Evaluating a Community-Delivered, Nature-based Mental Health Program for Rural Adolescents: Evidence from the Human Nature Program

Evaluating a Community-Delivered, Nature-based Mental Health Program for Rural Adolescents: Evidence from the Human Nature Program | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluating a Community-Delivered, Nature-based Mental Health Program for Rural Adolescents: Evidence from the Human Nature Program Nicole Snowdon, M Mamun Huda, Hazel Dalton, Julaine Allan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7909305/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Mental distress among adolescents is a growing public health concern, particularly for youth underserved by traditional mental health systems. This study evaluates the Human Nature program, a nature-based, trauma-informed, person-centred intervention designed to support adolescent mental health in non-clinical, rural settings across Northern New South Wales, Australia. Methods A pre-post observational design was used to assess psychological outcomes among 106 participants aged 14–18. Routinely collected data included measures of psychological wellbeing, life satisfaction, and engagement across diverse demographic groups. Outcome tools included the Outcome Rating Scale (ORS) and the My Mind Star (MMS) assessment, capturing changes across multiple domains of functioning. Results Statistically significant improvements were observed in symptom distress, interpersonal wellbeing, and social role functioning. All seven domains of the MMS scale showed positive change, with the most substantial gains in self-esteem, positive time use, and educational engagement. The program successfully engaged vulnerable populations, including Aboriginal and Torres Strait Islander youth, LGBTQIA + adolescents, and those facing multiple psychosocial challenges. Discussion Findings support the effectiveness of trauma-informed, nature-based interventions in enhancing youth mental health, particularly in rural and regional contexts. The Human Nature program demonstrates the value of flexible, relational models in reaching underserved populations. These results underscore the need for government investment in alternative mental health approaches that address service gaps and promote equity in access. Mental Health Adolescent Rural Health Services Nature Therapy Program Evaluation Health Equity Figures Figure 1 Figure 2 IMPLICATIONS AND CONTRIBUTIONS STATEMENT The findings highlight the potential of nature-based, trauma-informed care to improve youth mental health in rural areas. Human Nature’s inclusive model and tailored outcome measures demonstrate scalable, non-clinical approaches that can address service gaps and reduce untreated distress among adolescents through embedded evaluation and culturally responsive delivery. Introduction Mental distress accounts for nearly half of the global burden of disease in young people under the age of 25 years ( 1 ). In Australia, one in five (20%) young people aged 11–17 report high or very high levels of psychological distress ( 2 ). Mental distress has serious and wide ranging impacts on participation in usual life activities that can be long-term if unaddressed ( 3 ). Effective ways to prevent or treat mental distress that are tailored to both the developmental stage of a person and their specific condition are required to change the trajectory and potential outcomes of mental distress ( 1 ). However, existing service provision in Australia predominantly focuses on young people with either initial care needs or severe/complex presentations, leaving a cohort of young people, known as the "missing middle," under-serviced ( 4 , 5 ). This study used routine data to examine the outcomes from a service designed specifically to address this gap in support. Human Nature, a charity in Northern NSW, Australia, delivers person-centred mental health support services to young people facing mental health issues, childhood trauma, drug and alcohol problems, behavioural challenges, and social exclusion. Services are delivered in non-clinical settings, typically outdoors. The Human Nature program has not been previously evaluated. Interest in the impact of therapeutic environments on outcomes of healthcare interventions gained momentum in the 1960s, following Goffman's critical examination of institutional settings ( 6 ). Research on how the environment (including design, space, furnishings, feel, approach of the therapists and understanding of client needs and preferences) supports or interferes with therapeutic outcomes, particularly counselling, has come and gone over the years since ( 7 – 9 ). However, the concept of a therapeutic environment being important in the outcomes of interventions, treatment and programs has remained ( 7 , 10 ). Most studies of therapeutic environment factors have examined the physical space ( 9 , 11 ). This includes the layout of offices, access to them ( 12 ) and how the therapist and client interact with each other within the space ( 13 ). Few studies have examined the preferences and perceptions of young people for a therapeutic space. A study of service providers reported difficulties engaging young people with complex and chronic problems including for example PTSD, experiences of abuse and violence and homelessness in therapeutic interventions delivered in traditional clinic settings ( 14 ). Further, formal and clinical settings have been identified as anxiety provoking and can be intimidating for some people ( 15 ). However, frequently the problem is identified as the young person’s inability to engage rather than locating the need for change in the environment or therapeutic approach ( 16 ). A focus on trauma informed care has foregrounded the person’s experience of helping interventions. Orygen’s report ( 17 ) on trauma-informed systems for young people stresses the need for environments that support emotional safety and relational continuity, especially for those with complex trauma histories. The report clearly identifies how common the experience of trauma is with about half to two thirds of young people exposed to traumatic events ( 17 ). Trauma is commonly categorized into two types: Type I and Type II. Type I trauma typically refers to a single, acute incident—such as witnessing or directly experiencing a life-threatening event. In contrast, Type II trauma, often called complex trauma, involves ongoing or repeated exposure to distressing experiences, such as chronic abuse, neglect, or prolonged adversity ( 18 ). One study found a physical environment that addresses privacy, comfort and sensory factors such as temperature, lighting and sound has been identified as critical by young people with trauma experiences ( 10 ). Delivering programs and services in non-clinical settings including outdoors is one way constraints of built environments can be addressed. There is a growing body of literature supporting nature-focused programs as non-traditional and effective mental health interventions. Nature-based programs can reduce stress, anxiety and depression, improve memory, cognition, and attention, increase confidence, feelings of safety and sense of empowerment and purpose ( 19 – 24 ). Nature-based programs have been found to improve self-esteem, mood, and social functioning among adolescents ( 25 ). Similarly, nature exposure has been associated with improvements in attention deficit and hyperactivity disorder symptoms in young people, and resilience and health-related quality of life ( 26 ). A meta-synthesis of talking therapy conducted outdoors found that the environment enriched the therapeutic relationship and positioned engagement with nature as a restorative force with measurable mental health benefits ( 27 ). Although the benefits of nature-based and outdoor programs are well-documented, their implementation has often been hindered by organisational concerns ( 28 ). These include perceived risks associated with less controlled environments and limited awareness of the supporting evidence base. As a result, such programs are commonly found in private practice or user-pays sectors ( 26 – 28 ). The aims of this study were to 1. understand the characteristics (e.g., age, gender, socioeconomic status) of Human Nature participants and examine their patterns of engagement in the program, and 2. evaluate the effectiveness of the Human Nature program in improving wellbeing and self-reported satisfaction with various life domains including social relationships, educational engagement, and personal development. METHODS Study Design This study used a pre-post intervention-only observational design, relying on routinely collected administrative data from young people aged 14–18 years who had received at least one occasion of service from Human Nature over the two-year period (January 2023 to December 2024). Only existing data were analysed, without manipulation of the study environment or variables. Baseline data collected at the first session were considered pre-intervention data, while all follow-up session data after the first session were considered post-intervention data. Due to the data available for the project, there was no control arm; therefore, only pre- and post-program data were compared to estimate the program's effect on the outcome variables. Given the real-world, pragmatic nature of the program, implementing a control group was not feasible without compromising program delivery. HUMAN NATURE PROGRAM Through engaging young people in nature-based activities, the Human Nature program aims to improve psychological well-being and overall functioning for young people who have been unable to get support from traditional mental health services. Founded in 2015, the Human Nature program operates across the Far North Coast of New South Wales, Australia, and primarily depends on private donations to cover its operating costs. Using trained mental health clinicians, Human Nature aims to meet young people’s needs - psychologically, emotionally and developmentally. Support is provided in a variety of non-clinical settings where young people are most likely to feel safe and comfortable. These settings may include the home, school, or local cafes. Wherever possible, the team encourages outdoor activity, recognising that being in nature can help young people open up and connect with the trauma-informed therapeutic support provided by the service. Young people are given autonomy over