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Best Evidence Summaries of Topics in

Mental Healthcare

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Question

For people of any age with any mental health condition, how effective is gardening/horticulture

compared to any other intervention, for improving patient outcomes?

Clarification of question using PICO structure

Patients: People of any age with any mental health condition

Intervention: Gardening/horticulture

Comparator: Any other intervention

Outcome: All patient outcomes

Plain language summary

We don’t currently have enough high-quality evidence to be clear about how helpful

gardening/horticulture can be for mental health conditions. One small trial showed promising results

for severe mental health conditions (mainly schizophrenia), but it’s unclear how reliable these

results are.

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Clinical and research implications

Only one systematic review containing one small randomised controlled trial (RCT) was found for this question. As the review concluded, the lack of evidence means it is not possible to draw any conclusions about the effectiveness of horticultural therapy for people with schizophrenia and other psychiatric illnesses (schizoaffective, schizophreniform or bipolar disorder, major depression or unspecified psychosis). Therefore no firm clinical implications can be drawn from the available evidence. More large high quality RCTs are needed to evaluate the effects of horticulture across the wider mental health spectrum.

What does the evidence say? Number of included studies/reviews (number of participants)

One systematic review was found addressing this question (Liu et al., 2014). This included one small

RCT of 24 people with schizophrenia and other psychiatric illnesses (schizoaffective,

schizophreniform or bipolar disorder, major depression or unspecified psychosis), which was

conducted in Hong Kong (Kam & Siu, 2010).

Main findings

The trial compared one hour of horticultural therapy a day for 10 consecutive days plus standard

care to standard care alone, and measured wellbeing/quality of life and mental health outcomes

after 2 weeks. Horticultural therapy resulted in significant reductions in anxiety, stress, depression

and total scores on the Depression Anxiety Stress Scale compared to standard care. However there

was no evidence of a difference between the groups in the Personal Wellbeing Index change score.

Authors’ conclusions

The authors concluded that, based on a small amount of limited quality data, there was insufficient

evidence to make any conclusions about the benefits or harms of horticultural therapy for people

with schizophrenia and other psychiatric illnesses.

Reliability of conclusions/Strength of evidence

Given that there was only one small trial which was considered to be at an unclear risk of bias (the

randomisation and allocation concealment methods were appropriate, outcome assessment was

blinded but not participants or caregivers, participants lost to follow-up were excluded from the

analysis) then the strength of the evidence is low. The systematic review was well conducted

without any methodological problems so the conclusions are likely to be reliable.

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What do guidelines say?

Neither National Institute for Health and Care Excellence (NICE) nor Scottish Intercollegiate

Guidelines Network (SIGN) guidelines comment on gardening/horticultural therapy for Mental

Illness.

Date question received: 04/08/2015

Date searches conducted: 05/08/2015

Date answer completed: 14/08/2015

References Systematic reviews Liu, Y., Bo, L., Sampson, S., Roberts, S., Zhang, G., Wu, W. (2014). Horticultural therapy for schizophrenia. Cochrane Database of Systematic Review.

Randomised Controlled Trials (in Liu et al, 2014)

Kam, M. C., & Siu, A. M. (2010). Evaluation of a horticultural activity programme for persons with psychiatric illness. Hong Kong Journal of Occupational Therapy, 20(2), 80-86.

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Results

Systematic reviews

Author

(year)

Search

date Inclusion criteria

Number of

included

studies

Summary of results Risk of bias

Liu, Y. et

al. (2014)

Jan

2013

Participants

Adults with schizophrenia or related disorders

(schizophrenia, schizoaffective disorder,

schizophreniform disorder, psychosis not

otherwise specified), bipolar disorder, or major

depression.

Intervention

Horticultural therapy (any horticultural activities

facilitated by a trained therapist or healthcare

provider).

Comparator

Standard psychiatric care (including medication,

medication management, case management and

supportive psychology).

