Green prescriptions (GRx, green prescription, nature prescription, green social prescribing)
Green prescriptions are recommendations given by a healthcare specialist (doctor, physiotherapist, psychologist, nurse, psychotherapist, midwife, etc.) regarding engaging in activities that deepen the connection with nature to improve mental and physical health.
They may involve outdoor physical activities, social interactions, dietary habits, and nutrition, but can also be specifically focused on experiencing the natural environment, such as walks, nature observations, forest bathing, therapeutic ornithology, mindfulness practice in nature, and others.
Typically, they are written and pertain to preventive, supportive, as well as rehabilitative actions.
In some countries, these recommendations are proposed by the Ministry of Health (New Zealand, the United Kingdom, Canada) and are employed by various medical specialists, mainly primary care physicians and psychiatrists, but are also useful in specialties such as pediatrics, oncology, internal medicine, pulmonology, cardiology, diabetology, endocrinology, geriatrics, and others.
A green prescription may specify the time spent outdoors or be more detailed in terms of what the doctor/therapist believes the patient needs and how, or where, they can achieve it.
In our service, we aim to support both healthcare professionals and patients who are interested in incorporating interactions with the natural environment into a comprehensive set of activities aimed at supporting and improving health on all its levels: somatic, emotional, intellectual, social, or spiritual – in line with the latest definition of the World Health Organization (WHO).
About green prescriptions:
According to reports from the World Health Organization (WHO), nature is our greatest source of health and well-being. Unfortunately, with increasing urbanization and civilization progress, where over half of the world’s population already lives in cities, access to nature can be significantly challenging. As a result, many mechanisms that have supported our health, relationships with other species, and the landscape for thousands of years, maintaining a balance in the web of life and regulating many processes, are lost. The rapidly increasing incidence of civilization diseases such as metabolic syndrome, cancer, obesity, heart attacks, strokes, depression, and anxiety disorders has led the scientific community to consider restoring a balance that would protect both humans, other species, and the planet. According to the One Health approach, this is how we can achieve health – by caring for the environment and other organisms as well. If nature disappears from our daily landscape, it may become insignificant for our children, not worth the effort, and therefore not worth fighting for, caring for, or understanding the relationship with it. Future generations may increasingly fail to understand why the presence of plants in the environment can reduce stress, touching wood can have a calming effect on blood pressure, inhaling substances released by trees can affect the immune system, and watching birds can reduce anxiety levels. Without specialized knowledge and knowing how to verify all this in scientific databases (which is not that difficult), this information may sometimes seem unbelievable, childish, and not very credible. To popularize knowledge about the potential of the natural environment for restoration, prevention, support, and rehabilitation, to which our repair and regenerative mechanisms have been adapted for millennia, doctors in many countries have started implementing specific recommendations. These encourage patients to connect with nature in a way that is appropriate for their abilities and health status, as well as to change dietary habits and engage in physical activity and social activities. Thus, the so-called ‘green prescriptions’ were created.
The first country to implement green prescribing into public healthcare is New Zealand. The recommendations there mainly focus on regular physical activity and a healthy diet prescribed by doctors and nurses. The New Zealand Ministry of Health has been encouraging the use of green prescriptions since the 1990s. Results have been compiled and presented in scientific papers available worldwide. Green prescriptions are most commonly prescribed for the treatment of hypertension, obesity, depression, and type 2 diabetes, both by primary care doctors and specialists. More information about Green Prescriptions in New Zealand can be found on the Ministry of Health’s website ‘Manatu Hauora’: https://www.health.govt.nz/your-health/healthy-living/food-activity-and-sleep/green-prescriptions.
Canada has proposed interesting solutions to its patients. In 2013, the Institute at the Golden Gate and the National Recreation and Parks Association, with the support of the National Park Service, formed a team of specialists to move nature prescriptions from pilot programs into the mainstream of healthcare. The PaRx program (from park and Rx, meaning prescription) was implemented, allowing doctors to generate prescriptions with a special code enabling free annual access to national parks, marine protected areas, and historical sites. The Institute at the Golden Gate integrates various park prescription movements. More about this initiative can be read here: https://www.parkrx.org/, and about the specific ParkRx program here: https://www.parkprescriptions.ca/. The Canadian approach particularly emphasizes being in a natural environment and spending time in nature, especially to extend life, reduce stress, aid in the treatment of anxiety and depressive disorders and pain, as well as to strengthen the circulatory system.
A similar program operates in the USA based on similar principles, called Park Rx America. More information on this can be found on the website: https://parkrxamerica.org/.
