It is now widely accepted that spending time in natural or semi-natural environments (e.g., forests, grasslands, gardens and parks) can result in significant positive mental and physical health benefits [1
]. For example, the Japanese practice of Shinrin-yoku or ‘forest bathing’ has been shown to enhance innate immunity via lymphocyte cell activity and can reduce diastolic and systolic blood pressure [4
]; gardening can provide relief from acute stress and improve symptoms of depression [6
]; and simply spending time in nature can enhance psychological restoration (the ability to recover from stress) and can facilitate healthy child development [8
]. Through the biophilia hypothesis, Wilson (1984) argues that humans hold an innate affinity to seek connections with nature. Furthermore, there is evidence to suggest that the environmental microbiome—the diverse consortium of microorganisms in a given environment—can have positive developmental and regulatory influences on the immune system and potentially anxiolytic effects [11
]. This latter claim is supported by a recent mouse study, in which exposure to trace levels of biodiverse soil dust was significantly associated with reduced anxiety like behaviours [13
]. Natural environments can also provide important places for reflection and introspection, for cultivating feelings of awe, inspiration and freedom, and for facilitating group-based convivial activities, which could help to improve social cohesion and enhance mental health [14
Interacting with nature for salutogenic effects is by no means a novel concept. From a Western societal perspective, the fundamental principles of nature-based therapies can be traced back to the Hippocratic era (460–370 BC), when changing environments and lifestyle practices were advised by the physicians of the time [18
]. Furthermore, the Greeks and Romans established thermal spa baths to improve health and well-being [19
]. From a traditional ecological knowledge perspective, indigenous Australians recognised the deep connections between mental and physical health and the “land and river”, and Canadian First Nations’ holistic view of health highlights the interrelatedness of human well-being and the environment [22
]. It is important to recognise that our complex societies have evolving views, social behaviours and health-related needs, and it is unrealistic to view spending ‘time in nature’ as a panacea—i.e., it is unlikely to be suitable for everyone and for all conditions.
However, there is growing interest in ‘green prescribing’ (GRx) as a contemporary practice of prescribing nature-based health interventions, particularly for noncommunicable diseases [24
]. Green prescribing builds on the earlier concept of prescribing exercise and diet-based interventions [27
]—a variant that was pioneered by general practitioners (GPs) in New Zealand in the 1990s [28
]. It also builds on the recent social prescribing movement, which can be defined as: “a way of linking patients in primary care with sources of support within the community—usually provided by the voluntary and community sector, offering GPs a non-medical referral option that can operate alongside existing treatments to improve health and well-being”, [29
] (p. 7) [30
Green prescriptions are typically administered to patients with a defined need and can be used to complement orthodox medical practices [32
]. Nature-based intervention activities can include therapeutic horticulture, biodiversity conservation activities, care farming (i.e., farming practices for health, socialising and education), nature walks, and social activities in greenspaces [34
]—and although the social element is often important, it is not a necessity. To establish effective and sustainable green prescribing schemes, cooperative interactions between primary care professionals and nature-based organisations (NBOs) are typically required, and the ability to speak multiple disciplinary ‘languages’ is considered an essential asset [37
There is potential for green prescribing to contribute to health care (reactive) and sustainable health promotion (proactive), while potentially bringing important co-benefits (e.g., social, environmental, and economic benefits) [38
]. However, it is still an emerging and unorthodox strategy. As such, initial adoption may be sporadic and limited. In the UK, little is known about the status of (distribution and practice), and socioecological constraints and opportunities associated with green prescribing. To our knowledge, no one has explicitly mapped nationwide green prescribing services/infrastructure. To this end, mapping could be a useful policy action (e.g., for informing targeted resource allocation). Moreover, gaining insights into the perceived constraints of green prescribing from the view of primary care professionals and NBOs could help to synchronise knowledge and empathy and identify disciplinary barriers to aid in future management and delivery. Furthermore, exploring ecological, spatial and social factors that may affect green prescribing could also provide important insights for policy makers.