their sessions, choosing what they want to do and where they want to do it, reflecting the deliberate operationalising of person-centred care. Human Nature services are free and long-term. The length of time a young person attends the program is up to them. However, most will stay with the program for 12 to 18 months. The eligibility criteria for Human Nature participants are - Aged between 14 and 18 years living in the Far North Coast region of NSW, Australia presenting with significant challenges (e.g. trauma, substance use problems, mental health issues, social problems, behavioural difficulties or family conflict/breakdown) experiencing barriers to engaging with support in clinical settings, i.e. has refused to attend or has not returned to other health services. DATA SOURCES AND ANALYTIC Sample Human Nature retained client treatment records for young people aged 14–18 years who had received at least one occasion of service from Human Nature during the study period. Human Nature administrators (CV) matched participant outcome data and assigned random anonymised unique identifiers before transmitting the data to the research team. Data included treatment outcome measures collected throughout the course of treatment and were used to assess participant progress over time. Given the use of routinely collected administrative data, a convenience sampling strategy was used, without random selection or stratification. The sample included young people aged 14–18 who had received an assessment and at least one occasion of service from Human Nature during the two-year period (January 2023 to December 2024). As routinely collected data were used, young people did not directly participate in this research. A waiver of consent was used for access to the data, as Human Nature clients had not consented to their data being used specifically for this research. However, in line with organisational processes, staff at Human Nature had obtained consent from young people and/or their caregivers to use treatment data for evaluation and research purposes. The Human Research Ethics Committee from Charles Sturt University approved the study (H25114). Data Collection AND STUDY VARIABLES Data extracted from the service's database included: Outcome Rating Scale (ORS)( 29 ): A brief, session-by-session tool assessing symptom distress, interpersonal wellbeing, social role functioning, and overall wellbeing. It uses four visual analogue scales (0–10), with a total score range of 0–40. Cut-off scores are 28 for ages 13–17 and 25 for ages 18+. Designed for individuals aged 13+, it is accessible at a 13-year-old reading level. My Mind Star (MMS) ( 30 ) is a strengths-based, trauma-informed tool used collaboratively to track progress across seven wellbeing domains: feelings and emotions, healthy lifestyle, living situation, relationships, education/work, time use, and self-esteem. Each domain is rated on a five-stage visual chart from “stuck or unsafe” to “managing well.” Demographic and other Data: Data collected included age, gender, health concerns, and assessed level of care needs using the Initial Assessment and Referral Decision Support Tool or IAR-DST ( 31 ). Health concerns covered psychosocial and functional vulnerabilities such as mental health issues, neurodiversity, exposure to violence, and school disengagement. Additional data included Aboriginal and/or Torres Strait Islander status, CALD background, LGBTQIA + identification, living arrangements, and socio-economic status (SEIFA, based on postcode). All data were linked and de-identified by the host organisation prior to transmission to the research team. Data Analysis A descriptive analysis was conducted to understand the baseline characteristics of the Human Nature study. Depending on the type of variable, we used either chi-square tests or t-tests (with non-parametric alternatives where applicable) to compare the outcome variable across groups. The primary outcomes of interest in this study were improvements in therapeutic relationship as measured by the ORS score, as well as seven mental health and well-being outcomes measured by the MMS scale. Higher scores on these scales were indicative of a higher level of therapeutic relationship, whereas an MMS scale > 3 (4 or 5) for a specific domain represents that things are mostly good or okay for that domain. Average scores were compared between baseline and endline to evaluate changes, and considering the outcome measure of ORS score, a linear regression model was used to calculate effect sizes, adjusting for potential confounding factors. Furthermore, proportion of MMS scale > 3 across different mental and wellbeing domain including ‘feeling and emotions’, ‘healthy lifestyle’, ‘where you live’, ‘friends and relationships’, ‘school, training and work’, ‘how you use your time’ and ‘self-esteem’, were compared between baseline and endline to understand the changes in those mental and wellbeing outcomes. Considering the binary nature of the mental and well-being outcomes measures in MMS (> 3 = 1 vs else = 0), we use logistic regression models to calculate effect sizes, adjusting for potential confounding factors. Due to repeated measures data, panel liner and logistic regression models were used to adjust for the within-subject correlation. Initially, simple models were fitted considering only outcome and time (baseline vs endline) variables. Subsequently, adjusted models were fitted by incorporating some potential covariates, including age, sex, indigenous status, CALD, LGBTQIA + living arrangement, and SEIFA into the model. The significance of effect size is derived from the beta coefficients of the time variable for ORS score, whereas it was the odds ratio (OR) for MMS scale (> 3) for both the unadjusted and adjusted models, considered at a 95% confidence interval. All the data were analysed using STAT 18.5. Results Program participants characteristics About 70% of participants were early adolescents (< 15 years), and 52% were male. Just over one-quarter (27.36%) identified as Aboriginal and Torres Strait Islander, while 11.32% and 6.6% were identified as LGBTQIA + and CALD, respectively. A significant number of adolescents reported living in unstable conditions or in a single-parent household (46.22%) and residing in a lower socioeconomically disadvantaged community (42.45%) (Table 1 ). Table 1 Participant’S SOCIO-DEMOGRAPHIC CHARACTERISTICS, Psychosocial and functional vulnerabilities Total sample: N = 106 % (n) Socio-demographic characteristics Age ­ < 15 70.75(75) ­ 15–19 29.25( 31 ) Gender ­ Male 51.89(55) ­ Female 44.34(47) ­ Other 3.77( 4 ) Indigenous status ­ No 72.64(77) ­ Yes 27.36( 29 ) CALD ­ No 93.4(99) ­ Yes 6.6( 7 ) LGBTQIA+ ­ No 88.68(94) ­ yes 11.32( 12 ) Living with ­ Family/extended family 30.19( 32 ) ­ Single parent 31.13(33) ­ Unstable living 15.09( 16 ) ­ Unknown 23.58( 25 ) Neighbourhood socio-economic status ­ Lowest two quintile (Q1&2) 42.45(45) ­ Other (Q3-Q5) 57.55(61) Psychosocial and functional vulnerabilities Mental health concern ­ No 57.55(61) ­ Yes 42.45(45) Disability (e.g. neurodiversity) ­ No 82.08(87) ­ Yes 17.92( 19 ) Disclosed family and domestic violence (FDV) ­ No 36.79(39) ­ Yes 63.21(67) Disclosed sexual violence ­ No 72.64(77) ­ Yes 27.36( 29 ) School disengagement reported ­ No 89.62(95) ­ Yes 10.38( 11 ) Multiple vulnerabilities ­ None 9.43 ( 10 ) ­ Only one 37.74 (40) ­ Multiple (2 to 4) 52.83 (56) More than half of the study participants (52.83%) reported multiple vulnerabilities, meaning they experienced more than one vulnerability (Table 1 ). The highest proportion of vulnerability was exposure to family and domestic violence (63.21%), followed by mental health concerns (42.45%), sexual violence (27.36%), disability (17.92%), and school disengagement (10.38%) (Table 1 ). Program engagement Among the program participants, the majority (about 63%) were referred to the program by either parents or carer (30.19%) or school staff (33.02%). On average, participants attended 26 sessions, with one-third of them having shorter engagements (i.e., attending fewer than 18 sessions) (Table A – supplementary material). Most participants remained engaged with the program, whereas approximately 35% of participants left the program, mainly due to achieving their goals (24.32%), or exiting to Elev8, Human Nature’s step-down weekly group program (18.92%), or referred elsewhere (21.62%). However, approximately 30% of participants left the program, either of their own decision or because they migrated to other regions. The proportion of participants with shorter-term engagements varied across different participant groups. For example, the proportion of shorter-term engagement was 58.33% among those who identified as LGBTQA+, whereas it was 30.85% among those who didn’t. Similarly, the proportion of shorter-term attendance was 52.62% for those who reported disability, whereas it was 29.89% for those who did not report disability (Table B – supplementary). However, statistically significant differences were observed in the proportion of shorter-term engagement only among the different groups based on living status. Adolescents living with their family or extended family had a higher proportion of shorter-term engagement (59.38%) compared to other living condition groups (P = 0.003) (Table B supplementary). Program effect Participants' ORS scores significantly improved at the endline compared to its baseline condition. The mean (SD) ORS score increased from 22.01 (8.1) at baseline to 29.52 (8.1) at endline (p < 0.001) (Fig. 1 ). The program effect remained statistically significant after adjusting for potential confounders, including age, sex, Indigenous status, CALD, LGBTQIA + living arrangement, and SEIFA. Our adjusted regression model showed that the ORS score had a 7.5-unit higher score at the endline compared to its baseline score (β = 7.48, 95% CI, 5.67–9.28) (Fig. 1 and Table 2 ). Table 2 The effect of human nature intervention on ORS rating score; N = 106 ORS Rating score Effect: β (95% CI) [p-value] Time Mean (SD) Unadjusted Adjusted* Baseline 22.01 (8.1) -- -- Endline 29.52 (8.1) 7.5 (6.0, 9.3) [< 0.001 ] 7.48 (5.67, 9.28) [< 0.001 ] *Adjusted by socio-demographic characteristics such as age, sex, indigenous status, CALD, LGBTQIA+, Socio-Economic Indexes for Areas (SEIFA) and living arrangement β: rate of change (effect size) CI: Confidence interval Examining the effect of the MMS scale across various