Keywords

9.1 Introduction

There is now much evidence, from across the world, that access to nature and outdoor spaces, including ‘green’ and ‘blue’ spaces such as woodlands, parks, allotments, gardens and riverside or seaside settings, produces a range of positive psychological benefits (Alcock et al., 2014; Annerstedt et al., 2012; Bratman et al., 2012; de Vries et al., 2003; Grahn & Stigsdotter, 2003; Groenewegen et al., 2006; Hartig et al., 2003; Lovell et al., 2020; Maas et al., 2009a, 2009b; Thompson et al., 2012; Ulrich et al., 1991; van den Berg et al., 2010; White et al., 2013; White et al., 2017). Such benefits include reductions in stress, anxiety and depression (Beyer et al., 2014; Roe et al., 2013; Sarkar et al., 2018; van den Berg, et al., 2016; Vujcic et al., 2017), as well as improvements in attention and relaxation, self-esteem, mood and confidence (Barton & Pretty, 2010; Hartig et al., 2014; Houlden et al., 2018; Houlden et al., 2019). These benefits accrue at all ages. For example, exposure to nature is consistently associated with benefits for child and adolescent mental health, including improvements in emotional wellbeing and resilience (e.g. see Chawla, 2015; Chawla et al., 2014) and lower rates of depression (e.g. see Maas et al., 2009a). Likewise, studies of older adults show good evidence of reduced anxiety and improved cognitive functioning (e.g. see Sia et al., 2020).

On this basis, it has been argued that simply being in—or near to—nature has a salutogenic effect, acting as a buffer between our stressful daily lives and our mental health. However, it is also the case that such natural environments can shape our behaviour in ways that promote positive psychological experiences, and in turn our wellbeing. For example, accessing nature can lead adults and children to be physically more active, which can have important benefits for common mental illnesses such as anxiety and depression (Barton et al., 2016; Barton & Pretty, 2010). People who use the natural environment for physical activity at least once per week have about half the risk of poor mental health compared with those who do not do so; and each extra weekly use of the natural environment for physical activity reduces the risk of poor mental health by a further six per cent (Mitchell, 2013). In addition to this, natural spaces also offer chances to have positive interactions with others, thereby combating loneliness and promoting a sense of collective identity and resilience that is central to our sense of psychological wellbeing (Bowe et al., 2020; Gray & Stevenson, 2020; Jetten et al., 2012). Evidence shows that living in an environment with more parks, along with the presence of trees and grass in neighbourhoods, encourages greater use of outdoor spaces, and increases social contact with others (Brennan et al., 2017; Maas et al., 2009a; Sugiyama et al., 2008). In terms of these behaviours, blue spaces (rivers, lakes and coasts) are as important as green environments: it is not the colour that matters but the opportunity to behave and respond in a particular way (White et al., 2017).

These findings have led to urgent calls for ways to reprioritise the connection of people to the environment, as a key public health strategy (e.g. see Charles et al., 2018). One key example of this, is the Healthy Parks, Health People (HPHP) initiative (see Maller et al., 2009), which was first started by Parks Victoria, but is now a global movement including countries across Europe as well as South Korea, Singapore, Canada and the USA to name but a few. The focus of HPHP is to provide a framework for promoting the many health and wellbeing benefits of connecting with nature, with a strong focus on mental health. Such an approach is argued to have a series of wider ‘co-benefits’, beyond the health and wellbeing of any one person (Robinson & Breed, 2019). Mental health conditions are one of the main causes of the overall disease burden worldwide, at an estimated global cost of £1.6 trillion per year (Mental Health Taskforce, 2016). Health systems across the world have not yet responded adequately to the current burden of mental disorders, and the gap between the need for treatment and its provision is wide (WHO, 2001). Within this context, it is argued that nature can provide cost-effective and low-risk solutions (Allen et al., 2014; Townsend & Weerasuriya, 2010).

