Introduction
In South Korea, agro-healing is defined as follows: industries or activities related to the restoration or promotion of people’s psychological, social, cognitive, and physical health by providing services utilizing agriculture, rural resources and related activities and outputs, and society and culture in rural areas (Kim et al., 2013). Agro-healing was introduced in earnest in South Korea with the implementation of the Act on Research, Development and Promotion of Healing Agriculture (Agro-healing Act) on March 25, 2021. It is receiving the public’s attention as it is expected that the stress of modern people can be relieved and a therapeutic effect produced through various activities using agricultural materials and rural resources.
Agro-healing is also commonly defined as “activities that heal not only those who are under work-related psychological stress or who are unhealthy, but also those who need social and medical treatment for mental illness, depression, drug addiction, or learning disabilities” (Sempik et al., 2010). Agro-healing is sometimes focused on helping maintain residual physical functions in terms of rehabilitation (Kim, 2000). According to Kim and Ha (2004), developed countries that first experienced the problems of population aging and urbanization have actively introduced agro-healing, which involves agricultural activities using farms and natural landscapes to improve human physical and mental health. Kim and Kim (2001) reported that touching the soil, trimming materials, and engaging in physical activities released anxiety and aggression appropriately, and was also effective in reducing problematic behaviors. The first program to use gardening for the purpose of treatment or rehabilitation was developed by Mc Candliss in 1949, and the first occupational therapists who studied gardening at Michigan State University were produced (Matsuo, 2005).
As such, although the effects of treatment using agriculture have been reported, studies verifying the effects on rehabilitation of people with developmental disabilities (PDD) are limited. According to Article 2-1 of the Act on Welfare of Persons With Disabilities, persons with disabilities (PD) are persons with intellectual or autistic disabilities, and other persons prescribed by Presidential Decree, who are significantly restricted in their daily or social life because their normal development does not appear or is greatly delayed. PDD have difficulty in knowing their needs and requesting appropriate support for them due to their low cognitive abilities. Daycare centers for PD in South Korea are facilities that provide the rehabilitation services necessary for them by caring for them during the daytime. The number of such facilities is gradually increasing, with 592 in 2014, 625 in 2015, 663 in 2016, and 690 in 2017 (E-country indicator, 2019). The main services provided by daycare centers for PD include rehabilitation, field trips, support for hobbies, education & guidance, counseling, haircuts, hairdressing, lunch and snacks. However, there is a significant lack of services that promote PDD’s self-reliance while improving their activities of daily living and inducing their social participation (Yun, 2018). Bae and Jeong (2019) reported that interventions to improve the performance of activities of daily living are necessary based on a survey conducted on the demand for occupational therapy targeting social workers at daycare centers for PDD. In addition, those are also suggested as needed to improve physical activity, sensory integration, and hand function. Notably, one of the physical characteristics of PDD is that they cannot use their hands well for their own purposes (Jeong and Seo, 2005), so Case-Smith and O’Brien (2014) suggested that hand function and visual-motor integration of PDD are important skills to be intervened in the clinical practice of occupational therapy. According to Kim (2020), in the field of vocational rehabilitation for developmental disabilities, programs that can overcome psychological atrophy are being sought by resolving the lack of living ability, which is a characteristic of people with developmental disabilities, and strengthening the sense of achievement gained through work. In other words, programs are needed that enable PDD to adapt well to activities of daily living. In this study, we aimed to examine how a agro-healing program affects hand function, grip strength, and the ability to perform activities of daily living among people with developmental disabilities, and suggest the possibility of using such a program as a clinical intervention method.
Research Methods
Subjects
In this study, 32 people who understood the purpose of this study and agreed to participate in it were selected as subjects from among individuals who used P Lifelong Education Academy and H Developmental Rehabilitation Center, which are located in Wanju-gun and Jeonju-si, Jeollabuk-do, respectively, from April to July 2022. After fully explaining the purpose and method of this study to all subjects, we obtained their consent to all survey procedures. The criteria for selecting subjects are as follows: (1) PDD (20s – 50s) using the services of the Daytime Activity Service Support Project for Adults with Developmental Disabilities in Jeollabuk-do; (2) those who have been identified as having grade 1–3 intellectual disabilities under the Act on Welfare of Persons with Disabilities; and (3) people with disabilities who did not have multiple or physical disabilities other than intellectual disabilities. The exclusion criteria are as follows: (1) those who cannot participate in occupational activities under the guidance of an occupational therapist when performing individual assignments; and (2) persons whose hand function is below average of PDD.
