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

The review, led by Furqan Butt and colleagues at the University of Birmingham with collaborators at Keele University, the University of Warwick and other institutions, set out to synthesise the quantitative evidence on green health prescribing and nature-based interventions for adults aged 50 and over in primary care and community settings. The team followed Cochrane Handbook guidance, reported the work according to PRISMA and SWiM standards, and graded the certainty of findings using an approach informed by GRADE, the framework widely regarded as the gold standard for judging how much confidence can be placed in medical evidence. The review was registered prospectively on PROSPERO, and patient and public contributors with lived experience of nature-based programmes helped shape the design and interpretation throughout.

The search was exhaustive by any reasonable measure. An information specialist ran searches across MEDLINE, PsycINFO, ASSIA, GreenFILE, Web of Science and Dimensions, covering publications from 2000 through October 2024, supplemented by grey literature searches via Overton and Google. That trawl produced 12,520 unique records. After independent double-screening of titles and abstracts, 230 papers went forward to full-text assessment, and just 41 proved eligible for the wider evidence review. Of these, 21 studies reported quantitative data on the effectiveness of green health prescribing or nature-based interventions and formed the core of the synthesis. The attrition alone tells a story: the vast majority of published work in this field either lacks a natural environment component, studies younger populations, or fails to evaluate an intervention in a way that permits meaningful appraisal.

The 21 included studies comprised 11 randomised controlled trials, including one cluster-randomised trial and two pilot trials, alongside seven quasi-experimental non-randomised designs and three single-arm before-and-after studies. Together they evaluated four broad categories of intervention: activities in nature such as forest therapy, wetland walks and blue space exposure; structured exercise in green spaces, including park prescriptions; horticultural therapy programmes; and indoor gardening adapted for nursing home residents and people with mobility limitations. Collectively they involved roughly 1,300 participants, spanning community-dwelling older adults and people in residential care, including some living with dementia. Yet a striking detail emerges from the study characteristics: in only four of the 21 studies was the intervention actually prescribed by a health or care professional. The rest recruited participants directly through community organisations or research channels, which raises real questions about how well the findings apply to genuine clinical referral pathways.

The results, synthesised narratively because the heterogeneity of participants, interventions and outcome measures made meta-analysis inappropriate, paint a picture of tantalising but fragile signals. Many studies reported improvements in at least one health or wellbeing outcome, and the review identified potential benefits for quality of life, mental health, physical function, fatigue, loneliness and social connectedness. For activities in nature, involving 270 participants across six studies, improvements compared with control were observed in quality of life, anxiety and social functioning among people with long-term conditions, although results for blood pressure and depression were inconsistent, and one trial of post-cancer patients found that an indoor relaxation group actually reported greater reductions in fatigue than a nature walking group. For green space exercise, three randomised trials totalling 221 participants showed little convincing effect; systolic blood pressure, the only outcome informed by two trials, showed small and non-significant differences against usual care or indoor exercise.

The horticultural and indoor gardening evidence was somewhat more encouraging, particularly on social outcomes. Four indoor gardening studies, all rated low risk of bias and involving 310 participants, suggested improvements in overall quality of life and loneliness among nursing home residents, earning moderate-certainty GRADE ratings, the highest awarded anywhere in the review. Among nine horticultural intervention studies with 504 participants, statistically significant benefits emerged for self-efficacy and self-esteem, social connectedness, and activities of daily living, with individual trials reporting gains in these domains compared with waitlist or usual-care controls. But for most other outcomes, including wellbeing, cognitive function, psychological health and physiological measures, the findings were inconsistent, small, or not statistically significant, and the certainty of evidence was rated low or very low across the board.

Why does the evidence fall so short of the enthusiasm? The review authors point to a familiar cluster of methodological weaknesses. Sample sizes were typically small, often fewer than 50 participants per arm, leaving individual trials underpowered to detect meaningful differences. Follow-up was usually short, frequently limited to assessments immediately after the programme ended, so nothing can be said about whether any benefits persist. Blinding of outcome assessors was often absent, and many non-randomised studies struggled with incomplete outcome data and inadequate control of confounding. Perhaps most fundamentally, the interventions themselves were extraordinarily diverse, ranging from guided forest bathing to indoor herb cultivation, delivered in settings from care homes to wetlands, against comparators as varied as printed educational materials, art therapy and structured exercise. This heterogeneity defeated not only meta-analysis but also the planned subgroup analyses by deprivation level, geography and age band.

There is also a glaring equity gap. The review had hoped to examine whether green prescribing works particularly well, or particularly poorly, for older people in economically deprived communities, a question of real policy weight given that a survey of Scottish general practitioners found 80 per cent were willing to refer patients to green social prescribing but worried about accessibility for patients from disadvantaged areas. Very few included studies reported socioeconomic data at all, leaving the review unable to draw any conclusion about whether unequal access to safe, well-maintained green space shapes outcomes for the very populations that social prescribing is often meant to reach. Meanwhile, the funding and policy momentum continues: in 2024, one million pounds in green social prescribing grants was awarded to NHS charities in the United Kingdom, and implementation has been expanding across the country.

Interestingly, the gap between trial evidence and lived experience was one of the most striking findings. The public contributors involved in the review, including service users who had participated in nature-based programmes, consistently reported positive impacts on their mental and physical health. They emphasised connection with nature, social interaction, and a sense of meaning and purpose derived from these activities, and highlighted spiritual and psychosocial dimensions that they felt standard outcome measures fail to capture. They also valued green outdoor environments as venues for strengthening community cohesion in ways that traditional clinical settings cannot match. This disconnect between what patients say they gain and what small, short, heterogeneous trials can statistically detect is a recurring challenge in evaluating complex, person-centred interventions, and it does not necessarily mean the benefits are illusory; it may mean the measurement tools and study designs are inadequate to the task.

The review’s conclusions are measured but pointed. The available evidence remains limited in volume, heterogeneous in design and predominantly of low to very low certainty, and there is currently insufficient robust evidence to support widespread implementation of green health prescribing within routine care. Crucially, almost no studies evaluated prescribing itself, as a referral option delivered by primary care clinicians, rather than a specific activity offered directly to participants. The authors call for high-quality pragmatic trials, potentially using cluster or stepped-wedge designs, and implementation studies that evaluate green prescribing at the service level, with standardised outcome measures, longer follow-up, attention to cost-effectiveness and healthcare resource use, and deliberate focus on older adults with long-term conditions and those living in deprivation. As the World Health Organization identifies loneliness as a global health challenge and health systems search for scalable, preventative solutions, nature-based interventions may yet earn a firm place in the clinical toolkit. For now, however, the prescription is written more in hope than in hard evidence, and the task for researchers is to change that before policy outruns the science entirely.

Subject of Research: Effectiveness of green health prescribing and nature-based interventions for older adults in primary and community care

Article Title: Effectiveness of green health prescribing and nature-based interventions in primary care and community settings for older adults: a systematic review of health, wellbeing and social outcomes

Article References: Effectiveness of green health prescribing and nature-based interventions in primary care and community settings for older adults: a systematic review of health, wellbeing and social outcomes. (n.d.). https://doi.org/10.1186/s12916-026-05194-z

Image Credits: AI Generated

DOI: 10.1186/s12916-026-05194-z

Keywords: green health prescribing, nature-based interventions, older adults, social prescribing, horticultural therapy, primary care, systematic review, quality of life, loneliness, healthy ageing, mental health, evidence certainty