It has also been argued that improving nature-people connections is vital for promoting broader pro-environmental behaviours, and thereby achieving climate change goals, by overcoming what has been called the ‘the extinction of experience with nature’ (Soga & Gaston, 2016). A lack of personal experiences with nature limits our understanding of environmental challenges and appropriate actions to address those challenges (Cajete & Williams, 2020). Therefore, it is theorised that expanding people’s emotional connections to nature, and promoting deeper conceptualisations of the natural world through nature-based interventions, will improve public support for a move towards more sustainable cities (Ives et al., 2018). This is seen to be particularly vital for children and adolescents, as a number of studies, from across numerous countries, provide support for the important role of meaningful childhood experiences in nature as a predictor of behaviours to protect the environment (Chawla, 2020). For this reason, there are now many programmes, operating at a global scale, (e.g. Nature Clubs for Families by the Children & Nature Network), which are focused on trying to find ways to encourage young people, and their families, to be closer to nature (D’Amore & Chawla, 2017).

9.2 Moving Towards Nature-Based Interventions

Given these arguments, many have pushed for the development of evidenced-based interventions of natural, blue green settings, which are aimed at being truly health-creating, moving people towards a state of complete physical, mental and social wellbeing. Such interventions span a wide spectrum of activities and levels of engagement (see Fig. 9.1), some of which are focused on ‘bringing nature to people’ by greening of places in people’s nearby environment, particularly where greenspace access is currently limited, such as in urban public spaces, hospitals, classrooms and offices. Others, however, are aimed at ‘bringing people to nature’ by encouraging and facilitating adults and children to actively participate in nature-based activities (Bowler et al., 2010; Bragg & Atkins, 2016). More recently, there has been a move towards providing ‘nature on prescription’, in an effort to integrate such activities into routine medical practice (Garside et al., 2020; Husk et al., 2019; Husk et al., 2020; Robinson et al., 2020). Such programmes bring together concepts of ‘non-medical’ prescriptions (e.g. for exercise or diet) pioneered by general practitioners in New Zealand in the 1990s, with the more recent social prescribing movement (Robinson et al., 2020). Examples include Park Rx in the USA and Canada and ‘green social prescribing’ in the UK, and generally involve health care providers ‘prescribing’ nature-based interventions in the community.

Fig. 9.1
A chart maps the nature-based interventions under 2 categories. Experiencing nature includes interventions that begin from everyday life to green care involving nature-based therapy. Interacting with nature includes a move from farming to care farming and gardening to therapeutic horticulture.

(Source Bragg and Atkins 2016, 22)

Mapping nature-based interventions

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Nature-based interventions can vary considerably in their aims (Shanahan et al., 2019). Some are targeted at the general population as part of health promotion, especially those without the ability or opportunity to engage with greenspace as part of their usual lifestyle, e.g. the Danish TEACHOUT project which focuses on providing outdoor education in primary schools (Nielsen et al., 2016). However, others are targeted as therapeutic interventions to address the specific needs of a specific group; sometimes called ‘green care’ (Sempik, 2010; Sempik & Bragg, 2016), ‘ecotherapy’ (Hinds & Jordan, 2016) or simply ‘nature-based interventions’. Examples include programmes developed for at-risk youth, those living with a specific mental health condition, adults, and children with learning disabilities, those with a drug or alcohol addiction history, adults on probation and individuals living with dementia and their carers (Bragg & Atkins, 2016; see box text below for a case study of the development of such an intervention in Dorset, UK). These categories are, of course, not mutually exclusive, as people can move between a treatment intervention, health promotion programme and everyday activity within nature as their health and wellbeing needs dictate.

The types of activities that make up nature-based interventions can also vary considerably, ranging from wilderness therapy, social and therapeutic horticulture, facilitated environmental conservation, care farming, ecotherapy, nature-based arts and crafts, and animal-assisted interventions (see Bragg & Leck, 2017; Jepson et al., 2010 for an overview). Likewise, in some cases, the activity takes place in nature, but nature is not the focus (i.e. nature as ‘background’ to green exercise), whereas in others (and some might argue most cases) the natural environment is the focus of the activity and very much foregrounded (e.g. environmental conservation). There is also much variation in how these interventions have developed, with some developing from national and/or regional frameworks and practices, but with many programmes developed ad hoc, driven by locally available knowledge, settings and funding, and reliant on local connections between enthusiastic proponents within health services and/or local third sector groups. Community-based assets play a pivotal role, both in providing social interventions and in fostering volunteering, which has benefits for health (Bowe et al., 2020; Gray & Stevenson, 2020). Overall, this can mean that there is considerable variation in how interventions are managed and delivered, even where there are overlapping aims and contexts. Moreover, it can also mean that access to such interventions can be patchy, dependent on having individuals within local services who can champion nature-based interventions (Garside et al., 2020).

