Nature Prescriptions for Older Adults Face Real-World Barriers, Landmark Review Finds

Doctors have been writing prescriptions for nature for years, referring older patients to community gardens, forest walks and horticultural therapy programmes in the hope that time outdoors will ease the chronic loneliness, inactivity and depression that so often accompany ageing. The idea has captured the imagination of health systems around the world, and in the United Kingdom green social prescribing has been actively promoted through official primary care contracts. But a new systematic review published in BMC Medicine suggests that the vision of a doctor’s note that unlocks the healing power of the outdoors is running into stubborn, structural friction on the ground.

The review, led by Jeremiah Donoghue of the University of Birmingham together with colleagues at the University of Warwick, Keele University and the University of Edinburgh, set out to answer a deceptively simple question: what actually helps or hinders older adults from accessing and benefiting from green health prescribing? The team synthesised qualitative evidence from 25 studies published between 2000 and October 2024, drawn from an initial pool of 12,553 unique citations screened across Medline, PsycINFO, ASSIA, GreenFILE, Web of Science, Dimensions and grey literature sources. Most of the included studies were published after 2019, reflecting the rapid recent growth of interest in nature-based interventions.

Methodologically, the review followed the Cochrane Handbook and reported its results according to PRISMA and ENTREQ guidance, with the protocol registered on PROSPERO. Two reviewers independently screened studies, extracted data and appraised quality using the Mixed Methods Appraisal Tool, with disagreements resolved by a third reviewer. The qualitative findings were then synthesised inductively, and the confidence in each theme was formally assessed using the GRADE-CERQual framework. Notably, the researchers involved public contributors, including people who had actually received green prescriptions, at every stage of the review, following the ACTIVE framework for stakeholder involvement. Five of the ten themes identified were rated as high confidence, four as moderate and one as low.

The synthesis produced ten overarching factors, seven of them barriers and three enablers. On the barrier side, the most visceral findings concern accessibility. Older adults repeatedly described how parks and gardens were simply too far away, and how limited transport options turned a supposedly restorative outing into a logistical ordeal. One occupational therapist interviewed in an included study pointed out that if a patient’s goal is to look at the flowers in a botanical garden but they must take a bus to get there, the journey itself becomes a prerequisite that can overwhelm the therapeutic activity. For residents of care homes, the problem could be even more basic: one service user described long corridors they called runways, and the sadness of getting lost on the way to the garden.

Weather and environment emerged as another formidable obstacle. Extreme heat, winter ice, mud and darkness all compromised the safety and feasibility of outdoor settings. A physician practising in a far northern region described patients who hunker down in their apartments all winter as daylight shrinks to a few hours and temperatures sit between minus 35 and minus 45 degrees, becoming deeply depressed in the process. A forest therapy guide noted that a favourite park can turn into a mud pit under constant rain, and that suitable alternative spots are rare. For older people with impaired mobility or cognition, interventions that are too physically demanding simply cannot be followed, raising questions about how inclusive current programme designs really are.

Perhaps the most thought-provoking barrier is philosophical rather than practical: prescriber hesitancy rooted in a fear of over-medicalising nature. Some healthcare professionals expressed a deep ambivalence about turning engagement with the natural world into a formal clinical script, arguing that connection with nature should be embedded in everyday life and culturally normalised rather than administered as a treatment governed by medical formalism. One practitioner worried that prescribing nature risks turning it into just another form of consuming and commodifying something that should be innate, free and all around us. The review also documented acute cultural sensitivity around this issue: physicians working with Indigenous communities in Canada and Australia described profound discomfort with telling Indigenous patients to spend more time on the land, given that land-based healing is already a deep-rooted cultural practice and given the historical role of white institutions in dispossessing those communities. As one primary care director put it, if you go in thinking you know what is going to work, you are destined to fail.