Outcomes

Well-being and quality of life; clinical global

1 (24

participants)

One study conducted in Hong Kong was

included. Participants received one hour

of horticultural therapy for 10

consecutive days plus standard care or

standard care alone. The horticultural

therapy was led by an occupational

therapist and outcomes were measured

after 2 weeks.

The study was rated as being at an

unclear risk of bias. The mean participant

age was 44.3 (SD 11.6) years, 71% were

male, 22 had schizophrenia and the other

2 had other psychiatric illnesses

(schizoaffective, schizophreniform or

bipolar disorder, major depression or

unspecified psychosis).

There was no significant difference

between groups in well-being and quality

of life as measured by the PWI-C (mean

Low

This was a clearly

reported Cochrane

Review. The study

inclusion and

exclusion were

reported. Full

details of the

search strategy

were provided and

there were no

language

restrictions.

Risk of bias was

assessed and all

aspects of the

review were

performed by two

reviewers

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response; general functioning; physical function;

treatment satisfaction; mental state and

behaviour; adverse events. The included study

measured various outcomes including ‘Mental

State and behaviour’ (The Chinese version of

Depression Anxiety Stress Scale 21 (DASS21)) and

‘Wellbeing and Quality of life’ (Chinese version

Personal Wellbeing Index (PWI-C)).

Study design

Randomised controlled trials.

difference [MD] -0.90, 95% CI -10.35 to

8.55).

For mental state and behaviour measured

by the DASS21, the horticultural therapy

group had significant reductions in the

total score (MD -23.70, 95% CI -35.37 to -

12.03), depression (-8.03, 95% CI -15.40

to -0.66), anxiety (-9.67, 95% -15.87 to -

3.47) and stress (MD -5.50, 95% CI -10.57

to -0.43) compared to standard care.

independently.

As there was only

one study, no

synthesis was

possible.

Risk of bias

Systematic reviews

Author (year) RISK OF BIAS

Inclusion criteria Searches Review process Quality

assessment

Synthesis

Study 1

6

Search details

Source Search Strategy Number

of hits

Relevant

evidence

identified

Guidelines

NICE

Horticulture

Gardening

0

0

0

0

Systematic Reviews & Primary Studies

MEDLINE

1 exp Eating Disorders/ 23555

2 exp Anorexia Nervosa/ 11159

3 exp Bulimia/ 5004

4 Suicide, Attempted/ 15780

5 exp Self Mutilation/ 3117

6 exp Self-Injurious Behavior/ 56890

7 exp Mood Disorders/ 122426

8 exp Bipolar Disorder/ 33526

9 exp Neurotic Disorders/ 15962

10 exp Depressive Disorder/ 85867

11 exp Dysthymic Disorder/ 1043

12 exp Depression/ or exp Depression, Postpartum/ 87257

13 exp Seasonal Affective Disorder/ 1111

14 exp Anxiety/ or exp Dental Anxiety/ or exp Anxiety, Separation/ or exp Anxiety Disorders/ 129739

15 exp Panic/ or exp Panic Disorder/ 8537

16 exp Phobic Disorders/ 9618

17 exp Combat Disorders/ 2697

18 exp Stress Disorders, Post-Traumatic/ 23121

19 17 or 18 24380

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20 exp Somatoform Disorders/ 13493

21 exp Hypochondriasis/ 2162

22 exp Hysteria/ 3448

23 exp Conversion Disorder/ 1997

24 exp Munchausen Syndrome/ or exp Munchausen Syndrome by Proxy/ 1714

25 exp Neurasthenia/ 1318

26 exp Fatigue Syndrome, Chronic/ 4690

27 exp Obsessive-Compulsive Disorder/ 11950

28 exp Obsessive Behavior/ 1076

29 exp Compulsive Behavior/ 8206

30 exp Stress, Psychological/ 99198

31 *Mental Disorders/ 96111

32 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 19 or 20 or 21 or 22 or 23

or 24 or 25 or 26 or 27 or 28 or 29 or 30 or 31 549419

33 exp Schizophrenia/ 89584

34 exp Paranoid Disorders/ 3839

35 schizo$.mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword

heading word, protocol supplementary concept word, rare disease supplementary concept word, unique

identifier] 141432

36 hebephreni$.mp. [mp=title, abstract, original title, name of substance word, subject heading word,

keyword heading word, protocol supplementary concept word, rare disease supplementary concept word,

unique identifier] 274

37 hebephreni$.mp. [mp=title, abstract, original title, name of substance word, subject heading word,