Stepping into Nature (SiN)

Stepping into Nature is a programme of work that aims to help people be happier and healthier by connecting people with nature, using Dorset’s natural and cultural landscape to provide activities and sensory rich places for older adults, including those with living with dementia, and their care partners. Dorset has a higher proportion of people over the age of 65 than the national UK average, with a predicted increase of around six per cent by 2031. It is estimated that there are currently 13,000 people 65 or over living with dementia, with over 50,000 unpaid carers. We know that living with dementia, or providing care for a loved one, can affect daily lives. People can become isolated from society, their confidence, skills and physical fitness wane and their health and wellbeing deteriorates. However, it is important to remember that continued ill health in old age is not inevitable, improving social and emotional wellbeing, and healthy behaviours, can increase the time people can be independent and active in later life. Maintaining physical and cognitive function and increasing resilience are more likely to continue if built into everyday life.

SiN’s core belief is that being in nature and sharing an activity is a crucial part of living well. Regardless of where we live, nature is free and on our doorstep for our entire lives. However, many people experience barriers that stop them fully benefitting from this multisensory environment. Working with older people, and a network of organisations, SiN provided opportunities that promoted these healthy changes. From 2017 to 2023, two rounds of funding totalling £710,000 were secured from the National Lottery Community Fund. Through this funding, the team worked in collaboration with the health, environment and community sectors to:

  • Upskill staff and volunteers in the environment sector to become dementia-friendly through dementia awareness sessions linked to the natural environment. By increasing understanding of dementia and appreciation of needs, providers could adapt their activities and settings to become more inclusive and were better equipped to cater for varying abilities or unexpected situations.

  • Support community groups and organisation, via grants and advice, to deliver activities or improve inclusivity of greenspaces.

  • Evaluate whether engagement with the natural environment led to improved physical and emotional wellbeing, reduced social isolation and feelings of loneliness, increased motivation, independence, confidence and life skills with support of Public Health Dorset.

  • Promote a trusted, high-quality, inclusive brand that was created to helped promote various activities by reducing fragmentation of information, creating a consistent message and increasing the capacity of activity providers.

  • Provide networking opportunities for activity providers to connect to the target audience and health sector organisations through working groups, national conferences and Picnic in the Park events.

  • Pilot projects as new ideas come up and test different approaches, for example the development of nature buddies’ network, a one-to-one support service focused on linking people together to enjoy nature together on a more personalised level.

Over the lifetime of the project, more people have been engaged with nature by providing a variety of activities in different locations and other opportunities for people to connect with and increase the amount of time they spend in nature. This includes a range of different events including Sing and Stroll and Wellbeing Walks, see below. Through working in partnership with other NGOs, and local authorities, SiN has delivered over 400 activities which have been attended by over 3000 people.

Over 6,000 physical resources have been shared (such as history walks guides, seasonal books, a seasonal art and writing box, wild writing packs) and many more downloaded from online. Post activity, participants reported immediate feelings of fun, happiness and pleasure and found the activities interesting, enjoyable to do something different or liked to learn a new skill. From observations it was also noted that people looked visibly relaxed as an activity progressed—shoulders rested, open body language and sounding more confident. The inclusive approach of the Stepping into Nature activities enabled participants to meet new people within a ‘no pressure environment’. During activities people chatted, sharing stories, experiences, knowledge with each other and in some cases providing informal support through meeting others with similar issues or situations. Organisations reported that their capacity and confidence to deliver meaningful activities for this audience had increased and by being part of the project, staff and volunteers felt better equipped to be able to provide the support needed.

While there were many benefits, there were also several challenges that SiN faced on the journey. Overall, activity take-up was low at the start of the project as it took time to build a brand that gave some quality assurance and trust. There were common barriers related to the physical environment, often where environments were not suitable (e.g. because of stiles, uneven ground, mud or poor signage), or because of a lack of information that enabled people to make an informed decision about whether a particular environment was suitable for them (e.g. in relation to parking, facilities, directions). Some service users didn’t want to explore the area alone, because it felt unsafe, or they didn’t know the route. Moreover, a continuous stigma around dementia was conveyed, where providers and public weren’t aware of the symptoms and how to support people. In addition, COVID-19 impacted on their activities in many ways. The project supported was ongoing throughout the pandemic, but all group activities were put on hold. Staff in SiN had to learn and adapt their approach from direct delivery to the development of self-led activities, such as accessible introductory history walk guides and seasonal books along with resources that encouraged connection to others and nature through stories, poetry and art. These, along with other resources in the community, were promoted via our virtual festival Picnic in the Parks website, developed with Active Dorset and Dorset Local Nature Partnership.