National Forest Therapy Centers, mandated by government organizations, are located in Korea and Japan. South Korea is a pioneer in recommending forest baths as part of national health prevention. The National Forest Therapy Center offers dozens of different programs depending on the age, health needs, and life situation of patients. The Korean Forest Welfare Institute (FoWI) is a public organization operating within the Korean Forest Service since 2016. It manages National Forest Education Centers and the National Healing Forest, as well as the Forest Welfare Research and Development Center, conducting extensive scientific research on the impact of the forest on various aspects of health. The most promising results so far concern depression and high blood pressure. In Japan, forest therapy is handled by the International Society of Forest and Nature Medicine (INFOM), with doctors and qualified medical personnel conducting forest baths, and there is also a field of medical knowledge known as forest medicine. More about the Korean forest therapy system can be found on the website: https://www.fowi.or.kr/user/eng/engMain.do. Singapore also prescribes park visits as a prescription for physical activity. In a randomized controlled trial in the exercise group in the park, compared to the group recommended to exercise on their own (e.g., at home), not only somatic but also psychological benefits were observed.
The United Kingdom, especially Scotland, is a leader in ecotherapeutic recommendations provided by primary care doctors. The NHS (National Health Service, equivalent to the Polish NFZ) collaborated with the Royal Society for the Protection of Birds (RSPB) in 2017. Family doctors, initially from Shetland, began recommending patients to connect with nature as part of medical advice and green prescriptions. The program was soon expanded to include more outpatient clinics and primary care offices. As part of this collaboration, an online platform was created, allowing doctors and patients to see on a map what ecotherapeutic event would take place in their area soon. They also had access to leaflets on which the doctor, after consulting with the patient, marked what could be done in a given month to strengthen the connection with nature. In Dundee, doctors also issued referrals for forest baths. The British government invested £5.77 million in social green prescriptions to prevent mental illnesses and support healing. The goal was also to address other civilization diseases such as chronic stress syndrome, metabolic syndrome, diabetes, cardiovascular diseases, asthma, and cancer. Learn more about the work of the Dundee Green Health Partnership, coordinating the work of family doctors, specialists, nurses, and therapists recommending ecotherapy: https://www.greenhealth.scot/. The UK also has the Centre for Sustainable Healthcare (CHS), encouraging doctors and hospitals to engage in ecotherapeutic activities, including within the NHS. Check out “NHS Forest” for more information: https://nhsforest.org.
In July 2020, the British Secretary of the Environment, George Eustice, announced a £4 million investment in a cross-government project aimed at preventing mental illnesses and combating them through the implementation of social green prescriptions.
Countries implementing green prescriptions also include Finland and Norway with the concept of ‘living outdoors’ (friluftsliv), popularized in Poland by Dariusz Morsztyn from the Republika Ściborska.
For Medics and Therapeutists:
Dear Colleagues from the medical field: physicians, psychotherapists, occupational therapists, psychologists, nurses, paramedics, researchers, and others, with diverse expertise within the realm of healthcare – we joyfully welcome you to a website dedicated to ecotherapeutic interventions in Poland. With the growing digitization of the world, urbanization, rapidly changing climatic conditions, and the global decline of biodiversity, you probably observe in your practice that the ailments and disorders reported by our patients increasingly relate not only to isolated diseases associated with specific systems and organs but also to civilization-related diseases. These issues are broadly and multidimensionally linked to sedentary lifestyles, air and water pollution, unhealthy diets, withdrawal from non-virtual social life, information overload, and the intensification of stress resulting from the faster pace of life, detachment from natural evolutionary mechanisms regulating emotions, and the increasingly artificial conditions that accompany the daily lives of most people. These diseases include obesity, hypertension, diabetes, the entire metabolic syndrome, cancer, cardiovascular diseases, strokes, depressive and anxiety disorders, as well as addictions. Additionally, there are new, previously unknown and undescribed conditions such as climate anxiety, FOMO (fear of missing out), hikikomori, karoshi, and ecotrauma.
In outpatient psychiatry, we are increasingly encountering not only “classic” mental illnesses, as was more common twenty years ago, but also behavioral addictions, social phobias, sleep disorders, anxiety, adaptive and depressive disorders associated with changing living conditions with exceptional intensity. These issues are also affecting our youngest population more frequently.
The last decade has not been easy – we are grappling with challenges that leave an emotional mark on many of us – from the COVID-19 pandemic and lockdowns, through military and political conflicts nearby, global inflation, to difficulties related to the job market.
For millennia, the natural environment has allowed us to develop defense mechanisms at emotional, biochemical, microbiological, physical, and many other levels, which we are only now beginning to understand through the rapidly growing scientific research devoted to this topic.
