key: cord-0309698-v9nb94n1
authors: Alejandre, J. C.; Chastin, S.; Irvine, K.; Georgiou, M.; Khanna, P.; Tieges, Z.; Smith, N.; Chong, Y.-Y.; Onagan, F. C.; Price, L.; Pfleger, S.; Helliwell, R.; Singleton, J.; Curran, S.; Helwig, K.
title: Understanding the contexts and mechanisms of bluespace prescription programmes implemented in health and social care settings: a realist review
date: 2021-10-18
journal: nan
DOI: 10.1101/2021.10.15.21264908
sha: 1cdb7e821238b5d304f150ed9d73a14d46da96ca
doc_id: 309698
cord_uid: v9nb94n1

Abstract Background: Nature-based social prescribing programmes such as "bluespace prescription" may promote public health and health improvement of individuals with long-term conditions. However, there is limited systematically synthesised evidence that investigates the contexts and mechanisms of Bluespace Prescription Programmes (BPPs) that could inform programme theories for policy and practice. Methods: We conducted a realist review by searching six databases for articles published between January 2000 and February 2020, in English, about health and social care professionals providing referral to or prescription of blue space activities with health-related outcomes. We developed themes of contextual factors by analysing the contexts of BPPs. We used these contextual factors to develop programme theories describing the mechanisms of BPP implementation. Our study was registered with PROSPERO (CRD42020170660). Results: Fifteen studies with adequate to strong quality were included from 6,736 records. Service users had improvements on their physical, mental, social health, and environmental knowledge after participating in BPPs referred to or prescribed by health and social care professionals. Patient-related contextual factors were referral information, free equipment and transportation, social support, blue space environments, and skills of service providers. Intervention-related contextual factors were communication, multi-stakeholder collaboration, financing, and adequate service providers. Programme theories on patient enrolment, engagement, adherence, communication protocols, and long-term programme sustainability described the mechanisms of BPP implementation. Conclusion: BPPs could support health and social care services if contextual factors influencing patients and intervention delivery are considered for implementation. Our findings have implications in planning, development, and implementation of similar nature-based social prescribing programmes in health and social care settings. Keywords: sustainable healthcare, social prescribing, blue spaces, bluespace prescriptions

Social prescribing (SP) is a health and social care approach that promotes health by connecting individuals to community-based and non-medical programmes providing physical activity and social support (Teuton, 2015; Husk et al., 2020) . SP is delivered through four referral pathways: 1) signposting; 2) direct referral; 3) link worker, and 4) holistic link worker (Husk et al., 2020) . The process commonly starts with a consultation with a healthcare worker (general practitioner/GP). If GPs give information through leaflets and direct patients to community-based organisations (CBOs) or service providers, this is referred to as signposting.

Direct referral is when GPs contact CBOs and arrange patient enrolment. The link worker pathway comprises GPs connecting patients to link workers who arrange patient enrolment.

The holistic link worker pathway includes a feedback loop between CBOs and link workers (Husk et al., 2020) . Moreover, SP implementation is described by programme theories (Husk et al., 2020; Pawson et al., 2005; Rycroft-Malone et al., 2012) on patient enrolment (first successful referral), engagement (attendance to first session), adherence (maintained participation over time), link worker coordination (communication), and partnerships with CBOs (supportive interventions) (Husk et al., 2020; Bickerdike et al., 2017; Chatterjee et al., 2018; Bertotti et al., 2018) . SP could help motivate individuals to engage in health-promoting behaviours such as physical activity, socialisation, and self-management (Husk et al., 2020; Bickerdike et al., 2017; Bertotti et al., 2018) . It could also help reduce primary healthcare burden by depressurising healthcare professionals' workload through promotion of nonclinical interventions (Bertotti et al., 2018) . enhances these effects (Pouso et al., 2021; Benton et al., 2021; Völker and Kistemann, 2011) .

Contact with blue spaces are associated with health outcomes as illustrated by the 'Blue Space and Health/Wellbeing Model' (White et al., 2020) . Exposure to blue spaces in terms of duration, frequency, and intensity is associated with individuals' contact with blue spaces which could be indirect (window view), incidental (commute along a river path), or intentional (beach visit) (White et al., 2020; Keniger et al., 2013) . Contact with blue spaces improves health outcomes through mitigation (noise abatement), instoration (physical activity), and restoration (stress reduction) pathways (White et al., 2020; Markevych et al., 2017) , resulting in improved mood, self-esteem, physical activity, social interactions, and decrease in mortality (Georgiou et al., 2021; Tieges et al., 2020; Finlay et al., 2015) . These pathways are associated with environmental (type, quality, weather) or personal (age, gender, ethnicity) effect modifiers influencing engagement with blue space activities (BSAs) (White et al., 2020) . The exposureoutcome pathway is catalysed by feedback actions such as quality improvement (societal) and safe access (local) to blue spaces (White et al., 2020) . It also includes personal actions such as nature-based social prescribing (Blue Gyms and prescribing therapeutic BSAs) that targets individuals' motivations to have contact with blue spaces (White et al., 2020; Depledge and Bird, 2009; Britton et al., 2020) .

The knowledge base on social prescribing falls behind the fast growth and roll-out of social prescribing programmes on the ground (Husk et al., 2020) . There is limited understanding on the contextual implementation of specific types of SP (Husk et al., 2020) including nature-based social prescribing programmes the utilise blue spaces. There is also an evidence gap on the effectiveness (Bickerdike et al., 2017; Chatterjee et al., 2018; Pescheny et al., 2018) , suitability (Pilkington et al., 2017) , referral processes (Chatterjee et al., 2018) , and factors influencing SP uptake (Britton et al., 2020; Buckley and Brough, 2017) . Additionally, existing systematic reviews on social prescribing mainly focused on general and greenspace programmes (Husk et al., 2020; Bertotti et al., 2018; Masterton et al., 2020) . Considering these gaps and the growing evidence on the health benefits of blue spaces, we conducted a realist review to investigate the contexts and mechanisms of implementing Bluespace Prescription Programmes (BPPs) delivered to people with health conditions. We used realist synthesis (Pawson et al., 2005) to investigate the contextual factors influencing BPP implementation (Pawson et al., 2005; Rycroft-Malone et al., 2012) and used these contextual factors to develop programme theories describing the mechanisms of BPP implementation.

Our systematic realist review followed the PRISMA guidelines (Page et al., 2021) and realist reviews (Berg, 2016) . A realist review is way of evidence synthesis that provides explanation why interventions work or do not work in certain circumstances by interrogating the contextual complexities and mechanisms of implementing such interventions (Rycroft-Malone, 2012) . The steps of a realist review are: 1) identifying the question; 2) clarifying the purpose of the review; 3) finding and articulating the initial programme theories; 4) searching for evidence; 5) appraising the evidence; 6) extracting the data; 7) synthesising findings; and 8) drawing conclusions and recommendations (Berg, 2016) . and social care facilities and with health-related outcomes. We included case reports, qualitative, case-control, cohort, pre-post intervention studies, non-randomised, and randomised controlled trials published in English. We limited the publication period from January 2000 to February 2020 since research on the health benefits of blue spaces emerged in the early 2000s (Völker and Kistemann, 2011; Britton et al., 2020) . We excluded studies where non-health or non-social care workers referred BSAs to participants through advertisements and studies in which BSAs were not conducted in natural water environments.

Our search and data analysis were guided by the following initial social prescribing programme theories (PTs):

Initial PT1: If referral is presented in an acceptable manner, it is compatible with the patient's needs and expectations, and the patient believes that it will improve their condition, then they may enrol (enrolment) (Husk et al., 2020) .

Initial PT2: If transportation is provided making the socially prescribed activity accessible to the patient, then they will engage (engagement) (Husk et al., 2020) .

Initial PT3: If the service providers are skilled and there are improvements on patient's condition, then they are more likely to keep attending (adherence) (Husk et al., 2020) . Initial PT4: If there are link workers facilitating delivery of social prescriptions and liaising with health and social care facilities and third sector organisations, then the referral uptake will be successful (link worker coordination) (Husk et al., 2020; Bickerdike et al., 2017; Chatterjee et al., 2018; Bertotti et al., 2018) . is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted October 18, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 Initial PT5: If partnership between health and social care facilities and community-based organisations is financially supported, then the delivery of social prescribing programmes will be sustained (partnership with CBOs) (Bickerdike et al., 2017; Chatterjee et al., 2018; Bertotti et al., 2018) .

