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challenges
Perspective
Green Prescriptions and Their Co-Benefits:
Integrative Strategies for Public and
Environmental Health
Jake M. Robinson 1,2,3,4,* and Martin F. Breed 4,5
1Department of Landscape, University of Sheffield, Sheffield S10 2TN, UK
2inVIVO Planetary Health, of the Worldwide Universities Network (WUN), West New York, NJ 10704, USA
3Improving Wellbeing through Urban Nature (IWUN), Sheffield S10 2TN, UK
4
Healthy Urban Microbiome Initiative (HUMI), Adelaide, SA 5005, Australia; martin.breed@adelaide.edu.au
5
School of Biological Sciences and the Environment Institute, the University of Adelaide, Adelaide, SA 5005,
Australia
*Correspondence: jmrobinson3@sheffield.ac.uk
Received: 10 December 2018; Accepted: 11 January 2019; Published: 17 January 2019
Abstract:
There is a growing recognition of the links between the increasing prevalence of
noncommunicable diseases, environmental concerns including biodiversity loss and ecosystem
degradation, and socioecological issues such as ecological (in)justice. This has encouraged a number
of recent calls for the development of integrative approaches aimed at addressing these issues—also
known as nature-based solutions. An example of an emerging nature-based solution is a ‘green
prescription’, broadly defined as a nature-based health intervention. Green prescriptions are typically
designed for patients with a defined need and they have the potential to supplement orthodox medical
treatments, particularly those aimed at addressing noncommunicable diseases. It is also thought that
green prescriptions could bring about significant environmental, economic, and social co-benefits.
However, researchers have recently expressed concerns over taking the ‘dose of nature’ approach,
in that it may be too reductionistic for the complex social settings in which it is provided. Here we
frame a holistic philosophical perspective and discuss green prescribing logic, types, mechanisms
and fundamental remaining questions and challenges. We place a significant emphasis on the
potential co-benefits of green prescriptions, and the importance of taking a planetary health approach.
More research is needed to determine how this potential can be realised, and to further understand
the complexities of the nature–human health relationship. However, with additional research and
support, there is huge potential for green prescriptions to contribute to both reactive (health care)
and proactive (health promoting) public health solutions whilst enhancing the natural environment.
Keywords:
green prescriptions; planetary health; urban nature; biodiversity; microbiome; mental
health; nature connectedness; greenspace; noncommunicable diseases; nature-based interventions
1. Introduction, Issues and Philosophical Perspective
There have been many recent improvements to public health across the planet. Notable examples
of these include significant reductions in cases of measles, mumps and rubella (MMR) as a result
of widespread immunisation programmes in the mid-late 20th century [
1
,
2
], and an increase in
breast cancer survival rates following successful upstream mammography screening initiatives [
3
,
4
].
However, with such an abundant and ever-increasing global population, deeply intertwined with
social and cultural complexities (preventing equity in resource distribution and the associated health
benefits), there is still a significant amount of work to be done to improve human health and wellbeing.
Challenges 2019,10, 9; doi:10.3390/challe10010009 www.mdpi.com/journal/challenges
Challenges 2019,10, 9 2 of 14
Environmental health issues such as biodiversity loss and ecosystem degradation may at
first appear to develop independently to those in public health—however, they are often deeply
connected [
5
,
6
]. There is growing recognition and understanding of these links, particularly
between the increasing prevalence of noncommunicable human diseases, environmental concerns,
and socioecological issues such as ecological (in)justice. This has encouraged recent calls for the
development of integrative approaches that aim to address these issues holistically—also known as
nature-based solutions (NbS) [
7
,
8
]. An example of an emerging NbS is green prescribing, broadly
defined as a nature-based health intervention. Green prescriptions are typically designed for patients
with a defined need, and they have the potential to supplement orthodox medical treatments,
particularly those aimed at addressing noncommunicable diseases [
9
]. It is also thought that green
prescriptions have the potential to bring about significant environmental, economic, and social
co-benefits [10,11].