We already know how the forest environment positively affects our cellular immunity (NK cells producing granzymes and granulysins), hormonal homeostasis (regulation of adrenaline and cortisol levels), circulation (normalization of blood pressure, pulse, metabolism of the cerebral cortex), and the regulation of emotions and insomnia. We are aware of light pollution, nature deficit disorder, and the fact that access to green areas in childhood reduces the risk of depression in adulthood, while the amount of greenery in the living environment is associated with lower mortality, less use of certain drug groups, or, finally – a view from the window of green areas supports postoperative recovery. Facts are not up for debate; thousands of studies, including meta-analyses, emphasize that the One Health approach allows us to fully take care of the well-being of our patients and ourselves. This is crucial if we want to continue our profession with enthusiasm and without burnout.
Through this website, we warmly encourage you to engage in initiatives that restore relationships with the natural environment as part of preventive, rehabilitative, or supportive treatment in the evidence-based medicine paradigm (EBM).
We believe that mutual inspiration, knowledge exchange, sharing experiences and ideas, interdisciplinary work, and bold steps towards what may turn out to be crucial are possible, necessary, and supportive.
Therefore, we invite you to make use of what we share in the sections below and to contact us if you are undertaking similar initiatives, would like to collaborate, or wish to convey information to a wider audience. We will make every effort to ensure that this website facilitates your work, expands knowledge, and encourages you to take care of your well-being, which is essential in helping professions.
Green prescriptions from the perspective of the office – know-how:
In outpatient practice, the time of the visit is often limited, so it is worthwhile to prepare supplementary materials, scenarios, or algorithms in advance to streamline work while creating space for a dialogue with the patient about their relationship with nature in the context of health.
- Ask about the most common way of regeneration and leisure time – this will help determine whether the patient rests outdoors or indoors, what type of activity they prefer, and whether physical exertion is present in their life. Where does the patient prefer to relax? Forest/meadow/mountains/sea/lake? Actively or quietly?
- Ask about nature preferences and biophobia – does the patient like to spend time in nature? How? Are there things that scare or cause fears in a natural environment? This is important because an activity perceived as enjoyable will generate more internal motivation and will be more willingly undertaken, whereas if something in nature stresses the patient, it may intensify anxiety, produce the opposite effect, and discourage them (e.g., a visit to a dark or vast forest, a phobia directed against spiders, snakes, low awareness of tick prevention, traumas that may have occurred in the natural environment in the past, including in the patient’s family, such as assault, attack, getting lost, etc.).
- Convince the patient of the scientific basis of proposed interventions. It helps build trust if we refer to scientific research, showing the patient that their health is viewed holistically by the medical profession. To achieve this, you can recommend a book, a scientific article, or use previously printed materials referring to sources.
- Encourage the patient to engage in health-supporting activities in nature without generating excessive pressure. Research shows that internal motivation plays a significant role in people with emotional disorders, and forced “accountability” makes visits to nature more frequent but weakens health benefits. On the other hand, motivating individuals with metabolic syndrome systematically can solidify positive behavior patterns.
- Canadian specialists advise that our time in nature should be regular, last no less than 20 minutes at a time, and a minimum of 2 hours per week.
- Plan encounters with nature as business or social meetings. Record them in the schedule, in the online calendar, take them seriously. Combine time in nature with daily activities to avoid excessive scheduling, which can be discouraging. Have lunch outdoors at work instead of indoors, choose a forest clearing instead of a gym, and perform similar exercises. Go to a park for a date or a family outing instead of a shopping mall. Engage others in group ecotherapeutic activities to increase motivation.
- Take care of the relationship with nature instead of using it as a tool. Pay attention to not littering, the ecology of daily life, and a subjective, non-objective approach enrich emotionally, facilitate gratitude practice, mindfulness, reduce loneliness in alienated, older, minority, or financially challenging individuals.
- Emphasize that activities should be voluntary, comfortable, within the safety limits of patients, not undertaken “by force.”
Example interventions in outpatient medical practice:
- Provide written recommendations “for the next visit” – one or two simple recommendations, adequate to the patient’s capabilities, needs, and limitations (biophobia).
- Ask about adherence to recommendations during follow-up visits, without generating guilt if it was not successful. Motivation, psychoeducation, health education.
- Distribute leaflets with green prescription recommendations, ready-made forms (they can be stamped and signed by the doctor, personalized with the patient’s name).
- Recommend literature on the subject, events in the region (maps, websites, and social media where appropriate information can be obtained), audiobooks, relaxation exercises (also audio, available online or downloadable) involving contact with nature.