We searched PubMed, Web of Science, PsycInfo, MEDLINE, Scopus, and CINAHL using keyword strings (Appendix 1) and conducted snowball search by screening the reference lists of included studies (Schardt et al., 2007; Jalali and Wohlin, 2012) . Records were uploaded, de-duplicated, and screened using Rayyan QCRI (Ouzzani et al., 2016) . Title, abstract (JA, KH, SCh, and 17 researchers), and full-text screenings (JA-KH, JA-SCh) were independently conducted in pairs. KNI resolved conflicting decisions.

Included studies were categorised based on their methodological approaches to suit the QualSyst tools (Kmet et al., 2004) . Quality of studies was independently assessed in pairs (JA-KH, JA-SCh, JA-KNI). Conflicting ratings were reconciled by one-to-one discussion. We adopted strong (>0·80), good (0·71-0·79), adequate (0·51-0·70), and limited (<0·50) quality thresholds for quantitative papers (Lee et al., 2008) and used adequate (>0·55) and low (<0·54) for qualitative studies (Maharaj and Harding, 2016) . Quantitative and qualitative components of mixed method studies were assessed separately (Kmet et al., 2004; Maharaj and Harding, 2016) .

JA electronically extracted the names of authors, publication year, methodological approaches, participants, location, prescriber/referrers, referral pathways, facilities, intervention format, BSA type, facilitators, barriers, timescale/duration, dose/frequency, health . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

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The copyright holder for this this version posted October 18, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 conditions, and outcomes. Extracted data were inputted in a bespoke data collection form using Microsoft Excel.

We employed realist synthesis to analyse and synthesise extracted data (Pawson et al., 2005; Rycroft-Malone et al., 2012) about the facilitators, barriers, and descriptions of BPPs and how were they implemented. Using hybrid coding in NVivo 12 (Fereday and Muir-Cochrane, 2006) , JA developed themes of contextual factors associated with BPP implementation. These contextual factors were used to develop the context-mechanismoutcome configurations elaborated by 'if-then' statements for the development of programme theories describing the mechanism of BPP implementation (Pawson et al., 2005; Rycroft-Malone et al., 2012; Pawson and Bellamy, 2006; Thomas and Harden, 2008) . We developed programme theories for BPP implementation by refining the five initial social prescribing programme theories on patient enrolment, engagement, adherence, link worker coordination, and partnership with CBOs (Husk et al., 2020; Rycroft-Malone et al., 2012; Bickerdike et al., 2017; Chatterjee et al., 2018; Bertotti et al., 2018; Pawson and Bellamy, 2006) . The developed themes of contextual factors and programme theories for BPP implementation were consulted and validated by JA in a series of virtual meetings and presentations with KH, KNI, SCh; members of the research advisory team (RH, SP, SCu); and other stakeholders from the Hydro Nation Forum, the policy governing body of the Hydro Nation Scholars Programme, which is the funding organisation of this research. The themes of contextual factors and programme theories were refined and finalised based on the comments from these consultations.

Our study was registered with PROSPERO (CRD42020170660).

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We collected 6,736 records from the database and snowball search (Figure 1 ). We excluded 3,814 duplicates before screening and 2,483 reports due to irrelevancy at title and abstract screening stage. We excluded 136 and 288 reports from database and citation searches, respectively, at full-text screening stage (Appendix 2).

We included 15 studies. Four quantitative studies had strong (Razani et al., 2018; Rogers et al., 2014; Vella et al., 2013; Maund et al., 2019) , two had good (Godfrey et al., 2015; James et al., 2017) , and three had adequate quality (de Matos et al., 2017; Hignett et al., 2017; Cavanaugh and Rademacher, 2014) . Seven qualitative studies had adequate quality (Maund et al., 2019; White et al., 2016; Lopes, 2015; Bennett et al., 2014; Dustin et al., 2011; Fleischmann et al., 2011; Mowatt and Bennett, 2011) . Quantitative papers were downgraded due to . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

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The copyright holder for this this version posted October 18, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 strategies on controlling confounders and reporting variance estimates. Qualitative papers were downgraded because of data collection, verification, and reflexivity procedures (Table 1) ( Agarwal et al., 2013) .

Since realist reviews require contextual configurations to describe mechanisms of programme implementation, we did not exclude studies which had below average quality results (Pawson et al., 2005; Rycroft-Malone et al., 2012) .

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Eight studies were conducted in the USA (Razani et al., 2018; de Matos et al., 2017; Bennett et al., 2014; Rogers et al., 2014; Vella et al., 2013; Dustin et al., 2011; Fleischmann et al., 2011; Mowatt and Bennett, 2011) , five studies in the UK (Maund et al., 2019; Godfrey et al., 2015; Hignett et al., 2017; Cavanaugh and Rademacher, 2014; White et al., 2016) , and two in Portugal (de Matos et al., 2017; Lopes, 2015) (Table 2 ). Eight hundred three (803) service users aged between 2 and 85 years participated in the studies, of which 197 were veterans aged between 21 and 50 years. BSAs were referred to or prescribed by health, social care, and healthtrained teachers. The prescription or referral was provided in healthcare (Razani et al., 2018; Rogers et al., 2014; Vella et al., 2013; Godfrey et al., 2015; James et al., 2017; White et al., 2016; Bennett et al., 2014; Dustin et al., 2011; Fleischmann et al., 2011; Mowatt and Bennett, 2011), social care (Maund et al., 2019; Godfrey et al., 2015; James et al., 2017; de Matos et al., 2017; White et al., 2016) , and specialised educational facilities (Godfrey et al., 2015; Hignett et al., 2017; Cavanaugh and Rademacher, 2014) using SP referral pathways (Husk et al., 2020) .

In one study, all three facilities provided the referral or prescription (Godfrey et al., 2015) .

Ten studies were in military hospitals, GP practices, paediatric, and rehabilitation clinics (Razani et al., 2018; Rogers et al., 2014; Vella et al., 2013; Godfrey et al., 2015; James et al., 2017; White et al., 2016; Bennett et al., 2014; Dustin et al., 2011; Fleischmann et al., 2011; Mowatt and Bennett, 2011) . Veterans with hearing impairment, anxiety, depression, TBI, and PTSD were prescribed with fly-fishing by recreational therapists through signposting or direct referral (Vella et al., 2013; Bennett et al., 2014; Mowatt and Bennett, 2011) . Veterans with PTSD were directly referred to a combination of running, boating, kayaking, and paddling by a team of recreational therapist, nurse, psychologist, and social worker (Dustin et al., 2011) .

Some veterans with PTSD (Rogers et al., 2014) and children who were obese, had sensory . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

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The copyright holder for this this version posted October 18, 2021. ; https://doi.org/10.1101 .10.15.21264908 doi: medRxiv preprint problems, depression, anxiety, and PTSD (Godfrey et al., 2015 were prescribed with surfing by physicians (Rogers et al., 2014) or a team of GPs, nurses, and psychologists (Godfrey et al., 2015) through direct referral or holistic link worker. Socioeconomically deprived and ethnically diverse children with obesity, loneliness, and poor mental health were prescribed with play at a beach (Razani et al., 2018; James et al., 2017) by pediatricians using holistic link worker (James et al., 2017) or a combination of signposting and link worker pathways (Razani et al., 2018) . Patients who experienced substance abuse were directly referred to sailing by substance abuse specialists (White et al., 2016) . Participants had improvements in mood and emotions (Razani et al., 2018; White et al., 2016) , better sleep quality (Vella et al., 2013) , selfefficacy (White et al., 2016; Bennett et al., 2014; Mowatt and Bennett, 2011) , reduced substance intake (White et al., 2016; Dustin et al., 2011) , decreased stress and PTSD symptomatology (Rogers et al., 2014; Vella et al., 2013) , and increased relaxation (Razani et al., 2018; Vella et al., 2013; Mowatt and Bennett, 2011) . Some felt less depressed, anxious, and lonely (Razani et al., 2018) whilst others felt improvements in their mobility (Fleischmann et al., 2011) , physical activity (Razani et al., 2018; James et al., 2017) , and body weight (James et al., 2017) . Others had improved social skills and increased contact with nature (Razani et al., 2018) .

Four studies were in social care institution, foster care homes, and community wellbeing centre (Maund et al., 2019; Godfrey et al., 2015; de Matos et al., 2017; Lopes, 2015) .

Young people and adults with mobility and sensory impairment (Lopes, 2015) , psychosocial problems, anxiety, and depression were directly referred to surfing by either a team of social worker and therapist (Lopes, 2015) ; social worker and adolescent educators (de Matos et al., 2017) ; or social child support specialist (Godfrey et al., 2015; de Matos et al., 2017; Lopes, 2015) . Adults and elderly patients with anxiety and depression were referred to guided river . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

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The copyright holder for this this version posted October 18, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 walks, bird and otter watching, and canoeing by mental health workers through a link worker pathway (Maund et al., 2019) . Participants improved daily functioning, self-esteem (Godfrey et al., 2015) , fitness, physical activity (Godfrey et al., 2015; de Matos et al., 2017) , mental and emotional wellbeing (Godfrey et al., 2015; de Matos et al., 2017) , interpersonal competencies (Godfrey et al., 2015; de Matos et al., 2017; Lopes, 2015) , and environmental knowledge (Lopes, 2015) .

