Green Care as Alternative Therapy: The Situation in Ghana

Green care, an alternative healthcare system that involves the use of nature, is proven to be useful in the management of organic and psychological disorders worldwide. )ere are various forms of Green care including Animal-Assisted )erapy (AAT), a type where animals play pivotal roles in the healing process and is widely used in many developed countries. We assessed the level of awareness and attitude towards Green care among medical students of Ghana. Using a cross-sectional study design and a semistructured questionnaire designed on Google Forms, data were collected from randomly selected 4-, 5-, and 6-year medical students of the University for Development Studies, Tamale, Ghana. )e data submitted by 206 of the students were analyzed using Statistical Package for the Social Sciences, Version 25, and the results were presented as frequencies, percentages, and charts. )e association between sociodemographic characteristics of respondents and awareness about Animal-Assisted )erapy (AAT) was considered significant at p< 0.05.)e study found that only 7 (3.4%) of themedical students had ever heard of Green care while a higher number of 36 (17.5%) were aware of AATmostly through movies and television. However, the majority, 122 (59.3%), had a positive attitude towards the introduction of AAT, into their medical training curriculum. Up to 146 (70.9%) of the respondents suggested lectures and practical sessions as their preferred way of acquiring knowledge and skills on AAT. Only the sex of the respondents was significantly associated with awareness of AAT, with females having a better awareness of AAT (28.6% vs. 11.0%, p � 0.003). We conclude that awareness of Green care practices among medical students in Ghana was highly inadequate, but the desire of the majority of them to acquire knowledge and skills in this proven alternative therapy makes its future use in Ghana promising.


Introduction
e use of nature for the promotion of human health, which is collectively known as Green care, is becoming a promising alternative healthcare practice, especially in developed countries [1,2]. Green care is defined as an alternative therapy that uses the biotic (living) and abiotic (nonliving) components of nature to promote human health and wellbeing [1,3]. Although Green care may be linked to the natural environment, it can also occur in designated facilities such as hospitals, nursing homes, and prisons [4,5]. Green care intervention processes can be classified into social and therapeutic horticulture, care farming, ecotherapy, and animal-assisted therapy among others [1]. Social and therapeutic horticulture involves the use of plants and horticulture to promote human wellbeing [6]. Care farming processes, on the other hand, encompass the use of commercial farms and agricultural landscape to promote mental and physical health, while ecotherapies are techniques and practices which encourage clients to work with plants and animals and are supported to establish a green space to conserve local habitats [7][8][9][10]. Animal-assisted therapy involves the use of trained animals such as dogs, cats, horses, and donkeys to promote mental and physical health [1,11,12].
Animal-assisted therapy (AAT) is the most thoroughly studied Green care method [1,4]. Physiological benefits derived from Green care have been proven to be effective as its application had reportedly led to a significant reduction in abnormal heart rates, blood pressure, and pain [13][14][15]. Examples of documented psychiatric or neurological disorders that have been cured or managed using Green care or AAT include schizophrenia, personality disorders, depressions, acute stress reactions, multiple sclerosis, dementia, and bipolar affective disorders, as well as drug addictions [1,2,[16][17][18][19][20][21][22]. Historical records show that Green care was practiced in hospitals, prisons, monasteries, and churches in the Middle Ages, but the practice of this alternative therapy has recently gained enormous patronage in many developed countries including the United Kingdom, United States of America, Sweden, Norway, Germany, Spain, Australia, Netherlands, and Belgium among others [3,12,18,23,24].
Developing countries, especially those in the tropics, including sub-Saharan Africa, have the greatest diversity of fauna and flora, which are important components of Green care practices [25,26]. However, there seems to be a paucity of studies on the use of this alternative therapy in human health promotion in the developing world including Africa. Medical doctors and other health practitioners are key persons who could promote Green care therapy if they are abreast with the use and importance of Green care as an alternative therapy for some chronic diseases. e present study, therefore, evaluated the awareness level and attitude toward Green care therapy among medical students in Ghana. e result of this study could cause health educators and policymakers to take the appropriate actions on how these would-be physicians and other health practitioners can make this alternative therapy available and beneficial to the Ghanaian populace.