mental health and well-being domains, we found that the proportion of participants with a MMS scale > 3 out of five (meaning things are mostly good or OK) significantly improved for all domains at the endline compared to the baseline data, indicating a substantial improvement in the mental health and well-being of the study participants (Fig. 2 ). For example, the proportion of MMS scale > 3 for ‘feeling and emotions’ domain was 23.58% at baseline, which increased to 56.60% at endline (P = 3 was observed for other domains of ‘healthy lifestyle’ (30.19% vs 50.0%), ‘where you live’ (50.0% vs 70.75%), ‘friends and relationships’ (47.17% vs 62.26%), ‘school, training and work’(18.87% vs51.89%), ‘how you use your time’ (26.42% vs 53.77%) and ‘self-esteem’(31.13% vs 59.43%) at endline compared to its baseline estimate (Table 3 and Fig. 2 ). The program effect remained statistically significant on all mental health and well-being domains after adjusting for potential confounders. Our adjusted regression model showed that ‘self-esteem’ domain had the largest estimated odd ratio (AOR = 6.99, 95% CI, 2.74, 17.83) among other domains, suggesting a stronger association with the program engagement, followed by other domain of ‘how you use your time’ (AOR = 6.72, 95% CI, 2.63, 17.15), ‘school, training and work’(AOR = 5.50, 95% CI, 2.82, 10.7), and ‘feelings and emotions’ (AOR = 5.34, 95% CI, 2.52, 11.3) (Table 3 ). Table 3 The effect of human nature intervention on the Mind Star scale across different domains; N = 106 Mind Star scales > 3 Effect (95% CI) [p-value] Time % (n) Unadjusted (OR) Adjusted (AOR)* Feelings and emotions ­ Baseline 23.58 ( 25 ) Ref Ref ­ Endline 56.60 (60) 5.38(2.53, 11.43) [< 0.001] 5.34(2.52, 11.3) [< 0.001] Healthy lifestyle ­ Baseline 30.19 ( 32 ) Ref Ref ­ Endline 50.0(53) 5.34(2.52, 11.3) [< 0.001] 3.09(1.52, 6.28) [0.002] Where you live ­ Baseline 50.0 (53) Ref Ref ­ Endline 70.75 (75) 3.44(1.64, 7.23) [0.001] 3.43(1.63, 7.19) [0.001] Friends and relationships ­ Baseline 47.17 (50) Ref Ref ­ Endline 62.26 (66) 2.00(1.1, 3.64) [0.024] 2.00(1.1, 3.65) [0.023] School, training and work ­ Baseline 18.87 ( 20 ) Ref Ref ­ Endline 51.89(55) 5.38(2.53, 11.43) [< 0.001] 5.50(2.82, 10.7) [< 0.001] How you use your time ­ Baseline 26.42 ( 28 ) Ref Ref ­ Endline 53.77 (57) 6.80(2.66, 17.38) [< 0.001] 6.72(2.63, 17.15) [< 0.001] Self-esteem ­ Baseline 31.13 (33) Ref Ref ­ Endline 59.43 (63) 7.00(2.74, 17.86) [< 0.001] 6.99(2.74, 17.83) [< 0.001] *Adjusted by socio-demographic characteristics such as age, sex, indigenous status, CALD, LGBTQIA, SEIFA and living arrangement OR: Odds ratio CI: Confidence interval Discussion The results of this study provide strong evidence for the effectiveness of the Human Nature program in improving mental health and wellbeing among adolescents who have experienced trauma. The program’s nature-based, person-centred, and trauma-informed approach appears to offer a viable alternative to traditional clinical settings, particularly for young people who face barriers to engaging with conventional mental health services ( 8 ). The program achieved statistically significant improvements in symptom distress, interpersonal wellbeing, social role functioning, and overall life satisfaction. Gains were observed across all domains of the My Mind Star wellbeing scale, with particularly strong effects in self-esteem, time use, and educational engagement. These outcomes were consistent across diverse demographic groups, including Aboriginal and Torres Strait Islander youth, LGBTQIA + participants, and those living in socioeconomically disadvantaged communities. The demographic profile of participants highlights the program’s success in reaching vulnerable and underserved populations. A significant proportion of participants were early adolescents, male, and from socioeconomically disadvantaged backgrounds. Notably, 27% identified as Aboriginal and Torres Strait Islander, and over half reported multiple psychosocial vulnerabilities, including exposure to family and domestic violence (63%) and mental health concerns (42%). These figures underscore the importance of tailored interventions that address the complex needs of young people who are often excluded from mainstream services ( 1 , 4 ). Engagement levels varied across demographic groups, with shorter-term participation more common among LGBTQIA + youth and those with disabilities. Interestingly, adolescents living with family or extended family were more likely to have shorter engagements, suggesting that living arrangements may influence the duration and intensity of service use. While these differences were statistically significant in some cases, they warrant further exploration to understand the underlying mechanisms and to inform strategies for sustained engagement. The most striking finding is the significant improvement in participants’ wellbeing as measured by both the Outcome Rating Scale (ORS) and the My Mind Star (MMS) tool. The ORS scores increased from a mean of 22.01 at baseline to 29.52 at endline, surpassing the clinical cut-off and indicating meaningful therapeutic gains. These improvements remained robust after adjusting for confounding variables, suggesting that the program’s impact is consistent across diverse demographic groups. Similarly, the MMS results showed substantial gains across all seven wellbeing domains. The most pronounced improvements were observed in self-esteem (AOR = 6.99), use of time (AOR = 6.72), and educational engagement (AOR = 5.50). These findings align with previous literature on the benefits of nature-based interventions, which have been shown to enhance emotional regulation, social functioning, and cognitive engagement ( 22 – 24 ). The success of Human Nature reinforces the value of non-clinical, nature-based settings in fostering therapeutic relationships and promoting mental health recovery. The program’s emphasis on autonomy, flexibility, and outdoor engagement appears to mitigate the anxiety and stigma often associated with traditional clinical environments ( 10 , 15 ). This aligns with broader evidence suggesting that nature exposure can reduce stress, improve mood, and enhance resilience ( 25 – 27 ). LIMITATIONS AND FUTURE DIRECTIONS While the study’s observational design and lack of a control group limit causal inference, the use of repeated measures and adjusted analyses strengthens the validity of the findings. Future research could benefit from incorporating a matched comparison group or longitudinal follow-up to assess the sustainability of outcomes. Additionally, qualitative data on participant experiences could provide deeper insights into the mechanisms driving change. There is limited research on My Mind Star, and it has not been validated in the peer reviewed literature. However, related tools have been found useful for clinicians and clients to set goals and track progress ( 32 ). IMPLICATIONS FOR PRACTICE AND POLICY The findings have important implications for mental health service delivery, particularly in rural and regional contexts. Human Nature’s model demonstrates that effective, inclusive, and culturally responsive care can be delivered outside traditional clinical frameworks. The program’s use of multi-dimensional outcome measures designed for their client group facilitated the study and the demonstration of program outcomes. Scaling such programs with embedded evaluation designs could help address the crisis in youth mental health services ( 4 ) and reduce the burden of untreated distress among adolescents. CONCLUSION This study demonstrates that the Human Nature program offers a promising and effective model for supporting young people with moderate intensity mental health needs, particularly those who fall into the “missing middle” of service provision. By delivering trauma-informed, person-centred care in nature-based and non-clinical settings, Human Nature successfully engages adolescents who may otherwise struggle to access traditional mental health services. Importantly, the program’s flexible and relational approach appears to foster sustained engagement and therapeutic alliance, even among young people with complex psychosocial vulnerabilities. While further research is needed to explore long-term outcomes and comparative effectiveness, the findings support broader implementation of nature-based mental health interventions as a viable strategy to address service gaps and promote youth wellbeing. Human Nature’s model contributes to a growing evidence base advocating for innovative, inclusive, and contextually responsive mental health care. Its success underscores the need for continued investment in alternative service models that prioritise accessibility, cultural safety, and the lived experiences of young people. Abbreviations MMS My Mind Star ORS Outcome Rating Scale LGBTQIA+ lesbian, gay, bisexual, transgender, queer/questioning, intersex, and asexual/aromantic/agender, with the "+" representing all other identities not included in the letters PTSD Post Traumatic Stress Disorder IAR-DST Initial Assessment and Referral Decision Support Tool CALD Culturally and Linguistically Diverse SEIFA Socio-Economic Indexes for Areas SD Standard Deviation Declarations Funding: Australian Commonwealth Department of Health and Ageing, Grant ID 4-DGEJZ1O/4-CW7UT14 Disclosure of interests: NS, MMH, HD and JA have no interests to declare. CV worked in a paid position for Human Nature for 4 years until the end of 2024. CV was paid for 6 weeks during May and June 2025 to collate and deidentify the data that was supplied for analysis in accordance with the inclusion and exclusion criteria of the project. Clinical Trials registration – not applicable References Colizzi M, Lasalvia A, Ruggeri M. 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J Epidemiol Community Health. 2018;72(10):958-66. Cooley SJ, Jones CR, Kurtz A, Robertson N. 'Into the Wild': A meta-synthesis of talking therapy in natural outdoor spaces. Clin Psychol Rev. 2020;77:101841. Paquet S, Struthers NA, Gunz A, Gittings L. Barriers and facilitators to implementing nature prescriptions for child and youth health: a scoping review. Health Promotion International. 2025;40(2). Casey P, Patalay P, Deighton J, Miller SD, Wolpert M. The Child Outcome Rating Scale: validating a four-item measure of psychosocial functioning in community and clinic samples of children aged 10-15. Eur Child Adolesc Psychiatry. 