Nature on Prescription for Mental Health: Feasibility Stage for the ‘greENGAGE’ Trial Stage

Young woman walking through a sunny wooded area.
A team from the University of Exeter and University of Plymouth are conducting a feasibility study of nature-based activities reached through social prescribing.
The work is funded by the National Institute for Health Research (NIHR) and will help prepare for a full Randomised Controlled Trial which will aim to clarify whether such activities are effective in protecting and improving the mental health of participants with diagnosed conditions such as depression and anxiety. The team are working with the Wildfowl and Wetlands Trust, and Newquay Orchard.
The project is one of four funded by the NIHR and is linked to the national green social prescribing Test and Learn programme. It builds on previous work by the team including the Nature on Prescription Handbook funded by the MRC, and a report on Therapeutic Nature written for Defra. This project is also supported by The National Institute for Health and Care Research (NIHR) Applied Research Collaboration (ARC) South West Peninsula (PenARC).
Flourish in nature - getty. wood woodland forest

Background

Social prescribing, which is increasingly used in the UK, involves GPs referring people living with mental ill-health to community activities as part of their treatment. Frequently Link Workers help patients identify activities that may suit them. They might choose: community choirs; volunteering opportunities; physical activity; or nature-based activities.
There are a large number of nature-based social prescribing projects, yet few have been evaluated using robust methods. Healthcare commissioners and staff are increasingly seeking high quality evidence of the clinical effectiveness of nature-based social interventions to guide them in the best allocation of resources. Randomised controlled trials (RCTs) are widely accepted as the most reliable way to demonstrate effectiveness. This type of evaluation will support more confident decision making and help ensure that people with mental health needs are referred to the most appropriate interventions for them.
Nature-based social prescribing is what is known as a complex intervention. It uses several stages of consultation and referral to allocate people to interventions, each of which may involve different types of activities, taking place in different localities, organised and led in different ways. Before undertaking a full trial, it is important to ensure the plans for that research are feasible, appropriate and acceptable, so that the outcomes of the RCT will be meaningful.

The study

The team will design a research plan which will include defining the target population, determining the most appropriate measurable outcomes and identifying a comparison group. To do this the team will consult with people already involved in social prescribing including: GPs, Link Workers, and nature-based activity providers. By advertising the study through these partners, we will recruit some of their service users to assess whether our plans will be acceptable to participants in the future RCT.
The activities that will be tested will be mapped to the key pathways that we identified in the Nature on Prescription Handbook.
Graphic explaining the mechanics of nature on prescription. The 9 circles are titled: caring, creativity, being outside, physical activity, relationship with nature, personal growth, having fun, groups, making a difference. 
The plan will be tested with a small number of GPs, nature-based activity providers and their participants to make sure it is appropriate and feasible. This will ensure that the processes are sound and achievable, that we are able to recruit enough people to the study, and that questionnaires used to measure impact are appropriate.
The outcome of the study will be a fully designed protocol, a detailed plan, for a future RCT which will assess the effectiveness of nature-based social prescribing for people with mental ill-health.