The development of a nature-on-prescription group intervention for people with common mental health conditions

Primary care practitioners frequently see people who are distressed to the extent that it affects their ability to function. These people are at risk of, or may have had previously, a clinical diagnosis of stress, depression and/or anxiety in the future. These mental health conditions are common. For example, over their lifetime, one in four UK women and one in ten men experience depression serious enough to require treatment. A range of treatments are recommended by national guidelines including: therapies, such as cognitive behaviour therapy; activities, such as exercising; and medication, such as antidepressants.

Sometimes these treatments are not as effective as desired, the delivery methods or intervention activities are inappropriate, and some patients prefer, or avoid, particular treatments, such as medication. Because of this it is important to develop a range of treatment options that address mental health and wellbeing and which are suitable for diverse groups with differing needs and desires. One option is nature-based, group activities such as gardening and conservation work for which there is tentative evidence of some positive outcomes. A number of organisations, including MIND, have recognised the potential of such activities (gardening is one of the most popular leisure pursuits) and provide such activities which GPs, nurses or mental health workers can prescribe" (a form of 'social prescription'). There is variation in the type and scope of nature-based activities used, how frequently people attend, and for how long. It is unclear which are most likely to have a positive impact. A number of aspects of the intervention may have a positive impact. For example, group activities might mean people feel less isolated and pursue shared goals. Physical activity is also known to be beneficial for mental health. It is thought that spending time in nature can help, but we don't know how or what sort of engagement helps. We want to find out which ways of supporting people are most helpful for staff, and for patients. This will then allow us to design a programme that is most likely to benefit people with, or at risk of developing, common mental health conditions.

The project uses a structured approach to design a future programme of nature-based, group activities suitable for prescribing through primary care and other pathways. We will collect information from research literature, and work with three key groups of people: relevant NHS staff, people with common mental health conditions and their families, and those who organise nature-based activities. Using this information, we will analyse how, and why, different elements of a programme might help people with depression. We will also explore how it should be organised. Once this project is complete, we will be able to test the acceptability and effectiveness of nature-based, group treatment.

Mental health conditions, such as depression, anxiety and stress, are common. There is increasing interest in "social prescriptions" for people with, or at risk of, these conditions. One such offer is a nature-based intervention. Many of these exist and there is tentative evidence of effectiveness. Their content, delivery and approach varies widely. This project will use a structured approach to developing a complex intervention, to design a nature-based intervention for people with, or at risk of, common mental health conditions. In addition to the three core MRC phases of: (a) identifying existing evidence; (b) identifying or developing a theory and (c) modelling process and outcomes; four other phases will also to be incorporated: (d) problem identification and definition; (e) determining of recipients' and providers' needs; (f) examination of current practice and context and (g) intervention design. Three interlinked and iterative activities will inform phases (a) to (f): (i) Evidence syntheses (addressing phases a, b, c, e and f.) (ii) Stakeholder consultation: Initial consultation meetings with three core stakeholder groups: people with common mental health conditions and their families, including those who have previously taken part in nature-based activities, people from primary care, and those involved in delivering nature-based activities (phases b, c, d, f). iii) Formal focus groups with each of the stakeholder groups will allow better understanding of current practice, perceived impacts and the needs of those with mental health conditions, primary care practitioners, and those who deliver nature-based activities (phases c, e, f). A key output will be the detailed programme theory for the intervention. A consultation workshop with stakeholder groups will allow its refinement. We will produce an intervention manual (phase g) showing approaches to activity design; and a protocol for use in a future feasibility study.

This application describes the development of an evidence and experience based intervention manual for nature-based activities to support social prescriptions for people with common mental health conditions. Those who deliver and those who receive the intervention are partners in this development and members of the project team (DB, SW and RL) work closely with nature based activity delivery organisations (such as the Wildlife Trusts, RSPB, and RHS) and coordinating bodies (such as Natural England's Outdoors for All). The team also has strong connections with a range of relevant practitioner groups: RB is a GP with links to local and national primary care groups. RG, RB, DR, KH are part of PenCLAHRC with links across the Southwest to clinical practitioners. We will convene two rounds of stakeholder engagement and we will plan and draft dissemination material with these groups; we expect this to include, for example, a plain language summary of findings document which can be provided to all of those with whom we are working.

Prescriptions to non-NHS interventions ('social prescriptions') are gaining popularity but often in an ad hoc manner with little high-quality evidence in support. The output of this project is a highly specified intervention, a description of which can be disseminated broadly amongst academic and clinical partners. Traditional methods of publication in high impact, open-access journals, presentation at national conferences and distribution through professional networks. Additionally, PenCLAHRC will support wider dissemination of findings to the patient, practitioner and commissioning communities through their website, printed findings summaries and email updates across their networks.
We anticipate undertaking feasibility and piloting of the new intervention following this phase and, subsequently, assessing effectiveness using a national, multi-centre study. The results from this programme of work will be disseminated using high profile publication, conference presentation, and media engagement. Given the team's collective skillset, were this intervention to be assessed as effective and cost-effective we would be well placed to make policy makers aware of these results and aid translation in the relevant guidelines.