Our paper aims to explore green prescriptions and their co-benefits in greater detail. We provide
an overview of two of the key issues that green prescriptions could potentially help to address—a need
for public health innovation, and new strategies that support ecosystem resilience and biodiversity
conservation. This is followed by a planetary health-driven philosophical framework that underpins
this ‘integrative strategy’ approach. We then discuss green prescribing logic, types and mechanisms,
which are followed by a discussion of their potential co-benefits. Finally, we highlight some of the
fundamental remaining questions and concerns regarding their effectiveness.
1.1. Issue 1: A Need for Public Health Innovation
In a number of studies investigating the social determinants of public health, attention has
been drawn to the uncomfortable reality of the pressing need for public health and socioeconomic
innovation [
12
–
14
]. These studies highlight significant health inequalities in many countries. Other
studies arrive at equally striking conclusions regarding the risk factors for chronic diseases and the
associated impacts upon general health, mortality and the economy. For example, Scarborough et al.
(2011) estimated that in July 2006, chronic diseases related to poor dietary habits, physical inactivity
and obesity cost the UK National Health Service (NHS) £11.8 billion [
15
]. A similar story unfolds
for mental health and wellbeing, with an annual expenditure of up to £13 billion allocated to the
management of mental health conditions in England alone [16].
Despite significant improvements in certain areas of public health, recent estimates suggest that
61% of adults in England are considered to be overweight or obese [
17
]—both of which are risk factors
for noncommunicable diseases (NCDs) such as diabetes and cardiovascular-related illnesses [
18
,
19
].
Moreover, around one in four people experience mental health issues in the UK each year [
20
,
21
].
These conditions are diverse, often co-morbid with other NCDs [
22
,
23
], and they are thought to be
responsible for 38 million annual deaths across the planet [24,25].
These findings highlight the need to develop innovative strategies to:
•Improve public health and wellbeing;
•Close the health inequality gap; and,
•Alleviate the financial burden currently facing health services and the wider economy
1.2. Issue 2: Biodiversity Conservation and Ecosystem Resilience
The natural environment provides a significant amount of provisioning, supportive, regulatory
and cultural benefits to humans, and the processes and features that generate these benefits are now
commonly referred to as ‘ecosystem services’. It cannot be overstated that the existence of humanity,
along with societal health and wellbeing, is highly dependent upon these so-called ‘services’, and
the diverse array of organisms they support [
26
,
27
]. However, our decisions and actions are often
detrimental to the environment, and the urban lifestyle is one of the fundamental anthropogenic drivers
of biotic restructuring, often to the detriment of biological diversity and ecosystem functionality [
28
].
Challenges 2019,10, 9 3 of 14
For example, two issues associated with biodiversity loss are natural resource exploitation and
pollution. The former is a key input in the process of urban development, often resulting in habitat
loss and a subsequent reduction in genetic and species diversity [
29
,
30
]; whereas pollution is a key
output and ‘by-product’ of urbanisation, and it can lead to widespread negative impacts on the global
biological systems that support biodiversity [31].
There have been recent calls to take an integrative approach towards addressing challenges
associated with ecosystem resilience and human health and wellbeing (Figure 1). For example,
Raymond et al. (2017) put forward a framework to promote the co-benefits (for environmental and
public health) of nature-based solutions [
7
]. Furthermore, the field of planetary health also focuses
strongly on the simultaneous management of human and environmental health [8].
Challenges 2018, 9, x FOR PEER REVIEW 3 of 14
functionality [28]. For example, two issues associated with biodiversity loss are natural resource
exploitation and pollution. The former is a key input in the process of urban development, often
resulting in habitat loss and a subsequent reduction in genetic and species diversity [29,30]; whereas
pollution is a key output and ‘by-product’ of urbanisation, and it can lead to widespread negative
impacts on the global biological systems that support biodiversity [31].
There have been recent calls to take an integrative approach towards addressing challenges
associated with ecosystem resilience and human health and wellbeing (Figure 1). For example,
Raymond et al. (2017) put forward a framework to promote the co-benefits (for environmental and
public health) of nature-based solutions [7]. Furthermore, the field of planetary health also focuses
strongly on the simultaneous management of human and environmental health [8].
Figure 1. A call for integrative strategies that provide co-benefits for humans and nature (created by
the authors).