Building the team’s learning and experience, the team is now designing the next steps, the development of a wider Health and Nature Dorset collaboration which aims to help connect organisations that are working towards similar goals together. Through this, the aim is to identify ways in which collaboration can be improved to enhance the nature-based wellbeing offers in Dorset. For more information, refer to: https://www.dorsetaonb.org.uk/project/stepping-into-nature/.

9.3 Mapping the Evidence Base

The diversity of nature-based interventions, in terms of the range of different interventions and therapeutic opportunities available to people, make it difficult to understand what kinds of nature-based interventions (or elements of these) work best for whom, where and when. The evidence base is diluted by the considerable degree of variation in participants, mechanisms and outcomes (Bowler et al., 2010). There is some evidence that such interventions show great promise, in terms of improvements in psychological wellbeing, cognitive functioning, coping ability and reductions in social isolation, across diverse diagnoses, spanning from obesity to schizophrenia (e.g. Annerstedt & Wahrborg, 2011; Bragg & Atkins, 2016). Qualitative work in this area also highlights a broad and wide-reaching perceived impacts on wellbeing, mood and functioning from participants (see Garside et al., 2020). However, despite a large amount of research, the evidence for the outcomes and benefits of nature-based interventions is limited, relying on unvalidated measures, small sample sizes, often do not include a comparator group, have limited follow-up evidence and there are very few randomised control studies (Bragg & Atkins, 2016; Charles et al., 2018; Garside et al., 2020; Husk et al., 2019; Husk et al., 2020; Lovell et al., 2015). There are also very few longitudinal studies, and these are needed. Overall, there is a lack of robust evidence that such interventions are effective, for whom and what is needed to make them work (or work better). Key questions remain concerning mechanisms of change, context and the replicability of interventions in different environments, and access and the potential for such interventions to address (or worsen) health inequalities. Each of these is covered in more depth below.

9.3.1 Mechanisms of Change

Some have questioned why such evidence is needed, given that there is such consensus in the published literature that nature contributes to enhanced wellbeing, mental development and personal fulfilment. However, it is also the case that much of evidence about the health and wellbeing benefits of nature are based at the population level—focused on the quantity or proximity of greenspace within a specific place, and its relationship to levels of wellbeing (e.g. Alcock et al., 2014). It is not always clear how these relationships at a population level will—or should—translate down into interventions in ways that produce specific wellbeing benefits. Indeed, many interventions are not theoretically driven, or the rationale for the intervention that informed its design, delivery and intervention components are not always entirely explicit. Broader theories from environmental or evolutionary psychology, are sometimes used, including Biophilia (Wilson, 1986), Attention Restoration Theory (ART; Kaplan & Kaplan, 1989), Psycho-evolutionary Theory (PET; Ulrich et al., 1991), Supportive Environment Theory (Grahn et al., 2017) and Contemplative Landscape Theory (Olszewska et al., 2018). However, it is not yet explicit how these theories relate to a clear understanding and integration of active elements (the mechanism and mediators of change) that can produce hypothesised results.

Added to this, is the fact that health and wellbeing is itself a complex construct with multiple determinants, and there are multiple hypothesised (but not always agreed) pathways through which nature is meant to relate to health (see Hartig et al., 2014). Often this is not well recognised, amid a growing tendency to present ‘health as much simpler than it actually is’ (Wolf, 2010, 84). Potential mechanisms are likely to include sensory-perceptual and immunological processes, air quality, learning new skills, the restorative qualities of nature and reduced social isolation (Kuo, 2015; Shanahan et al., 2015). However, what is not clear is whether interventions that incorporate these mechanisms are more successful than those that do not, or indeed what the ‘optimal dose’ of these factors would be (Olszewska et al., 2018). Some have argued that we need to ask if such an ‘optimal dose’ of nature can even exist, given the diverse ways in which individuals experience and interpret nature (e.g. Bell et al., 2019). There is also the risk that inappropriate nature-based activity components, or group dynamics exacerbates or worsens existing mental health conditions. This is a concern for health care professionals who are asked to prescribe such interventions to their patients, and as a result, referral rates are currently very low (Van den Berg, 2017). To begin to address some of these questions, a more convincing explanatory framework is needed, that specifies the main pathways and mechanisms of these interventions, and which considers the ways these may be impacted by an intervention (Van den Berg, 2017).