In this study, we conducted a socioecological exploration of the green prescribing health intervention model in the UK. Our primary aims for this study were to (a) explore awareness, constraints and opportunities associated with green prescribing, focusing on general practitioners (as potential prescribers) and nature-based organisations (as potential providers) around the UK; (b) collect spatial data to estimate the general distribution of green prescribing; and (c) to explore whether available services, geography, greenspace, and deprivation influenced green prescribing awareness, provision and constraints.
In this study, we aimed to contribute to the growing but still limited knowledge base underlying green prescribing (i.e., prescribing nature-based health interventions) as a practical service. To this end, we mapped green prescribing services in the UK, explored spatial and socioecological relationships, and acquired the views from both GPs (as potential prescribers) and NBOs (as potential providers).
A diverse suite of studies now supports the concept that spending time in nature can improve one’s health and well-being [58
], and calls have been made to integrate nature-based and social prescribing into public health strategies [61
]. There is also growing advocacy to support holistic integrative strategies such as green prescribing to enhance planetary health (through co-benefits to humans and the environment) [38
]. However, there is limited understanding of the current status of (awareness and distribution), and socioecological relationships and constraints associated with green prescribing as a practical model of health care. An improved understanding of this could aid the optimization of management strategies and spur further research to overcome the constraints.
Our study confirms that green prescribing is active in numerous areas of the UK. We mapped some of the potential prescribers (GPs) and providers (NBOs) and acquired a diverse list of nature-based activities across the UK via a comprehensive web-scrape. With additional collaborative input, this latter process could form the basis of an expandable/editable database to allow primary health care professionals to search for local nature-based organisations and services that could support their patients.
Our results suggest that GPs and NBOs perceived and expressed some common but also distinct constraints to green prescribing. Some of the common constraints included a shortfall of funding and time, and a lack of awareness of the green prescribing concept. The constraint most frequently expressed by GPs was not funding but the perceived lack of available services (i.e., organisations to support patients in engaging with interventions). Interestingly, a key constraint expressed by NBOs was the inability to engage with GPs and other primary care professionals. This disharmonic perception exemplifies the importance of establishing transdisciplinary collaborative pathways that are time efficient, and a common vocabulary in the area of green prescribing. Alongside the research that is needed to gain a greater understanding of the interventions themselves (as evidence may be lagging behind practice) [66
], additional action is needed to improve the infrastructure management required to connect the different stakeholders (e.g., primary and social care, NBOs and patients) and to establish effective referral and monitoring processes—with personalised approaches in mind. In the UK, the recent formation of primary care networks (PCNs) (networks of practices that serve 30,000–50,000 patients)—and the provision of funding to employ ‘social prescribers’—could provide an important opportunity for early integration of green prescribing and could stimulate support for the additional research that is needed.
It is widely accepted that greenspaces have an important role to play—ecologically and socially—in supporting personal, community and planetary health [68
]. Furthermore, greenspaces are a fundamental resource (e.g., the archetypal setting) for GRx activities [72
]. The significant association between greenspace presence and abundance within a 100 and 250 m radius of GP surgeries and the likelihood of providing green prescriptions was an interesting finding. This prompts a suite of additional questions such as: does the presence of local greenspaces influence the decisions by the GPs to prescribe GRx, or the decision by patients to enquire about GRx? Is the presence of greenspaces an indication of potential GRx activities in the area, and as such, does the availability of services equate to increased GRx provision and vice versa, i.e., does the lack of available services/infrastructure equate to limited GRx provision? Another of our findings suggests that significantly more NBOs were present within 5 km of GP practices that did prescribe GRx. This implies that the presence of available services could indeed affect the provision of GRx. However, further research is needed to verify this. Promisingly, collaborative networks involving medical authorities and nature-based organisations are increasing in presence and activity (e.g., the Centre for Sustainable Health care; www.sustainablehealth
care.org.uk). Providing more support for these kinds of networks at a local scale would likely bring considerable value.