1.3. Planetary Health, Biophilosophy and the Symbiocene
Issues surrounding public health––particularly noncommunicable diseases––and the growing
threats to biodiversity and ecosystem resilience, can be viewed from a single overarching
philosophical perspective, that is, from a planetary health perspective. Planetary health is an
increasingly popular term that is used to describe the coupling nature of human and environmental
health [32]. The concept was born out of the view that both of these growing issues are inextricably
linked. For example, anthropogenic habitat alteration increases the risk of infectious diseases across
the planet, and pollution increases the risk of cardiovascular diseases and cancer [33]; there are also
strong relationships between planetary health and the quality of human nutrition, as well as
displacement, conflict and mental health [33–35].
From an anthropocentric perspective, there are social, biological and psychological determinants
of public health, and each domain can influence the other in a complex bio-eco-psycho-social network
Figure 1.
A call for integrative strategies that provide co-benefits for humans and nature (created by
the authors).
1.3. Planetary Health, Biophilosophy and the Symbiocene
Issues surrounding public health—particularly noncommunicable diseases—and the growing
threats to biodiversity and ecosystem resilience, can be viewed from a single overarching philosophical
perspective, that is, from a planetary health perspective. Planetary health is an increasingly popular
term that is used to describe the coupling nature of human and environmental health [
32
]. The concept
was born out of the view that both of these growing issues are inextricably linked. For example,
anthropogenic habitat alteration increases the risk of infectious diseases across the planet, and pollution
increases the risk of cardiovascular diseases and cancer [
33
]; there are also strong relationships between
planetary health and the quality of human nutrition, as well as displacement, conflict and mental
health [33–35].
Challenges 2019,10, 9 4 of 14
From an anthropocentric perspective, there are social, biological and psychological determinants
of public health, and each domain can influence the other in a complex bio-eco-psycho-social
network [
36
]. This phenomenon, along with the notion that all realms of life—both seen and
unseen—are interconnected [
37
], is central to the philosophical foundations of this narrative.
This philosophy lends itself to emerging calls for a newly recognised epoch, as voiced by
several researchers and eco-philosophers [
37
,
38
]. These calls refer to an epoch dominated by
mutually-advantageous relationships between humans and the environment, and not simply a
unidirectional and exploitative relationship, as often characterised by the current ‘anthropocene’.
This proposed epoch has been labelled the ‘symbiocene’ [
39
], based upon aspirations for a move
towards a more symbiotic, holistic and ecological approach to living. The symbiocene also
includes a drive towards a healthcare model dominated by holistic medical and social practices [
37
].
However, epochs aside, to contribute to a value system characterised by a human–nature relationship
with mutually-beneficial health outcomes, a philosophical approach similar to the ‘biophilosophy’
popularised by Salk appears to be a worthy starting point [
40
]. This approach requires a “coalition of
thought from biologists, philosophers and humanists” [
37
], and has parallels with the recent interests
in transdisciplinary research and the calls for integrative models, which include considerations for
both biodiversity and healthcare (reactive) and health promotion (proactive) [41,42].
Also central to this narrative is the perceived growing ‘disconnect’ between human beings and
natural environments [
43
]. Public health and social issues attributed to this disconnect manifest in
various forms, including social stress and reduced psychological wellbeing [
44
,
45
]. Potential pathways
leading to this disconnect include reduced exposure to natural environments, green space access issues,
reduced environmental awareness and time spent in nature [
46
,
47
]. Furthermore, immunodeficiency
disorders such as asthma and inflammatory bowel disease (IBD) are on the rise [
48
]. This has
been partially attributed to reduced exposure to immunoregulatory microorganisms and other
health-inducing biological compounds [
49
–
52
]. Obesity has also increased, resulting in part, from lower
levels of outdoor-based physical activity and an increasing intake of ultra-processed foods [53,54].
Many ecological issues associated with the human–nature disconnect are multidimensional
and include habitat destruction, pollution, biodiversity loss and human–wildlife conflict [
43
,
55
].