2020;29(8):1089-102. MacKeith J, Good A, Burns S. Development of a co-produced tool for monitoring and supporting the mental health of young people. BJPsych Open. 2021;7(S1):S267-S. Australian Government Department of Health DaA. Initial Assessment and Referral Decision Support Tool – IAR Decision Support Tool. In: Department of Health DaA, editor. Canberra: Australian Government; 2019. Lloyd C, Williams PL, Machingura T, Tse S. A focus on recovery: using the Mental Health Recovery Star as an outcome measure. Advances in Mental Health. 2016;14(1):57-64. Additional Declarations The authors declare potential competing interests as follows: NS, MMH, HD and JA have no interests to declare. CV worked in a paid position for Human Nature for 4 years until the end of 2024. CV was paid for 6 weeks during May and June 2025 to collate and deidentify the data that was supplied for analysis in accordance with the inclusion and exclusion criteria of the project. Supplementary Files SupplementaryMaterial.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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19:00:32","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":126628,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7909305/v1/5cd7324d0a9c4cc665d6331c.html"},{"id":94135748,"identity":"aaf6d3bb-2127-4ca1-aafc-be28c019fbc1","added_by":"auto","created_at":"2025-10-22 19:00:32","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":61241,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of ORS rating scores at baseline and endline\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7909305/v1/a6da7d76df1ac7431ee6d265.png"},{"id":94135750,"identity":"dc451aeb-293f-439a-b934-cc6e747853d6","added_by":"auto","created_at":"2025-10-22 19:00:32","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":87447,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eProportion of Mind Star scales \u0026gt;3 at baseline and endline across different domains\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7909305/v1/a88b602241fbb9f41a1c6e81.png"},{"id":94136582,"identity":"4d422922-77a0-4620-8945-7dc38e9ac708","added_by":"auto","created_at":"2025-10-22 19:16:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1170896,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7909305/v1/55aa5767-125b-4aec-ade2-c41b1f22d72d.pdf"},{"id":94135745,"identity":"631d6d4b-6a97-46b3-a37e-4b8dcd52d156","added_by":"auto","created_at":"2025-10-22 19:00:32","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":22129,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-7909305/v1/0b49113f92e97228c6ac0c12.docx"}],"financialInterests":"The authors declare potential competing interests as follows: NS, MMH, HD and JA have no interests to declare. CV worked in a paid position for Human Nature for 4 years until the end of 2024. CV was paid for 6 weeks during May and June 2025 to collate and deidentify the data that was supplied for analysis in accordance with the inclusion and exclusion criteria of the project.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eEvaluating a Community-Delivered, Nature-based Mental Health Program for Rural Adolescents: Evidence from the Human Nature Program\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"IMPLICATIONS AND CONTRIBUTIONS STATEMENT","content":"\u003cp\u003eThe findings highlight the potential of nature-based, trauma-informed care to improve youth mental health in rural areas. Human Nature\u0026rsquo;s inclusive model and tailored outcome measures demonstrate scalable, non-clinical approaches that can address service gaps and reduce untreated distress among adolescents through embedded evaluation and culturally responsive delivery.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eMental distress accounts for nearly half of the global burden of disease in young people under the age of 25 years (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In Australia, one in five (20%) young people aged 11\u0026ndash;17 report high or very high levels of psychological distress (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Mental distress has serious and wide ranging impacts on participation in usual life activities that can be long-term if unaddressed (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Effective ways to prevent or treat mental distress that are tailored to both the developmental stage of a person and their specific condition are required to change the trajectory and potential outcomes of mental distress (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). However, existing service provision in Australia predominantly focuses on young people with either initial care needs or severe/complex presentations, leaving a cohort of young people, known as the \"missing middle,\" under-serviced (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). This study used routine data to examine the outcomes from a service designed specifically to address this gap in support. Human Nature, a charity in Northern NSW, Australia, delivers person-centred mental health support services to young people facing mental health issues, childhood trauma, drug and alcohol problems, behavioural challenges, and social exclusion. Services are delivered in non-clinical settings, typically outdoors. The Human Nature program has not been previously evaluated.\u003c/p\u003e\u003cp\u003eInterest in the impact of therapeutic environments on outcomes of healthcare interventions gained momentum in the 1960s, following Goffman's critical examination of institutional settings (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Research on how the environment (including design, space, furnishings, feel, approach of the therapists and understanding of client needs and preferences) supports or interferes with therapeutic outcomes, particularly counselling, has come and gone over the years since (\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). However, the concept of a therapeutic environment being important in the outcomes of interventions, treatment and programs has remained (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Most studies of therapeutic environment factors have examined the physical space (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). This includes the layout of offices, access to them (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) and how the therapist and client interact with each other within the space (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Few studies have examined the preferences and perceptions of young people for a therapeutic space. A study of service providers reported difficulties engaging young people with complex and chronic problems including for example PTSD, experiences of abuse and violence and homelessness in therapeutic interventions delivered in traditional clinic settings (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Further, formal and clinical settings have been identified as anxiety provoking and can be intimidating for some people (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). However, frequently the problem is identified as the young person\u0026rsquo;s inability to engage rather than locating the need for change in the environment or therapeutic approach (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eA focus on trauma informed care has foregrounded the person\u0026rsquo;s experience of helping interventions. Orygen\u0026rsquo;s report (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) on trauma-informed systems for young people stresses the need for environments that support emotional safety and relational continuity, especially for those with complex trauma histories. The report clearly identifies how common the experience of trauma is with about half to two thirds of young people exposed to traumatic events (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Trauma is commonly categorized into two types: Type I and Type II. Type I trauma typically refers to a single, acute incident\u0026mdash;such as witnessing or directly experiencing a life-threatening event. In contrast, Type II trauma, often called complex trauma, involves ongoing or repeated exposure to distressing experiences, such as chronic abuse, neglect, or prolonged adversity (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). One study found a physical environment that addresses privacy, comfort and sensory factors such as temperature, lighting and sound has been identified as critical by young people with trauma experiences (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Delivering programs and services in non-clinical settings including outdoors is one way constraints of built environments can be addressed.\u003c/p\u003e\u003cp\u003eThere is a growing body of literature supporting nature-focused programs as non-traditional and effective mental health interventions. Nature-based programs can reduce stress, anxiety and depression, improve memory, cognition, and attention, increase confidence, feelings of safety and sense of empowerment and purpose (\u003cspan additionalcitationids=\"CR20 CR21 CR22 CR23\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Nature-based programs have been found to improve self-esteem, mood, and social functioning among adolescents (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Similarly, nature exposure has been associated with improvements in attention deficit and hyperactivity disorder symptoms in young people, and resilience and health-related quality of life (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). A meta-synthesis of talking therapy conducted outdoors found that the environment enriched the therapeutic relationship and positioned engagement with nature as a restorative force with measurable mental health benefits (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Although the benefits of nature-based and outdoor programs are well-documented, their implementation has often been hindered by organisational concerns (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). These include perceived risks associated with less controlled environments and limited awareness of the supporting evidence base. As a result, such programs are commonly found in private practice or user-pays sectors (\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe aims of this study were to 1. understand the characteristics (e.g., age, gender, socioeconomic status) of Human Nature participants and examine their patterns of engagement in the program, and 2. evaluate the effectiveness of the Human Nature program in improving wellbeing and self-reported satisfaction with various life domains including social relationships, educational engagement, and personal development.