenness and the health of individuals and ecosystems is a topic of current and growing interest. This review aims to examine and summarise the results of studies conducted to evaluate the effects of exposure to greenness on various aspects of human health and the natural environment. For this purpose, in April 2024 we searched PubMed, Web of Science, and Scopus databases, Google Scholar and specialised books. Evidence gathered demonstrates a remarkable correlation between exposure to outdoor and indoor greenness and the improvement of mental health, including the reduction of stress, anxiety, and depression. Contact with greenness is also associated with improvements in physical health, such as reductions in blood pressure, heart rate, and inflammation, as well as in cognitive abilities, concentration, and overall recovery. These benefits are recognisable both in outdoor spaces, such as urban parks, oases, and public gardens, and in indoor spaces, through the introduction of plants and nature-evoking elements in living and working environments. The presence of vegetation in indoor environments, such as offices, schools, healthcare facilities, prisons, and others, can contribute to improving the quality of social spaces, fostering communication, and collaboration, and attenuating aggressiveness and inequalities, thereby increasing employee satisfaction and work efficiency. The combination of outdoor/indoor green spaces and the well-being of the living environment includes exposure to greater biodiversity, mitigation of extreme weather events, absorption of atmospheric pollutants, attenuation of urban background noise, and increased privacy. The presence of vegetation in urban areas has a positive impact on social cohesion, promoting interpersonal interaction and facilitating the development of more cohesive and inclusive communities, thus supporting a sense of belonging and collective identity. In conclusion, these results underline the importance of considering contact with greenness as a fundamental element in promoting the psychophysical health and well-being of individuals and ecosystems, suggesting the adoption of nature-based therapies and interventions in public health policies and urban planning practices.

Cytotoxic and apoptotic effect of Vernonia amygdalina Delile. fractions against Hs578t triple-negative breast cancer cell lines

BackgroundTriple-negative breast cancer (TNBC) is a type of breast cancer whose treatment is significantly more complicated than that for other forms of breast cancer. Chemotherapy is now the mainstay of treatment, but it often causes adverse effects for patients, making nature-based therapies an alternative. Aim of the studyVernonia amygdalina is a medicinal plant with significant potential to be utilised as a chemo-preventive agent due to its exceptional antioxidant qualities. This research aims to evaluate the anticancer properties of this plant on Hs587t breast cancer cells. MethodsThe extract was extracted using ethanol and fractionated with n-hexane and ethyl acetate, then separated by column chromatography. The toxicity was tested on the Hs587t cell line using the micro-tetrazolium technique. The three best subfractions for phytochemical constituents were analyzed using LCHRMS. Flow cytometry was used to analyze the patterns of apoptosis and cell cycle. ResultsCytotoxicity on cells showed that subfractions 1, 2, and 3 (IC50 13.76 ± 0.10, 4.57 ± 0.22, and 9.77 ± 0.27 µg/mL) were the best. This subfraction induces both early and late apoptosis while inhibiting the advancement of the G2−M phase of the cell cycle. ConclusionThe study found that subfractions 1, 2, and 3 of V. amygdalina leaves demonstrated significant anticancer properties against breast cancer. This was observed through their toxicity and ability to induce apoptosis in Hs587t cells. However, additional clinical trial investigations are necessary to obtain more dependable outcomes.

Living lab modelling as a pilot study assessing the potential psychological health benefits of forest environment for cancer survivors.

To evaluate the physiological and psychological changes in cancer survivors who engage in repeated forest therapy in a living environment. This study included stay-based forest therapy for female cancer survivors aged ≥40 years. The program was conducted in two cycles, each spanning 3 weeks and consisting of a 2-night, 3-day stay, followed by daily life integration. The cycles were repeated from July 2, 2022, to August 18, 2022. Participant assessment included standard physical health parameters and a questionnaire on general characteristics, lifestyle habits, stress levels, and health status. Thirty-seven female cancer survivors participated in the forest healing program, 56.8% of whom had a history of breast cancer. The median body mass index (BMI) was 23.80 kg/m2 (range, 21.00-25.60). More than half of the patients reported mild-to-moderate fatigue, chronic pain, and mild-to-moderate depression (81%, 65%, and 73%, respectively). After two cycles of forest therapy, no significant differences were observed in terms of fatigue, pain, or BMI levels. However, significant improvements were found in quality of life measures, particularly the psychological quality of life (mean score 12.54 at baseline vs. 13.48 after cycle 2; P=0.007). Positive improvements were also observed in terms of stress (mean score 17.03 vs. 13.76; P=0.002) and depression (mean score 8.35 vs. 6.11; P=0.002) levels. Our forest-healing program demonstrated that nature-based therapies improve the mental health and quality of life of female cancer survivors, suggesting the need for further research on nature-based interventions to better support cancer survivors.

