Barriers and Facilitators for Therapeutic Green Exercise in Patients with Chronic Conditions: A Qualitative Focus Group Study

Abstract

Background: Exercise has indisputable advantages for people with chronic conditions. Engaging in physical activity within natural environments, known as green exercise, contributes to both physical and mental well-being. The aim of this study was to investigate the perceptions of people with chronic conditions and health professionals and the perceived facilitators and barriers to therapeutic green exercise. Methods: This was a qualitative study based on two focus groups. Ethical approval was received, and a thematic analysis was used to analyze the discussions. Results: Seven patients and eight health professionals participated in the study. The thematic analysis yielded thirteen main themes. Safety concerns and inadequate infrastructures were key barriers. Core facilitators were socialization, and multisensory exposure. Conclusions: Patients with chronic conditions and health professionals believe that green exercise improves physical activity engagement, and it would be beneficial if incorporated in the rehabilitation process. There are challenges to overcome to make therapeutic green exercise for people with chronic conditions more accessible.

1. Introduction

1.1. Exercise and Chronic Conditions

Chronic conditions are usually of long duration and occur in the context of a combination of genetic, physiological, environmental, and behavioral factors. The main types of chronic diseases are cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes. These diseases are noncommunicable and are characterized by gradual advancement [1].

Physical activity and exercise are recognized as effective tools that contribute to maintaining optimal levels of health. The World Health Organization (WHO) has highlighted that insufficient physical activity ranks among the risk factors contributing to worldwide mortality, accounting for a significant 6% of global deaths. Thus, the WHO has published a set of recommendations on physical activity for high-risk health groups such as patients with chronic conditions [2].

The World Health Organization has mapped the adverse financial implications of the lack of physical activity on healthcare [3]. Two studies performed in the USA and Indonesia confirm that low physical activity levels are associated with increased healthcare costs [4,5]. In the context of recent estimates Santos et al. mention that 492.2 million preventable major non-communicable diseases would occur globally due to the current level of physical inactivity [6]. The financial burden of Non-Communicable Diseases (NCDs) on healthcare is striking. Annual global health expenditures total approximately USD 8.5 trillion, with NCDs being a significant contributor due to their widespread prevalence and lasting nature [7]. Beyond direct costs, the economic repercussions of NCDs are even more substantial. These conditions hinder individuals from earning income by limiting their capacity to work. Projections estimate that between 2011 and 2030, the combined cost of productivity loss resulting from the four major NCDs will be an astounding USD 30 trillion. When factoring in mental health, this number rises to USD 47 trillion. Cardiovascular diseases (CVDs) alone could account for more than half of this amount. The magnitude of these losses underscores the urgency for governments to prioritize NCDs, as they play a pivotal role in driving economic growth [7]. Engaging in regular physical activity could potentially lead to significant cost savings in healthcare expenditure. It is estimated that if people are more physically active and maintain a healthier lifestyle, there could be a reduction in the amount of money spent on healthcare-related costs. This includes expenses associated with treating various health conditions and diseases that might arise due to a sedentary lifestyle or lack of exercise. These estimated savings are nearly 8 billion euros per year [8].

1.2. Green Exercise

Green exercise can be attributed as “adopting physical activities whilst at the same time being directly exposed to nature” that not only takes place in green natural settings such as forests and parks, but also in blue spaces such as lakes and rivers [9].

It has been documented that green exercise can improve mental well-being and markers of physiological health. Particularly, parasympathetic nervous activity is increased during exercise in nature and positive mood and satisfaction with life are positively associated with green exercise [10,11,12]. There is successive preliminary evidence at physiological [12,13,14,15], psychological [11,16,17,18,19,20], biochemical [21,22] and social levels [12,20], which suggests that green exercise might have a useful role in primary and secondary prevention or treatment of chronic diseases. Notably, walking in forest environments has positive effects on blood adiponectin and on blood pressure [21].