As for the general characteristics of the subjects, males represented 53.3% and 76.5% of the experimental and control groups, respectively. The average age was 35.53 and 40.47 years in the experimental and control groups, respectively. In terms of the age groups of the control group, the majority were in their 50s at 6 people (35.3%), followed by 5 in their 30s (29.4%), 4 in their 20s (23.5%), and 2 in their 40s (11.8%). Among the experimental group, the majority were in their 20s with 8 (53.3%), followed by 4 in their 50s (26.7%), 2 in their 60s (13.3%), and 1 in their 40s (6.7%; Table 1).
Design
This study was designed as a pre- and post-test, and the details are shown in Fig. 1. Simple random assignment was used to place the subjects into the experimental or control groups, and pre- and post-tests were conducted by occupational therapists. The functional independence measure (FIM), Jamar hydraulic hand dynamometer (Hand Dynamometer), and Jebsen-Taylor hand function test (JTHFT) were used as test tools. The agro-healing program applied to the experimental group was carried out once a week, and the topics for each session were agricultural activities that included sowing and raising seedlings, planning a garden, planting, growing, gardening activities, managing a garden, cuttings, and harvesting. Agricultural activities for each session were conducted for a total of 60 minutes, including 10 minutes for the introduction and preparation of the agro-healing program, and 50 minutes for the healing agriculture program where participants interacted with each other; after a 10-minute break, the activities continued. The activities were conducted for 120 minutes per day. The treatment program applied to the control group was general rehabilitation therapy of the Daytime Activity Service Support Project, including hand function therapy and activity of daily living training.
Procedure
This study was conducted after approval by the Institutional Review Board (7001355-202205-HR-551) of K University. The subjects were recruited through promotional materials attached to bulletin boards at the National Institute of Horticultural and Herbal Science (NIHHS) under the Rural Development Administration (RDA). The institution to which the subjects belonged voluntarily expressed their intention to participate in this study and submitted the application form to us by e-mail, and the chief of this study contacted the person in charge of the institution to proceed with the subject selection. The agro-healing program applied in this study was selected as an intervention method by a professor of occupational therapy, a social worker who treated children with developmental disabilities for more than 10 years in clinical practice, and five researchers from the NIHHS. Activities including sowing, recognizing plant characteristics, and planning a garden (IG1–3) were mainly conducted indoors, whereas those including creating a vegetable garden, planting seedlings (pumpkins, peanuts, lettuce, onions, leeks, and corn), and making natural liquid fertilizers and pesticides for eco-friendly management (OG1–5) were performed outdoors. In addition, interventions consisting of healing activities with sensory stimulation by harvesting herb plants, taking cuttings and making various products (AM1–2), and activities of packaging and utilizing products after harvest (SI1–2) were applied to the subjects. Details of each activity are shown in Table 2.
Measurement method
Jebsen-Taylor hand function test (JTHFT)
The JTHFT is an assessment tool designed to evaluate hand function in activities of daily living. It consists of 7 items with a total of 67 tasks, including writing short sentences, turning over cards, picking up small common objects and putting them in cans (hereinafter referred to picking up small common objects), simulated feeding, stacking checkers, carrying large light objects, and carrying large heavy objects. Hand function is assessed by measuring the time taken to complete tasks for each item. The test-retest reliability ranged from .96 to .99. Hand function is defined as the movement and stability of the arm and hand to pick up target objects with hands: the movement of the arm in a space to move objects in the hand from one place to another and the placement of objects in the hand at a specific time and place as planned; holding an object and manipulating it in the hand; effective use of both hands to perform an activity (Jeong and Paek, 2004). In this study, 5 items of the JTHFT were used to measure hand function: turning over cards, picking up small common objects, stacking checks, carrying large light objects, and carrying large and heavy objects.
JAMAR Hydraulic hand dynamometer
In this study, using the method suggested by the American Society of Hand Therapists, grip and pinch strength were measured in a sitting position, and shoulder joint adduction, elbow joint flexion at 90 degrees, and forearm and wrist joints were measured in a standing position.
Functional independence measure (FIM)
The FIM is a measurement tool for assessing the ability to independently perform activities of daily living and measures the actual movement of the subject. It is comprised of 18 items, including 13 motor items and 5 cognition items. Each item is scored on a 7-point ordinal scale according to the degree of independence-dependency. The total score is obtained by summing the scores of all items, and will be a value between 18 and 126. The inter-rater reliability of FIM is known to be .89.
Statistical analysis
In this study, a statistical analysis was performed using SPSS Statistics version 18.0 (IBM, NY, USA). A descriptive analysis was made of the general characteristics of the subjects. A paired t-test was used to identify the change before and after the program and verify the effect.