Publishi a map of the region with marked hiking trails, forest therapy paths, viewpoints, and naturally valuable places to encourage patients to visit them
Encourag to outdoor physical activity and a healthy diet in accordance with the food pyramid
Propose exercises supporting recovery within a specific specialization (breathing exercises, visualizations, Simonton method exercises, cardiac rehabilitation), which can and are worth undertaking in nature due to valuable climatic values (e.g. humidity, essential oils in the forest, monoterpenes produced by trees supporting natural immune defense), etc.
Actions in the educational system:
- Bring educators into collaboration and cooperation. Knowledge about the benefits of green areas can be used to improve the effectiveness of therapeutic work, reduce burnout, and prevent psychopathology in children and adolescents.
- Prepare a manual for schools on how to incorporate green elements into their environment, even in large cities. Include information on the benefits of green spaces, the importance of school gardens, and eco-education.
- Designate school hours dedicated to the environment. Teach children and adolescents about the natural environment, about the concept of “ecotherapy,” and about the importance of being in nature for physical and mental health.
- Collaborate with local governments to create green areas around schools, kindergartens, and universities.
- Include outdoor activities in the school curriculum. Regular nature classes, excursions, and educational games in green areas can significantly contribute to the health and well-being of students.
Examples of interventions within 24-hour psychiatric units:
– taking care of the green space available to patients: outside (horticultural therapy garden, hospital park, flower meadow, relaxation zone in nature) and inside (“green room” with the presence of plants/photo images of nature, periodically switching on the singing of birds, the murmur of a stream, gentle, natural light where you can relax, read or engage in creative activity as part of art therapy. The silence zone can also be arranged in a similar way)
– arranging relaxation activities using elements of nature – music therapy with a natural sound background, art therapy with natural materials, nature-themed, outdoor walks with an occupational therapist, forest bathing, relaxation in nature (Jacobson’s training, Schultz’s autogenic training, others) undertaken in the hospital garden or park, joint observation of birds or plants and comparing them with drawings in the atlas, discussions about natural impressions and reflections that appear during these activities as part of group activities.
Examples of ecotherapeutic activities in the practice of an occupational therapist:
-conducting forest bathing in the hospital park (if available)
-conducting hortitherapy classes in the hospital garden or inside, as part of caring for potted flowers
-art therapy inspired by nature, using natural raw materials
-music therapy using the sounds of nature
-visualization embedding you in your favorite, safe natural landscapes
-aromatherapy based on woody or herbal scents
-reading books together, watching nature albums,
– starting a discussion about the observed nature, in the context of which it is easier to talk about emotions (externalization, safe perspective, distance)
– adapting activities to the needs and limitations of patients (in forest bathing, avoiding metaphors and working with imagination with schizophrenic/autistic patients, focusing on the sensual part of the process, simple, open and sensory-oriented activities (P-O-Z), avoiding topics related to the degradation of nature in depressed and anxious patients, emphasizing the theme of coexistence and relationships with other beings, reducing the feeling of loneliness)
– in hospital gardens, planting sensory-activating plant species associated with childhood, e.g. in the countryside (in many cases, such feelings are evoked by dahlias, roses, phloxes, hollyhocks).
IN A WIDER PERSPECTIVE:
Scientific and research activities:
- Actively participate in scientific research on ecotherapy, documenting its effectiveness, and contributing to the development of evidence-based practices.
- Conduct studies on the impact of green prescriptions on different age groups and various health conditions.
- Publish articles in medical and psychological journals to disseminate knowledge about the positive effects of nature on health.
- Organize conferences, symposia, and workshops on the subject, bringing together professionals from various fields to exchange ideas and experiences.
- Collaborate with environmental organizations, universities, and research institutions to promote interdisciplinary research on the relationship between nature and health.
- Collaborate with local communities to create and maintain green spaces. Involve community members in the planning and development of parks, community gardens, and natural areas.
- Organize community events and activities in green spaces to promote a sense of belonging and connection among residents.
- Provide education and workshops to the community on the health benefits of spending time in nature and encourage the use of green prescriptions.
- Partner with local businesses and organizations to support initiatives that promote ecotherapy and the development of green spaces in urban areas.
Media and communication:
- Use various media channels to raise awareness about the importance of ecotherapy and green prescriptions.
- Collaborate with journalists and influencers to share stories and testimonials about the positive impact of nature on health.
- Create engaging and informative content for social media platforms to reach a wider audience.
- Organize campaigns and challenges to encourage individuals to adopt green prescriptions and share their experiences.
Advocacy and policy:
- Advocate for the inclusion of ecotherapy and green prescriptions in healthcare policies and guidelines.
- Collaborate with policymakers to develop initiatives that promote the integration of nature-based interventions in healthcare practices.
- Participate in discussions and forums related to public health to emphasize the role of nature in preventing and managing various health conditions.
- Work towards the recognition of ecotherapy as a valid and effective form of treatment in the healthcare system.