August 2023 correspondence

I write in response to the paper by Ivers and Astell-Burt published in the Australian Journal of General Practice in April 2023, titled ‘Nature Rx: Nature prescribing in general practice’.¹ This article provides ideas for implementation of nature prescribing in general practice.

As a General Practitioner of almost 30 years, I have found nature prescribing to be well received by patients and encourage other primary care providers to incorporate it into their therapeutic toolkit. It is possible to use existing practice software and modify an exercise-prescription template to generate a prescription that prints onto script paper, although it is hoped software manufacturers get on board to provide a specific nature prescription template.

I suggest that for maximum psychological benefit, patients disconnect from technology by turning their phone off and removing ear buds (unlike in the accompanying photo of the Ivers and Astell-Burt paper).² This removes distraction, enables a richer, more mindful engagement with nature and incorporates an integrated use of all sensory faculties.³ It therefore reduces some of the risks posed by not paying attention when outdoors.⁴

An additional modality, not mentioned by the authors, is nature play. Nature play is providing children with simple opportunities to play in nature in a child-led, child-focussed way – without a predetermined, adult-defined outcome as occurs in organised activities. Bush Kinders and playgroups incorporate this approach, but nature play is something all children can engage in if simply given free time outdoors. It has been found to increase physical activity, foster problem-solving and improve focus.^5–8

Author

Dimity Williams MBBS (Hons), FRACGP, CSCT (Women’s Health), Founder Biodiversity Special Interest Group, Doctors for the Environment Australia, Melbourne, Vic; Co-Founder, Kids In Nature Network, Melbourne, Vic

References

1. Ivers R, Astell-Burt T. Nature Rx: Nature prescribing in general practice. Aust J Gen Pract 2023; 52(4):183–87.
2. Wacks Y, Weinstein AM. Excessive smartphone use is associated with health problems in adolescents and young adults. Front Psychiatry 2021;12:669042. doi: 10.3389/fpsyt.2021.669042.
3. Atchley RA, Strayer DL, Atchley P. Creativity in the wild: Improving creative reasoning through immersion in natural settings. PLoS One 2012;7(12):e51474. doi: 10.1371/journal.pone.0051474.
4. Byington KW, Schwebel DC. Effects of mobile Internet use on college student pedestrian injury risk. Accid Anal Prev 2013;51:78–83. doi: 10.1016/j.aap.2012.11.001.
5. Prins J, van der Wilt F, van der Veen C, Hovinga D. Nature play in early childhood education: A systematic review and meta ethnography of qualitative research. Front Psychol 2022;13:995164. doi: 10.3389/fpsyg.2022.995164.
6. Herrington S, Brussoni M. Beyond physical activity: The importance of play and nature-based play spaces for children’s health and development. Curr Obes Rep 2015;4(4):477–83. doi: 10.1007/s13679-015-0179-2.
7. Stevenson MP, Schilhab T, Bentsen P. Attention Restoration Theory II: A systematic review to clarify attention processes affected by exposure to natural environments. J Toxicol Environ Health B Crit Rev 2018;21(4):227–68. doi: 10.1080/10937404.2018.1505571.
8. Burdette HL, Whitaker RC. Resurrecting free play in young children: Looking beyond fitness and fatness to attention, affiliation, and affect. Arch Pediatr Adolesc Med 2005;159(1):46–50. doi: 10.1001/archpedi.159.1.46.

Reply

We thank the correspondent for her comments. As for Lifescripts,¹ prescriptions for physical activity and nutritional intervention previously used in general practice, nature prescriptions can be hand-written or typed. The recommendation to be incorporated into software could be considered. Advice recommending nature interventions is more likely to be effective when tailored to an individual’s preferences, located close-by and when low cost.

Our paper did not focus on paediatric use of nature therapy, rather focussing on adults, although many of the potential interventions can be used by children and adolescents; for example, Parkrun.² Contact with nature should be considered as part of preventive medicine. Fyfe-Johnson et al, in a systematic literature review of 296 studies, documented a positive relationship between contact with nature and children’s health; particularly for mental health and physical activity.³

Nature-based playgroups or preschool activities and ‘bush school’ for primary school children, preschool or school community gardens and physical activity in green and blue spaces are growing in popularity. There are also examples of nature therapy being used therapeutically with children and adolescents; for example, horticultural therapy for children with cerebral palsy,⁴ and as for adults, it can be prescribed or incorporated into care plans or National Disability Insurance Scheme plans for children and adolescents. Evidence indicates increasing contact with quality natural environments in cities may be especially beneficial for the mental wellbeing of adolescents prone to chronic rumination or introversion.⁵

More research is needed to define how we can enable everyone to reap the rewards of nature contact, through nature prescriptions and other strategies. Our newly funded PANDA randomised trial (Physical Activity in Nature for people with cardiometabolic Diseases Aged 45yr+; www.powerlab.site/research/panda-trial) will go some way in beginning to address this policy-relevant gap in knowledge for delivering sustainable preventive healthcare.

Authors

Rowena Ivers MBBD, FRACGP, PhD, Academic Leader Community Based Education, Graduate School of Medicine, University of Wollongong, Wollongong, NSW

Thomas Astell-Burt PhD, Professor of Population Health and Environmental Data Science, University of Wollongong, Wollongong, NSW; Founding Co-Director of the Population Wellbeing and Environment Research Lab (PowerLab), Wollongong, NSW

References

1. Eley DS, Eley RM. How do rural GPs manage their inactive and overweight patients?--A pilot study of rural GPs in Queensland. Aust Fam Physician 2009;38(9):747–48.
2. Grunseit A, Richards J, Merom D. Running on a high: Parkrun and personal well-being. BMC Public Health 2017;18(1):59. doi: 10.1186/s12889-017-4620-1.
3. Fyfe-Johnson AL, Hazlehurst MF, Perrins SP, et al. Nature and children’s health: A systematic review. Pediatrics 2021;148(4):e2020049155. doi: 10.1542/peds.2020-049155.
4. Ackley D, Cole L. The effect of a horticultural therapy program on children with cerebral palsy. J Rehabil 1987;53(4):70–73.
5. Feng X, Astell-Burt T, Standl M, Flexeder C, Heinrich J, Markevych I. Green space quality and adolescent mental health: Do personality traits matter? Environ Res 2022;206:112591. doi: 10.1016/j.envres.2021.112591.