This disconnect likely diminishes pro-environmental behaviours and a general sense of environmental
stewardship [
55
]. This may further exacerbate the pressures exerted on the environment, and
subsequently exacerbate the human health issues, potentially setting a negative feedback loop in
motion. Integrative strategies that exploit the reverse positive nature of the aforementioned feedback
loop have huge potential. Green prescribing (Box 1) is one example of an integrative strategy that aims
to support the nature–human relationship, and this will now be discussed in greater detail.
Box 1. A definition of a green prescription.
Green Prescription:
A prescription for a monitorable activity that involves spending time in natural environments for the benefit
of human health and wellbeing.
2. Green Prescriptions: An Integrative Approach
It is perhaps important to note here that although the use (or at least the popularisation) of the
term ‘green prescription’ has been a recent occurrence, the fundamental principles of nature-based
therapies have been applied for centuries. For example, the Romans (influenced by the Greeks)
constructed spa baths at thermal springs to enhance health and wellbeing [
56
]. Furthermore, to
treat the symptoms of disease in the times of Hippocrates (460–370 BC) a “change of habits and
environment was advised, which included bathing, perspiration, walking, and massages” [
57
] (p. 1).
In Germany a similar practice called the Kur (cure or treatment) was also influenced by the Roman
practice of therapeutic bathing, and became mainstream by the 1700s [
58
]. The Kur is now “part of a
complex system of rehabilitation medicine utilizing medical bathing and environmental stimuli” [
58
]
Challenges 2019,10, 9 5 of 14
(p. 1). Recent evidence (including the use of cortisol as a biomarker) points to the use of spas/Kur
as an effective intervention for managing stress-related disorders [
59
]. These treatments have also
been associated with improvements in a number of conditions, from rheumatic and musculoskeletal
diseases, to circulatory and nervous disorders [59].
A green prescription (in its contemporary form), also known as a nature-based health intervention,
is an emerging, innovative strategy that is designed to improve physical and mental health and
wellbeing through exposure to, and often multisensorial interaction with natural environments [
9
].
A regular walk through a green space, systematic participation in gardening (horticultural therapy),
and/or the undertaking of biodiversity conservation activities, such as habitat creation and restoration,
are all potential examples of green prescribing activities [
9
,
60
]. They can be viewed as a monitorable
activity that involves spending time in natural environments for the benefits of health and wellbeing.
Green prescriptions are typically designed for patients with a defined need, and they have the
potential to supplement orthodox medical treatments, particularly those that are aimed at addressing
noncommunicable diseases and mental health issues [
9
]. Furthermore, it could be argued that green
prescriptions could provide a reactive (health care) and a proactive (health promoting) solution to
public health issues. Indeed, this dual approach could potentially materialize through contributions to
improving the health of patients whilst promoting a healthy lifestyle and supporting the development
and maintenance of health-promoting infrastructure.
The term ‘green prescription’ or ‘GRx’ was first coined by health professionals in New Zealand in
the late 1990s to underscore a range of physical and dietary activities that aim to enhance the health
and wellbeing of patients, and reduce NCDs such as Type-2 diabetes [
61
]. In this initiative, GPs
provide patients with diet plans and strategic physical activities such as ‘progressively increasing’
steps, monitored with pedometers and follow-up telephone counselling [
62
]. The term has since
been broadened to include nature-derived activities (e.g., horticulture, nature walks, biodiversity
conservation) as part of a holistic and integrative approach aimed at addressing NCDs, mental health
issues and social isolation.
It is acknowledged that the foundations of green prescribing often require the interactions of three
main phenomena—natural environments, a social context and meaningful activities [
9
]. However,
there is still a significant amount of research to be undertaken to answer a number of fundamental
questions (Figure 2), such as what kinds of nature-based interventions (or elements of these) work best
for whom, where and when?