Involving physically inactive people in physical activities within natural outdoor settings could encourage them to adopt healthier habits. This change could be driven by the positive impact that green exercise has on their enjoyment, motivation, and overall experience of physical activity. As a result, they might be more likely to stick to their exercise routines, leading to long-term behavioral changes and improved health outcomes [20]. There is evidence indicating that when people exercise outdoors in natural environments, they often feel like the exercise is easier and less physically demanding compared to when they exercise indoors. Individuals might be more motivated to continue exercising and find it easier to adhere to their fitness routines when they are in a natural outdoor environment due to this perceived reduction in effort [23,24,25]. Furthermore, green exercise results in greater mental health and attention levels, compared to exercise in an indoor environment [21,22,26]. Outdoor environments surrounded by nature may enhance the rehabilitation of people with disabilities [27]. Lastly, social interactions are facilitated by nature, and social cohesion can function as a mediator for general health [24,28,29]. Social support in green exercise has the potential to augment social opportunity [30] for patients with chronic conditions and help them be more physically active, facilitating increased engagement in physical activity.

Natural settings inherently provide a more appealing and enjoyable backdrop for physical activity. The beauty and tranquility of nature can motivate individuals to engage in exercise more willingly and consistently. People with chronic conditions may find traditional exercise settings mundane or intimidating, but the allure of natural environments can foster a sense of intrinsic motivation [31,32]. Individuals with chronic conditions often deal with higher stress levels due to the challenges they face [33]. Engaging in physical activity in natural settings can help alleviate stress and anxiety, making the activity more appealing and sustainable [15].

1.3. Barriers to Physical Activity

A wealth of research highlights the positive impact of regular exercise on managing and improving various chronic health issues, such as cardiovascular diseases, cancer, diabetes, and arthritis [34,35,36]. However, patients keep finding obstacles when it comes to physical activity [37,38,39]. Barriers of physical activity consist of organizational determinants, individual limitations and influences coming from the external environment. Some of the main obstacles for physical activity are linked to patients’ health status, inadequacy of appropriate support, and incomplete information [40]. Chronic illnesses, mental health problems, osteoarthritis, and pain are numbered among the barriers as regards participation in physical activities [41]. Fear of injury, low levels of confidence, economic burden, and the daily routine might also play a notably negative role [42,43,44].

1.4. Facilitators for Physical Activity

Motivation, affordability, and convenience play a crucial role in influencing people’s engagement in exercise. Motivation, driven by enjoyment, and health aspirations, serves as a driving force behind active participation. Affordability is pivotal, as accessible physical activities that do not pose significant financial burdens are more likely to be embraced by individuals. Moreover, the factor of convenience, encompassing easily available options like proximal parks and gyms, significantly contributes to individuals incorporating physical activity into their daily lives. Social interaction, safe, proximal, and adequate service provision are particularly important in older adults [41,45]. Primary caregivers play a crucial role in fostering a positive approach towards physical activity and providing consistent guidance to patients about participating in exercise within natural outdoor environments [46,47].

1.5. Barriers and Facilitators for Therapeutic Green Exercise

In the context of a comprehensive exposition on therapeutic green exercise and chronic diseases, there is a shortage of the relevant literature. Patients with chronic pain have raised concerns regarding the pharmaceutical approach on their treatment, the lack of time, safety, and an underlying sense of fear, and the difficulty due to the large distance between the location of residency and the green environment [48]. Barriers related to safety, negative components of natural settings, and financial constraints, limit accessibility to green spaces [49]. In this regard, the socio-economic status is perceived as a factor that facilitates access to outdoor settings [10].

1.6. Aim

While the potential of green exercise and the benefits of physical activity for people with chronic conditions have been examined in depth, many of these patients remain inactive [17,50,51]. The aim of the current study is to thoroughly examine the barriers and facilitators for green exercise in patients with chronic conditions, taking into consideration patients’ and healthcare professionals’ perspectives.

2. Materials and Methods

2.1. Design

A qualitative design with data from two focus groups (FG) was used in this study [52]. Focus group discussions enable participants to collaboratively expand on each other’s remarks. This dynamic interaction stimulates thoughtful discussions, leading to a comprehensive exploration of topics. Additionally, this method yields high-quality data due to the moderator’s ability to address queries, delve deeper for clarity, and encourage more elaborate responses [53].

This study was approved by Committee for Research Ethics of Department of Physiotherapy of the University of Thessaly (ethical approval number: 3889-ΣΕ2/07-10-2019).