Other future pertinent questions include does surrounding greenspace influence the decision of eco-centric GPs (who may be more likely to prescribe GRx) to move to a given practice? Does the presence of greenspace reflect the socioeconomic status of an area, and does this increase the likelihood of GRx provision? And what element/s of the greenspace are important (e.g., size, type, quality, greenness, biodiversity)? We have made an initial contribution towards understanding this latter point—i.e., our results suggest that greenness (based on mean NDVI calculations for different buffer radii around GP surgeries) may not be a significant factor. Further research into the quality of greenspaces may be beneficial and there are several dimensions that could be explored, such as: maintenance, biodiversity, aesthetics, accessibility and the presence of facilities [52
Studies have suggested that less deprived areas have a much higher prevalence of voluntary organisations than more deprived areas [79
]. Considering that the majority of NBOs fall into the voluntary sector category, our results echo these previous studies and support the calls for governments, local authorities and also the NBOs themselves, to help secure ecological justice and provision of resources in areas of greatest need.
Nonetheless, it is positive to see the initial indication of no significant differences between provision of GRx in areas of low and high deprivation—however, the small sample size calls for a cautionary approach to interpretation. Equitable access to high-quality greenspaces is likely to be important for personal and planetary health, and should therefore be a primary goal of health-centric urban policies [81
]. If green prescribing is to play a key role in future health care strategies—alongside research that is needed to personalise these strategies—additional research into infrastructure management is needed to strengthen transdisciplinary collaborations. Further research into how local greenspace accessibility and quality may influence GRx would be beneficial, as would research that further scrutinises the equitable status of GRx resources. It could also prove valuable to explore the professional development experiences of prescribers and NBOs to identify their backgrounds and motivations—this could allow for a stronger indication of why and how their GRx strategies become successful.
Our study has some important limitations to consider. For example, the relatively small sample size for the questionnaire element means that our findings should be interpreted with caution—particularly in the realm of representativeness (for both the significant and nonsignificant results). Our questionnaires did not reach all of the GP practices in the UK due to ethical and hierarchical issues, and the lack of a comprehensive list of contacts. Secondly, the results of our study are correlational and, as such, more conclusive evidence is required to infer causation for any of the findings. Thirdly, our list of NBOs from the web-scrape process is highly unlikely to be an exhaustive list of these organisations in practice. The records only represent NBOs that are sufficiently advertised (with appropriate search engine optimization, e.g., the inclusion of relevant keywords) and have an active web presence. We were unable to isolate the intended stakeholder for ‘awareness’ category in the questionnaire (i.e., whether this refers to GP, patients or both). There are several categories in the questionnaire results for perceived constraints that may have a degree of overlap—for example, “funding” and “resources” may overlap, as may “engaging GPs” and “lack of referrals”. However, these were considered to not significantly affect the interpretation the results. “Ecotherapy” is also a vague category from the web-scrape that could include several the other activities.
We have shown that green prescribing is happening in numerous parts of the UK. We created GIS outputs to highlight (based on the questionnaire results) the distribution of GPs that did prescribe nature-based interventions and the GPs that did not. We also plotted where NBOs facilitated green prescribing activities and where they did not, and we provided a comprehensive distribution map of NBOs (i.e., those with an online presence) via the web-scrape process. Our results suggest that GPs and NBOs perceive and express some common but also distinct constraints to green prescribing. Greenspace presence (but not greenness) and abundance within close proximity (100 and 250 m) to GP surgeries and NBO presence within 5 km were associated with higher levels of green prescribing provision. Lower levels of deprivation were associated with a higher frequency of NBOs but not with higher levels of green prescribing provision.
We hope that mapping green prescribing resources, acquiring views from GPs and NBOs, and conducting spatial/socioecological analyses will spur further research in this area. Establishing transdisciplinary collaborative pathways and a common vocabulary in the area of green prescribing would no doubt bring immense value, as would more research on personalised interventions. Action is needed to improve infrastructure management, particularly strategies that optimize stakeholder connectivity, referral mechanisms and monitoring processes. Further research into how local greenspace accessibility and quality may influence green prescribing could also bring value. Green prescribing has the potential to make an important contribution to personal and planetary health, but more support and research are needed to initiate, optimize and sustain these strategies.