Factors influencing access to green health prescribing in primary care for older adults – A qualitative systematic review

Background Green health prescribing (GHP) refers to nature-based interventions (NBIs) prescribed by a clinician or qualified health or social care professional. Given the ageing global population and increasing care needs posing severe challenges for healthcare systems, green health prescribing has emerged as a potentially effective and efficient to support healthy ageing in older people living with long-term conditions. This evidence review aimed to identify the barriers and enablers to access, uptake, implementation and delivery of NBIs Methods We undertook a systematic review of qualitative evidence exploring the barriers and enablers of green health prescribing and engagement with nature-based interventions. Searches from 2000 up to October 2024 were conducted in Medline, PsycINFO, ASSIA (Applied Social Sciences Index and Abstracts), GreenFILE, Web of Science and Dimensions and Overton and Google for grey literature. Study selection (based on a priori -defined eligibility criteria), data extraction, and quality appraisal were conducted independently by two reviewers and discrepancies were resolved by a third reviewer. Qualitative data were extracted from each article, and we conducted an inductive thematic synthesis of data. We followed reporting guidance from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), the Enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) and GRIPP2 for patient and public involvement and engagement (PPI-E) Results Ten overarching factors were identified from 27 included studies representing barriers and enablers of access to or implementation of green health prescribing and nature-based interventions. Key barriers included challenges in programme accessibility, gaps in service provision and healthcare professionals’ knowledge, prescriber hesitancy, limited organisational capacity, socioeconomic disparities, and limited evidence of effectiveness. Conversely, enablers included accessibility of green spaces, positive experiences in social engagement and connecting to nature and provider’s enthusiasm and commitment. Conclusions Our findings explore factors that can directly influence access and engagement of older people with NBIs, and organisational capacity of service providers and prescribers. To realise the full potential of green health prescribing in supporting healthy ageing and reducing health inequalities, future efforts should prioritise accessible programme design, invest in community provision infrastructure, and improve the integration within primary and community care settings. Systematic review registration CRD42025603199