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eStudy Design\u003c/p\u003e\u003cp\u003eThis study used a pre-post intervention-only observational design, relying on routinely collected administrative data from young people aged 14\u0026ndash;18 years who had received at least one occasion of service from Human Nature over the two-year period (January 2023 to December 2024). Only existing data were analysed, without manipulation of the study environment or variables. Baseline data collected at the first session were considered pre-intervention data, while all follow-up session data after the first session were considered post-intervention data.\u003c/p\u003e\u003cp\u003eDue to the data available for the project, there was no control arm; therefore, only pre- and post-program data were compared to estimate the program's effect on the outcome variables. Given the real-world, pragmatic nature of the program, implementing a control group was not feasible without compromising program delivery.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eHUMAN NATURE PROGRAM\u003c/h2\u003e\u003cp\u003eThrough engaging young people in nature-based activities, the Human Nature program aims to improve psychological well-being and overall functioning for young people who have been unable to get support from traditional mental health services. Founded in 2015, the Human Nature program operates across the Far North Coast of New South Wales, Australia, and primarily depends on private donations to cover its operating costs. Using trained mental health clinicians, Human Nature aims to meet young people\u0026rsquo;s needs - psychologically, emotionally and developmentally. Support is provided in a variety of non-clinical settings where young people are most likely to feel safe and comfortable. These settings may include the home, school, or local cafes. Wherever possible, the team encourages outdoor activity, recognising that being in nature can help young people open up and connect with the trauma-informed therapeutic support provided by the service. Young people are given autonomy over their sessions, choosing what they want to do and where they want to do it, reflecting the deliberate operationalising of person-centred care. Human Nature services are free and long-term. The length of time a young person attends the program is up to them. However, most will stay with the program for 12 to 18 months.\u003c/p\u003e\u003cp\u003eThe eligibility criteria for Human Nature participants are -\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eAged between 14 and 18 years\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eliving in the Far North Coast region of NSW, Australia\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003epresenting with significant challenges (e.g. trauma, substance use problems, mental health issues, social problems, behavioural difficulties or family conflict/breakdown)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eexperiencing barriers to engaging with support in clinical settings, i.e. has refused to attend or has not returned to other health services.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eDATA SOURCES AND ANALYTIC Sample\u003c/p\u003e\u003cp\u003eHuman Nature retained client treatment records for young people aged 14\u0026ndash;18 years who had received at least one occasion of service from Human Nature during the study period. Human Nature administrators (CV) matched participant outcome data and assigned random anonymised unique identifiers before transmitting the data to the research team. Data included treatment outcome measures collected throughout the course of treatment and were used to assess participant progress over time.\u003c/p\u003e\u003cp\u003eGiven the use of routinely collected administrative data, a convenience sampling strategy was used, without random selection or stratification. The sample included young people aged 14\u0026ndash;18 who had received an assessment and at least one occasion of service from Human Nature during the two-year period (January 2023 to December 2024). As routinely collected data were used, young people did not directly participate in this research.\u003c/p\u003e\u003cp\u003e A waiver of consent was used for access to the data, as Human Nature clients had not consented to their data being used specifically for this research. However, in line with organisational processes, staff at Human Nature had obtained consent from young people and/or their caregivers to use treatment data for evaluation and research purposes. The Human Research Ethics Committee from Charles Sturt University approved the study (H25114).\u003c/p\u003e\u003cp\u003eData Collection AND STUDY VARIABLES\u003c/p\u003e\u003cp\u003eData extracted from the service's database included:\u003c/p\u003e\u003cp\u003e\u003col style=\"list-style-type:lower-alpha;\"\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eOutcome Rating Scale (ORS)(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e): A brief, session-by-session tool assessing symptom distress, interpersonal wellbeing, social role functioning, and overall wellbeing. It uses four visual analogue scales (0\u0026ndash;10), with a total score range of 0\u0026ndash;40. Cut-off scores are 28 for ages 13\u0026ndash;17 and 25 for ages 18+. Designed for individuals aged 13+, it is accessible at a 13-year-old reading level.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eMy Mind Star (MMS) (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) is a strengths-based, trauma-informed tool used collaboratively to track progress across seven wellbeing domains: feelings and emotions, healthy lifestyle, living situation, relationships, education/work, time use, and self-esteem. Each domain is rated on a five-stage visual chart from \u0026ldquo;stuck or unsafe\u0026rdquo; to \u0026ldquo;managing well.\u0026rdquo;\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eDemographic and other Data: Data collected included age, gender, health concerns, and assessed level of care needs using the Initial Assessment and Referral Decision Support Tool or IAR-DST (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Health concerns covered psychosocial and functional vulnerabilities such as mental health issues, neurodiversity, exposure to violence, and school disengagement. Additional data included Aboriginal and/or Torres Strait Islander status, CALD background, LGBTQIA\u0026thinsp;+\u0026thinsp;identification, living arrangements, and socio-economic status (SEIFA, based on postcode).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eAll data were linked and de-identified by the host organisation prior to transmission to the research team.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eA descriptive analysis was conducted to understand the baseline characteristics of the Human Nature study. Depending on the type of variable, we used either chi-square tests or t-tests (with non-parametric alternatives where applicable) to compare the outcome variable across groups.\u003c/p\u003e\u003cp\u003eThe primary outcomes of interest in this study were improvements in therapeutic relationship as measured by the ORS score, as well as seven mental health and well-being outcomes measured by the MMS scale. Higher scores on these scales were indicative of a higher level of therapeutic relationship, whereas an MMS scale\u0026thinsp;\u0026gt;\u0026thinsp;3 (4 or 5) for a specific domain represents that things are mostly good or okay for that domain.\u003c/p\u003e\u003cp\u003eAverage scores were compared between baseline and endline to evaluate changes, and considering the outcome measure of ORS score, a linear regression model was used to calculate effect sizes, adjusting for potential confounding factors. Furthermore, proportion of MMS scale\u0026thinsp;\u0026gt;\u0026thinsp;3 across different mental and wellbeing domain including \u0026lsquo;feeling and emotions\u0026rsquo;, \u0026lsquo;healthy lifestyle\u0026rsquo;, \u0026lsquo;where you live\u0026rsquo;, \u0026lsquo;friends and relationships\u0026rsquo;, \u0026lsquo;school, training and work\u0026rsquo;, \u0026lsquo;how you use your time\u0026rsquo; and \u0026lsquo;self-esteem\u0026rsquo;, were compared between baseline and endline to understand the changes in those mental and wellbeing outcomes. Considering the binary nature of the mental and well-being outcomes measures in MMS (\u0026gt;\u0026thinsp;3\u0026thinsp;=\u0026thinsp;1 vs else\u0026thinsp;=\u0026thinsp;0), we use logistic regression models to calculate effect sizes, adjusting for potential confounding factors. Due to repeated measures data, panel liner and logistic regression models were used to adjust for the within-subject correlation. Initially, simple models were fitted considering only outcome and time (baseline vs endline) variables. Subsequently, adjusted models were fitted by incorporating some potential covariates, including age, sex, indigenous status, CALD, LGBTQIA\u0026thinsp;+\u0026thinsp;living arrangement, and SEIFA into the model. The significance of effect size is derived from the beta coefficients of the time variable for ORS score, whereas it was the odds ratio (OR) for MMS scale (\u0026gt;\u0026thinsp;3) for both the unadjusted and adjusted models, considered at a 95% confidence interval. All the data were analysed using STAT 18.5.