Knowledge gaps compounded the problem on both sides of the prescription pad. Many older adults were simply unaware that time in nature could function as a credible health intervention, while many primary care professionals lacked the awareness, personal experience or practical confidence to offer green prescriptions. Service providers observed that doctors who do not have positive personal outdoor experiences are reluctant to prescribe. Layered on top of this were stark socioeconomic disparities: deprived neighbourhoods tend to have fewer, poorly maintained and less safe green spaces, and people on low incomes may lack the equipment, transport or sense of welcome needed to participate. The review notes that although some studies find no simple relationship between green space proximity and use, lower household incomes are consistently associated with reduced access to safe, secure green spaces and a greater prevalence of abandoned parks, meaning the communities that could benefit most from nature prescriptions are often the least able to receive them.

Organisational capacity emerged as perhaps the most consequential systemic barrier, with four interlocking sub-themes: consultation time, financial instability, staffing and training. Physicians described how a conversation about nature-based activity simply does not happen in depth when it is squeezed into a visit dominated by blood pressure checks and chronic disease management. Community organisations, often best placed to run nature-based activities, reported that every conversation comes back to funding, and that short-term, unstable funding cycles make it nearly impossible to sustain services. High staff turnover, difficulty recruiting volunteers with the right combination of affinity for older people and for the outdoors, and the absence of any standardised training or accreditation framework all undermine safe, consistent delivery. Practitioners described their work as done by feel, intuitive rather than formalised, and called for overarching standards covering quality, safeguarding and legitimacy. The lack of randomised controlled trial evidence linking outdoor settings to the treatment of specific medical conditions further leaves willing doctors without the evidence base they are accustomed to relying on.

Against this catalogue of obstacles, the review identified three enablers, and they are strikingly human. Proximity to accessible green space and good weather clearly increase uptake, with one physician in a nature-rich region describing how patients can reach the outdoors within minutes of almost anywhere. More powerfully, participants consistently reported that nature-based interventions fostered social engagement, motivation and confidence. Older adults described the pleasure of chatting while working together in horticultural therapy groups, of having someone to talk to about their health worries, and of the sense of purpose that comes from having tasks to do in a garden. One participant said gardening made her feel she was not useless, dodging about the house, while another spoke of wanting to share her gardening knowledge with local schoolchildren and help feed neighbours who cannot afford proper food. Provider enthusiasm also proved decisive: the review describes individuals whose energy and commitment single-handedly built green care networks, suggesting that committed champions can hold services together even where funding and structure are lacking.

The authors conclude that realising the full potential of green health prescribing for healthy ageing, and for reducing rather than amplifying health inequalities, will require deliberate investment: accessible programme design, community provision infrastructure, training and accreditation, and deeper integration of green prescribing within primary and community care. They also flag a critical evidence gap, noting that very few studies reported data on marginalised or socioeconomically deprived groups, and that service users’ voices remain underrepresented compared with those of providers. The review does not claim that nature prescriptions fail; rather, it shows that their success depends on a fragile ecosystem of transport, weather, funding, staff, cultural humility and trust. As populations age, with the number of people over 60 projected to reach 1.4 billion by 2030, the question is no longer whether time in nature can help older people, but whether health systems can build the pathways that let a green prescription actually be filled.

Subject of Research: Barriers and enablers to green health prescribing and nature-based interventions for older adults in primary care

Article Title: Factors influencing access to green health prescribing in primary care for older adults – a qualitative systematic review

Article References: Donoghue, J., Butt, F., Ley, C., Dracup, N., Staniszewska, S., Al-Khudairy, L., Smith, T. M., Corp, N., Parsons, J., Frost, H., Grove, A., Chen, Y.-F., & van der Windt, D. A. (2026). Factors influencing access to green health prescribing in primary care for older adults – a qualitative systematic review. BMC Medicine, 24(1), Article 534. https://doi.org/10.1186/s12916-026-05195-y

Image Credits: AI Generated

DOI: 10.1186/s12916-026-05195-y

Keywords: green health prescribing, nature-based interventions, older adults, primary care, social prescribing, health inequalities, systematic review, qualitative synthesis, healthy ageing, community gardens, access barriers, GRADE-CERQual