Jepson, Robertson and Cameron (2010) [
60
] and Bragg and Leck (2017) [
9
] highlight the range of
potential activities that may constitute a green prescription, and these include:
•therapeutic horticulture;
•biodiversity conservation;
•care farming (the use of farming practices for health, socialising and education);
•green exercise (e.g. nature walks, biking, climbing);
•wilderness arts and crafts
Many of the activities are suitable for a diverse range of users. Taking biodiversity
conservation-based green prescriptions as an example, the associated tasks (often group-focused)
are typically aimed at restoring, conserving and enhancing the diversity of flora and fauna. Whilst it is
recognised that biodiversity conservation activities are not suitable for everybody, due to ability, interest
and willingness (e.g., there may be several physical, mental, social, and/or access issues to take into
consideration), based on the authors’ experience of attending a wide range of conservation groups, the
events tend to be highly sociable and attended by a diverse cohort. Furthermore, whilst acknowledging
that this may differ between groups, no apparent pressure to participate in the more physical aspects
of the activities was witnessed in the groups attended by the authors. Conservation activities are
considered to be highly flexible in type and timescale, providing a range of benefits to people with
Challenges 2019,10, 9 6 of 14
very different abilities and backgrounds [
11
]. As with gardening equipment [
63
], conservation tools
and infrastructure can also be adapted for people with disabilities.
Challenges 2018, 9, x FOR PEER REVIEW 5 of 14
an effective intervention for managing stress-related disorders [59]. These treatments have also been
associated with improvements in a number of conditions, from rheumatic and musculoskeletal
diseases, to circulatory and nervous disorders [59].
A green prescription (in its contemporary form), also known as a nature-based health
intervention, is an emerging, innovative strategy that is designed to improve physical and mental
health and wellbeing through exposure to, and often multisensorial interaction with natural
environments [9]. A regular walk through a green space, systematic participation in gardening
(horticultural therapy), and/or the undertaking of biodiversity conservation activities, such as habitat
creation and restoration, are all potential examples of green prescribing activities [9,60]. They can be
viewed as a monitorable activity that involves spending time in natural environments for the benefits
of health and wellbeing.
Green prescriptions are typically designed for patients with a defined need, and they have the
potential to supplement orthodox medical treatments, particularly those that are aimed at addressing
noncommunicable diseases and mental health issues [9]. Furthermore, it could be argued that green
prescriptions could provide a reactive (health care) and a proactive (health promoting) solution to
public health issues. Indeed, this dual approach could potentially materialize through contributions
to improving the health of patients whilst promoting a healthy lifestyle and supporting the
development and maintenance of health-promoting infrastructure.
The term ‘green prescription’ or ‘GRx’ was first coined by health professionals in New Zealand
in the late 1990s to underscore a range of physical and dietary activities that aim to enhance the health
and wellbeing of patients, and reduce NCDs such as Type-2 diabetes [61]. In this initiative, GPs
provide patients with diet plans and strategic physical activities such as ‘progressively increasing’
steps, monitored with pedometers and follow-up telephone counselling [62]. The term has since been
broadened to include nature-derived activities (e.g., horticulture, nature walks, biodiversity
conservation) as part of a holistic and integrative approach aimed at addressing NCDs, mental health
issues and social isolation.
It is acknowledged that the foundations of green prescribing often require the interactions of
three main phenomena—natural environments, a social context and meaningful activities [9].
However, there is still a significant amount of research to be undertaken to answer a number of
fundamental questions (Figure 2), such as what kinds of nature-based interventions (or elements of
these) work best for whom, where and when?
Figure 2. The interaction of the social context, natural environments and meaningful activities, and
the potential types of nature-based interventions (created by the authors, partially adapted from [9]).
Figure 2.
The interaction of the social context, natural environments and meaningful activities, and the
potential types of nature-based interventions (created by the authors, partially adapted from [9]).
3. Green Prescriptions: Potential Co-Benefits
Hitherto, variations of green prescribing have been shown to generate health, social and financial
gains, but only in a limited number of studies with small sample sizes and an absence of robust
control measures [
10
,
64
]—hence the emphasis on ‘potential’ co-benefits. However, a large number
of potential co-benefits spanning areas of health, socioeconomics, and the environment have been
identified by the authors (Figure 3). Mounting evidence from a wide range of studies investigating the
relationship between nature and human health supports this—and in particular—the environmental
benefits [10,65–67].