Greenspaces and Health: Scoping Review of studies in Europe.

Access to greenspaces and contact with nature can promote physical activity and have positive effects on physical and mental health. This scoping literature review aims to examine current evidence linking greenspaces and (a) behaviour change, (b) health outcomes and (c) co-benefits. This review was conducted in accordance with the PRISMA scoping review guidelines. Searches were conducted through PubMed and EMBASE databases for studies published between 2000 and March 2023 with a focus on Europe. 122 scientific articles and grey literature reports were identified. Access to greenspaces is positively associated with physical and mental health, and reduced risk of all-cause mortality and some non-communicable diseases. Greenspace quality is associated with increased physical activity and reduced risk of obesity. Nature-based therapies or green prescription are effective in improving mental health outcomes and overall health. Importantly, numerous co-benefits of greenspaces are identified. Increasing access to greenspaces for populations with particular attention to greenspace quality is important for co-benefits. Responsible governance and use of greenspaces are crucial to minimize public health risks and human disturbance of nature.

A Nature-Based Intervention to Support the Well-Being of Baccalaureate Nursing Students.

The high stress of nursing education can adversely affect students' well-being. Nature-based therapies aim to lessen stress. There is a gap in knowledge related to nature-based therapies and the nursing student population. The aims of this study were: (1) to describe the well-being of nursing students; and (2) to assess the effects of a nature-based intervention on students' anxiety, stress, relatedness, resilience, and well-being. This descriptive study included 28 nursing students at a midwestern university. Participants completed online questionnaires before and after a nature-based intervention at an arboretum that consisted of five 1-hour designated nature walks guided by an audio recording. Participants' mean (SD) scores for well-being were classified as average before the intervention (54.3 [3.7]) and increased significantly after the intervention (55.3 [3.2]) (p = .04). With rising stress and anxiety levels among college students, nature interventions can support nursing students' overall well-being. [J Nurs Educ. 2024;63(2):116-119.].

An overview of some pharmacologically relevant therapeutic plants from Kerala's sacred groves

In Kerala's native culture, sacred groves are referred to as "Kavu" and have long been used as archives for traditional knowledge and biodiversity. Many medicinal plants with strong pharmacological properties can be found in these distinctive habitats, and they have historically provided local populations with medicine. Studying the pharmacological significance of plants from Kerala's sacred groves will help us to gain a better understanding of the value of nature-based therapies in a time when both natural resources and traditional knowledge systems are more crucial than ever. This comprehensive review article seeks to study wide variety of medicinal plants present in Kerala's sacred groves, including Murdannia pauciflora, Osbeckia muralis and Indoneesiella echioides, offering light on their historical use and pharmacological qualities that have been proven.

The mechanisms of nature-based therapy on depression, anxiety, stress, and life satisfaction: examining mindfulness in a two-wave mediation model.

Nature-based therapy (NBT), which centers around engaging in activities within natural surroundings, has consistently demonstrated therapeutic benefits for mental health. While NBT highlights the potential of nature as a therapeutic resource for promoting mental health, there is limited knowledge regarding its underlying mechanisms. Two hundred seventy-six Korean participants (204 women, mean age = 54.99 ± 23.25 years) participated in a 30-session gardening program held twice weekly for 15 weeks. Structural equation modeling with a two-wave autoregressive cross-lagged model was used to investigate the mediating effects of mindfulness. NBT significantly improved the mean scores of all psychological variables. The mediation model was partially confirmed, with mindfulness at post-intervention (T2) mediating the relationship between baseline (T1) depression and anxiety and post-intervention (T2) life satisfaction. However, no significant indirect effect was observed between the path from stress (T1) to life satisfaction (T2). Mindfulness is a crucial component for improving mental health outcomes. This study underscores the need to prioritize and emphasize mindfulness practices in NBT.