Study Design, Setting, and Population.
Data were collected from clinical-level medical students of the University for Development Studies, Tamale, Ghana, in a quantitative research using a cross-sectional study design. e study was conducted between July and August 2020. e University for Development Studies (UDS) was established as the first university in Northern Ghana in 1992. It is located in the Tamale metropolis, the only northerly located city in Ghana, and is geographically situated between latitude 9°16 and 9°3 4 North and longitude 0°36 and 0°57 West [27]. During the last national population census in 2010, Tamale was reported to have a population of 233,252 [27]. e respondents were clinical-level medical students of the School of Medicine and Health Sciences of the UDS undertaking their junior and senior clerkships at the Tamale Teaching Hospital, the only tertiary-level medical facility in Northern Ghana.

Sample Size.
e Cochran formula, n 0 � t 2 (p)(q)/d 2 [28], was used to calculate the sample size for this study, where t � 1.96, the value for a selected alpha level of 0.025 in each tail; d � 0.05 considered as an acceptable margin of error for proportion; and p is the estimated proportion of an attribute that is present in the population, which is considered as 0.5 or 50% since there is a paucity of data on the level of awareness on Green care in Ghana; hence, q � 0.5 (q � 1 − p). (1) Since 384 exceeds the 5% (487 × 0.05 � 24.4) of the eligible study population of 487 and excluding the 28 students who took part in the piloting of the study tool, an adjusted sample size n 1 was calculated using the Cochran correction formula: with a total response of 206 obtained at the end of the data collection, and this study had a response rate of 98.6% (206/ 209 * 100).

Sampling Procedure.
Simple random and proportionate sampling techniques were applied in this study. e lists of all the students in the 4 th -(215), 5 th -(137), and 6 th -(135) year classes were obtained together with their WhatsApp numbers from their class leaders who sought their consent on behalf of the researchers. Using the Microsoft Rand function, the arrangement of the class lists was randomized. Using proportionate sampling, the numbers required for the piloting of the questionnaire and the actual data collection were obtained.

Study Tool and Data Collection.
e study tool for this study was a semistructured questionnaire that was piloted from 29 th April to 6 th May 2020. e outcome of the piloting aided in the removal of ambiguous questions and restructuring where necessary. e researchers undertook an analysis of all the questions to ensure the face validity of the study tool. is semistructured questionnaire was divided into sections that aimed at collecting data on respondents' sociodemographic characteristics as well as their level of awareness of Green care. e link to the questionnaire in the Google Forms, https://forms.gle/NZFE1rgHnRk44bKi8 was sent to the WhatsApp accounts of the randomly selected students between 6 th July and 7 th August 2020 for those who consented to be part of the study, to complete the form and then submit. If a respondent was unavailable, the next respondent in the list was contacted. Reminder messages were sent to the respondents to encourage them to complete the forms after which they were to alert the researchers of their successful submission of the form. e results were presented into frequencies and percentages, as well as a chart. e association between the sociodemographic characteristics and respondents' awareness of Green care was measured using Chi-square. e relationship between variables was considered as statistically significant only if p value < 0.05 at a confidence interval of 95%.

Awareness Level of Green Care among Respondents.
Only a paltry, 7 (3.4%), of the respondents had ever heard of Green care with a lesser number, 5 (2.4%), indicating they knew what Green care is. Even of those who indicated knowing what Green care was, only 3 (60%) were able to correctly define what it was. Again, the majority, 170 (82.5%), had never heard of Animal-Assisted erapy (AAT) or Animal-Assisted Intervention (AAI). For those who had ever heard of AAT, movies, 10 (27.8%), and television, 10 (27.8%), were their first-ever sources of information on this alternative therapy. roughout the educational lives of these respondents, only 1 (0.5%) had ever been exposed to AAT during academic activities. Table 2 shows the level of awareness of respondents on Green care as an alternative therapy. Although most respondents, 63 (30.6%) were not sure if they would welcome the introduction of AAT as a course of study during their university education, cumulative majority, 122 (59.3%), exhibited various levels of interest in registering for such a course whenever it becomes part of their academic curriculum.

How Respondents Wish to Be Educated on Animal-Assisted erapy.
A combination of lectures and the practical sessions was the most preferred method of course delivery by the majority, 146 (70.9%), of respondents who wish to acquire knowledge and skills on Animal-Assisted erapy and it should be introduced as part of their academic activity. e least-preferred method was tutorials only, 1 (0.5%). Figure 1 shows methods by which respondents would wish to be educated on Animal-Assisted erapy.