By developing strategic nature-based activities, there is an important opportunity to help address
public and environmental health issues—that is, through the application of a well-defined co-beneficial
strategy. An example where this could be realised is the Healthy Urban Microbiome Initiative
(HUMI; www.humi.site)—a multidisciplinary initiative that was recently supported by the United
Nations Secretariat for the Convention on Biological Diversity (CBD; https://www.cbd.int/health/
cop14/default.shtml). This initiative aims to understand and recreate the immune-boosting power of
high quality, biodiverse green spaces in our cities to maximise population health benefits, bringing
significant savings to health budgets while delivering gains for biodiversity [
68
]. Although more
evidence of the mechanisms linking nature to health is needed, improving and maintaining green
spaces in urban areas, particularly with high levels of biodiversity, could potentially lead to important
health and environmental benefits. Enhancing the diversity of the human microbiome by encouraging
interactions with natural environments and their microbial inhabitants (microbiome rewilding) is one
such potential route [
69
]. Building on this theory, microbiome-inspired green infrastructure (MIGI) has
recently been proposed as a collective term for the design and management of innovative living urban
features that could potentially facilitate the process of microbiome rewilding in towns and cities across
the planet [50,51].
Challenges 2019,10, 9 7 of 14
Challenges 2018, 9, x FOR PEER REVIEW 7 of 14
biodiverse urban green spaces and MIGI, whilst improving their own health as a result of their
participation.
Figure 3. Potential green prescribing activities and co-benefits (created by the authors).
In addition to physical and practical aspects (such as enhancing ecosystem services), gaining
ecological knowledge, social confidence and communication skills are all potential co-benefits
associated with nature-based interventions. Enhanced pro-ecological behaviours and environmental
stewardship are some of the key potential co-benefits that could conceivably generate positive
cascading impacts on the natural environment by influencing lifestyle decisions and positive changes
that benefit nature. For example, these changes could include deciding to recycle, reducing the
consumption of unsustainable products, and simply being more mindful of the wider biotic
community.
However, although the potential co-benefits of green prescriptions are promising, there is still a
need for further rigorous and evaluative research and interventions to confirm this, and to
understand the dynamic complexity of the way in which individuals experience the natural world.
As mentioned earlier, green prescriptions also have a potential financial co-benefit associated
with them. Bloomfield (2017) pointed out that Mind’s ‘Ecominds’ (a nature-based intervention
programme) [70], reported savings per participant of £7082 via reduced costs to the NHS [10] (p. 83).
This further corroborates studies that report significant financial gains in non-nature-based social
prescribing [71,72].
Figure 3. Potential green prescribing activities and co-benefits (created by the authors).
Green prescriptions potentially fit into this by providing an important social interface—a
systematic process to enhance one’s connection with biodiverse urban green spaces, which could be
designed and monitored to suit the individual needs of the patients. As mentioned, biodiversity
conservation volunteering is an activity that is associated with green prescriptions; therefore,
the enhancement of green spaces and biodiversity across urban areas could be incorporated into a
green prescribing strategy itself. Patients could contribute towards the enhancement and maintenance
of biodiverse urban green spaces and MIGI, whilst improving their own health as a result of
their participation.
In addition to physical and practical aspects (such as enhancing ecosystem services), gaining
ecological knowledge, social confidence and communication skills are all potential co-benefits
associated with nature-based interventions. Enhanced pro-ecological behaviours and environmental
stewardship are some of the key potential co-benefits that could conceivably generate positive
cascading impacts on the natural environment by influencing lifestyle decisions and positive changes
that benefit nature. For example, these changes could include deciding to recycle, reducing the
consumption of unsustainable products, and simply being more mindful of the wider biotic community.
However, although the potential co-benefits of green prescriptions are promising, there is still a
need for further rigorous and evaluative research and interventions to confirm this, and to understand
the dynamic complexity of the way in which individuals experience the natural world.
Challenges 2019,10, 9 8 of 14
As mentioned earlier, green prescriptions also have a potential financial co-benefit associated
with them. Bloomfield (2017) pointed out that Mind’s ‘Ecominds’ (a nature-based intervention
programme) [
70
], reported savings per participant of £7082 via reduced costs to the NHS [
10
] (p. 83).
This further corroborates studies that report significant financial gains in non-nature-based social
prescribing [71,72].