2.2. Participants

The participants were selected through purposive sampling [53,54]. All participants were residents of an urban area with forests and natural settings nearby, aged ≥18 years. Health professionals were recruited after an open call that was publicly advertised in the region. Patients with chronic conditions were referred to the study by a medical doctor or a physiotherapist. Health professionals (HP) were included in this study if they had a broad knowledge and experience in the fields of physical activity and chronic diseases. Selection criterion for the patients was to have at least one non-communicable chronic disease. In order to explore the perspectives on green exercise for people with chronic conditions, it was important that the sample of both focus groups contained people representing various chronic conditions. This heterogeneity in the sample provided a more comprehensive understanding of the facilitators and the barriers of these patients.

An official invitation via email was sent to invite the people that were eligible for the study. Eighteen people were initially invited in the study—nine health professionals and nine patients with chronic conditions. Upon agreement to participate in the study, they were then screened for eligibility via telephone. One health professional and two patients with chronic conditions, while initially answered positively to participate in the study, could not attend the meetings due to other obligations.

Participants were segmented in two focus groups in order that the level of knowledge in the fields of physical activity and chronic diseases was homogenous among people taking part in one FG. Consecutively, one FG was scheduled with health professionals and another with patients with chronic conditions [53].

The participants were informed about the purpose of the study, the procedure of FGs, and the personal data protection. Information was given about the moderator’s and facilitator’s roles, the time, the place, and the duration of the meeting. It was declared that participating in the study was voluntary. Volunteers confirmed their participation two days before the meetings.

2.3. Procedure

Two FG meetings took place on the same day and in the same place in a conference room with a boardroom table in the Department of Physiotherapy of the University of Thessaly. The room’s configuration would let all the participants feel comfortable, and free to take part in the conversation equally. The physical setting was conductive to discussion, participants were seated around a round table with direct eye contact with each other and with the moderator of the conversation. The location of the setting was close to the residential area of the town (5 min driving distance), and easy to access by the participants [53].

Three experts in exercise for clinical populations consulted with each other and provided input to build the questions of the focus groups. When created, the questions of the topic guide were piloted in a team of students to ensure they were understood and effective and to check if any adjustments were needed. The semi-structured FG interview guide is presented in

Table 1. Semi-structured interview guide.

Questions of focus group with patients	1. Do you believe that physical exercise/physical activity promotes prevention of chronic diseases?
	2. Do you believe that physical exercise/physical activity may help manage chronic diseases?
	3. Has any health professional recommended exercise/physical activity? If yes, who has recommended it and what kind of exercise have they recommended? If not, which is the reason in your opinion?
	4. As far as your health condition is concerned, what are the facilitators of physical exercise/physical activity in natural environments (overall and, in comparison to other forms of exercise)?
	5. As far as your health condition is concerned, according to your point of view, what are the barriers of doing physical exercise/physical activity in natural environments (overall and, in comparison to other forms of exercise)?
Questions of focus group with health professionals	1. Do you believe that physical exercise/physical activity promotes prevention of chronic diseases?
	2. Do you believe that physical exercise/physical activity may help manage chronic diseases?
	3. As a health professional do you recommend exercise to your patients? If yes, what kind of exercise? If not, which is the reason for not recommending it?
	4. As far as your patients’ condition is concerned, what are the facilitators of physical exercise/physical activity in natural environments (overall and, in comparison to other forms of exercise?
	5. As far as your patients’ condition is concerned, according to your point of view, what are the barriers of doing physical exercise/physical activity in natural environments (overall and, in comparison to other forms of exercise)?

.

Participants had to read an information brochure about the study, sign a consent form, and fill in a preliminary brief questionnaire with demographic information. The moderator initiated the discussion asking the participants to respect each other, and to express themselves unhesitatingly. The first question had general content to encourage them to take part in the discussion. The moderator of the FGs then used the questions previously designed by the researcher’s team according to the aims of the study. The moderator was a person educated in moderating focus groups with significant prior experience in this role.

Participants were able to take notes during the meeting. The FGs lasted from 75–80 min. The discussions of the two FGs were audio recorded and then transcribed verbatim. A microphone and a computer were used for the recordings.