The effectiveness of nature-based therapy for community psychological distress and well-being during COVID-19: a multi-site trial

During the COVID-19 pandemic, the world population faced various mental health challenges, highlighting a need for new community-based psychosocial interventions. This study aimed to investigate the effectiveness and feasibility of Nature-Based Therapy (NBT) for the community experiencing psychological distress during the pandemic. A multi-site trial comparing NBT and control groups was conducted in Korea with 291 participants exhibiting mild to severe depression or anxiety. A total of 192 participated in 30 sessions of therapeutic gardening, while 99 remained in the control group. Psychological distress and well-being were assessed using seven measures of depression, anxiety, daily activity, life satisfaction, mindfulness, stress, and loneliness. The effect sizes (Cohen’s d) of NBT compared to the control group were medium to large: depression (0.583), anxiety (0.728), daily activity (1.002), life satisfaction (0.786), mindfulness (0.645), stress (0.903), and loneliness (0.695). Multilevel analysis revealed significant Time × Group interaction effects for all measures. Pearson correlation (r = − 0.28 to 0.71) showed that changes in all variables correlated significantly with each other, with small to large effect sizes. Therapeutic alliance at post-test positively moderated the intervention effects on the outcomes. We concluded that NBT is a promising psychosocial intervention for treating psychological distress for community dwellers.

Forest therapy as a trauma-informed approach to disaster recovery: Insights from a wildfire-affected community

A trauma-informed approach to disaster recovery recognizes the potential impacts of trauma, promotes resilience to protect against retraumatization, and can support catering the needs of disaster survivors in affected communities. A growing body of evidence demonstrates that interaction with nature is associated with a number of physical and mental health benefits, though literature surrounding nature-based therapy and disaster survivors is limited. Through key informant interviews with forest therapy guides from a program in wildfire affected Butte County, CA, this exploratory study investigates if and how “Forest Therapy ’’ can serve as a trauma-informed approach to promote wellbeing in the face of climate change and associated disasters. We find that community-based forest therapy programs offer a promising, flexible approach to community-based trauma-informed mental health servicest in disaster-affected communities. Findings also identify opportunities to tailor implementation of future programs to better reach populations most impacted by disasters, including through targeted outreach and diverse guide recruitment. Future research should investigate the impacts of forest therapy on the mental health and wellbeing of participants, as well as the scalability of forest therapy programs in disaster-affected communities.

Embracing Nature's Therapeutic Potential: Herbal Medicine

This study investigates the significant relationship between nature and human well-being, proposing for the incorporation of nature-based therapies into modern healthcare procedures. In a society dominated by technology and fast-paced living, the need to reconnect with nature and embrace its therapeutic power has never been more pressing. The paper emphasizes the inherent connection between humans and the natural environment, drawing on evolutionary history and scientific research that indicate nature's positive impact on mental, emotional, and physical health. The concept of nature-based therapies, such as ecotherapy, horticultural therapy, forest bathing, wilderness therapy, and nature meditation, lies at the heart of this holistic approach to healing. Each of these therapies uses natural ingredients to promote healing and well-being, responding to individual requirements and developing a sense of connection with the natural environment. The report delves into the unique benefits of each nature-based therapy, emphasizing its usefulness in lowering stress, increasing mood, enhancing cognitive function, and strengthening the immune system. This comprehensive approach to healthcare, with a focus on prevention, personalized care, and root-cause investigation, is in sync with the concepts of nature-based therapies. The incorporation of herbal medicine into modern healthcare supplements this approach by providing natural and gentle healing therapies that target the full person—mind, body, and spirit. The report also underlines the significance of the biophilia concept, which emphasizes humans' inherent affinity for nature. Embracing nature's therapeutic potential not only increases personal well-being but also instills a sense of responsibility for environmental protection and sustainability. The greater connection individuals create with nature through nature-based therapies fosters a heightened respect for the natural environment, encouraging a dedication to safeguard it for future generations. As the future of healthcare develops, embracing nature's therapeutic potential serves as a light of hope and transformation. The incorporation of nature-based therapies into current healthcare procedures provides an inclusive and holistic approach that improves conventional treatments, empowers patients in their healing path, and promotes general well-being.

Bibliometric Analysis of Nature-Based Therapy Research.