It could be argued that green prescribing is founded on holistic principles (as with social
prescribing models), and so it is also important to recognise that in addition to the proposed
nature-derived pathways to health, green prescribing activities are often considered ‘social events’,
which could potentially facilitate other indirect health-inducing benefits that have a social and
community focus. This, in itself is another potential co-benefit.
4. Challenges and Remaining Fundamental Questions
There are copious studies promoting the potential benefits of nature-based health
interventions
[73,74]
and the evidence-base supporting the broader concept in terms of the
nature–health relationship is growing increasingly stronger. However, there are limited empirical
studies that scrutinise the functionality and sustainability of green prescribing schemes in practice.
This is a key knowledge gap that warrants further in-depth investigation, preferably based on
longitudinal study designs with robust evaluation frameworks.
One study conducted recently in Cornwall, UK [
10
] adopted different nature-based interventions.
The different interventions included conservation activities, nature-walking and meditation.
The interventions were carried out in areas defined as ‘highly biodiverse’; however, the methods for
determining this were not defined, and the habitats in which the interventions took place differed
and included woodland and coastal habitats, which could have affected the results. For example,
the various biotic and abiotic features of a woodland may (or may not) elicit different psychological,
microbial and biochemical-based health-inducing mechanisms and effect sizes when compared to
coastal habitats.
In terms of practical challenges associated with green prescriptions, Bloomfield highlighted an
important point—that it will be imperative for coordinators of green prescribing schemes to speak
two disciplinary ‘languages’: the language of healthcare, and the language of ecology. The author
suggested that unless these two languages are acknowledged, coordinators may focus on gains for
their respective disciplines, which could potentially devalue the important co-benefits.
Numerous researchers from New Zealand have evaluated the views of general practitioners
(GPs) in relation to green prescribing [
61
,
75
,
76
]. Although these studies focus on the non-nature-based
form of green prescribing (physical activity and diet), they do provide some interesting insights into
unorthodox prescriptions, and the constraints and barriers associated with early implementation.
For example, one study found that GPs were generally very receptive to the concept of green
prescribing [
75
]. Another study assessed GP views following a green prescribing programme [
76
].
The authors identified several implementation-related constraints, namely, lack of time, perceived
loss of revenue and the simplistic perception of green prescribing. However, these constraints, the
authors suggested, were subsequently assisted in the wide-spread development of green prescriptions
in New Zealand.
It could be argued that another key challenge facing the application of green prescribing is
the way in which we currently think about public health—both in research and practice. This has
recently been highlighted in a publication on biodiversity and urban healthcare initiatives, where the
authors argue that we need more “place-based, preventative, wellness-focused healthcare systems
that interact with urban planners, environmental managers and politicians to promote healthy urban
designs and living” [
68
] (p. 5). There is no doubt that forming multi-stakeholder collaborations and
taking integrative approaches (such as green prescriptions) to public and environmental health will be
challenging, but they are challenges that are worth rising to, as the coupling issues of noncommunicable
diseases and environmental degradation increase.
Challenges 2019,10, 9 9 of 14
Although green prescriptions have the potential to enhance human and environmental health,
important questions are now being asked in terms of what works best for whom, where and
when [
77
]. Answering these questions is critical if we are to gain the level of understanding that
is needed to develop effective nature-based interventions that can justify the reallocation of limited
resources. Rigorous evaluations are needed to identify appropriate interventions, and to understand
the mechanisms and the contexts in which they are effective. There have been recent calls to take a
more critical view of the ‘dose of nature’ approach, and to include a focus on social practices to cater
for the complexities of how individuals experience and interpret nature [
78
]. This exemplifies the
importance of diversity and holism in our approaches to public and planetary health.
5. Future Studies
It would be prudent for researchers to continue conducting natural experiments to assess the
health and social impacts of green prescriptions, and in particular—to grasp research opportunities
where green prescriptions are already (or are in the process of being) implemented. For this approach
to be effective, systems must be developed to maximise intervention uptake (and engage those
who will benefit the most), minimise ‘drop out’ rates, and ensure that the green prescribing in
practice is both sustainable and consistent [
79
]. Furthermore, understanding who is currently
prescribing nature-based interventions, and gaining insights into how they are funded, as well as
what infrastructure/resources are needed, will play an important role in establishing productive
collaborations between researchers and practitioners. By working closely with green prescription
providers (e.g., environmental conservation charities) and prescribers (e.g., general practitioners),
researchers have the opportunity to not only apply existing and to acquire new knowledge of the
processes that influence exposure and effect, but importantly, to shape the intervention approach.