Three studies were in specialised educational facilities and pupil referral units (Godfrey et al., 2015; Hignett et al., 2017; Cavanaugh and Rademacher, 2014) . Young people with behavioural problems, ASD, depression, anxiety, and sensory problems were referred to surfing by psychologists, health-trained educators, or social and child support specialists using direct referral or holistic link worker pathways (Godfrey et al., 2015; Hignett et al., 2017; Cavanaugh and Rademacher, 2014) . Participants had improvements in their attitude (Hignett is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted October 18, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 Alcohol and drug use

Self-insight, perseverance, and inner strength; social skills; increased confidence; abstinence to substance abuse; and positive future framing PTSD-post traumatic stress disorder; TBI-traumatic brain injury; ASD-autism spectrum disorder; GP-general practitioner

The patterns of contextual factors (CFs) associated with the implementation of BPPs are either patient-related or programme-related. In total, we identified 20 patient and programme-related contextual factors (Table 3) (Husk et al., 2020; Bickerdike et al., 2017; Chatterjee et al., 2018; Bertotti et al., 2018) .

People with physical and/or mental health conditions seek health and social care (some were accompanied by their carers)

If partnership between health and social care facilities and community-based organisations is financially supported, then the delivery of social prescribing programmes will be sustained (Bickerdike et al., 2017; Chatterjee et al., 2018; Bertotti et al., 2018) . 

Some service users were optimistic towards BPPs, whilst others had apprehensions (Rogers et al., 2014; Lopes, 2015) . The novelty of BPPs, unfamiliar environments, and patient's lack of experience generated fear and anxiety (Lopes, 2015) . Knowledge sharing through counselling using information about the type, structure, and benefits of BPPs, coupled with maps, pedometers, and activity guides informed patients' decisions to enrol (Razani et al., 2018; James et al., 2017) . Patients' enrolment was guided by written prescriptions and initiated contact by link workers (James et al., 2017) . Some healthcare workers raised concerns about filling out paper prescriptions being time-consuming and suggested integrating prescriptions of BSAs in the electronic prescribing system (James et al., 2017). Structured BSAs followed programmes of activities (Rogers et al., 2014; Vella et al., 2013; Maund et al., 2019; Godfrey et al., 2015; James et al., 2017; de Matos et al., 2017; Hignett et al., 2017; Bennett et al., 2014) whilst others were provided in an unstructured manner (Razani et al., 2018; James et al., 2017; Mowatt and Bennett, 2011) . BPPs were provided as stay-in which required free meals and lodging (Vella et al., 2013; Hignett et al., 2017; Bennett et al., 2014; Dustin et al., 2011; Mowatt and Bennett, 2011) , or stay-out (Razani et al., 2018; Rogers et al., 2014; Maund et al., 2019; Godfrey et al., 2015; James et al., 2017; White et al., 2016; Lopes, 2015; Fleischmann et al., 2011) . is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted October 18, 2021. ; https://doi.org/10. 1101 Final Programme Theory 2: If service users are provided with free logistics, equipment, and transportation to access a socially supportive and client-centred blue space activity and environment, then they may engage.

Patient engagement was associated with patient preference, skills, and psychosocial fulfilment after initial sessions (Godfrey et al., 2015; Hignett et al., 2017) . Consulting people with disabilities about the design of safety and supportive infrastructure making the environment accessible and adaptive to their needs enabled engagement (Lopes, 2015; Bennett et al., 2014) .

Service users had strong interests in BPPs because these were free (James et al., 2017).

However, some BPPs (surfing, canoeing, kayaking) required costly equipment, especially for economically deprived service users. Providing equipment, transportation, and camping fees encouraged engagement especially for activities in distant locations (Razani et al., 2018; Rogers et al., 2014; Vella et al., 2013; Maund et al., 2019; Godfrey et al., 2015; James et al., 2017; Bennett et al., 2014) . Travelling in groups to new places also relieved anxious participants (Maund et al., 2019) . Wildlife and natural blue space or water environments . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

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The copyright holder for this this version posted October 18, 2021. ; https://doi.org/10.1101/2021.10.15.21264908 doi: medRxiv preprint facilitated relaxing experiences, distraction, engagement of human senses, self-strength, and acclimatisation (Vella et al., 2013; Maund et al., 2019; White et al., 2016; Bennett et al., 2014; Dustin et al., 2011) . Weather was an environmental effect modifier (White et al., 2020; Hignett et al., 2017) .

Final Programme Theory 3: If service users experience social support and health improvement through blue space activities delivered by knowledgeable and skilled service providers, then they may adhere.

Skilled service providers ensured standardised programme delivery using regularly evaluated guidelines (Hignett et al., 2017) . Service providers were also trained on working with clients with disabilities (proper use of surfing boards for children with ASD) (Cavanaugh and Rademacher, 2014; Lopes, 2015) . Positive values of service providers were appreciated by participants (Razani et al., 2018; Rogers et al., 2014; Maund et al., 2019; Hignett et al., 2017; White et al., 2016; Lopes, 2015; Bennett et al., 2014) . Encouragement, enthusiasm, and positive reinforcement through constructive observations created a friendly atmosphere and empowered participants to explore new activities (Razani et al., 2018; Rogers et al., 2014;  . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint (Razani et al., 2018) . This was perceived by clients as genuine care and willingness to help (Rogers et al., 2014) . Improvements in environmental awareness and knowledge (Hignett et al., 2017; Lopes, 2015) , self-esteem (Rogers et al., 2014; Vella et al., 2013; Maund et al., 2019; Godfrey et al., 2015; Cavanaugh and Rademacher, 2014; White et al., 2016; Lopes, 2015) , mental health (Razani et al., 2018; Rogers et al., 2014; Vella et al., 2013; Maund et al., is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted October 18, 2021. ; https://doi.org/10.1101/2021.10.15.21264908 doi: medRxiv preprint communications provided feedback channels to discuss patients' health conditions (James et al., 2017) . Champions or advocates of BPPs in health and social care settings acted as programme leads and maintained coordination and programme visibility in health and social care facilities (James et al., 2017) . Inclusive communication between health and social care workers, patients, and service providers facilitated by link workers and considered patientpreferred mechanisms and related attributes (Razani et al., 2018; James et al., 2017; Mowatt and Bennett, 2011) were also associated with health improvements (Rogers et al., 2014) .

Communications between patients and carers provided spaces for awareness raising and socialisation (Lopes, 2015) . Socialisation between patients through interest-based grouping and matching also contributed to self-improvement (Razani et al., 2018; Rogers et al., 2014; James et al., 2017; de Matos et al., 2017; Lopes, 2015; Mowatt and Bennett, 2011) . Surfing was perceived as a beneficial health and social care intervention by health sector stakeholders, general public, and policymakers (Lopes, 2015) . The health and social benefits of BPPs convinced funders, councils, and schools to support the programme (Hignett is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

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The copyright holder for this this version posted October 18, 2021. ; https://doi.org/10.1101/2021.10.15.21264908 doi: medRxiv preprint swimming (van Tulleken et al., 2018; Huttunen et al., 2004) , and cycling near blue spaces (Roberts et al., 2018; Mackay and Neill, 2010; Pretty et al., 2007) is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

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The copyright holder for this this version posted October 18, 2021. ; https://doi.org/10.1101/2021.10.15.21264908 doi: medRxiv preprint tackling the mental health epidemic compounded by lockdowns and social isolation will not work as we transition to a 'better normal' after the COVID-19 pandemic. Approaches should include strong collaboration between health, environment, urban planning, third sector, amongst others to share more resources toward integrating BPPs in primary healthcare with appropriate environmental-economic accounting (United Nations-Food and Agriculture Organisation, European Union, Organisation for Economic Co-operation and Development, and World Bank Group, 2014). These collaborations and resources should ensure that contextual factors influencing enrolment, engagement, and adherence to BPPs are addressed along with effective communication and programme continuity.

We did not include grey literature and we only focused on BPPs prescribed in health and social care settings. Reports on BPPs in other facilities which are unpublished or not peerreviewed could provide more information about other contextual factors and mechanisms of implementation. There were also limitations on the quality of individual studies. Many quantitative studies had quality issues on the strategies for controlling confounders and reporting variance estimates, whilst qualitative papers had issues on strategies for data collection, verification, and reflexivity.