38 oligophreni$.mp. [mp=title, abstract, original title, name of substance word, subject heading word,



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39 psychotic$.mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword


identifier] 52248

40 psychos#s.mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword


identifier] 42837

41 (chronic$ adj mental$).ti,ab. 1774

42 (sever$ adj mental).ti,ab. 6348

43 (mental$ adj disorder$).ti,ab. 26404

44 (mental$ adj ill$).ti,ab. 25688

45 (emotion$ adj disorder$).ti,ab. 1985

46 or/33-45 233745

47 32 or 46 711996

48 gardening.ti,ab. 854

49 horticultur*.ti,ab. 1585

50 48 or 49 2413

51 47 and 50 53

EMBASE

1. EMBASE; exp EATING DISORDERS/; 38255 results.

2. EMBASE; exp ANOREXIA NERVOSA/; 16028 results.

3. EMBASE; exp BULIMIA/; 11398 results.

4. EMBASE; exp SUICIDE, ATTEMPTED/; 21761 results.

5. EMBASE; exp SELF MUTILATION/; 11466 results.

6. EMBASE; exp SELF-INJURIOUS BEHAVIOR/; 11466 results.

7. EMBASE; exp MOOD DISORDERS/; 366695 results.

8. EMBASE; exp BIPOLAR DISORDER/; 44619 results.

9. EMBASE; exp NEUROTIC DISORDERS/; 50789 results.

10. EMBASE; exp DEPRESSIVE DISORDER/; 335646 results.

11. EMBASE; exp DYSTHYMIC DISORDER/; 6524 results.

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12. EMBASE; exp DEPRESSION/ OR exp DEPRESSION, POSTPARTUM/; 335646 results.

13. EMBASE; exp SEASONAL AFFECTIVE DISORDER/; 1029 results.

14. EMBASE; exp ANXIETY/ OR exp ANXIETY DISORDERS/ OR exp ANXIETY, SEPARATION/ OR exp DENTAL

ANXIETY/; 272846 results.

15. EMBASE; exp PANIC/ OR exp PANIC DISORDER/; 18635 results.

16. EMBASE; exp PHOBIC DISORDERS/; 22935 results.

17. EMBASE; exp STRESS DISORDERS, POST-TRAUMATIC/; 38994 results.

18. EMBASE; exp COMBAT DISORDERS/; 38994 results.

19. EMBASE; exp SOMATOFORM DISORDERS/; 19326 results.

20. EMBASE; exp HYPOCHONDRIASIS/; 3514 results.

21. EMBASE; exp HYSTERIA/; 5381 results.

22. EMBASE; (Conversion AND disorder).ti,ab; 2999 results.

23. EMBASE; exp CONVERSION DISORDER/; 1772 results.

24. EMBASE; exp MUNCHAUSEN SYNDROME/ OR exp MUNCHAUSEN SYNDROME BY PROXY/; 2021 results.

25. EMBASE; 17 OR 18; 38994 results.

26. EMBASE; exp NEURASTHENIA/; 1505 results.

27. EMBASE; exp FATIGUE SYNDROME, CHRONIC/; 7750 results.

28. EMBASE; exp OBSESSIVE-COMPULSIVE DISORDER/; 29471 results.

29. EMBASE; exp OBSESSIVE BEHAVIOR/; 8144 results.

30. EMBASE; exp COMPULSIVE BEHAVIOR/; 8006 results.

31. EMBASE; exp STRESS, PSYCHOLOGICAL/; 63063 results.

32. EMBASE; 1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR 9 OR 10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16 OR 19

OR 20 OR 21 OR 22 OR 23 OR 24 OR 25 OR 26 OR 27 OR 28 OR 29 OR 30 OR 31; 668930 results.