2.4. Data Analysis

A thematic analysis was conducted for the current qualitative study [55,56]. A researcher transcribed verbatim the content of the discussions and the verbatim transcription was read by three researchers various times. Unique identifiers (P1-P7, HP1-HP9) were assigned to the participants for their personal data protection. Extensive reading and revisiting of the discussions and noting down initial insights were conducted. Subsequently, notable features were systematically coded across both discussions. These codes were then organized into potential themes, with corresponding phrases gathered for each theme. A comprehensive review was conducted to validate the alignment of themes with the discussions of the focus groups. Two researchers separately isolated the expressions of the discussions and added labels on the identified subthemes and themes. Subsequently, they compared their results and, in case of any inconsistencies, a third researcher resolved them. The researchers defined the themes and named them to closely align with the overarching analytical narrative. For the final report, impactful illustrative examples were selected and were associated with the research question. The research team had several meetings to discuss in depth and conclude on the final themes of the FG’s discussions.

3. Results

3.1. Participants’ Characteristics

Fifteen people participated in the study. Seven people with chronic conditions (P1–P7) and eight health professionals (HP1–HP8) participated the two FGs accordingly. From those invited to the meetings, two people with chronic conditions and one HP could not attend.

Participants’ characteristics are presented in

Table 2. Patients’ characteristics.

Age (years)	53 ± 17
Gender	Four women (57.1%) Three men (42.9%)
Level of education	High school education (n = 5) (71.4%) Bachelor’s degree (n = 2) (28.6%)
Exercising regularly	3/7 (42.9%)
Conditions	psoriatic arthritis (n = 1) cancer (n = 1) Chronic Obstructive Pulmonary Disease (COPD) (n = 1) Coronary Heart Disease (CHD) (n = 1) endocrine disease (n = 1) psychiatric disease (n = 1) risk factors (n = 1)
Duration of the condition (years)	5.5 ± 4.8

and

Table 3. Professionals’ characteristics.

Age (years)	49 ± 8.7
Gender	Five women (62.5%) Three men (37.5%)
Level of education	Bachelor’s degree (n = 5) (62.5%) Master’s degree (n = 3) (37.5%)
Exercising regularly	6/8 (75%)
Professions	orthopedic surgeon (n = 1) rheumatologist (n = 1) general practitioner (n = 1) pathologist-oncologist (n = 1) cardiologist (n = 1) pathologist-diabetologist (n = 1) psychiatrist (n = 1) physiotherapist (n = 1)
Work experience (years)	7.5 ± 10

.

3.2. Barriers to Green Exercise

The thematic analysis resulted in five main themes as barriers for green exercise. The main barriers were weather conditions, safety, inadequate infrastructure, applicability, and low compliance. Themes and subthemes are presented in

Table 4. Barriers to green exercise.

Main Themes	Subthemes
	Professionals	Patients
Weather conditions	Wintry weather	Wintry weather Hot weather and intense sunlight
Safety	Risk of animal attack Risk of accidents (cars, bicycles, drivers) Risk of human attack Mosquito-borne diseases Air pollution	Risk of animal attack Road safety Risk of human attack Lack of night lighting Risk of injury due to uneven terrain
Inadequate infrastructure	Lack of urban “green” space City planning	Inaccessibility Inappropriate facilities Proximity
Applicability	Specific health conditions
Low compliance	Lack of medical advisory and support

.

Weather conditions were mentioned by HPs and chronic patients as a barrier to exercise in nature. Either wintry weather or extreme heat and sunlight were both reasons to not exercise outdoors. Participants were worried that in the colder months, wintry conditions like freezing temperatures and rainfall can make outdoor physical activity uncomfortable, unsafe, or even impractical for many patients. On the other hand, during periods of extreme heat and intense sunlight, there is a heightened risk of heat exhaustion. The combination of high temperatures, high humidity, and exposure to intense UV radiation can create unfavorable exercising conditions that can lead to discomfort, dehydration, and potential health risks. As one patient explained:

“During summer I was walking from one shady place to another because of the sun.”