Results and Discussion
Effects of agro-healing program on hand function
Based on the results of the JTHFT, hand function was improved mainly in the experimental group (Table 3). For the item of picking up small common objects, after participating in the program, the experimental group showed significant improvements in both right and left hand functions (Z = .000, p < .01), while the control group only showed significant improvements in right hand function (Z = 9.00, p < .01). For the item of simulated feeding, both hands in the experimental group significantly improved after participating in the program (Z = .000, p < .01), but in the control group only the left hand significantly improved (Z = 13.00, p < .01). For the item of stacking checkers, the right hand was significantly improved in the experimental group (Z = 2.000, p < .01), but the left hand was significantly decreased (Z = 5.00, p < .01). For the item of carrying large light objects, the left hand in the experimental group significantly improved (Z = 10.00, p < .01), and for the item of carrying large heavy objects, both right hand (Z = 19.00, p < .01) and left hand (Z = 13.00, p < .01) were significantly improved.
Overall, in the pre- and post-tests of hand function, the scores of the dominant hand and the non-dominant hand were found to be similar. This indicates that, neurodevelopmentally, the establishment of the dominant hand in the subjects has not yet been fully made. The result that the dominant hand improved more compared to the non-dominant hand in the post-test after the intervention program is consistent with the finding that development was gradually enhanced with the use of the dominant hand (Kim et al., 2011). It also showed a similar trend to the findings of other studies on the improvement of hand function in people with developmental disabilities (Noe et al., 2011) and the effect on the upper limb function of children with cerebral palsy (Kim, 2006).
Effect of agro-healing program on grip strength
As for grip strength, in the domain of pinch grip the right hand (Z = 68.00, p < .05) and left hand (Z = 82.50, p < .05) of the experimental group improved significantly, and both hands of the control group also significantly improved (Z = 95.00, p < .01). In the 3-jaw chuck pinch domain, only the experimental group significantly improved the left hand (Z = 47.50, p < .05; Table 4).
Aryes (1972) suggested that the motor pattern of hand function is composed of control of neck and eye movements; stability and balance of the trunk; stability and movement of the scapula and shoulder; elbow movement; gripping big things; position and movement of the wrist; releasing the object gripped; supination and pronation of the forearm; and individual finger manipulation.
The density of neuromuscular spindles in human muscles varies. Large muscles with unsophisticated movements have relatively few neuromuscular spindles, while extraocular and hand muscles have many neuromuscular spindles. This reflects the importance of precise ocular movements and the need to manipulate objects with great precision. Therefore, the activity of actively and evenly touching objects with the hand (occupational therapy; Steultjens et al., 2003) not only activates the cutaneous sensation, but also allows the position and movement of hands and fingers to be perceived (Goldstein, 2002). It also enables us to accept tactile information through the afferent nerve pathway and create smooth movements through the efferent nerve pathway, helping control fine movements (Kim, 2009). PDD cannot accept various sensory information from the surrounding environment or experiences, and thus have difficulties in exploratory behavior, play, daily life, and school life (Case-Smith, 2002). In this study, the intervention of a master gardener was utilized for the activities of PDD. It seems that this led them to think of these activities that enhance motivation, hand function, and use of the hands as an enjoy able play time rather than agriculture. The results of this study were similar to the findings of Yun et al. (2002), who reported that the hand function, especially grip strength, was enhanced in the process of holding and creating a topiary in the topiary gardening program for the elderly with dementia. Through the pressed flower program, fingertip strength was significantly improved, which was reported to be because the participants were instructed to use their fingertips by using tweezers to pick up materials and using both hands to apply glue. Through the flower decoration program, the grip strength was greatly improved, suggesting that the grip strength improved in the process of removing leaves with hands and using scissors. On the other hand, in a study by Tak (2004), which conducted a flower arrangement program for terminal cancer patients, various flower arrangement techniques and scissoring were effective in restoring hand functions by promoting sophisticated hand and finger movements. It was reported that planting programs were effective in improving wrist strength.
In this study, the wrist was also often used in the process of containing and moving culture soil using tools such as trowels. This seems to have improved the function and grip strength of the hand that was used awkwardly while communicating with other subjects, cultivating plants, and harvesting through various five-sensory stimulation via repetitive work.