Certain limitations are also anchored in employing a realist review. Realist synthesis is interpretative and subjective in nature (Masterton et al., 2020) , especially in interpreting how contextual factors inform the development of programme theories. We ensured to remove this subjectivity bias by validating the results of the analysis during a series of stakeholders' meetings and consultation with a multidisciplinary set of co-authors that informed the finalisation of the programme theories for BPP implementation. We were also limited on the available information about the contexts and mechanisms of each bluespace prescription . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

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The copyright holder for this this version posted October 18, 2021. ; https://doi.org/10.1101/2021.10.15.21264908 doi: medRxiv preprint programme in each study, especially when there is no detailed information about the intervention.

Geographical homogeneity was also a limitation. Some studies had participants from different ethnicities and sociodemographic backgrounds, but all studies were conducted in the Global North. Nonetheless, our study offers pragmatic recommendations for policy development supporting BPP implementation in different contexts. In the context of Global South countries, it is important to be cognisant of the political and social constructs surrounding blue space accessibility and the readiness of health systems for large-scale BPP implementation. Nevertheless, universal healthcare reforms in developing countries could leverage the groundwork on BPP integration in health promotion strategies to deliver the vision of healthy, liveable, and sustainable environments for all.

We suggest the conduct of intervention studies examining the intersection of BPPs, physical, and mental health as cost-effective programmes. Implementation research and pilot studies are needed to establish the 'proof of concept' of BPPs as a viable public health intervention for scaling-up and institutionalisation in national and local health and social care systems. Causation and long-term implications of BPPs on population health, healthcare delivery, and the environment should be investigated through randomised controlled trials and longitudinal studies.

In summary, this realist review demonstrates that health, social care, and health-trained professionals working in health, social care, and specialised educational facilities provided referral to or prescription of BSAs. Service users of BPPs were veterans, adults, older people, and children who experienced physical and mental health conditions, social isolation, . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

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The copyright holder for this this version posted October 18, 2021. ; https://doi.org/10.1101/2021.10.15.21264908 doi: medRxiv preprint addiction, and/or behavioural issues. BPPs improved the physical, mental, and social health, as well as environmental knowledge of service users. The implementation of BPPs is associated with 20 unique patient and programme-related contextual factors on patient needs and characteristics, accessibility, compatibility, social and blue space environments, skills and values of service providers, patient health improvement, communication, multi-stakeholder partnership, financing, and policy. The configurations of these contextual factors informed the refinement of pre-existing social prescribing programme theories for the development of programme theories of BPPs. If implementation of accessible and patient centred BPPs is sustainably supported by multi-stakeholder partnerships, funding, policy interventions, effective communication protocols, skilled health and social care workers and service providers, then service users are more likely to enrol in, engage with, adhere to, and have improvements to health and environmental knowledge after the programme. Contextual factors and programme theories of investigated BPPs could inform development and implementation of similar nature-based social prescribing programmes in other contexts. BPPs could be an additional health and social care service that promote exposure to blue spaces for public health promotion and health improvement of individuals with multiple and long-term health conditions. With inaccessibility, long waiting list, adverse effects, incompatibility, cost, and environmental impacts of conventional healthcare, integrating patient centred and sustainable BPPs into a suite of healthcare services is beneficial.

Scholars Programme.

We declare no competing interests. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted October 18, 2021. ; https://doi.org/10.1101/2021.10.15.21264908 doi: medRxiv preprint

Beginning three months after publication until September 2023, database records and extracted data from included studies will be electronically shared to researchers who provide a methodologically sound proposal sent to the corresponding author. The request will be approved by the corresponding author and the director of studies.

The corresponding author acknowledges funding from the Hydro Nation Scholars Programme is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted October 18, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted October 18, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 Graham AL, Cooke SJ. The effects of noise disturbance from various recreational boating activities common to inland waters on the cardiac physiology of a freshwater fish, the largemouth bass (Micropterus salmoides). Aquat Conserv 2008; 18 (7) is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

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The copyright holder for this this version posted October 18, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted October 18, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted October 18, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted October 18, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted October 18, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

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The copyright holder for this this version posted October 18, 2021. ;

A Large Cross-Sectional Study of Health Attitudes, Knowledge, Behaviour and Risks in the Post-War Croatian Population (The First Croatian Health Project*) Wrong intervention S8

A mixed method Investigation into the perception and measurement of success in the Healthwise Exercise Referral Scheme Wrong intervention S9

A pragmatic randomised controlled trial of hydrotherapy and land exercises on overall well being and quality of life in rheumatoid arthritis Wrong intervention S10

A randomized and controlled trial of hydrotherapy in rheumatoid arthritis Wrong intervention S11

A randomized controlled graded exercise trial for chronic fatigue syndrome: outcomes and mechanisms of change Wrong intervention S12

A Randomized Controlled Trial of Aquatic and Land-Based Exercise in Patients with Knee Osteoarthritis Wrong intervention S13

A repeated measures experiment of green exercise to improve self-esteem in UK school children Wrong context S14

A repeated measures experiment of school playing environment to increase physical activity and enhance self-esteem in UK school children Wrong context S15 Accessibility and use of urban green spaces, and cardiovascular health: Findings from a kaunas cohort study Wrong intervention S16

Accounting for the daily locations visited in the study of the built environment correlates of recreational walking (the RECORD Cohort Study) Wrong context S17 Active commuting to school, weight status, and cardiometabolic risk in children from rural areas: The Cuenca study Wrong intervention S18

Acute effects of walking in forest environments on cardiovascular and metabolic parameters Wrong context S20

Adding natural areas to social indicators of intra-urban health inequalities among children: A case study from Berlin, Germany Wrong intervention S21

Aerobic exercise in water versus walking on land: effects on indices of fat reduction and weight loss of obese women Wrong intervention S22

An interpretative phenomenological examination of psychosocial changes among breast cancer survivors in their first season of dragon boating Wrong context S23 Aquatic progressions. The buoyancy of water facilitates balance and gait Not retrieved S24

Assessing the restorative potential of contemporary urban environment(s): beyond the nature versus urban dichotomy Wrong context S25

Associations between environmental value orien-tations and landscape preferences Wrong intervention S26

Associations between green space and health in english cities: An ecological, cross-sectional study Wrong intervention S27

Associations between neighbourhood greenness and asthma in preschool children in Kaunas, Lithuania: a case-control study Wrong intervention S28

Associations between residential greenness and birth outcomes across Texas Wrong intervention S29

Associations between urban greenspace and health-related quality of life in children Wrong intervention S30

Associations of location and perceived environmental attributes with walking in neighborhoods Wrong context S31

Associations of neighbourhood greenness with physical and mental health: Do walking, social coherence and local social interaction explain the relationships? Wrong intervention S32

At Effect of aquatic respiratory exercise-based program in patients with fibromyalgia Wrong intervention S63

Effect of exposure to natural environment on health inequalities: An observational population study Wrong intervention S64

Effect of forest bathing on physiological and psychological responses in young Japanese male subjects Wrong intervention S65

Effect of forest walking on autonomic nervous system activity in middle-aged hypertensive individuals: A pilot study Wrong intervention S66

Effect of park prescriptions with and without group visits to parks on stress reduction in low-income parents: SHINE randomized trial Wrong intervention S67

Effectiveness of low-intensity aquatic exercise on COPD: a randomized clinical trial Wrong intervention S68

Effects of a tall ship sail training experience on adolescents' self-concept Wrong intervention S69

Effects of aquatic resistance training on health and fitness in post-menopausal women Wrong context S70

Effects of aquatic resistance training on neuromuscular performance in healthy women Wrong intervention S71

Effects of changing exposure to neighbourhood greenness on general and mental health: A longitudinal study Wrong intervention S72

Effects of forest bathing on cardiovascular and metabolic parameters in middle-aged males Wrong context S73

Effects of pool-based exercise in fibromyalgia symptomatology and sleep quality: a prospective randomised comparison between stretching and Ai Chi Wrong intervention S74

Effects of short-term forest bathing on human health in a broad-leaved evergreen forest in Zhejiang Province, China Wrong context S77

Effects of woodland walking on salivary stress markers cortisol and chromogranin a Wrong intervention S78

Energy expenditure on recreational visits to different natural environments Wrong context S79 Enhancing resilience in youth through a 10-day developmental voyage Wrong context S80 Environmental preference and restoration: (how) are they related? Wrong context S81 Epidemiology of hypertension in Yemen: effects of urbanization and geographical area Wrong intervention S82

Ethnic differences in the effect of environmental stressors on blood pressure and hypertension in The Netherlands Wrong intervention S85

Exploring pathways linking greenspace to health: theoretical and methodological guidance Wrong intervention S86

