Green prescribing and inclusion health: a protocol for systematic search and thematic synthesis regarding barriers and facilitators to accessing and engaging in green prescriptions for those experiencing health inequalities

Imagine the healthcare system as a giant, bustling library. For years, librarians (doctors) have been handing out books on how to stay healthy. But recently, they've started handing out "nature tickets" instead. This is called green prescribing. Instead of just giving a pill for stress or aches, a doctor might send a person out to a park, a forest, or by a river to walk, garden, or just breathe fresh air. Scientists have found that spending time in these green (or blue, if water is involved) spaces can actually heal our bodies and minds, making us feel less lonely and more energetic. It's like a free, natural medicine that grows outside.

However, there's a catch. Just like some people in a library might struggle to find the right aisle or feel too intimidated to ask for help, some groups of people find it incredibly hard to get to these nature spots. These are the people the paper calls "inclusion health" groups—folks facing tough times like homelessness, addiction, or living in extreme poverty. They often need this "nature medicine" the most, but they might be the least likely to get it. This paper is a detective story about why that happens. It's not testing a new drug; it's a plan to gather all the existing stories and interviews to figure out exactly what stops these people from getting their nature tickets and what helps them succeed.

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The Detective's Plan: Hunting for "Nature Ticket" Barriers

This paper isn't a finished mystery novel yet; it's the detailed map and rulebook the detectives are using to solve the case. The team, led by researchers from the University of Dundee and the University of St Andrews, has drawn up a strict protocol to find and organize every single study that talks about how people from "inclusion health" groups experience green prescribing.

Think of the internet and academic databases as a massive, chaotic ocean of information. The researchers are building a very specific net to catch only the fish they need. They are looking for qualitative studies—which means they want stories, interviews, and personal experiences, not just cold numbers or statistics. They want to hear the voices of the people themselves.

The Net (Search Strategy)
The team will cast their net into nine different digital oceans, including places like Medline, PsycInfo, and CINAHL. They are looking for any study that mentions "green prescribing" (nature-based health activities) and "inclusion health" (people facing multiple hardships). They are specifically hunting for the "why" and "how."

• What they want: Stories about people who were referred to outdoor activities by a doctor or link worker.
• What they reject: Studies that only happen indoors (like gardening inside a gym), studies that are just opinions or editorials, and studies that don't have real data from people. They also won't include studies where they can't separate the "inclusion health" group from everyone else, because they need to know specifically what those groups are facing.

The Sorting Process
Once they pull in thousands of potential articles, the team will play a rigorous game of "keep or toss."

1. First Pass: One researcher reads the titles and summaries (abstracts) to see if they look promising.
2. Double Check: A second researcher will randomly check 10% of the pile to make sure they aren't missing anything or tossing the wrong things. If they disagree, a third person acts as the referee.
3. Deep Dive: The full text of the promising papers will be read carefully to see if they truly fit the criteria.

The Treasure Hunt (Data Synthesis)
Once they have their final pile of "gold" papers, they won't just list them. They will use special software called NVivo 14 to act like a giant puzzle solver. They will break down the stories into small pieces (codes), group similar pieces together (themes), and then build a bigger picture (analytical themes).

• The Goal: To answer three big questions:
  1. What stops these groups from even getting the referral? (The barriers to access).
  2. What stops them from sticking with the activity once they start? (The barriers to engagement).
  3. What helps them succeed? (The facilitators).

The Stakes
The authors are worried that without understanding these barriers, green prescribing might accidentally make health inequalities worse. Imagine a health program that only helps the people who already have easy lives, while leaving the most vulnerable behind. That would be like giving a free bus pass only to people who already own a car.

This review suggests that for people facing homelessness, addiction, or extreme poverty, the barriers might be huge. They might not have money for transport, feel unsafe in parks, or feel like they don't belong in nature spaces. The paper argues that if we don't fix these specific hurdles, the "nature medicine" might never reach the people who need it most.

The Verdict So Far
This paper is a proposal, a roadmap for a study that hasn't finished yet. The authors haven't found the final answers to the questions; they are explaining how they will find them. They suggest that by listening to the voices of these marginalized groups, we can redesign green prescribing so it actually works for everyone, not just the lucky few. They hope this work will help future projects stop widening the gap in health and start closing it.

The team is confident that this is the first time anyone has tried to gather all these specific stories into one big picture. By doing this, they hope to turn green prescribing from a well-intentioned idea that sometimes fails the most vulnerable, into a truly inclusive tool that heals everyone.