Effects of agro-healing program on the ability to perform activities of daily living
PDD have physical, motor, surgical, visual/auditory damage, and health problems, attributable to biological causes. Individuals with mild or severe intellectual disabilities have difficulty being independent in all areas of self-care, including eating and toileting, compared to their peers in general, and have problems in walking, sitting, and standing in terms of motor functions (Jang et al., 2003; Park et al, 2012). Hand dysfunction causes serious impairment in most activities of daily living, including eating, dressing, and personal care, which rely heavily on the upper limbs (Tong and Mak, 2001). This movement disorder of PDD causes them to frequently drop things held in their hands, and often bump into objects and get hurt, which makes it hard for them to play games or hang out with their peers, leading them to become less active and more clumsy in activities of daily living. They also have problems with the proprioceptive system, which senses the direction and speed of movement and determines the amount of energy required to grasp and lift objects; in general, they may have problems with both gross motor and functional hand motor skills. Notably, they have difficulty in activities of daily living including writing, buttoning clothes, and tying sneakers due to hand dysfunction.
Table 5 shows the changes in the subjects’ ability to perform activities of daily living after 12 sessions of a agro-healing program based on the results of FIM. The scores of the experimental group before and after the intervention were 104.73 and 107.60, respectively, showing that the changes were statistically significant. PDD who participated in the program showed effects in the areas of memory, communication skills (expression), and self-care among activities of daily living while interacting with each other. This result showed similar tendencies to the findings of a study that mediated on the effects of seeing, touching, and feeling exercises on the oculomotor ability and visual motor coordination function in children with spastic cerebral palsy (Kong and Lee, 2012). It also supports the findings of a study reporting that students with mental retardation improved their efficiency and skills through horticultural activities (Cho, 2001). In addition, it is related to the findings of Kang (2004) who reported that agricultural activities improved social, psychological, and emotional behaviors of persons with mental retardation, and were effective in their participation, self-concept, subjective desire, desire-impulsive adaptability, cognition, problem-solving ability, perceptual motor skills, proficiency, and vocational adaptability. In particular, a study has reported that group horticultural therapy programs are effective in improving social and psychological behavior characteristics, as well as emotional behavior characteristics, cognitive ability, and occupational interests (Jeong et al., 2006), so it is expected that agricultural activities of PDD would be more effective when done in groups rather than as individual activities. However, since the number of subjects in this study was circumstantially small, the results have limitations when it comes to generalizing them to all PDD. This study seems to have the same limitations as a study on making theme-based garden books with 36 college students with developmental disabilities (Kim, 2021). In particular, due to the characteristics of PDD, a comparative analysis was conducted between the control and experimental groups, but continuous research is needed to determine more objective and reliable evidence-based effects in the future.
Conclusion
As PDD perform less of the physical activity that would assist them in developing muscle strength and endurance in daily life, they need activities for physical development. Upper limb function is closely related to writing and learning ability, and is an essential element for manipulation and coordination, stability, sensory expression and transmission, and daily life. In-hand manipulation is a movement related to gripping an object within one hand and inability to grip one. Therefore, by providing a agro-healing program to PDD, this study aimed to determine the effects of the program on their hand function, grip strength, and ability to perform activities of daily living. The findings are as follows.
First, the results of the Jebsen-Taylor hand function test (JTHFT) showed that hand function was the main area of improvement in the experimental group. Of the hand function skills, both hands of the experimental group were significantly improved for the items of picking up small common objects and simulated feeding, and the right hand for the item of stacking checkers. The left hand significantly improved for the item of carrying large light objects, and both hands significantly improved for the item of carrying large heavy objects. Since among the physical functions, hand function was used the most in activities such as sowing, creating a garden, and planting, hand function seems to have improved; hands were often used along with force control according to the tasks given during the agro-healing program, including flower arrangement, transplanting, and flower stalk cutting.
Second, in the area of grip strength, both hands significantly improved in the domain of pinch grip, and the left hand in that of 3-jaw chuck pinch. It seems that grip strength was involved substantially in the process of mixing and breaking the soil, transplanting plants, and trimming the roots.
Third, performance scores for activities of daily living of the subjects before and after the intervention were 104.73 and 107.60, respectively, indicating that the change was statistically significant. PDD who participated in the program showed effects in the areas of memory, communication skills (expression), and self-care among activities of daily living while interacting with each other. However, the number of subjects in this study was circumstantially small, so further research is needed in the future to determine more objective and reliable evidence-based effects.
For PDD to successfully adapt to community life, they need to improve their activities of daily living and lead independent daily lives. Therefore, it is necessary to enable them to participate in agro-healing activities on a long-term basis and learn a lot of skills, and then to apply these to their daily lives. In addition, since PDD have different individual inclinations and degrees of disabilities, it would be more effective if programs suitable for such characteristics were applied. In the future, it is necessary to develop programs and present new models that can enable various economic synergies by promoting the relationship between urban and rural communities.
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