Relationship between Sociodemographic Characteristics of Respondents and eir Awareness of Animal-Assisted erapy.
e relationship between the sociodemographic characteristics and the level of awareness of respondents about AAT is as shown in Table 3. Respondents older than 29 years were most aware of AAT (23.5% vs. 12.4%-20.7%) just as persons ascribing to other religions besides Islam and Christianity (66.7% vs. 15.7%-18.0%), but there were no significant differences between the various categories of these variables. Attaining higher educational qualifications by parents, especially the mothers, increases the level of awareness of respondents, although no significant relationship was found (24.4% vs. 7.1%-18.6%; p > 0.05). e 4 th -year clinical-level medical students exhibited the highest level of awareness of AAT compared to their seniors in the 5 th and 6 th year, but there was no significant association in their awareness levels (21.1% vs. 13.5%-13.6%). Female respondents showed better awareness of AAT than their male counterparts, and the difference was found to be statistically significant (28.6% vs. 11.0%; p � 0.003). Respondents from middle-income families showed the greatest awareness level compared to those from the low-and highincome homes, but the difference was not statistically significant (24.7% vs. 10.7-12.9%).

Discussion
e use of Green care for the promotion of health and management of various human physiological disorders is reported to be in great use in Europe, North America, and some Nordic countries [4,12,23]. Green care had proven useful in the management of psychiatric clients, vulnerable children, persons with learning disabilities, and drug addicts, as well as persons experiencing burnouts [1,2]. In countries where Green care service is widely used, several professionals such as a physical and occupational therapist, social workers, teachers, and others of various specialties form an integral part of this treatment method [4]. ese professionals could have clients referred to them by medical doctors who appreciate the relevance of this alternative therapy to the restoration of good health. is study found as low as 3.4% ever hearing of Green care in general, although a higher number of 17.5% had heard of AAT. If almost half (53.8%) of the respondents were in their 5 th or 6 th year of medical training possess such a low level of awareness about Green care and AAT, it provides an inkling of the present and the immediate future state of Green care in a developing country such as Ghana that is endowed with a great diversity of flora and fauna. Nevertheless, almost 6 out of 10 respondents (59.3%) willing to acquire knowledge on AAT during their medical training through lectures and practical sessions bodes well for the future of Green care in Ghana if it is included in the curriculum of health-training institutions. e zeal to acquire knowledge and skills on AAT among the respondents in this study was greater than the 48% reported among graduate Clinical Psychology students in Canada where there is a growing practice of Green care [29].
ese Canadian students, just like the respondents in this study, also had almost no exposure to AAT during their time in school. is suggests that even in some developed countries, Green care is yet to be incorporated into their health systems. is study did not find any statistically significant association with several of the Evidence-Based Complementary and Alternative Medicine  greater concern for animal welfare and rights than males and also were more likely to keep pets, hence possessing high awareness level on the use of animals for therapy [30]. Herzog also reported that females commonly have more positive behaviours and attitudes towards animals than their male counterparts [31]. is, therefore, explains why this study found female medical students being significantly more aware of AAT than their male colleagues. is study, however, brings to the fore the need for more studies in other developing countries and among healthcare professionals. Considering how valuable Green care practices have been in restoring the health of patients in developed  Evidence-Based Complementary and Alternative Medicine countries [13][14][15]32], health-related institutions, especially medical schools, in developing countries must expose their students to the various forms of Green care so that they can recommend this well-proven treatment modality to those whose conventional medicines seem unable to resolve their health challenges. Although using simple randomization limited biases, the results of this study may not represent the true knowledge on Green care among all medical students in Ghana since the study was carried out in only one out of the five public medical schools in Ghana. is study seems to be the first ever in Ghana and especially among medical students, and conducting similar studies across all other medical schools in Ghana in the future would provide a better assessment of medical students knowledge of and attitude towards this alternative healthcare system. To ascertain the true state of knowledge on Green care among practicing doctors, there may be a need for a similar study to be conducted amongst them. Similar studies can also be conducted among all other categories of practicing health professionals.

Conclusions
Awareness of Green care practices among medical students in Ghana was highly inadequate, but the desire of the majority of them to acquire knowledge and skills in this proven alternative therapy makes its future use in Ghana promising. Including Green care in the academic curriculum of medical schools could enhance its use. is will go a long way to offer patients in Ghana an alternative healthcare system.

Data Availability
e results presented are adequate to support the conclusion of this study. However, the lead author is available to provide extra data upon request.

Ethical Approval
e Ethics Committee of the School of Medicine and Health Sciences of the University for Development Studies provided prior approval for this study with a certificate number of SMSAHS/JIRC/0005.

Consent
Data were collected from participants only after they gave their informed consent to take part in the study.