P4

Safety was one of the biggest issues of outdoor physical activity for the members of the two FGs, with six safety issues emerging. Participants were concerned about the possibility of encountering dangerous humans or animals during outdoor physical activities. This includes the fear of theft, harassment, or encountering aggressive animals. Additionally, the quality of the air in outdoor environments was a worry for participants, particularly in areas with high levels of pollution. Poor air quality could have negative impacts on respiratory health while exercising. The absence of adequate lighting in outdoor areas during the night was highlighted as a safety issue. Poor lighting can make it difficult to see hazards and obstacles, increasing the risk of accidents. Participants acknowledged the potential for accidents to occur during outdoor physical activities, such as slips, falls, or car accidents. These accidents could lead to injuries. As a result, the possibility of getting injured while exercising outdoors was a significant concern. The risk of contracting diseases transmitted by mosquitoes was another safety issue that was only raised by healthcare professionals. Relevant statements by patients and healthcare professionals were:

“Safety issues overall, animals and people.”

P5

“If the terrain is unsuitable, because in green spaces, there are many rocks and dirt paths.”

P7

“If you have to walk in roads with cars there is no safety…”

HP6

Inadequate infrastructure was a challenging factor. It was noted that some green spaces are not easily reachable or reachable at all due to obstacles such as lack of proper pathways, transportation options, or ramps for people with mobility challenges. This can prevent individuals from accessing and using these spaces. Some green spaces might be located far away from where people live or work, requiring considerable time and effort to travel to them. This was a discouraging factor people for using these spaces regularly. On the other hand, the green spaces that exist nearby the city center are not often maintained in a good condition. One health professional and one patient stated:

“Aren’t urban green spaces abandoned?”

HP4

“People that live downtown should have their own means of transport to go somewhere out of town and enjoy walking.”

P5

Healthcare professionals identified two more themes that were not brought up by the patients. These were low applicability of green exercise due to chronic patients’ specific health issues and low compliance. One health professional explained that certain health concerns or conditions make the concept of green exercise less suitable or adaptable. This could include physical limitations, or specific medical needs that hindered the practicality of engaging in outdoor physical activities. Lack of consistent adherence to the recommended exercise routines among the participants also occurs due to a variety of reasons such as discomfort, lack of motivation, and conflicting schedules, according to health professionals. Particularly, they indicated:

“They have serious respiratory problems; they probably need supplemental oxygen… it’s difficult to mobilize these people because of their health issues.”

HP4

“They (the patients) stop exercising after six months.”

HP6

3.3. Facilitators for Green Exercise

There were eight themes that emerged as facilitating factors for green exercise. These were socialization, sensory enrichment, mental health, wellbeing, exercise tolerance, cost savings, convenience, and safety. Themes and subthemes identified as facilitators are presented in

Table 5. Facilitators for green exercise.

Main Themes	Subthemes
	Professionals	Patients
Socialization	Group interaction Positive peer influence Reduced focus on symptoms	Reduced focus on symptoms
Sensory enrichment	Multisensory effect Air quality	Multisensory effect Air quality
Mental health	Enjoyment Distraction from negative thoughts	Mood
Wellbeing	Nature connectedness	Wellness
Exercise tolerance	Reduced fatigue effect	Reduced fatigue effect
Convenience		Easy access
Cost savings		Reduced cost
Safety		Reduced risk of communicable diseases

.

Mental health was a major theme that was brought out in the discussions. It was stated multiple times that green exercise improves mental health of patients with chronic diseases as it offers enjoyment and causes positive mood while it distracts them from negative thoughts. Participants believe that being in a natural environment while exercising leads to increased enjoyment and a more positive mood compared to indoor activities or urban settings. The presence of trees, fresh air, sunlight, and natural landscapes tends to have a calming and revitalizing effect on individuals. This immersive experience of the natural environment can capture an individual’s focus, making it easier for them to temporarily set aside their worries, anxieties, or negative emotions. As the participants stated:

“Exercising outdoors is entertaining.”

HP5

“It’s really beneficial for their psychology, people feel happiness when they see natural environments.”

HP4

“It improves (our) mood.”

P4

Sensory enrichment was a main advance of green exercise. The multisensory effect of nature and air quality were the subthemes for both the focus groups. Natural outdoor environments offer a diverse range of sensory stimuli. These include visual elements such as greenery, colorful flowers, and scenic landscapes; auditory experiences like birdsong and the sound of water; tactile sensations from walking on different surfaces, feeling the sensation of wind on the skin; and even smelling the scents of flowers and trees. Engaging multiple senses simultaneously can trigger feelings of happiness and relaxation. Participants indicated:

“The fresh air, the sounds you hear, and if we talk about green exercise, the green color around us, the sun as well, it helps.”