9.3.2 Intervention Context

As with the mechanisms of change, the context within which nature-based interventions occur is currently under-theorised—or indeed often unspecified, beyond being a local natural environment of some sort. However, key questions remain about the unique qualities of a setting, or how varying configurations of greenspace could offer different opportunities for physical exercise, psychological restoration, relaxation or social connections, leading to different mental health outcomes (Alcock et al., 2015). The limited work in this area has produced mixed results. For example, well-maintained and tended natural spaces have been found to produce more significant improvements in affect and mood (e.g. Martens et al., 2011). However, such findings do not necessarily hold at a population level (e.g. Alcock et al., 2015). Importantly, there is some debate about whether all natural environments are beneficial to mental health. For example, there is some evidence that low in prospect and high in refuge (e.g. dense wooded areas) can increase stress levels and fatigue and thereby, negatively impact on mental health (Gatersleben & Andrews, 2013; see also Milligan & Bingley, 2007; Van den Berg & Ter Heijne, 2005).

Landscape perceptions are important to consider here, as empirical work has consistently demonstrated that such perceptions are key to how people experience and use space (Hägerhäll et al., 2018; Knez & Eliasson, 2017; Korpela et al., 2001; Shanahan et al., 2015). Indeed, there is already much research that demonstrates that access to urban greenspaces (such as parks) does not translate directly into actual use. Rather, it is people’s perception of spaces that is an influential factor for or against using a park (Byrne & Wolch, 2009). Perceived quality and maintenance of a space is important, as empirical studies show that such spaces tend to be seen as safer and therefore used more widely (Jansson et al., 2013; Milligan & Bingley, 2007). It is also well established that this matters more for some groups than others.

Research from the UK, the USA, Sweden, China, Mexico and South Africa highlights that perceptions of quality and maintenance in urban greenspaces are vitally important to women, as it is linked to perceptions of safety, which is crucial for their decisions to use such spaces (e.g. see Mayen Huerta & Utomo, 2022). The perceptions of others are also important. Public greenspaces, such as parks, can be contested spaces, where ideologies about ‘who belongs where clash’ (Manzo, 2003, 55). For example, we know that young people’s use of public spaces—including urban greenspaces such as parks—is often controlled by (typically) adult others in ways that limit their use of such spaces (Gray & Manning, 2014, 2022; Gray et al., 2021). Likewise, such places can invoke a strong sense of place identity, which in turn can foster a sense of ‘togetherness’, self-esteem, self-worth and self-pride (Korpela et al., 2001). Places can act as symbolic repositories of national and cultural values (Twigger-Ross & Uzzell, 1996) in ways that are meaningful to psychological health and wellbeing.

These findings would indicate that where interventions take place is an important consideration and more research is needed to fully understand how such landscapes and other forms of greenspaces in urban and rural areas can—and should—be used as a resource for psychological wellbeing. Moreover, it also raises questions about how transferable evidence is between different contexts and whether, for example, the outcomes of nature-based interventions in highly differing environments, such as densely forested mountains, large urban parks and coastal landscapes, reasonably ought to be compared. This requires more research on how different types and characteristics of greenspaces are perceived and/or experienced in a multisensory manner, through sight, hearing, touching and smell, explicitly linking such perceptions to specific mental health outcomes (see also Alcock et al., 2015).

9.3.3 Impact on Health Inequalities

There is evidence that inequalities in health are lower in greener communities, meaning that providing effective nature-based interventions that (re)connect people to nature can be an important way to help to reduce health inequalities (e.g. Mitchell & Popham, 2008; Roe et al., 2013). However, there is a need for further research to ensure that benefits are maximised while not increasing the health inequalities it is trying to eliminate. In part, this relates to already existing, and well-documented concerns about barriers to accessing natural environments (Boyd et al., 2018; Cole et al., 2017; Richardson & Mitchell, 2010). What is clear from this research is that barriers faced by different groups (and in different countries) are multiple and complex and include a range of physical (e.g. relating to topography and facilities) and sociocultural (e.g. feeling ‘out of place’) factors, which will feed into people’s willingness to engage with, and benefit from, nature-based interventions in different ways (see Wolff et al. 2022 for an overview).