33. EMBASE; exp SCHIZOPHRENIA/; 147222 results.

34. EMBASE; exp SCHIZOPHRENIA, PARANOID/; 3727 results.

35. EMBASE; schizo*.ti,ab; 139218 results.

36. EMBASE; hebephrenic*.ti,ab; 199 results.

37. EMBASE; oligophreni*.ti,ab; 798 results.

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38. EMBASE; psychotic*.ti,ab; 38381 results.

39. EMBASE; psychos*.ti,ab; 152191 results.

40. EMBASE; (chronic* ADJ mental*).ti,ab; 2071 results.

41. EMBASE; (sever* ADJ mental).ti,ab; 8177 results.

42. EMBASE; (mental* ADJ disorder*).ti,ab; 32884 results.

43. EMBASE; (mental* ADJ ill*).ti,ab; 31689 results.

44. EMBASE; (emotion* ADJ disorder*).ti,ab; 2580 results.

45. EMBASE; 33 OR 34 OR 35 OR 36 OR 37 OR 38 OR 39 OR 40 OR 41 OR 42 OR 43 OR 44; 368750 results.


47. EMBASE; gardening.ti,ab; 1039 results.

48. EMBASE; horticultur*.ti,ab; 1860 results.


50. EMBASE; 46 AND 49; 88 results.

PsycINFO

1. PsycInfo; exp EATING DISORDERS/; 30704 results.

2. PsycInfo; exp ANOREXIA NERVOSA/; 9423 results.

3. PsycInfo; exp BULIMIA/; 6929 results.

4. PsycInfo; exp ATTEMPTED SUICIDE/; 8356 results.

5. PsycInfo; exp SELF MUTILATION/; 1107 results.

6. PsycInfo; exp SELF INJURIOUS BEHAVIOR/; 4035 results.

7. PsycInfo; exp AFFECTIVE DISORDERS/; 131041 results.

8. PsycInfo; exp BIPOLAR DISORDER/; 21510 results.

9. PsycInfo; (Mood ADJ disorder*).ti,ab; 11822 results.

10. PsycInfo; exp MAJOR DEPRESSION/; 101379 results.

11. PsycInfo; exp DYSTHYMIC DISORDER/; 1415 results.

12. PsycInfo; exp NEUROSIS/; 7581 results.

13. PsycInfo; exp SEASONAL AFFECTIVE DISORDER/; 950 results.

14. PsycInfo; exp ANXIETY DISORDERS/; 66644 results.

15. PsycInfo; exp PANIC DISORDER/; 7075 results.

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16. PsycInfo; exp PHOBIAS/; 11387 results.