P7

“All the colors and the odors of the season.”

HP4

“Constant change of images… you listen to the birds; you see the flowing stream.”

P1

“It gives you the opportunity to increase your stability, it triggers the receptors, it increases proprioception, that is something you don’t get (exercising) indoors, right? When you ‘re indoors you… don’t get concentrated.”

HP3

Wellbeing was a motivator for green exercise. Participants indicated that exercising in natural settings promotes both a healthy mind and a healthy body and this result may last throughout life. Patients and HPs mentioned the feelings of wellness and nature connectedness:

“It improves wellbeing.”

P6

“Walking outdoors is better than walking indoors… you get in touch with nature.”

HP3

Exercise tolerance was also a facilitator as green exercise gives the reduced sensation of fatigue effect and diverges the focus from the symptoms. The natural surroundings, such as trees, plants, and open spaces, capture an individual’s attention and provide positive distractions. This can lead to a reduced awareness of physical discomfort or effort, resulting in a feeling of decreased fatigue. As an HP explained:

“It’s easier, meaning that someone can exercise for more time, while feeling that less effort is consumed.”

HP7

Socialization was a theme that emerged in health professionals’ but not mentioned in patients’ FGs. The group interaction, positive peer influence and reduced focus on symptoms were the subthemes of socialization. Health professionals stated:

“They combine a walk with meeting a fellow patient, they discuss about their issues.”

HP4

“You see people walking, you have thoughts like “should I do that too? Why are they doing this (exercising outdoors)?”

HP6

During the patients’ focus group, three more themes were pointed out that were not recognized by HPs. The first constitutes the convenience of green exercise as it is easy to access, the second is cost savings, and the third is safety as far as communicable diseases are considered. Unlike some indoor gyms or sports facilities that might require memberships or entry fees, many green spaces are open to the public without any monetary or membership constraints. Furthermore, anyone can engage in green exercise at their own convenience, fitting it into their schedules without the limitations of opening hours or class schedules. The above seemed to be important facilitating elements for patients with chronic conditions. It was also stated that open spaces also have the asset of natural ventilation, reducing the concentration of potentially contaminated air compared to indoor spaces with limited air circulation. As one patient explained:

“It’s the most inexpensive form of exercise… if you go to the gym you have to spend money.”

P5

“Viruses are not transmitted outdoors, while they can be transmitted indoors.”

P5

4. Discussion

This study explored patients’ and health professionals’ perceptions on therapeutic green exercise. Participants had a generally positive attitude towards green exercise, encompassed by certain concerns referring to the barriers a patient might encounter. A notable convergence has been identified concerning views on facilitating and impeditive factors within the above focus groups (Figure 1).

The results showed that green exercise is a form of physical activity that might be well tolerated by people with chronic conditions. Other studies confirm that physical activity in natural settings is a feasible intervention that could be used in the rehabilitation of chronic diseases with encouraging effects, especially on mental health [57,58].

Safety was a major concern for performing green exercise. Patients and HPs were apprehensive about potential risks of therapeutic green exercise. Participants indicated that road conditions might be unfriendly, with cars, bicycles, and pedestrians being plausible causes of accidents, noting that dangers might also occur via assailants or animals. Health professionals noted that air pollution and insect bites are further risks. These results are in accordance with Krenichyn who indicated that physical safety was a major concern for women exercising outdoors [59]. A qualitative study on chronic pain also showed that safety is a perceived barrier to engage with green exercise [48].

Inadequate infrastructures were also a limiting factor for participating in therapeutic green exercise. The poor city planning and the very few and/or inaccessible green spaces are reasons for not performing green exercise. In other studies, pedestrian infrastructures in built environments were principal for outdoor walking, and proper green urban spaces enhanced physical activity [60,61].

Bad and rainy weather or too warm weather were inhibitory factors for green exercise. Heat has been confirmed as a barrier to use urban parks in Japan [62]. In a study in six European countries, warmer temperatures were associated with outdoor physical activity in older people [63]. Respectively, mild temperatures seem to be more adequate for therapeutic green exercise.