Exploring the relationship between childhood obesity and proximity to the coast: A rural/urban perspective Wrong context S87

Exposure to greenness and mortality in a nationwide prospective cohort study of women Wrong intervention S127

In the eye of the dragon: women's experience of breast cancer and the occupation of dragon boat racing Wrong context S128

Increases in global and domain specific self-esteem following a 10 day developmental voyage Wrong context S129

Influence of a medium-impact aquaerobic program on health-related quality of life and fitness level in healthy adult females Wrong intervention S130

Influence of aquariums on resident behavior and staff satisfaction in dementia units Wrong intervention S131

Influence of forest therapy on cardiovascular relaxation in young adults Wrong intervention S132

Influence of green spaces on environmental satisfaction and physiological status of urban residents Wrong intervention S133

Influence of immersion in water on muscle function and breathing pattern in patients with severe diaphragm weakness Wrong intervention S134

Is neighborhood green space associated with a lower risk of type 2 diabetes evidence from 267,072 Australians Wrong intervention S135

Land-based versus pool-based exercise for people awaiting joint replacement surgery of the hip or knee: results of a randomized controlled trial Wrong intervention S136

Landscape as playscape: The effects of natural environments on children's play and motor development Wrong intervention S137

Landscape mirror: the attractiveness of reflecting water Wrong context S138

Linking green space to health: A comparative study of two urban neighbourhoods in Ghent, Belgium Wrong intervention S139

Linking stroke mortality with air pollution, income, and greenness in northwest Florida: An ecological geographical study Wrong intervention S140

Living environment matters: Relationships between neighborhood characteristics and health of the residents in a dutch municipality Wrong intervention S141

Living life to the limits: dragon boaters and breast cancer Wrong context S142

Mapping distance-decay of cardiorespiratory disease risk related to neighborhood environments Wrong intervention S143 Mitigating stress and supporting health in deprived urban communities: The importance of green space and the social environment Wrong intervention S144

Modification of heat-related mortality in an elderly urban population by vegetation (urban green) and proximity to water (urban blue): Evidence from Lisbon, Portugal Wrong intervention S145

Morbidity is related to a green living environment Wrong intervention S146

More green space is linked to less stress in deprived communities: Evidence from salivary cortisol patterns Wrong intervention S147

Multiple dimensions of residential environments, neighborhood experiences, and jogging behavior in the RECORD Study Wrong intervention S148

Multiple health benefits of urban tree canopy: The mounting evidence for a green prescription Duplicated from database search S149

Natural environments-Healthy environments? An exploratory analysis of the relationship between greenspace and health Wrong intervention S151

Natural outdoor environments and mental and physical health: Relationships and mechanisms Wrong research design S152 Nature and death: An individual level analysis of the relationship between biophilic environments and premature mortality in Florida Wrong research design S153

Neighborhood and healthy aging in a german city: Distances to green space and senior service centers and their associations with physical constitution, disability, and health-related quality of life Wrong research design S154 Neighborhood greenness and chronic health conditions in medicare beneficiaries Wrong intervention S155

Neighborhood greenspace and health in a large urban center Wrong intervention S156

Neighbourhood access to open spaces and the physical activity of residents: a national study Wrong intervention S157

Neighbourhood blue space, health and wellbeing: the mediating role of different types of physical activity Wrong context S158 Neighbourhood green space and the odds of having skin cancer: Multilevel evidence of survey data from 267 072 Australians Wrong intervention S159

Neighbourhood green space, physical function and participation in physical activities among elderly men: The Caerphilly prospective study Wrong intervention S160

Nine vignettes exploring dragon boat racing for breast cancer survivors Wrong context S161

No association between the frequency of forest walking and blood pressure levels or the prevalence of hypertension in a cross-sectional study of a japanese population Wrong intervention S162

No wilderness for immigrants: Cultural differences in images of nature and landscape preferences Wrong intervention S163

Noticing nature: individual and social benefits of a two-week intervention Wrong context S164 Nurse led, home based self help treatment for patients in primary care with chronic fatigue syndrome: randomised controlled trial Wrong intervention S165

Objective versus subjective assessments of environmental quality of standing and running waters in a large city Wrong context S166 Objectively measured residential environment and self-reported health: A multilevel analysis of uk census data Wrong intervention S167

Opportunities to explore nature and wellbeing through kayaking for inner-city youth Wrong context S168

Parks and green areas are associated with decreased risk for hyperlipidemia Wrong intervention S170

Perceived environment attributes, residential location, and walking for particular purposes Wrong intervention S171

Perceived green qualities were associated with neighborhood satisfaction, physical activity, and general health: Results from a cross-sectional study in suburban and rural scania, southern Sweden Wrong intervention S172 Perception and evaluation of water in landscape: use of Photo-Projective Method to compare child and adult residents' perceptions of a Japanese river environment Wrong context S173

Perceptions of urban stream corridors within the greenway system of Sapporo, Japan Wrong context S174

Personal, social and environmental determinants of educational inequalities in walking: a multilevel study Wrong intervention S175

Physical activity as a possible mechanism behind the relationship between green space and health: A multilevel analysis Wrong intervention S176

Physical activity for osteoarthritis management: a randomized controlled clinical trial evaluating hydrotherapy or Tai Chi classes. Arthritis & Rheumatism Wrong intervention S177

Physiological and psychological effects of a walk in urban parks in fall Wrong context S178

Physiological and psychological effects of forest therapy on middle-aged males with high-normal blood pressure Wrong intervention S179

Physiological and psychological effects of viewing urban forest landscapes assessed by multiple measurements Wrong intervention S180

Physiological and psychological effects of walking on young males in urban parks in winter Wrong intervention S181

Physiological effects of forest recreation in a young conifer forest in Hinokage Town, Japan Wrong context S182

Physiological effects of shinrin-yoku (taking in the atmosphere of the forest) in an old-growth broadleaf forest in Yamagata Prefecture, Japan Wrong context S183

Physiological effects of shinrin-yoku (taking in the atmosphere of the forest)-using salivary cortisol and cerebral activity as indicators Wrong context S184

Physiologically relaxing effect of a hospital rooftop forest on older women requiring care Wrong intervention S185

Planning for health: A community-based spatial analysis of park availability and chronic disease across the lifespan Wrong intervention S186

Pool exercise for patients with fibromyalgia or chronic widespread pain: a randomized controlled trial and subgroup analyses Wrong intervention S188 Prevalence and regional disparities in abdominal obesity among children and adolescents in Shandong, China, surveyed in 2010 Wrong intervention S189

Prevalence of obesity, abdominal obesity and associated factors in hypertensive adults aged 45-75 years Wrong intervention S190

Promoting physical activity in South Asian Muslim women through" exercise on prescription" Wrong intervention S191

Promoting resilience and wellbeing through an outdoor intervention designed for Aboriginal adolescents. Wrong context S192 Psychosocial aspects of scuba diving for people with physical disabilities: an occupational science perspective Wrong context S193 Psychosocial experiences of breast cancer survivors involved in a dragon boat program: exploring links to positive psychological growth Wrong context S194

Public parks and wellbeing in urban areas of the united states Wrong research design S195

Quality of life and physical performance in land-and water-based pulmonary rehabilitation Wrong intervention S196

Randomised controlled trial of graded exercise in chronic fatigue syndrome Wrong intervention S197

Randomised controlled trial of patient education to encourage graded exercise in chronic fatigue syndrome Wrong intervention S198

Rating scale measures of restorative components of environments Wrong research design S200

Recreational visits to marine and coastal environments in England: Where, what, who, why, and when? Wrong context S201

Refining of asthma prevalence spatial distribution and visualization of outdoor environment factors using gis and its application for identification of mutual associations Wrong intervention S202

Regional pattern of cardiovascular risk burden in Croatia Wrong intervention S203

Relationship between built environment, physical activity, adiposity, and health in adults aged 46-80 in Shanghai, China Wrong intervention 50 S204 Relationships between exposure to urban green spaces, physical activity and self-rated health Wrong intervention S205

Relationships between visual landscape preferences and map-based indicators of landscape structure Wrong intervention S206

Residential distance and recreational visits to coastal and inland blue spaces in eighteen countries Wrong context S207 Residential exposure to visible blue space (but not green space) associated with lower psychological distress in a capital city Wrong research design S208

Residential greenness and birth outcomes: Evaluating the influence of spatially correlated built-environment factors Wrong intervention S209

Residential greenness and blood lipids in children: A longitudinal analysis in giniplus and lisaplus Wrong intervention S210

Residential greenness and risk of prostate cancer: A case-control study in Montreal, Canada Wrong intervention S211

Residential neighbourhood greenspace is associated with reduced risk of incident diabetes in older people: A prospective cohort study Wrong intervention S212