Unrestrained urbanisation and natural space loss are reducing contact with nature in today's society, producing negative consequences for people's mental and physical health and wellbeing. Nature-based therapies, such as physical activity in natural settings, forest bathing, therapeutic hiking, or experiential learning, reduce anxiety and depressive symptoms and improve the quality of life in both general and specific populations. A bibliometric analysis of research on nature-based therapies was performed by applying the traditional laws of bibliometrics (exponential growth law, Bradford's concentration law, Lotka's law, Zipf's law, etc.) to documents published in journals indexed in the Core Collection of the Web of Science (WoS). Graphical visualisation was performed using the VOSviewer software. Annual publications between 2006 and 2021 presented an exponential growth trend (R2 = 91%). The International Journal of Environmental Research and Public Health (MDPI) and Urban Forestry & Urban Greening (Elsevier) were the most productive and cited journals. Ikei, Miyazaki, and Song are the most cited prolific authors. The USA and South Korea were the countries with the highest scientific production. In recent years, there has been a growing interest in adventure, nature, and forest therapies among researchers. Nature-based therapies have experienced a growing interest in recent years. Positive effects on mental, physical, and emotional health have been found in different populations and research lines, although more studies with different designs and populations are needed.

Why losing Australia's biodiversity matters for human health: insights from the latest State of the Environment assessment.

Why losing Australia's biodiversity matters for human health: insights from the latest State of the Environment assessment.

Key Factors Strengthening Residents’ Psychological Well-Being and Critical Human-Nature Connections within the Living Spaces—An Example from Beijing

Background: Residential green spaces and the co-inhabiting bird communities provide critical cultural ecosystem services for urban dwellers, which is critical for citizens’ psychological well-being but has largely been overlooked, especially in China. This study attempted to delineate the relationship between human-nature interactions occurring at different scenarios in the health deriving procedure, and identify the key factors influencing urban residents’ psychological well-being and the potential critical human-nature connections within their living spaces. Methods: Bird, plant, and social surveys were sequentially conducted. A model selection procedure based on AICc information was used to find the key factors that are responsible for residents’ psychological well-being, and logistic regression analysis was conducted to figure out the key drivers for the occurrence of critical within-living-space human-nature connections. Results: Most of the respondents are aware of the neighborhood biodiversity and most of them are fond of it, and respondents who prefer fauna over flora have a considerably lower depression degree. Watching birds is the only critical within-living-space nature-related activity that is responsible for residents’ psychological well-being. Both residents’ psychological well-being and bird watching activity were simultaneously affected by nature-related activities within and outside the living spaces, while their preference for different aspects of biodiversity and their capability in perceiving them were also important, despite the difference in exact parameters. In addition, personal attributes such as age, financial income, and physical or mental health status also contribute to psychological well-being. Conclusions: This study successfully bridged citizens’ minds with health products, and the major contribution was the demonstration of a spatial-scale-oriented circuit for people-nature connections, which contributes to the practical application of nature-based therapy.

Nature-Based Therapy in Individuals with Mental Health Disorders, with a Focus on Mental Well-Being and Connectedness to Nature-A Pilot Study.

In times of social and ecological crises, such as COVID-19 with lockdowns and implementing the impact of climate change, mental health degrades. Being outdoors in nature can be health-promoting, can decrease depression, and increase mental well-being. This pilot study investigated the relationships between nature-based therapy, mental health, and individuals' connectedness to nature. We hypothesize that nature-based therapy has a positive impact on individual mental health and connectedness to nature. A mixed-method approach was used to evaluate the effectiveness of nature-based therapy for young psychosomatic patients. The results demonstrated improvements in mental well-being and connectedness to nature through therapy. Additionally, depression scores decreased. Patients reported the importance of the therapist setting the space, the supportive environment, the poems that fostered the nature connection, improvement at the soul level, and overall doing something meaningful. Every patient experienced nature-based therapy as effective. To conclude, the study gives a first insight into the processes of nature-based therapy in the German population at work and the effectiveness of nature-based therapy. Further questions, e.g., season effects, longitudinal effects, and whether patients with low connectedness to nature gain more out of the intervention remain unanswered.