There are also subjective factors that prohibit green exercise. According to HPs, patients abstain from exercise due to their illness and the lack of motivation. Health professionals recognized that they do not provide sufficient support to their patients in relation to their involvement in therapeutic green exercise. However, these findings seem to be relevant to exercise engagement overall, and not particularly with green exercise [64].

Green exercise positively affects chronic patients’ mental health and averts them from negative feelings and thoughts. In a study with in-patients with mild to moderate depression, outdoor physical activity was more advantageous than indoor physical activity [65]. The engagement in therapeutic green exercise is entertaining and improves their mood. The feeling of nature connectedness helps immerse themselves in the natural surroundings and promotes wellbeing. Nature provides high air quality and has a wide variety of images, odors, and sounds. As has been proven by a meta-analysis, people who feel connected to nature seem to have greater levels of self-reported personal growth [66].

Patients agreed that natural environments are unfavorable places for the spread of diseases. However, HPs indicated that there might be a risk of diseases transmitted by mosquitoes. In effect, it is proven that airborne transmitted diseases are dispersed much more indoors than outdoors, even compared with crowded outdoor areas [67].

It is a good opportunity for patients with chronic diseases to socialize with peers during therapeutic green exercise. It is a form of exercise that facilitates group interaction, and participants can set a good example for their co-patients. Organizing and performing physical activity in natural environments leads to reduced focus on their disease and reduced fatigue. Eventually, patients who choose green exercise consider it more sustainable in terms of energy expenditure, accessibility, financial burden, and human-to-human transmission of diseases. These results are substantiated by other studies that indicate increased physical activity levels in the green outdoors are linked to social networking and companionship [17,68].

Therapeutic green exercise seems to be a powerful tool for behavior change as described by Michie et al. in the COM-B model [30], especially for improving the levels of physical activity among people with chronic conditions. In order for green exercise to be fruitful in this direction, any psychological barriers should be addressed by educating participants about the adaptability of green exercise to their condition. Building their confidence by showcasing success stories of individuals like them who have benefited from outdoor physical activity will enhance their capability. Additionally, policy makers and city planners should make green exercise convenient and accessible to increase the opportunity for participation. Green exercise, when strategically designed to align with the capability, opportunity, and motivation components of the COM-B model, may effectively promote physical activity levels among people with chronic conditions. By addressing psychological barriers, providing favorable environments, and tapping into intrinsic motivation, a comprehensive approach that empowers individuals to embrace outdoor physical activity for improved wellbeing will be created.This qualitative study derives a significant strength from its comprehensive inclusivity, characterized by the wide spectrum of participants engaged in the focus groups. While each patient faced a different chronic condition, having a shared background and mutual understanding on green exercise made the discussion inclusive and enriched the study’s depth and breadth. The involvement of such a diverse group of patients ensures that a broad range of experiences, perspectives, and insights related to chronic diseases are represented. Likewise, the engagement of experts from different specialties brings a multifaceted dimension to the discussions. Their diverse perspectives contribute to the robustness of the study’s outcomes. The interplay of insights among participants not only stimulated rich dialogue but also facilitated the exploration of nuanced aspects of chronic diseases that might not have been as thoroughly addressed in a more homogeneous group.

A limitation of the study is that the participants were recruited from a semi-urban region, and more themes might have emerged if people from both rural areas and urban centers were included. In addition, the potential for a broader spectrum of themes could have been realized with a larger sample size. By expanding the sample size, the study could possibly have tapped into a greater range of viewpoints.

5. Conclusions

The purpose of this study was to explore health professionals’ and chronic patients’ perceptions of therapeutic green exercise through the qualitative method of focus groups. The participants described therapeutic green exercise as beneficial and sustainable for most chronic patients. However, there are barriers to performing green exercise seamlessly, like the accessibility and safety of natural environments. Future research should further examine the reasons that chronic patients do not participate in green exercise therapeutic programs and explore the ways to overcome these barriers.

The findings of this study can be utilized by HPs that offer consultation to chronic patients toward engaging in therapeutic green exercise. Based on the identified facilitators and barriers to adherence to green exercise, health professionals can design an adequate therapeutic plan for them. After assessing patients’ clinical condition, green exercise can be a useful rehabilitative option, taking into consideration that patients with chronic diseases find it enjoyable and convenient.