Ride every challenge: the impact of surfing on 100 young people facing personal and emotional challenges Wrong context S213

Risks and benefits of green spaces for children: A cross-sectional study of associations with sedentary behavior, obesity, asthma, and allergy Wrong research design S214

Role of physical activity in the relationship between urban green space and health Wrong intervention S215

Sail training as education: More than mere adventure Wrong context S216

Sleep insufficiency and the natural environment: Results from the us behavioral risk factor surveillance system survey Wrong intervention S217

Social contacts as a possible mechanism behind the relation between green space and health Wrong context S218 Spiritual care of cancer patients by integrated medicine in urban green space: A pilot study Wrong intervention S219

Spiritual therapeutic landscapes and healing: a case study of St. Anne de Beaupre, Quebec, Canada Wrong intervention S220

Studies on the amounts of serum hydroperoxide, mmp-3, urinary 8-ohdg, and salivary iga in rheumatoid arthritis patients who experienced shinrin-yoku (forest-air bathing and walking)

Wrong intervention

Associations between neighborhood open space attributes and quality of life for older people in Britain Wrong intervention S224

Surrounding greenness and pregnancy outcomes in four spanish birth cohorts Wrong intervention S225

Surrounding greenness, proximity to city parks and pregnancy outcomes in kaunas cohort study Wrong research design S226

Survivor dragon boating: a vehicle to reclaim and enhance life after treatment for breast cancer Wrong context S227

The aesthetic value of river flows: an assess-ment of flow preferences for large and small rivers Wrong context S228

The association between green space and cause-specific mortality in urban new zealand: An ecological analysis of green space utility Wrong intervention S229

The association between neighborhood greenness and cardiovascular disease: An observational study Wrong intervention S230

The association between neighbourhood greenspace and type 2 diabetes in a large cross-sectional study Wrong research design S231

The association between objectively measured neighborhood features and walking in middle-aged adults Wrong intervention S232

The contribution of dragon boat racing to women's health and breast cancer survivorship Wrong context S233

The effect of a community garden on hga1c in diabetics of marshallese descent Wrong intervention S234

The effect of cognitive behavior therapy-based "forest therapy" program on blood pressure, salivary cortisol level, and quality of life in elderly hypertensive patients Wrong intervention S235

The effect of park and urban environments on coronary artery disease patients: A randomized trial Wrong intervention S236

The effect of proximity on park and beach use and physical activity among rural adolescents Wrong context S237

The effect of urban green on small-area (healthy) life expectancy Wrong intervention S238

The effects of a twenty-four-week aquatic training program on muscular strength performance in healthy elderly women Wrong intervention S239

The effects of aquatic and traditional exercise programs on persons with knee osteoarthritis Wrong intervention S240

The effects of exercise in forest and urban environments on sympathetic nervous activity of normal young adults Wrong intervention S241

The effects of surfing and the natural environment on the well-being of combat veterans Wrong context S242

The effects of the natural environment on attention and family cohesion: an experimental study Wrong outcome 51 S243

The effects of water exercise on physical functioning in older people Wrong intervention S244

The effects of water-based exercise on glucose and insulin response in overweight women: a pilot study Wrong context S245

The enchanting forest and the healing sand-Nature therapy with people coping with psychiatric difficulties Wrong intervention S246

The impact of children's exposure to greenspace on physical activity, cognitive development, emotional wellbeing, and ability to appraise risk Wrong intervention S247

The impact of intervening in green space in dutch deprived neighbourhoods on physical activity and general health: Results from the quasi-experimental urban40 study Wrong intervention S248

The influence of ethical attitudes on the demand for environmental recreation: incorporating lexicographic preferences Wrong intervention S249

The influence of proximity to city parks on blood pressure in early pregnancy Wrong research design S250

The influence of urban green environments on stress relief measures: A field experiment Wrong intervention S251

The influence of urban natural and built environments on physiological and psychological measures of stress-a pilot study Wrong intervention S252

The meaning of the experience of sea kayaking for persons with spinal cord injury Wrong context S253

The ocean as a unique therapeutic environment: Developing a surfing program Wrong context S254

The physiological effects of shinrin-yoku (taking in the forest atmosphere or forest bathing): Evidence from field experiments in 24 forests across Japan Wrong context S257

The relationship between perceived health and physical activity indoors, outdoors in built environments, and outdoors in nature Wrong research design S258

The relationship of green space, depressive symptoms and perceived general health in urban population Wrong intervention S259

The restorative outcomes of forest school and conventional school in young people with good and poor behaviour Wrong intervention S260

The role of neighborhood characteristics in racial/ethnic disparities in type 2 diabetes: Results from the boston area community health (bach) survey Wrong intervention S261

The value of trees, water and open space as reflected by house prices in The Netherlands Wrong context S262 Therapeutic benefit of aquaerobics for individuals with rheumatoid arthritis Not retrieved S263

Therapeutic effect of forest bathing on human hypertension in the elderly Wrong intervention S264

To nature or not to nature: associations between environmental preferences, mood states and demographic factors Wrong intervention S265

Topophilia and the quality of life Wrong context S266

Tracking restoration in natural and urban field settings Wrong research design S267

Tracking restoration of park and urban street settings in coronary artery disease patients Wrong intervention S268

Type and proximity of green spaces are important for preventing cardiovascular morbidity and diabetes-a cross-sectional study for Quebec, Canada Wrong intervention S269

Understanding relationships between health, ethnicity, place and the role of urban green space in deprived urban communities Wrong intervention S270

Understanding the independent and joint associations of the home and workplace built environments on cardiorespiratory fitness and body mass index Wrong intervention S272

Urban green space visits and mortality among older adults Wrong intervention S273

Urban residential environments and senior citizens' longevity in megacity areas: The importance of walkable green spaces Wrong context S274 Urban tree canopy and asthma, wheeze, rhinitis, and allergic sensitization to tree pollen in a New York City birth cohort Wrong intervention S275

Urban trees and the risk of poor birth outcomes Wrong intervention S276

Use of geographic indicators of healthcare, environment and socioeconomic factors to characterize environmental health disparities Wrong intervention S278 Using geographical information system to model the effects of green space accessibility on mortality in Florida Wrong intervention S279

Validation of walking trails for the urban training tm of chronic obstructive pulmonary disease patients Wrong research design S282

Visiting a forest, but not a city, increases human natural killer activity and expression of anti-cancer proteins Wrong intervention S283

Water-versus land-based exercise effects on physical fitness in older women Wrong intervention S284

Water-based exercise for cardiovascular fitness in people with chronic stroke: a randomized controlled trial Wrong intervention S285

Water-based exercise improves health-related aspects of fitness in older women Wrong intervention S286

Water-based exercise in COPD with physical comorbidities: a randomised controlled trial Wrong intervention 52 S287 What accounts for 'England's green and pleasant land'? A panel data analysis of mental health and land cover types in rural England Wrong intervention S288

Where to take a study break on the college campus: an attention restoration theory perspective Wrong context S289 Would you be happier living in a greener urban area? A fixed-effects analysis of panel data Wrong context S290 Youth characteristics and contextual variables influencing physical activity in young adolescents of parents with premature coronary heart disease Wrong intervention S291

Natural environments and prescribing in England Wrong context S292 Social prescribing for mental health-a guide to commissioning and delivery. Care Services Improvement Partnership (CSIP). Wrong context S293 Developing a social prescribing approach for Bristol. Wrong intervention S294

Investigation into the feasibility of a social prescribing service in primary care: a pilot project. Wrong research design S295

Exercise referral systems: a national quality assurance framework. Not retrieved S296

Social prescribing in very deprived areas An evaluation of social prescribing health trainers in South and West Bradford. Wrong research design S297

Can social prescribing provide the missing link? Wrong research design S298

Social prescribing in general practice: adding meaning to medicine. Wrong research design S299

Evidence to inform the commissioning of social prescribing. Not retrieved S300

The development of green care in western European countries.

Does participating in physical activity in outdoor natural environments have a greater effect on physical and mental well-being than physical activity indoors? Wrong research design S302

The effect of aquatic therapy on postural balance and muscle strength in stroke survivors-A randomized controlled pilot trial. Wrong context S303

Effects of hydrotherapy in static and dynamic balance among elderly men. Wrong context S304

Effects of hydrotherapy in balance and prevention of falls among elderly women. Wrong context S305 Hydrotherapy vs. conventional land-based exercise for improving walking and balance after stroke: A randomized controlled trial. Wrong intervention S306

Comparing the effects of hydrotherapy and land-based therapy on balance in patients with Parkinson's disease: A randomized controlled pilot study.

Effects of a water-based program on women 65 years and over: A randomised controlled trial.