17. PsycInfo; exp POSTTRAUMATIC STRESS DISORDER/; 24092 results.

18. PsycInfo; exp SOMATOFORM DISORDERS/; 11251 results.

19. PsycInfo; exp HYPOCHONDRIASIS/; 1160 results.

20. PsycInfo; exp HYSTERIA/; 2021 results.

21. PsycInfo; exp CONVERSION DISORDER/; 1121 results.

22. PsycInfo; exp MUNCHAUSEN SYNDROME/ OR exp MUNCHAUSEN SYNDROME BY PROXY/; 313 results.

23. PsycInfo; exp CHRONIC FATIGUE SYNDROME/; 1622 results.

24. PsycInfo; exp OBSESSIVE COMPULSIVE DISORDER/; 11030 results.

25. PsycInfo; exp PSYCHOLOGICAL STRESS/; 7953 results.

26. PsycInfo; (Mental adj6 Disorders).ti,ab; 40982 results.

27. PsycInfo; exp SCHIZOPHRENIA/; 76993 results.

28. PsycInfo; exp "PARANOIA (PSYCHOSIS)"/; 1344 results.

29. PsycInfo; schizo*.ti,ab; 105890 results.

30. PsycInfo; hebephrenic*.ti,ab; 403 results.

31. PsycInfo; oligophreni*.ti,ab; 516 results.

32. PsycInfo; psychotic*.ti,ab; 37325 results.

33. PsycInfo; psychos*.ti,ab; 115438 results.

34. PsycInfo; (chronic* ADJ mental*).ti,ab; 2403 results.

35. PsycInfo; (severe* ADJ mental*).ti,ab; 7051 results.

36. PsycInfo; (mental* ADJ disorder*).ti,ab; 41132 results.

37. PsycInfo; (mental* ADJ ill*).ti,ab; 38671 results.

38. PsycInfo; (emotion* ADJ disorder*).ti,ab; 3112 results.

39. PsycInfo; 1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR 9 OR 10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16 OR 17

OR 18 OR 19 OR 20 OR 21 OR 22 OR 23 OR 24 OR 25 OR 26 OR 27 OR 28 OR 29 OR 30 OR 31 OR 32 OR 33 OR

34 OR 35 OR 36 OR 37 OR 38; 494353 results.

40. PsycInfo; gardening.ti,ab; 416 results.

41. PsycInfo; horticultur*.ti,ab; 308 results.

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42. PsycInfo; 40 OR 41; 689 results.

43. PsycInfo; 39 AND 42; 43 results.

CINAHL

1. CINAHL; (Adjustment AND Disorders).ti,ab; 835 results.

2. CINAHL; (Mental AND Disorders,AND Chronic).ti,ab; 604 results.

3. CINAHL; exp AFFECTIVE DISORDERS/; 50851 results.

4. CINAHL; exp OBSESSIVE-COMPULSIVE DISORDER/; 2391 results.

5. CINAHL; exp ANXIETY DISORDERS/; 17359 results.

6. CINAHL; (Panic AND disorder).ti,ab; 799 results.

7. CINAHL; exp PHOBIC DISORDERS/; 2231 results.

8. CINAHL; exp STRESS DISORDERS, POST-TRAUMATIC/; 9123 results.

9. CINAHL; exp DISSOCIATIVE DISORDERS/; 572 results.

10. CINAHL; exp FACTITIOUS DISORDERS/; 397 results.

11. CINAHL; exp SOMATOFORM DISORDERS/; 1877 results.

12. CINAHL; exp PREGNANCY COMPLICATIONS, PSYCHIATRIC/; 1335 results.

13. CINAHL; exp PSYCHOSEXUAL DISORDERS/; 4393 results.

14. CINAHL; exp AFFECTIVE DISORDERS, PSYCHOTIC/; 4625 results.

15. CINAHL; (ICU AND Psychosis).ti,ab; 22 results.

16. CINAHL; exp ORGANIC MENTAL DISORDERS, PSYCHOTIC/; 40379 results.

17. CINAHL; (Paranoid AND Disorders).ti,ab; 102 results.

18. CINAHL; exp SCHIZOPHRENIA/; 9893 results.

19. CINAHL; (Mental AND Disorder*).ti,ab; 11273 results.

20. CINAHL; (chronic* ADJ mental*).ti,ab; 541 results.

21. CINAHL; (severe ADJ mental).ti,ab; 1769 results.

22. CINAHL; (mental* ADJ disorder*).ti,ab; 4545 results.

23. CINAHL; (emotion* ADJ disorder*).ti,ab; 259 results.

24. CINAHL; 1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR 9 OR 10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16 OR 17

OR 18 OR 19 OR 20 OR 21 OR 22 OR 23; 129997 results.

25. CINAHL; gardening.ti,ab; 378 results.

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26. CINAHL; horticultur*.ti,ab; 124 results.