Such features have the possibility of exacerbating inequalities through processes of enrolment, engagement and adherence (Husk et al., 2019; Husk et al., 2020). For example, as documented in the case study in the box text, a lack of facilities such as toilets, sitting spots or challenging topography can make it harder to recruit older adults or those living with a disability to interventions in those spaces. Likewise, many health care professionals are reluctant to prescribe nature if they do not think that their patients will be able to adhere to the prescription, because they believe that their patients lack resources in terms of time, money, not having access to nearby outdoor spaces due to transportation and availability, and not having motivation (Christiana et al., 2017). This means that those who are at greatest risk of poor mental health may be the least likely to be offered an intervention based in nature. There is also the danger that nature-based interventions can reproduce already existing spatial inequalities through unequal provision and the availability of resources (e.g. sites).

We know that good quality greenspaces are unequally distributed, with those living in economically deprived areas having the least available good quality public greenspace (Schüle et al., 2019). However, it is also the case that having access to a good range of good quality local greenspaces is a vital element for the development and provision of nature-based interventions (Robinson et al., 2020). Meaning that there can be significant differences in access to such interventions across different geographical areas in ways that can further entrench existing spatialised health inequalities. Indeed, in their study, Robinson et al. (2020) found an association between the abundance of greenspace near to GP surgeries and the likelihood of a GP providing green prescriptions. As they note, this raises several important questions about whether (and how) the lack of available services/infrastructure equates to more limited provision. This would suggest that a dual approach is needed that includes both improvements to the provision of, and access to, good quality and inclusive natural environment, that speak to a diverse range of needs and preferences, alongside interventions that work to improve people’s engagement with those environments. However, this clearly has an impact on the management of those environments, which could become overwhelmed with demand.

Overall, what this points to, is the need to critically examine the assumption that the health benefits of green or blue spaces will be the same across all population groups. Caution needs to be taken about transferring the findings from one population group to another, if they have different sociocultural perspectives on the natural environment, as well as differing values on how the natural environment relates to health. Currently, there is little evidence about how nature-based interventions vary in experience across different populations, e.g. which delivery modes or activities are most valued by participants, whether it is better for activity groups to comprise only those with particular needs, conditions or ages, or whether these should be mixed or how best to harness the group effects for positive interaction (Garside et al., 2020). There are also some key groups which are currently under-represented in the body of evidence. For example, despite the fact that many of the policies about improving nature connections are specifically aimed at children, and the fact that many countries already have historically developed nature programmes for children (e.g. The Children and Nature Initiative in the USA; Louv, 2011), most green (and social) prescriptions currently are targeted at adults, and there is relatively little research with young people. This means that we know much less about how such interventions are experienced or effective for children and young people (see Garside et al., 2020; Kondo et al., 2020). However, given the rising mental health issues within this age group—particularly the post-COVID-19 pandemic (Ma et al., 2021)—and the fact that 75% of all mental health issues that start in childhood continue to adulthood, this is an important group on which to focus attention (Kondo et al., 2020).

9.4 Conclusions

Given the prevalence and burden of mental ill health worldwide, there is a pressing need for interventions and solutions that provide effective, equitable and cost-effective ways of promoting better mental health and wellbeing. Nature-based interventions, that seek to prioritise the (re)connection of people to nature, are an integral part of this solution, with great promise to address the social determinants of mental health. However, this field as a whole is complex and diverse and, while nature-based interventions are not new, models and processes for integrating these into public health systems (e.g. through green prescriptions) are in their infancy. Currently, little is understood about how green (or social) prescribing interacts with the health service or the capacity of the community sector to offer activities or manage the demands of the health service moving forward. In addition, without engaging effectively with practitioners those areas will not be available and not be managed appropriately to allow access to nature. As the field matures, there is a great need for robust study designs, and a greater focus on what works, understanding mechanisms of change, and clarifying the health associations for different contexts and population groups. Such interventions are not without risks to patients and finances, and there are clear consequences of developing interventions that offer poor outcomes (and hence poor value for money), because they are developed without evidence about what should be offered or the processes that are required to support them, resulting in patients not getting a green prescription that is appropriate to their needs. All stakeholders in the pathway from commissioning and promotion, to referral, and the development and delivery of sustainable, fundable interventions, require a better understanding of nature-based interventions.