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eProgram participants characteristics\u003c/p\u003e\u003cp\u003eAbout 70% of participants were early adolescents (\u0026lt;\u0026thinsp;15 years), and 52% were male. Just over one-quarter (27.36%) identified as Aboriginal and Torres Strait Islander, while 11.32% and 6.6% were identified as LGBTQIA\u0026thinsp;+\u0026thinsp;and CALD, respectively. A significant number of adolescents reported living in unstable conditions or in a single-parent household (46.22%) and residing in a lower socioeconomically disadvantaged community (42.45%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipant\u0026rsquo;S SOCIO-DEMOGRAPHIC CHARACTERISTICS, Psychosocial and functional vulnerabilities\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal sample: N\u0026thinsp;=\u0026thinsp;106\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e% (n)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocio-demographic characteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; \u0026lt;\u0026thinsp;15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e70.75(75)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; 15\u0026ndash;19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29.25(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Male\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e51.89(55)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Female\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e44.34(47)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Other\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.77(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndigenous status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; No\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e72.64(77)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Yes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27.36(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCALD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; No\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e93.4(99)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Yes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6.6(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLGBTQIA+\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; No\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e88.68(94)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; yes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11.32(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLiving with\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Family/extended family\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30.19(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Single parent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31.13(33)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Unstable living\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15.09(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Unknown\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23.58(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeighbourhood socio-economic status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Lowest two quintile (Q1\u0026amp;2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e42.45(45)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Other (Q3-Q5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e57.55(61)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePsychosocial and functional vulnerabilities\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMental health concern\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; No\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e57.55(61)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Yes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e42.45(45)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDisability (e.g. neurodiversity)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; No\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82.08(87)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Yes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17.92(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDisclosed family and domestic violence (FDV)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; No\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36.79(39)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Yes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e63.21(67)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDisclosed sexual violence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; No\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e72.64(77)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Yes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27.36(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSchool disengagement reported\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; No\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e89.62(95)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Yes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10.38(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMultiple vulnerabilities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; None\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.43 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Only one\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37.74 (40)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Multiple (2 to 4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e52.83 (56)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMore than half of the study participants (52.83%) reported multiple vulnerabilities, meaning they experienced more than one vulnerability (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The highest proportion of vulnerability was exposure to family and domestic violence (63.21%), followed by mental health concerns (42.45%), sexual violence (27.36%), disability (17.92%), and school disengagement (10.38%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eProgram engagement\u003c/p\u003e\u003cp\u003eAmong the program participants, the majority (about 63%) were referred to the program by either parents or carer (30.19%) or school staff (33.02%). On average, participants attended 26 sessions, with one-third of them having shorter engagements (i.e., attending fewer than 18 sessions) (Table A \u0026ndash; supplementary material). Most participants remained engaged with the program, whereas approximately 35% of participants left the program, mainly due to achieving their goals (24.32%), or exiting to Elev8, Human Nature\u0026rsquo;s step-down weekly group program (18.92%), or referred elsewhere (21.62%). However, approximately 30% of participants left the program, either of their own decision or because they migrated to other regions.\u003c/p\u003e\u003cp\u003eThe proportion of participants with shorter-term engagements varied across different participant groups. For example, the proportion of shorter-term engagement was 58.33% among those who identified as LGBTQA+, whereas it was 30.85% among those who didn\u0026rsquo;t. Similarly, the proportion of shorter-term attendance was 52.62% for those who reported disability, whereas it was 29.89% for those who did not report disability (Table B \u0026ndash; supplementary). However, statistically significant differences were observed in the proportion of shorter-term engagement only among the different groups based on living status. Adolescents living with their family or extended family had a higher proportion of shorter-term engagement (59.38%) compared to other living condition groups (P\u0026thinsp;=\u0026thinsp;0.003) (Table B supplementary).\u003c/p\u003e\u003cp\u003eProgram effect\u003c/p\u003e\u003cp\u003e Participants' ORS scores significantly improved at the endline compared to its baseline condition. The mean (SD) ORS score increased from 22.01 (8.1) at baseline to 29.52 (8.1) at endline (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The program effect remained statistically significant after adjusting for potential confounders, including age, sex, Indigenous status, CALD, LGBTQIA\u0026thinsp;+\u0026thinsp;living arrangement, and SEIFA. Our adjusted regression model showed that the ORS score had a 7.5-unit higher score at the endline compared to its baseline score (β\u0026thinsp;=\u0026thinsp;7.48, 95% CI, 5.67\u0026ndash;9.28) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe effect of human nature intervention on ORS rating score; N\u0026thinsp;=\u0026thinsp;106\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eORS Rating score\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eEffect: β (95% CI) [p-value]\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTime\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean (SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUnadjusted\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAdjusted*\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBaseline\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e22.01 (8.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e--\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e--\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEndline\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e29.52 (8.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.5 (6.0, 9.3) \u003cb\u003e[\u0026lt;\u0026thinsp;0.001\u003c/b\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.48 (5.67, 9.28) \u003cb\u003e[\u0026lt;\u0026thinsp;0.001\u003c/b\u003e]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e*Adjusted by socio-demographic characteristics such as age, sex, indigenous status, CALD, LGBTQIA+, Socio-Economic Indexes for Areas (SEIFA) and living arrangement\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eβ: rate of change (effect size)\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eCI: Confidence interval\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eExamining the effect of the MMS scale across various mental health and well-being domains, we found that the proportion of participants with a MMS scale\u0026thinsp;\u0026gt;\u0026thinsp;3 out of five (meaning things are mostly good or OK) significantly improved for all domains at the endline compared to the baseline data, indicating a substantial improvement in the mental health and well-being of the study participants (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e ). For example, the proportion of MMS scale\u0026thinsp;\u0026gt;\u0026thinsp;3 for \u0026lsquo;feeling and emotions\u0026rsquo; domain was 23.58% at baseline, which increased to 56.60% at endline (P\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Similarly, the increased proportion of MMS scale\u0026thinsp;\u0026gt;\u0026thinsp;3 was observed for other domains of \u0026lsquo;healthy lifestyle\u0026rsquo; (30.19% vs 50.0%), \u0026lsquo;where you live\u0026rsquo; (50.0% vs 70.75%), \u0026lsquo;friends and relationships\u0026rsquo; (47.17% vs 62.26%), \u0026lsquo;school, training and work\u0026rsquo;(18.87% vs51.89%), \u0026lsquo;how you use your time\u0026rsquo; (26.42% vs 53.77%) and \u0026lsquo;self-esteem\u0026rsquo;(31.13% vs 59.43%) at endline compared to its baseline estimate (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe program effect remained statistically significant on all mental health and well-being domains after adjusting for potential confounders. Our adjusted regression model showed that \u0026lsquo;self-esteem\u0026rsquo; domain had the largest estimated odd ratio (AOR\u0026thinsp;=\u0026thinsp;6.99, 95% CI, 2.74, 17.83) among other domains, suggesting a stronger association with the program engagement, followed by other domain of \u0026lsquo;how you use your time\u0026rsquo; (AOR\u0026thinsp;=\u0026thinsp;6.72, 95% CI, 2.63, 17.15), \u0026lsquo;school, training and work\u0026rsquo;(AOR\u0026thinsp;=\u0026thinsp;5.50, 95% CI, 2.82, 10.7), and \u0026lsquo;feelings and emotions\u0026rsquo; (AOR\u0026thinsp;=\u0026thinsp;5.34, 95% CI, 2.52, 11.3) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe effect of human nature intervention on the Mind Star scale across different domains; N\u0026thinsp;=\u0026thinsp;106\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMind Star scales\u0026thinsp;\u0026gt;\u0026thinsp;3\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eEffect (95% CI) [p-value]\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTime\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e% (n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUnadjusted (OR)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAdjusted (AOR)*\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFeelings and emotions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Baseline\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23.58 (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRef\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Endline\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e56.60 (60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.38(2.53, 11.43) [\u0026lt;\u0026thinsp;0.001]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e5.34(2.52, 11.3) [\u0026lt;\u0026thinsp;0.001]\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealthy lifestyle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Baseline\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30.19 (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRef\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eRef\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Endline\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50.0(53)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.34(2.52, 11.3) [\u0026lt;\u0026thinsp;0.001]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e3.09(1.52, 6.28) [0.002]\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWhere you live\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Baseline\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50.0 (53)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRef\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eRef\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Endline\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e70.75 (75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.44(1.64, 7.23) [0.001]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e3.43(1.63, 7.19) [0.001]\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFriends and relationships\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Baseline\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e47.17 (50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRef\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Endline\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e62.26 (66)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.00(1.1, 3.64) [0.024]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e2.00(1.1, 3.65) [0.023]\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSchool, training and work\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Baseline\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18.87 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRef\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Endline\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e51.89(55)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.38(2.53, 11.43) [\u0026lt;\u0026thinsp;0.001]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e5.50(2.82, 10.7) [\u0026lt;\u0026thinsp;0.001]\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHow you use your time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Baseline\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26.42 (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRef\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Endline\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e53.77 (57)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.80(2.66, 17.38) [\u0026lt;\u0026thinsp;0.001]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e6.72(2.63, 17.15) [\u0026lt;\u0026thinsp;0.001]\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-esteem\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Baseline\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31.13 (33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRef\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026shy; Endline\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e59.43 (63)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.00(2.74, 17.86) [\u0026lt;\u0026thinsp;0.001]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e6.99(2.74, 17.83) [\u0026lt;\u0026thinsp;0.001]\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e*Adjusted by socio-demographic characteristics such as age, sex, indigenous status, CALD, LGBTQIA, SEIFA and living arrangement\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eOR: Odds ratio\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eCI: Confidence interval\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe results of this study provide strong evidence for the effectiveness of the Human Nature program in improving mental health and wellbeing among adolescents who have experienced trauma. The program\u0026rsquo;s nature-based, person-centred, and trauma-informed approach appears to offer a viable alternative to traditional clinical settings, particularly for young people who face barriers to engaging with conventional mental health services (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The program achieved statistically significant improvements in symptom distress, interpersonal wellbeing, social role functioning, and overall life satisfaction. Gains were observed across all domains of the My Mind Star wellbeing scale, with particularly strong effects in self-esteem, time use, and educational engagement. These outcomes were consistent across diverse demographic groups, including Aboriginal and Torres Strait Islander youth, LGBTQIA\u0026thinsp;+\u0026thinsp;participants, and those living in socioeconomically disadvantaged communities.\u003c/p\u003e\u003cp\u003eThe demographic profile of participants highlights the program\u0026rsquo;s success in reaching vulnerable and underserved populations. A significant proportion of participants were early adolescents, male, and from socioeconomically disadvantaged backgrounds. Notably, 27% identified as Aboriginal and Torres Strait Islander, and over half reported multiple psychosocial vulnerabilities, including exposure to family and domestic violence (63%) and mental health concerns (42%). These figures underscore the importance of tailored interventions that address the complex needs of young people who are often excluded from mainstream services (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEngagement levels varied across demographic groups, with shorter-term participation more common among LGBTQIA\u0026thinsp;+\u0026thinsp;youth and those with disabilities. Interestingly, adolescents living with family or extended family were more likely to have shorter engagements, suggesting that living arrangements may influence the duration and intensity of service use. While these differences were statistically significant in some cases, they warrant further exploration to understand the underlying mechanisms and to inform strategies for sustained engagement.\u003c/p\u003e\u003cp\u003eThe most striking finding is the significant improvement in participants\u0026rsquo; wellbeing as measured by both the Outcome Rating Scale (ORS) and the My Mind Star (MMS) tool. The ORS scores increased from a mean of 22.01 at baseline to 29.52 at endline, surpassing the clinical cut-off and indicating meaningful therapeutic gains. These improvements remained robust after adjusting for confounding variables, suggesting that the program\u0026rsquo;s impact is consistent across diverse demographic groups.\u003c/p\u003e\u003cp\u003eSimilarly, the MMS results showed substantial gains across all seven wellbeing domains. The most pronounced improvements were observed in self-esteem (AOR\u0026thinsp;=\u0026thinsp;6.99), use of time (AOR\u0026thinsp;=\u0026thinsp;6.72), and educational engagement (AOR\u0026thinsp;=\u0026thinsp;5.50). These findings align with previous literature on the benefits of nature-based interventions, which have been shown to enhance emotional regulation, social functioning, and cognitive engagement (\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe success of Human Nature reinforces the value of non-clinical, nature-based settings in fostering therapeutic relationships and promoting mental health recovery. The program\u0026rsquo;s emphasis on autonomy, flexibility, and outdoor engagement appears to mitigate the anxiety and stigma often associated with traditional clinical environments (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). This aligns with broader evidence suggesting that nature exposure can reduce stress, improve mood, and enhance resilience (\u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eLIMITATIONS AND FUTURE DIRECTIONS\u003c/h3\u003e\n\u003cp\u003eWhile the study\u0026rsquo;s observational design and lack of a control group limit causal inference, the use of repeated measures and adjusted analyses strengthens the validity of the findings. Future research could benefit from incorporating a matched comparison group or longitudinal follow-up to assess the sustainability of outcomes. Additionally, qualitative data on participant experiences could provide deeper insights into the mechanisms driving change. There is limited research on My Mind Star, and it has not been validated in the peer reviewed literature. However, related tools have been found useful for clinicians and clients to set goals and track progress (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eIMPLICATIONS FOR PRACTICE AND POLICY\u003c/h2\u003e\u003cp\u003eThe findings have important implications for mental health service delivery, particularly in rural and regional contexts. Human Nature\u0026rsquo;s model demonstrates that effective, inclusive, and culturally responsive care can be delivered outside traditional clinical frameworks. The program\u0026rsquo;s use of multi-dimensional outcome measures designed for their client group facilitated the study and the demonstration of program outcomes. Scaling such programs with embedded evaluation designs could help address the crisis in youth mental health services (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) and reduce the burden of untreated distress among adolescents.