Blue Prescription Programmes in Health and Social Care Settings and their Implications for Current and Post COVID-19 Pandemic Mental Healthcare

A Systematic Review of Evidence Using Realist Synthesis


Background: The importance of mental health is increasingly recognised, but mental health services are under strain to meet demand, and this is compounded by the impact of COVID-19. Evidence suggests how blue spaces improve health and wellbeing. Acknowledging the growing interest in nature-based social prescribing, we investigated how blue prescriptions are implemented in health and social care settings, developed determinant frameworks, and extrapolated these to current and post COVID-19 blue space management measures to support mental health.

Methods: We conducted a systematic review by searching six databases for original research, published between January 2000 and February 2020, in English, on blue prescriptions by health or social care workers with the outcome of improved health or wellbeing. We excluded studies where participants were recruited by non-health professionals. We also added articles cited in relevant literature. We employed thematic analysis and realist synthesis to describe beneficiaries, mechanisms, outcomes, and contexts where blue prescriptions work. Our study was registered with PROSPERO, CRD42020170660.

Findings: We identified 5447 records, of which after screening, 15 studies with adequate to strong quality based on QualSyst tool were included. Health, social care workers, or health-trained professionals referred or prescribed blue space activities to individuals with physical, mental, and social health conditions. Patient- (enrolment, engagement, adherence) and programme-related (communication protocol and long-term programme sustainability) implementation principles described successful blue prescription programmes. Patient-related determinants were clear referral information reinforcing patient belief; free blue space activities and logistics; social support; natural environment and biodiversity; skills and values of service providers. Effective communication channels, multi-stakeholder collaboration, financing, and trained link workers sustained implementation of blue prescription programmes.

Interpretation: Findings underscore critical determinant frameworks generating outcomes of successful blue prescription programmes in health, social care, and educational facilities that could be adopted during and post-pandemic.

Funding: Scottish Government Hydro Nation Scholars Programme

Citation: Alejandre, Julius Cesar P. and Chastin, Sebastien and Irvine, Katherine N. and Price, Lesley and Pfleger, Sharon and Helliwell, Rachel and Singleton, Judith and Curran, Samuel and Helwig, Karin, Blue Prescription Programmes in Health and Social Care Settings and Their Implications for Current and Post COVID-19 Pandemic Mental Healthcare: A Systematic Review of Evidence Using Realist Synthesis. The Lancet (2021).

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