27. CINAHL; 25 OR 26; 480 results.

28. CINAHL; 24 AND 27; 43 results.

CENTRAL

#1 MeSH descriptor: [Eating Disorders] explode all trees 858

#2 MeSH descriptor: [Anorexia Nervosa] explode all trees 319

#3 MeSH descriptor: [Bulimia] explode all trees 359

#4 MeSH descriptor: [Suicide, Attempted] explode all trees 264

#5 MeSH descriptor: [Self Mutilation] explode all trees 25

#6 MeSH descriptor: [Self-Injurious Behavior] explode all trees 768

#7 MeSH descriptor: [Mood Disorders] explode all trees 9452

#8 MeSH descriptor: [Bipolar Disorder] explode all trees 1628

#9 MeSH descriptor: [Neurotic Disorders] explode all trees 299

#10 MeSH descriptor: [Depressive Disorder] explode all trees 7737

#11 MeSH descriptor: [Dysthymic Disorder] explode all trees 141

#12 MeSH descriptor: [Depression] explode all trees 5644

#13 MeSH descriptor: [Depression, Postpartum] explode all trees 318

#14 #12 or #13 5945

#15 MeSH descriptor: [Seasonal Affective Disorder] explode all trees 139

#16 MeSH descriptor: [Anxiety] explode all trees 5275

#17 MeSH descriptor: [Dental Anxiety] explode all trees 232

#18 MeSH descriptor: [Anxiety, Separation] explode all trees 54

#19 MeSH descriptor: [Anxiety Disorders] explode all trees 5077

#20 #16 or #17 or #18 or #19 9988

#21 MeSH descriptor: [Panic] explode all trees 258

#22 MeSH descriptor: [Panic Disorder] explode all trees 759

#23 #21 or #22 980

#24 MeSH descriptor: [Phobic Disorders] explode all trees 857

#25 MeSH descriptor: [Combat Disorders] explode all trees 78

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14

#26 MeSH descriptor: [Stress Disorders, Post-Traumatic] explode all trees 997

#27 #25 or #26 1027

#28 MeSH descriptor: [Somatoform Disorders] explode all trees 427

#29 MeSH descriptor: [Hypochondriasis] explode all trees 65

#30 MeSH descriptor: [Hysteria] explode all trees 11

#31 MeSH descriptor: [Conversion Disorder] explode all trees 20

#32 MeSH descriptor: [Munchausen Syndrome] explode all trees 2

#33 MeSH descriptor: [Munchausen Syndrome by Proxy] explode all trees 0

#34 #32 or #33 2

#35 MeSH descriptor: [Neurasthenia] explode all trees 26

#36 MeSH descriptor: [Fatigue Syndrome, Chronic] explode all trees 281

#37 MeSH descriptor: [Obsessive-Compulsive Disorder] explode all trees 668

#38 MeSH descriptor: [Obsessive Behavior] explode all trees 30

#39 MeSH descriptor: [Compulsive Behavior] explode all trees 393

#40 MeSH descriptor: [Stress, Psychological] explode all trees 3792

#41 #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11 or #14 or #15 or #20 or #23 or #24 or

#27 or #28 or #29 or #30 or #31 or #34 or #35 or #36 or #37 or #38 or #39 or #40 27013

#42 MeSH descriptor: [Schizophrenia] explode all trees 5012

#43 MeSH descriptor: [Schizophrenia, Paranoid] explode all trees 84

#44 schizo* 11705

#45 hebephrenic* 28

#46 oligophreni* 33

#47 psychotic* 4075

#48 psychos* 13923

#49 chronic* ADJ mental* 528

#50 mental* ADJ disorder* 584

#51 sever* ADJ mental 698

#52 mental* ADJ ill* 620

15

#53 emotion* ADJ disorder* 388

#54 #42 or #43 or #44 or #45 or #46 or #47 or #48 or #49 or #50 or #51 or #52 or #53 24742

#55 #41 or #54 48188

#56 gardening 87

#57 horticultur* 39

#58 #56 or #57 117

#59 #55 and #58 50

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