A randomized controlled trial to investigate the effects of water-based exercise to improve falls risk and physical function in older adults with lower-extremity osteoarthritis.

A water-based training program that include perturbation exercises to improve stepping responses in older adults: Study protocol for a randomized controlled cross-over trial.

Wrong intervention S310 An evaluation of social prescribing health trainers in Sout and West Bradford Wrong intervention

Misunderstandings in prescribing decisions in general practice: qualitative study

Blue care: a systematic review of blue space interventions for health and wellbeing

Nature, eco, and adventure therapies for mental health and chronic disease

The direct physical, chemical and biotic impacts on Australian coastal waters due to recreational boating

How a SURFing Social Skills Curriculum Can Impact Children with Autism Spectrum Disorders

Non-clinical community interventions: a systematised review of social prescribing schemes

Prescribing behaviour in clinical practice: patients' expectations and doctors' perceptions of patients' expectations-a questionnaire study

Home garden use during COVID-19: Associations with

Demonstrating rigor using thematic analysis: A hybrid approach of inductive and deductive coding and theme development

Therapeutic landscapes and wellbeing in later life: Impacts of blue and green spaces for older adults

Surf medicine: Surfing as a means of therapy for combat-related polytrauma

Urban blue space and health and wellbeing in Hong Kong: Results from a survey of older adults

Outdoor blue spaces, human health and well-being: A systematic review of quantitative studies

Impacts of COVID-19 pandemic on urban park visitation: a global analysis

Mechanisms of Impact of Blue Spaces on Human Health: A Systematic Literature Review and Meta-Analysis

Self-management education programs for age-related macular degeneration: A systematic review

Preliminary Estimates from Version 1-6: Coastal Recreation Participation. US Department of Commerce

Preferences of patients for patient centred approach to consultation in primary care: observational study

Adapted surfing as a tool to promote inclusion and rising disability awareness in Portugal

The effect of "green exercise" on state anxiety and the role of exercise duration, intensity, and greenness: A quasi-experimental study

The needs, models of care, interventions and outcomes of palliative care in the Caribbean: a systematic review of the evidence

Exploring pathways linking greenspace to health: theoretical and methodological guidance

Greenspace interventions for mental health in clinical and non-clinical populations: What works, for whom, and in what circumstances?

Mitigating the psychological effects of social isolation during the COVID-19 pandemic

Effect of park prescriptions with and without group visits to parks on stress reduction in low-income parents: SHINE randomized trial

Why Do You Ride?: A Characterization of Mountain Bikers, Their Engagement Methods, and Perceived Links to Mental Health and Well-Being

High-intensity sports for posttraumatic stress disorder and depression: Feasibility study of ocean therapy with veterans of Operation Enduring Freedom and Operation Iraqi Freedom

Realist synthesis: illustrating the method for implementation research

Utilization of the PICO framework to improve searching PubMed for clinical questions

Keywords and search strings Yielded records PubMed ((((((prescri*[tiab] ) OR "non-drug prescribing"[tiab]) OR "cognitive therapy"[tiab])) AND (((((((((((((((((((((((((((((((((blue*[tiab] Web of Science TS= ((((((prescri*) OR "non-drug prescribing") OR "cognitive therapy")) AND (((((((((((((((((((((((((((((((((blue*) OR water*) OR river*) OR pond) OR lake) OR sea) OR beach) OR fountain) OR ocean) OR coast*) OR marin*) OR aqua*) OR wild*) OR marsh*) OR shore) OR sub-aqua) OR riparian) OR aqueduct) OR surf*) OR harbour) OR harbor) OR swim*) OR diving) OR snorkel*) OR boat*) OR fishing) OR port) OR canal) OR kayak*) OR canoe*) OR sail*) OR natur*) OR "built environment")) AND (((((general) OR physical) OR mental) OR psychological) OR social)) AND (((health) OR wellbeing) OR well-being) 1,377Medline ((((((prescri*.ti,ab.) OR non-drug prescribing.ti,ab.) OR cognitive therapy.ti,ab.)) AND (((((((((((((((((((((((((((((((((blue*.ti,ab.) OR water*.ti,ab.) OR river*.ti,ab.) OR pond.ti,ab.) OR lake.ti,ab.) OR sea.ti,ab.) OR beach.ti,ab.) OR fountain.ti,ab.) OR ocean.ti,ab.) OR coast*.ti,ab.) OR marin*.ti,ab.) OR aqua*.ti,ab.) OR wild*.ti,ab.) OR marsh*.ti,ab.) OR shore.ti,ab.) OR sub-aqua.ti,ab.) OR riparian.ti,ab.) OR aqueduct.ti,ab.) OR surf*.ti,ab.) OR harbour.ti,ab.) OR harbor.ti,ab.) OR swim*.ti,ab.) OR diving.ti,ab.) OR snorkel*.ti,ab.) OR boat*.ti,ab.) OR fishing.ti,ab.) OR port.ti,ab.) OR canal.ti,ab.) OR kayak*.ti,ab.) OR canoe*.ti,ab.) OR sail*.ti,ab.) OR natur*.ti,ab.) OR built environment.ti,ab.)) AND (((((general.ti,ab.) OR physical.ti,ab.) OR mental.ti,ab.) OR psychological.ti,ab.) OR social.ti,ab.)) AND (((health.ti,ab.) OR wellbeing.ti,ab.) OR well-being.ti,ab.) 662 CINAHL ((((((TI prescri* OR AB prescri*) OR TI "non-drug prescribing" OR AB "non-drug prescribing") OR TI "cognitive therapy" OR AB "cognitive therapy")) AND (((((((((((((((((((((((((((((((((TI blue* OR AB blue*) OR TI water* OR AB water*) OR TI river* OR AB river*) OR TI pond OR AB pond) OR TI lake OR AB lake) OR TI sea OR AB sea) OR TI beach OR AB beach) OR TI fountain OR AB fountain) OR TI ocean OR AB ocean) OR TI coast* OR AB coast*) OR TI marin* OR AB marin*) OR TI aqua* OR AB aqua*) OR TI wild* OR AB wild*) OR TI marsh* OR AB marsh*) OR TI shore OR AB shore) OR TI sub-aqua OR AB sub-aqua) OR TI riparian OR AB riparian) OR TI aqueduct OR AB aqueduct) OR TI surf* OR AB surf*) OR TI harbour OR AB harbour) OR TI harbor OR AB harbor) OR TI swim* OR AB swim*) OR TI diving OR AB diving) OR TI snorkel* OR AB snorkel*) OR TI boat* OR AB boat*) OR TI fishing OR AB fishing) OR TI port OR AB port) OR TI canal OR AB canal) OR TI kayak* OR AB kayak*) OR TI canoe* OR AB canoe*) OR TI sail* OR AB sail*) OR TI natur* OR AB natur*) OR TI "built environment" OR AB "built environment")) AND (((((TI general OR AB general) OR TI physical OR AB physical) OR TI mental OR AB mental) OR TI psychological OR AB psychological) OR TI social OR AB social)) AND (((TI health OR AB health) OR TI wellbeing OR AB wellbeing) OR TI well-being OR AB well-being)