This will be vital when it comes to gathering the appropriate evidence to inform the choice of
intervention, and to maximise their potential co-benefits (e.g., health, environmental, social and
economic).
Natural experiments are particularly important for population-based and epidemiological studies.
However, studies with a clinical-style design, such as randomized control trials (RCT) will also be
important for gaining a greater mechanistic understanding of the factors involved with health gains
from green prescriptions. However, RCTs present a distinct set of challenges in natural environments,
and they comprise less than 1% of published research in the field of environmental health [
80
].
As with any health-centric study, there are many potential confounding factors to consider (e.g.,
genetics, general health, diet, physical exercise, pets, age, and social contact), and the challenges
are compounded by the complexity of the natural environment. However, with appropriate control
measures and thorough consideration for these factors, RCTs are most certainly feasible.
Additional research should also be carried out to evaluate the potential economic impact of green
prescribing on general medical practice. This will undoubtedly influence the sustainability of the
interventions, and researchers may ask questions such as:
•Can green prescriptions save medical practices money and other resources?
•If so, which type of intervention is most effective?
•
Does this vary between geographic regions or between areas with different
socioeconomic statuses?
•Which patients will benefit the most from green prescriptions?
It will also be vital to gain a greater understanding of the downstream social and environmental
impacts of green prescriptions. To investigate these factors, studies will likely benefit from longitudinal
and mixed method designs. This further highlights the importance of establishing systems and
collaborations that focus on the sustainability of nature-based (and other social) interventions.
Challenges 2019,10, 9 10 of 14
6. Conclusions
Green prescriptions have the potential to contribute towards improving human health and
wellbeing. As an integrative strategy, green prescriptions also have a wide range of potential co-benefits.
These include environmental benefits that are generated through the involvement of patients in
activities that are aimed at enhancing biodiversity and by influencing the allocation of resources to
maintain green infrastructure. The concept of green prescribing could also add an important dimension
to the recent calls to rewild the microbiome by establishing microbiome-inspired green infrastructure
(MIGI) in towns and cities—in that it could provide an interface that helps to facilitate health-inducing
interactions with biodiverse environments.
Enhancements in pro-ecological behaviours and environmental stewardship could result from
participating in nature-based interventions, and this could have important longer-term positive impacts
on the environment. There is also evidence to suggest that nature-based interventions can generate a
range of important social and financial benefits.
However, more research is needed—particularly longitudinal studies and evaluations of
interventions—in order to fully understand the mechanisms behind the interventions, and the contexts
in which they are most effective. The shift in thinking towards embracing a mutually advantageous
relationship with nature and a move towards place-based health interventions will be challenging,
but they are challenges worth rising to in the face of increasing noncommunicable diseases and
environmental degradation. The importance of taking a holistic and diverse approach to enhance
public and planetary health cannot be overstated. With further research, green prescriptions could
make an important contribution to this approach, whilst providing reactive (health care) and proactive
(health promoting) solutions to public health.
Author Contributions:
Conceptualization, J.M.R.; methodology, J.M.R.; investigation, J.M.R. and M.F.B.;
writing—original draft preparation, J.M.R. and M.F.B.; writing—review and editing, J.M.R. and M.F.B.;
visualization, J.M.R.
Funding:
J.M.R. is undertaking a PhD, funded by the Economic and Social Research Council (ESRC). M.F.B. is
supported by the Australian Research Council and Australian Smart Cities Consortium.
Acknowledgments:
Some of the work in this article was adapted from J.M.R.’s Masters in Social Research Thesis:
A Dose of Nature: an interdisciplinary study of green prescriptions and the environment-microbiome-health axis. 2018,
University of Sheffield.
Conflicts of Interest: The authors declare no conflict of interest.
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