\u003c/p\u003e\u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis study demonstrates that the Human Nature program offers a promising and effective model for supporting young people with moderate intensity mental health needs, particularly those who fall into the \u0026ldquo;missing middle\u0026rdquo; of service provision. By delivering trauma-informed, person-centred care in nature-based and non-clinical settings, Human Nature successfully engages adolescents who may otherwise struggle to access traditional mental health services.\u003c/p\u003e\u003cp\u003eImportantly, the program\u0026rsquo;s flexible and relational approach appears to foster sustained engagement and therapeutic alliance, even among young people with complex psychosocial vulnerabilities. While further research is needed to explore long-term outcomes and comparative effectiveness, the findings support broader implementation of nature-based mental health interventions as a viable strategy to address service gaps and promote youth wellbeing.\u003c/p\u003e\u003cp\u003eHuman Nature\u0026rsquo;s model contributes to a growing evidence base advocating for innovative, inclusive, and contextually responsive mental health care. Its success underscores the need for continued investment in alternative service models that prioritise accessibility, cultural safety, and the lived experiences of young people.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eMMS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 497px;\"\u003e\n \u003cp\u003eMy Mind Star\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eORS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 497px;\"\u003e\n \u003cp\u003eOutcome Rating Scale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eLGBTQIA+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 497px;\"\u003e\n \u003cp\u003elesbian, gay, bisexual, transgender, queer/questioning, intersex, and asexual/aromantic/agender, with the \u0026quot;+\u0026quot; representing all other identities not included in the letters\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003ePTSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 497px;\"\u003e\n \u003cp\u003ePost Traumatic Stress Disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eIAR-DST\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 497px;\"\u003e\n \u003cp\u003eInitial Assessment and Referral Decision Support Tool\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eCALD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 497px;\"\u003e\n \u003cp\u003eCulturally and Linguistically Diverse\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eSEIFA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 497px;\"\u003e\n \u003cp\u003eSocio-Economic Indexes for Areas\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 497px;\"\u003e\n \u003cp\u003eStandard Deviation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e Australian Commonwealth Department of Health and Ageing, Grant ID 4-DGEJZ1O/4-CW7UT14\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure of interests:\u003c/strong\u003e NS, MMH, HD and JA have no interests to declare. CV worked in a paid position for Human Nature for 4 years until the end of 2024. CV was paid for 6 weeks during May and June 2025 to collate and deidentify the data that was supplied for analysis in accordance with the inclusion and exclusion criteria of the project.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trials registration\u003c/strong\u003e \u0026ndash; not applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eColizzi M, Lasalvia A, Ruggeri M. Prevention and early intervention in youth mental health: is it time for a multidisciplinary and trans-diagnostic model for care? International Journal of Mental Health Systems. 2020;14(1):23.\u003c/li\u003e\n\u003cli\u003eWelfare AIoHa. Health of Young People Canberra: Australian Institute of Health and Welfare; 2024 [updated 16 April 2024. Available from: https://www.aihw.gov.au/reports/children-youth/health-of-young-people.\u003c/li\u003e\n\u003cli\u003eOrganisation WH. 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Am J Psychiatry. 1991;148(1):10-20.\u003c/li\u003e\n\u003cli\u003eAlegr\u0026iacute;a M, NeMoyer A, Falg\u0026agrave;s Bagu\u0026eacute; I, Wang Y, Alvarez K. Social Determinants of Mental Health: Where We Are and Where We Need to Go. Current Psychiatry Reports. 2018;20(11):95.\u003c/li\u003e\n\u003cli\u003eAstell-Burt T, Hartig T, Eckermann S, Nieuwenhuijsen M, McMunn A, Frumkin H, et al. More green, less lonely? A longitudinal cohort study. Int J Epidemiol. 2022;51(1):99-110.\u003c/li\u003e\n\u003cli\u003eHolmes MP, W. Wissing, R., Zylstra, M. Nature-based solutions for the health sector: opportunities and returns on investment.; 2023.\u003c/li\u003e\n\u003cli\u003eMarselle MR, Warber SL, Irvine KN. Growing Resilience through Interaction with Nature: Can Group Walks in Nature Buffer the Effects of Stressful Life Events on Mental Health? 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Mental health benefits of interactions with nature in children and teenagers: a systematic review. J Epidemiol Community Health. 2018;72(10):958-66.\u003c/li\u003e\n\u003cli\u003eCooley SJ, Jones CR, Kurtz A, Robertson N. \u0026apos;Into the Wild\u0026apos;: A meta-synthesis of talking therapy in natural outdoor spaces. Clin Psychol Rev. 2020;77:101841.\u003c/li\u003e\n\u003cli\u003ePaquet S, Struthers NA, Gunz A, Gittings L. Barriers and facilitators to implementing nature prescriptions for child and youth health: a scoping review. Health Promotion International. 2025;40(2).\u003c/li\u003e\n\u003cli\u003eCasey P, Patalay P, Deighton J, Miller SD, Wolpert M. The Child Outcome Rating Scale: validating a four-item measure of psychosocial functioning in community and clinic samples of children aged 10-15. Eur Child Adolesc Psychiatry. 2020;29(8):1089-102.\u003c/li\u003e\n\u003cli\u003eMacKeith J, Good A, Burns S. Development of a co-produced tool for monitoring and supporting the mental health of young people. BJPsych Open. 2021;7(S1):S267-S.\u003c/li\u003e\n\u003cli\u003eAustralian Government Department of Health DaA. Initial Assessment and Referral Decision Support Tool \u0026ndash; IAR Decision Support Tool. In: Department of Health DaA, editor. Canberra: Australian Government; 2019.\u003c/li\u003e\n\u003cli\u003eLloyd C, Williams PL, Machingura T, Tse S. A focus on recovery: using the Mental Health Recovery Star as an outcome measure. Advances in Mental Health. 2016;14(1):57-64.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Rural Health Research Institute, Charles Sturt University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Mental Health, Adolescent, Rural Health Services, Nature Therapy, Program Evaluation, Health Equity","lastPublishedDoi":"10.21203/rs.3.rs-7909305/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7909305/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eMental distress among adolescents is a growing public health concern, particularly for youth underserved by traditional mental health systems. This study evaluates the \u003cem\u003eHuman Nature\u003c/em\u003e program, a nature-based, trauma-informed, person-centred intervention designed to support adolescent mental health in non-clinical, rural settings across Northern New South Wales, Australia.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA pre-post observational design was used to assess psychological outcomes among 106 participants aged 14\u0026ndash;18. Routinely collected data included measures of psychological wellbeing, life satisfaction, and engagement across diverse demographic groups. Outcome tools included the Outcome Rating Scale (ORS) and the My Mind Star (MMS) assessment, capturing changes across multiple domains of functioning.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eStatistically significant improvements were observed in symptom distress, interpersonal wellbeing, and social role functioning. All seven domains of the MMS scale showed positive change, with the most substantial gains in self-esteem, positive time use, and educational engagement. The program successfully engaged vulnerable populations, including Aboriginal and Torres Strait Islander youth, LGBTQIA\u0026thinsp;+\u0026thinsp;adolescents, and those facing multiple psychosocial challenges.\u003c/p\u003e\u003ch2\u003eDiscussion\u003c/h2\u003e\u003cp\u003eFindings support the effectiveness of trauma-informed, nature-based interventions in enhancing youth mental health, particularly in rural and regional contexts. The \u003cem\u003eHuman Nature\u003c/em\u003e program demonstrates the value of flexible, relational models in reaching underserved populations. These results underscore the need for government investment in alternative mental health approaches that address service gaps and promote equity in access.\u003c/p\u003e","manuscriptTitle":"Evaluating a Community-Delivered, Nature-based Mental Health Program for Rural Adolescents: Evidence from the Human Nature Program","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-22 19:00:27","doi":"10.21203/rs.3.rs-7909305/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5399112b-cdc2-4927-856a-60cc8142fcb3","owner":[],"postedDate":"October 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-22T19:00:28+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-22 19:00:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7909305","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7909305","identity":"rs-7909305","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}