Nature prescriptions should address motivations and barriers to be effective, equitable, and sustainable

Equitable, effective, and durable solutions to address social determinants of health remain elusive and ever more urgent in the context of climate change.1Sherman JD McGain F Lem M Mortimer F Jonas WB MacNeill AJ Net zero healthcare: a call for clinician action.BMJ. 2021; 374n1323 Google Scholar Contact with natural environments, such as parks and forests, is associated with better health.2Astell-Burt T Hartig T Putra IGNE Walsan R Dendup T Feng X Green space and loneliness: a systematic review with theoretical and methodological guidance for future research.Sci Total Environ. 2022; 847157521 Crossref PubMed Scopus (9) Google Scholar Enabling people to increasingly interact with nature is recognised by some health professionals as an option for addressing unmet health and social needs (eg, physical activity and connections with others).3Astell-Burt T Pappas E Redfern J Feng X Nature prescriptions for community and planetary health: unrealised potential to improve compliance and outcomes in physiotherapy.J Physiother. 2022; 68: 151-152Crossref PubMed Scopus (4) Google Scholar Seeking contact with natural environments for restoration of health is not new, but many people receive limited health benefits as they spend minimal time in nature. One way people are being encouraged to have more contact with nature—and for which interest is high in some countries, such as Australia—is via so-called nature prescriptions.4Astell-Burt T Hipp JA Gatersleben B et al.Need and interest in nature prescriptions to protect cardiovascular and mental health: a nationally-representative study with insights for future randomised trials.Heart Lung Circ. 2023; 32: 114-123Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar Nature prescribing is an accessible and low-cost adjunct to routine medical care, comprising written directives by health professionals for visits to natural settings either individually or in groups for recreation, relaxation, and reconnection.5Kondo MC Oyekanmi KO Gibson A South EC Bocarro J Hipp JA Nature prescriptions for health: a review of evidence and research opportunities.Int J Environ Res Public Health. 2020; 174213 Crossref Scopus (34) Google Scholar Although robust experimental, health-economic, and implementation-science-focused evaluations of co-designed nature prescriptions are in the nascent period of development and implementation,5Kondo MC Oyekanmi KO Gibson A South EC Bocarro J Hipp JA Nature prescriptions for health: a review of evidence and research opportunities.Int J Environ Res Public Health. 2020; 174213 Crossref Scopus (34) Google Scholar early results are promising. Nature-prescription activities can lead to an increase in physical activity (especially walking) and reductions in depression, anxiety, and blood pressure.6Nguyen P-Y Astell-Burt T Rahimi-Ardabili H Feng X Effect of nature prescriptions on cardiometabolic and mental health, and physical activity: a systematic review.Lancet Planet Health. 2023; 7: e313-e328Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar However, as with other behavioural interventions, an exclusive focus on educating people about the scientific benefits of contact with nature without supporting access might be somewhat ineffective. Delivery of behavioural interventions that preferentially benefit people in more privileged societal positions could ultimately widen health inequities. We propose that for nature prescriptions to be effective, equitable, and sustainable, interventions should be co-designed with people who use them or could benefit from using them, health-care providers, and experienced professionals who specialise in facilitating activities in natural environments (eg, accredited nature therapists and community gardeners). This co-design with key stakeholder groups is necessary to ensure that interventions are acceptable to intended beneficiaries, credible to those who are expected to recommend them, and achievable for those who deliver them. Co-design of nature prescriptions should attend to differences in personal capacities that enable—and external barriers that inhibit—time spent in natural environments and the ways they intersect with variations in autonomous motivations for nature contact. Attending to these factors is crucial to maximise uptake and adherence.3Astell-Burt T Pappas E Redfern J Feng X Nature prescriptions for community and planetary health: unrealised potential to improve compliance and outcomes in physiotherapy.J Physiother. 2022; 68: 151-152Crossref PubMed Scopus (4) Google Scholar Accordingly, we propose a four-quadrant, multilevel framework to inform the development of nature-prescription interventions (figure). For example, a person might be receptive to a nature prescription but experience substantial barriers to interacting with natural environments. Access is not only influenced by availability, but also time scarcity, inclement weather, transportation, and even financial access—for example, entry or vehicle fees are charged by some national parks in Australia and Canada. Cultural and gender norms (eg, about being alone) and disability can also influence access;7Wojnowska-Heciak M Suchocka M Błaszczyk M Muszyńska M Urban parks as perceived by city residents with mobility difficulties: a qualitative study with in-depth interviews.Int J Environ Res Public Health. 2022; 192018 Crossref Scopus (4) Google Scholar planners have crucial roles in designing or redesigning more inclusive ways for everyone to engage with nature. Furthermore, an individual might have a green or blue space nearby and experience few barriers to accessing nature but might have little motivation to spend time in natural settings for several reasons (eg, perceived risk of injury or concerns related to personal safety). Differences in types of motivation for behavioural change have long been recognised8Deci EL Ryan RM The “what” and “why” of goal pursuits: human needs and the self-determination of behavior.Psychol Inq. 2000; 11: 227-268Crossref Google Scholar but are under-researched for nature contact specifically. Unfortunately, not everyone will find the idea of a nature prescription rewarding (ie, intrinsic motivation) or value it as part of their personal identity (ie, integrated motivation). Some people might not even recognise a green or blue space as an attractive alternative to an indoor gym for health improvement (ie, identified motivation). Low levels of these autonomous motivations might potentially be due to a loss of direct, even lifelong, contact with natural and community-oriented settings that is the result of negligent city planning that obliterates green and blue spaces and their resident wildlife in favour of commercial interests, cars, and motorways. These conditions, which might lead to a so-called lonelygenic environment, are likely to disproportionately affect people living with socioeconomic disadvantage.9Feng X Astell-Burt T Lonelygenic environments: a call for research on multilevel determinants of loneliness.Lancet Planet Health. 2022; 6: e933-e934Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar Finding methods to remove barriers and strengthen autonomous motivation for contact with nature is crucial. Interventions that are focused on introjected and external (ie, controlled) motivations involving guilt or social pressure are not useful for sustained behavioural change after interventions and could undermine intrinsic motivation for nature contact.8Deci EL Ryan RM The “what” and “why” of goal pursuits: human needs and the self-determination of behavior.Psychol Inq. 2000; 11: 227-268Crossref Google Scholar Potential solutions include testing group-based and person-based activities and incorporating intrinsically motivating commitment devices (eg, temptation bundling)10Rogers T Milkman KL Volpp KG Commitment devices: using initiatives to change behavior.JAMA. 2014; 311: 2065-2066Crossref PubMed Scopus (110) Google Scholar that indirectly increase time in nature as a way to familiarise and refamiliarise individuals who feel disconnected from natural environments with the more-than-human world. Our proposed framework emphasises the need to segment trial populations and supports the application of avant-garde study designs, such as a factorial experiment, that are capable of defining what intervention components maximise positive outcomes for which population while considering the challenges we have mentioned. Identifying the size of the population in each quadrant with representative surveys will help to define the scope for future benefit. We declare no competing interests.