PsycInfo ((((((prescri*.ti,ab) OR "non-drug prescribing".ti,ab) OR "cognitive therapy".ti,ab)) AND (((((((((((((((((((((((((((((((((blue*.ti,ab) OR water*.ti,ab) OR river*.ti,ab) OR pond.ti,ab) OR lake.ti,ab) OR sea.ti,ab) OR beach.ti,ab) OR fountain.ti,ab) OR ocean.ti,ab) OR coast*.ti,ab) OR marin*.ti,ab) OR aqua*.ti,ab) OR wild*.ti,ab) OR marsh*.ti,ab) OR shore.ti,ab) OR sub-aqua.ti,ab) OR riparian.ti,ab) OR aqueduct.ti,ab) OR surf*.ti,ab) OR harbour.ti,ab) OR harbor.ti,ab) OR swim*.ti,ab) OR diving.ti,ab) OR snorkel*.ti,ab) OR boat*.ti,ab) OR fishing.ti,ab) OR port.ti,ab) OR canal.ti,ab) OR kayak*.ti,ab) OR canoe*.ti,ab) OR sail*.ti,ab) OR natur*.ti,ab) OR "built environment".ti,ab)) AND (((((general.ti,ab) OR physical.ti,ab) OR mental.ti,ab) OR psychological.ti,ab) OR social.ti,ab)) AND (((health.ti,ab) OR wellbeing.ti,ab) OR well-being.ti,ab) 1,748 Scopus ((((((TITLE-ABS("prescri*")) OR TITLE-ABS("non-drug prescribing")) OR TITLE-ABS("cognitive therapy"))) AND (((((((((((((((((((((((((((((((((TITLE-ABS ("blue*")) OR TITLE-ABS("water*")) OR TITLE-ABS("river*")) OR TITLE-ABS("pond")) OR TITLE-ABS("lake")) OR TITLE-ABS("sea")) OR TITLE-ABS("beach")) OR TITLE-ABS("fountain")) OR TITLE-ABS("ocean")) OR TITLE-ABS("coast*")) OR TITLE-ABS("marin*")) OR TITLE-ABS("aqua*")) OR TITLE-ABS("wild*")) OR TITLE-ABS("marsh*")) OR TITLE-ABS("shore")) OR TITLE-ABS("sub-aqua")) OR TITLE-ABS("riparian")) OR TITLE-ABS("aqueduct")) OR TITLE-ABS("surf*")) OR TITLE-ABS("harbour")) OR TITLE-ABS("harbor")) OR TITLE-ABS("swim*")) OR TITLE-ABS("diving")) OR TITLE-ABS("snorkel*")) OR TITLE-ABS("boat*")) OR TITLE-ABS("fishing")) OR TITLE-ABS("port")) OR TITLE-ABS("canal")) OR TITLE-ABS("kayak*")) OR TITLE-ABS("canoe*")) OR TITLE-ABS("sail*")) OR TITLE-ABS("natur*")) OR TITLE-ABS("built environment"))) AND (((((TITLE-ABS("general")) OR TITLE-ABS("physical")) OR TITLE-ABS("mental")) OR TITLE-ABS("psychological")) OR TITLE-ABS("social"))) AND (((TITLE-ABS("health")) OR TITLE-ABS("wellbeing")) OR TITLE-ABS("well-being")) 1,438 Consumer responses towards non-prescription and prescription drug advertising in the US and Germany Wrong intervention 12Determinants of adherence to exercise in women treated for breast cancer Wrong intervention 13Adherence to exercise referral schemes by participants -what do providers and commissioners need to know? A systematic reivew of barriers and facilitators Wrong research design 14Mental health and functional impairment outcomes following a 6-week intensive treatment programme for UK military veterans with post-traumatic stress disorder (PTSD): a naturalistic study to explore dropout and health outcomes at follow-up Relationship between exposure to the natural environment and recovery from hip or knee arthroplasty: A New Zealand retrospective cohort study Wrong intervention 48Targeting lifestyle energy expenditure in the management of obesity and health: from biology to built environment Wrong intervention 49Prescribing physical activity in parks to improve health and wellbeing: Protocol of the park prescription randomized controlled trial Wrong intervention 50What approaches to social prescribing work, for whom, and in what circumstances? A protocol for a realist review Wrong research design 51 "Swimming against the tide" restricting prescribing practices in a prison: A personal journey Wrong intervention 52 'At-risk' places: Inequities in the distribution of environmental stressors and prescription rates of mental health medications in Glasgow, Scotland Wrong intervention 53Policy prescriptions for healthier communities Wrong intervention 54Walking for well-being: are group walks in certain types of natural environments better for well-being than group walks in urban environments?.

Combining self-help and professional help to minimize barriers to physical activity in persons with multiple sclerosis: a trial of the "Blue Prescription" approach in New Zealand.Wrong intervention 56 Aquatics, health-promoting self-care behaviours and adults with brain injuries. Working out what works: The role of tacit knowledge where urban greenspace research, policy and practice intersect Wrong intervention 114A narrative and systematic review of the behavioural, cognitive and emotional effects of passive nature exposure on young people: Evidence for prescribing change Wrong research design 115Arts for the Bluesa new creative psychological therapy for depression: a pilot workshop report Wrong intervention 116Nature RX: Reemergence of pediatric nature-based therapeutic programs from the late 19th and early 20th centuries Wrong research design 117Identifying and resisting the technological drift: green space, blue space and ecotherapy Wrong research design 118The "healthy dose" of nature: A cautionary tale Wrong research design 119Falls in geriatric populations and hydrotherapy as an intervention: A brief review Wrong research design 120Like a Fish out of Water: Managing Chronic Pain in the Urban Safety Net Wrong intervention 121Cognitive benefits of walking in natural versus built environments Wrong intervention 122Patient uptake and adherence to social prescribing: A qualitative study Wrong intervention 123More green space is related to less antidepressant prescription rates in the Netherlands: A Bayesian geoadditive quantile regression approach Wrong intervention 124Growing spaces: an evaluation of the mental health recovery programme using mixed methods Wrong intervention 125Exercise Prescription for a Healthy Heart Wrong intervention 126Hiking: A Low-Cost, Accessible Intervention to Promote Health Benefits Wrong research design 127 A prescription for "nature" -The potential of using virtual nature in therapeutics Wrong intervention 128The adventure therapy experience scale: The psychometric properties of a scale to measure the unique factors moderating an adventure therapy experience Wrong intervention 129When Pediatric Primary Care Providers Prescribe Nature Engagement at a State Park, Do Children "fill" the Prescription? Wrong intervention 130Multiple health benefits of urban tree canopy: The mounting evidence for a green prescription Wrong intervention 131Prescribing Nature Therapy for Improved Mental Health Wrong intervention 132Promoting nature-based activity for people with mental illness through the US "exercise is medicine" initiative Wrong research design 133What is green care? Introduction, history, and origins Wrong research design 134 Swimming as exercise prescription for breast cancer patients Wrong research design 135Oceans and human health in the Caribbean region Wrong intervention 136Participant perceptions of a novel physiotherapy approach ("Blue Prescription") for increasing levels of physical activity in people with multiple sclerosis: A qualitative study following intervention Wrong intervention 137 A study on management system design of swimming exercise prescription by using fussy ANP Wrong intervention 138Interagency oceans and human health research implementation plan: A prescription for the future Wrong research design 139The sense of self inside and environments outside: how the two grow together and become one in healthy psychological development Wrong intervention S1A cohort study relating urban green space with mortality in Ontario, Canada Wrong context S2A comparison of four typical green exercise environments and prediction of psychological health outcomes Wrong context S3A comparison of green space indicators for epidemiological research Wrong intervention S4A cross-sectional analysis of the effects of residential greenness on blood pressure in 10-year old children: Results from the giniplus and lisaplus studies Wrong intervention S5A day trip to a forest park increases human natural killer activity and the expression of anti-cancer proteins in male subjects Not retrieved S6A forest bathing trip increases human natural killer activity and expression of anti-cancer proteins in female subjects Wrong intervention Green exercise as a workplace intervention to reduce job stress Wrong intervention S99Green space and mortality following ischemic stroke Wrong intervention S100Green space and stress: Evidence from cortisol measures in deprived urban communities Wrong intervention S101Green space, health inequality and pregnancy Wrong intervention S102Green space, social inequalities and neonatal mortality in France Wrong intervention S103Green space, urbanity, and health: How strong is the relation? Wrong intervention S104Green spaces and adverse pregnancy outcomes Wrong intervention S105Green spaces and cognitive development in primary schoolchildren. Proceedings of the National Academy of Sciences of the United States of America Wrong context S106 Green spaces and general health: Roles of mental health status, social support, and physical activity Wrong intervention S107Green spaces and pregnancy outcomes in southern California Wrong intervention S108Greener living environment healthier people? Exploring green space, physical activity and health in the doetinchem cohort study Wrong intervention S109Greenness and allergies: Evidence of differential associations in two areas in germany Wrong intervention S110Greenness and birth outcomes in a range of pennsylvania communities Wrong intervention S111Greenness and incident childhood asthma: A 10-year follow-up in a population-based birth cohort Wrong intervention S112Greenspace in urban neighbourhoods and residents' health: Adding quality to quantity Wrong intervention S113Greenspace, urbanity and health: Relationships in England Wrong intervention S114Happiness is greater in natural environments Wrong context S115Happiness, geography and the environment Wrong context S116Healing Waters: Therapeutic Landscapes in Historic and Contemporary Ireland Wrong research design S117Health benefits of physical activity related to an urban Riverside regeneration Wrong context S118Health effect of forest bathing trip on elderly patients with chronic obstructive pulmonary disease Wrong context S119Health effects of viewing landscapeslandscape types in environmental psychology Wrong intervention S120Health promoting outdoor environments --associations between green space, and health, health-related quality of life and stress based on a danish national representative survey Wrong intervention S121 Heartlinks-A real world approach to effective Exercise Referral: Reducing coronary heart disease risk and improving health through a negotiated exercise programme Wrong intervention S122High intensity deep water training can improve aerobic power in elderly women Wrong intervention S123High intensity physical group training in water-an effective training modality for patients with COPD Wrong intervention S126 Impact of a riverside accessibility intervention on use, physical activity, and wellbeing: A mixed methods pre-post evaluation Wrong context