Multisite Agricultural Veterans Affairs Farming and Recovery Mental Health Services (VA FARMS) Pilot Program: Protocol for a Responsive Mixed Methods Evaluation Study

Veterans Affairs Farming and Recovery Mental Health Services (VA FARMS) is an innovative pilot program to provide supportive resources for veterans with interests in agricultural vocations. Implemented at 10 pilot sites, VA FARMS will provide mental health services and resources for veterans while supporting training in gardening and agriculture. As each pilot site project has unique goals, outreach strategies, and implementation efforts based on the local environment and veteran population, evaluating the pilot program provides a unique challenge for evaluators. This paper describes the protocol to evaluate VA FARMS, which was specifically designed to enable site variation by providing both site-specific and cross-site understanding of site implementation processes and outcomes. The objectives of this paper are to (1) describe the protocol used for evaluating VA FARMS, as an innovative Department of Veterans Affairs (VA) agriculturally based, mental health, and employment pilot program serving veterans at 10 pilot sites across the Veterans Health Administration enterprise; and (2) provide guidance to other evaluators assessing innovative programs. This evaluation uses the context, inputs, process, product (CIPP) model, which evaluates a program's content and implementation to identify strengths and areas for improvement. Data collection will use a concurrent mixed methods approach. Quantitative data collection will involve quarterly program surveys, as well as three individual veteran participant surveys administered upon the veteran's entrance and exit of the pilot program and 3 months postexit. Quantitative data will include baseline descriptive statistics and follow-up statistics on veteran health care utilization, health care status, and agriculture employment status. Qualitative data collection will include participant observation at each pilot site, and interviews with participants, staff, and community stakeholders. Qualitative data will provide insights about pilot program implementation processes, veterans' experiences, and short-term participation outcomes. Evaluation efforts began in December 2018 and are ongoing. Between October 2018 and September 2020, 494 veterans had enrolled in VA FARMS and 1326 veterans were reached through program activities such as demonstrations, informational presentations, and town-hall discussions. A total of 1623 community members and 655 VA employees were similarly reached by VA FARMS programming during that time. Data were collected between October 2018 and September 2020 in the form of 336 veteran surveys, 30 veteran interviews, 27 staff interviews, and 11 community partner interviews. Data analysis is expected to be completed by October 2022. This evaluation protocol will provide guidance to other evaluators assessing innovative programs. In its application to the VA FARMS pilot, the evaluation aims to add to existing literature on nature-based therapies and the rehabilitation outcomes of agricultural training programs for veterans. Results will provide programmatic insights on the implementation of pilot programs, along with needed improvements and modifications for the future expansion of VA FARMS and other veteran-focused agricultural programs. DERR1-10.2196/40496.

Natural Volatile Organic Compounds (NVOCs) Are Greater and More Diverse in UK Forests Compared with a Public Garden

Forest bathing is based upon a Japanese practice known as Shinrin–Yoku and is a nature-based therapy involving mindful walks through ancient woodland to reduce stress and anxiety. One proposed mechanism behind the effectiveness of Forest bathing is based on the potential mental and physical health benefits of the natural volatile organic compounds (NVOCs) that fill the forest understory. Surprisingly little is known about the concentrations and diversity of plant NVOCs in ambient air particularly in the UK and this study aims to increase that knowledge. Air samples were collected in July 2022 in a UK forest and compared with samples from a walled garden environment. The samples were collected over a 2 h time period and analysed using GC-MS and showed clear differences in the chemical composition of the air. This study revealed NVOCs including limonene, carvone, terpenes, terpenoids and sesquiterpenoids were present within a UK forest but were either not present or present at little to low levels in the control setting of a walled garden. This study also found that the typical 2 h duration of a Forest bathing session was a long enough sampling period to detect these NVOCs, indicating that Forest bathers could benefit from exposure to NVOCs.

Care Farming: A Natural Therapy for Healthy Life

Care farming is a form of 'Green Care' providing opportunities for those suffering from a range of health problems to work in horticultural/agricultural activities as a means of physical health, promoting mental and social wellbeing. This type of naturebased therapy or therapeutic intervention uses farms and agricultural landscapes to boost mental, social, and physical health through routine farming activities for people with a specified need.

The Role of Nutrition and Forest-Bathing in the Physical Rehabilitation of Physically Inactive Patients: From the Molecular Aspects to New Nature-Inspired Techniques.

