Developing Scotland’s First Green Health Prescription Pathway: A One-Stop Shop for Nature-Based Intervention Referrals

Viola Marx1*† and Kimberly R. More2†

  • 1Dundee City Council, Dundee, United Kingdom
  • 2Department of Psychology, University of Dundee, Dundee, United Kingdom

Introduction: Lifestyle modifications are part of comprehensive treatment plans to help manage the symptoms of pre-existing chronic conditions. However, behavior change is notoriously difficult as patients often lack the necessary support. The present manuscript outlines the development of a Green Health Prescription pathway that was designed to link patients with appropriate lifestyle interventions (i.e., nature-based interventions) and to support attendance. Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis was undertaken in three focus groups (i.e., National Health Service healthcare professionals, service-users, and nature-based intervention delivery partners) to highlight areas of strength and weakness within the proposed pathway prior to delivery. The SWOT analyses revealed that the pathway was supported by all three focus groups. Weaknesses and threats were identified including sustainability of nature-based interventions in terms of funding, the need to connect patients with appropriate interventions based on their physical and mental health needs, and the requirement to have a “one-stop shop” for information to ensure that the pathway was accessible for all service-users and healthcare professionals. Results were addressed and considered throughout the development of the pathway.

Discussion: The Green Health Prescription pathway was launched in 2019 and gave patients the ability to receive a prescription from a healthcare professional, community service, or to self-refer. The pathway allows patients to contact a consultant, via a telephone service, who is trained to match them with a programme that the patient believes will be enjoyable and that fits their treatment needs. Data collection to assess the efficacy of the pathway is ongoing.


Worldwide, 60% of deaths are traceable to a chronic illness (World Health Organization, 2005). Such illnesses can place a burden on the healthcare system. For example, patients with chronic illnesses account for approximately 80% of all general practitioner appointments in the United Kingdom where they are twice as likely to be a hospital patient. Although medication can be an important component of a treatment-plan, it has long been recognized that lifestyle modifications can help manage the symptoms of pre-existing chronic conditions including cardiovascular disease (Chow et al., 2010; de Lorgeril and Salen, 2011), type 2 diabetes (Chen et al., 2015), obesity (Biedert, 2003), and mental illnesses (e.g., anxiety and depression; Martinsen, 2008), among others. Unfortunately, lifestyle modifications are not an obvious form of treatment for patients (Jarbøl et al., 2017) and even if prescribed by a physician, patients have difficulty engaging with and reaping the benefits of these lifestyle modifications as support is often unavailable (McAvoy et al., 1999; Svetkey et al., 2009). The present manuscript outlines the policy development of a Green Health Prescription pathway, by Dundee’s Green Health Partnership, that was created with the goal of linking patients to lifestyle nature-based interventions that could be prescribed by their healthcare professional (e.g., general practitioner, nurse, and healthcare specialist), community service, or be accessed through self-referral.

Evidence for Nature-Based Interventions

Engaging in nature has been linked to improvements in both physical (e.g., normalizing blood pressure) and mental health outcomes (e.g., lower incidence of mental illnesses such as depression and anxiety; Shanahan et al., 2016). Nature-based interventions capitalize on these benefits and use a structured programme designed to engage participants with nature (Cox et al., 2017; Shanahan et al., 2019). For example, exercising in greenspace improves anxiety, depression, and general mood post-activity regardless of exercise type or intensity (e.g., walking, cycling, fishing; Pretty et al., 2007; Barton and Pretty, 2010). Moreover, meta-analytic evidence has shown that engaging in greenspace leads to reduced salivary cortisol, heart rate, high-density lipoprotein cholesterol, diastolic blood pressure, and triglycerides (Twohig-Bennett and Jones, 2018). Preliminary evidence also suggests that exposure to greenspace leads to reduced incidence of stroke, hypertension, coronary heart disease, and asthma. Although accumulating preliminary observational and intervention evidence supports the relationship between exposure to greenspace and enhanced physical and mental wellbeing, making use of the outdoors purely for health objectives does not motivate everyone and for many people, other factors, such as social engagement and support (Ingledew and Markland, 2008), are the driving force behind their use of greenspace activity programs.

Social Support and Health Engagement

Engaging in healthy behaviors as part of a group has direct benefits to the individual as well as benefits for sustained behavioral engagement. Social support has been shown to directly lead to improved mental wellbeing and improved management of chronic conditions in both correlational (Harandi et al., 2017) and experimental (Brunelli et al., 2016) meta-analytic studies. Social support has also been found to form naturally in group settings without being targeted directly by an intervention. This process occurs through informal social support, which refers to support that is offered by an unpaid person (McCamish-Svensson et al., 1999). For example, social support has been found to occur naturally in exercise classes (Christensen et al., 2006), the workplace (Harris et al., 2007), and in online (Wright, 2002), and in-person community groups (Groh et al., 2008). Further, engagement in lifestyle modifications within a group setting has potential benefits directly on the maintenance of behavior change through social identity modification. Individuals who form social identities around a health behavior or activity within a group setting are more likely to sustain engagement over time (Chatzisarantis et al., 2009; Buckingham et al., 2013).

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