Physical rehabilitation plays a fundamental role in the management of individuals with disabilities associated with age-related muscle loss or affected by catastrophic conditions such as trauma, surgery, cancer or other severe pathologies. These events have in common an extended period of physical inactivity. Patients who undergo prolonged bed rest often present with a number of complications; for example, muscle loss that can exacerbate existing conditions determined by sarcopenia, which in turn greatly limits physical functions. The main scope of this work is to summarize certain key strategies for the physiotherapeutic management of physically inactive patients, regardless of the reason behind their prolonged bed rest, with a particular focus on physical rehabilitation, nutrition and forest-bathing. The importance of correct nutrition in counter-acting the loss of muscle mass and consequent function is explored alongside a description of the main nutrients that are needed for muscle regeneration. From a biomolecular perspective, some specific molecular mechanisms associated with physical rehabilitation are also reported not only in the context of physical therapy, but also within nature-inspired techniques, such as forest-bathing as well as body self-healing. Combining a targeted physiotherapeutic approach with an appropriate diet as well as nature-based therapy could thus help with the recovery of bed ridden patients.

Does living near blue space modify the effect of socioeconomic deprivation on mental health in urban areas: a population-based retrospective study

BackgroundThe incidence of mental health disorders in urban areas is increasing and there is a growing interest in using urban blue spaces as nature-based therapy to prevent and manage mental health. However, there is a dearth of longitudinal evidence of the mechanisms and effect of blue spaces on clinical markers of mental health to support and inform such interventions. Restoration of the north Glasgow branch of the Forth and Clyde canal began in 2000 as part of Glasgow's Smart Canal project, which is the largest programme of canal regeneration in the UK. The canal was completely closed and left to dereliction for more than 40 years and the first canal lock reopened as a space for recreation in 2006. Situated within the most deprived neighbourhoods in Europe and characterised by a clustering of environmental and socioeconomic deprivation, physical and mental health challenges, substantial health disparities, and climate change vulnerabilities, this is a unique natural experiment that was primarily developed to increase the communities’ resilience to climate change. MethodsTo investigate the mental health cobenefits deriving from the canal regeneration project, we conducted a population-based retrospective cohort study and explored whether living near blue space modified the negative effect of socioeconomic deprivation on the mental health of the population of north Glasgow, Scotland, using routinely collected NHS data, over a 10-year period (2009–18). We developed two Cox proportional hazards models; a base model estimating the effect of socioeconomic deprivation on mental health and a second identical model with an additional variable of distance to blue space. We then investigated the modifying effect of living near blue space by comparing the effects between the two models. FindingsOur findings indicate that living near blue space modified the risk of mental health disorders deriving from socioeconomic deprivation by 6% (hazard ratio [HR] 2·48, 95% CI 2·39–2·57) for those living in the most deprived tertile, and 4% (1·66, 1·60–1·72) for those in the medium-deprivation tertile. InterpretationThe findings of this study support the notion that living near blue space could play an important role in reducing the burden of mental health inequalities in urban populations. FundingThe Data Lab (to SC).

Economic Evaluation of Nature-Based Therapy Interventions—A Scoping Review

Introduction: Nature-based therapy (NBT) has shown positive effects on different health-related outcomes and is becoming a more frequent approach in various rehabilitative interventions. Economic evaluations are widely used to inform decision makers of cost-effective interventions. However, economic evaluations of NBT have not yet been reviewed. The aim of this review was to uncover existing types and characteristics of economic evaluations in the field of nature-based therapeutic interventions. Methods: In this scoping review available knowledge about the topic was mapped. A comprehensive search of selected databases (MEDLINE; EMBASE; CINAHL; Scopus; Cochrane; PSYCinfo; Web of Science) and grey literature was conducted in November 2021. Data was synthesised in a thematic presentation. Results: Three papers met the inclusion criteria, containing differences in design, types and dose of nature-based therapeutic interventions, outcome measures and target groups (n = 648). The papers showed tendencies toward a good treatment effect and positive economic effect in favour of NBT. Conclusions: Three different cohort studies have tried calculating the economic impact of NBT indicating a good effect of the NBT. The evidence on the economic benefits of NBT is still sparse though promising, bearing the limitations of the studies in mind. Economic evaluation of NBT is a new area needing more research, including high-quality research studies where the economic evaluation model is included/incorporated from the beginning of the study design. This will enhance the credibility and usefulness to policy makers and clinicians.