November 1, 2023

Prescription: Nature

A meta-analysis of nature Rx studies
Impact of healthcare provider–based nature prescriptions on measures of cardiovascular health, psychological health, and physical activity.

This article is part of our February 2024 special issue. Download the full issue here.


Nguyen P-Y, Astell-Burt T, Rahimi-Ardabili H, Feng X. Effect of nature prescriptions on cardiometabolic and mental health, and physical activity: a systematic review. Lancet Planet Health. 2023;7(4):e313-328.

Study Objective

To synthesize evidence on the effectiveness of nature prescriptions and determine which factors are important for their success

Key Takeaway

Nature prescriptions (NRx) given by healthcare- and social-service providers have been shown to improve systolic and diastolic blood pressure and scores of depression and anxiety and to increase step-count and time spent engaging in moderate physical activity through regular involvement in local natural environmental settings. 


Systematic review and meta-analysis 


From an initial search of 5 databases from 1999 to July 2021 (MEDLINE [Ovid], Embase [Ovid], PsycINFO [Ovid], CINAHL [EBSCO], and CENTRAL/CDSR [Cochrane]), investigators reviewed a total of 4,309 unique records and assessed 615 reports, of which 92 studies were included in the final systematic review and 28 were included in meta-analysis. The total number of participants was N=9,304, with a mean study size of n=102.

Studies were from a variety of countries, including South Korea (n=18; 20%), USA (n=16; 17%), Japan (n=10; 11%), UK (n=7; 8%), and China (n=5; 5%). A diverse range of ages, from children to elderly, and socioeconomic backgrounds was represented. The reasons for NRx included many different clinical diagnoses, with mental health (n=13; 14%), cardiovascular (n=12; 13%), and musculoskeletal (n=6; 7%) conditions being the most common.

Inclusion criteria were for controlled trials of nature-based interventions (NRx, see below) recommended by health or social providers that collected data on physical, psychological, cognitive, or behavioral health outcomes. Exclusion criteria included nonhuman participants, noncontrolled studies, simulated nature exposure (eg, video, virtual reality), specialized environments (eg, wilderness therapy), and school/after-school based activities. 


The reviewed NRx studies used a variety of nature-based settings. The most common were forests and nature reserves (n=32; 35%), urban parks (n=26; 28%), or community/allotment, botanical, or personal gardens (n=25; 27%). NRx activities included walking in nature (n=42; 46%), individual or group sports (n=30; 33%), gardening (n=27; 29%), meditation/breathwork (n=25; 27%), arts and crafts (n=4; 4%), and just relaxing/enjoying the setting (n=2; 2%). Frequency and duration of exposures were highly variable between studies. 

Study Parameters Assessed

Data included in the meta-analysis were systolic blood pressure, diastolic blood pressure, depression (various scales), anxiety (various scales), daily step counts, and weekly time spent on moderate physical activity. 

Risk of bias was determined to be moderate to high, based on small study sizes, high study dropout/noncompletion rates without participant explanation, the inherently subjective nature of many of the psychometric scales used in the various studies, and (based on the intervention method) a lack of possible blind/double-blind study designs. 

Key Findings

NRx resulted in improvements in:

  • Systolic blood pressure (mean difference –4.82 mm Hg [–8.92 to –0.72], I²=60%);
  • Diastolic blood pressure (mean difference –3.82 mm Hg [–6.47 to –1.16], I²=59%);
  • Depression scores (postintervention standardized mean difference –0.50 [–0.84 to –0.16], I²=83%);
  • Depression change from baseline (standardized mean difference –0.42 [–0.82 to –0.03], I²=0%);
  • Anxiety scores (postintervention standardized mean difference –0.57 [–1.12 to –0.03], I²=91%); 
  • Anxiety change from baseline standardized mean difference –1.27 (–2.20 to –0.33);
  • Daily step counts greater than control conditions (mean difference 900 steps [790 to 1010]); and
  • Weekly time of moderate physical activity (mean difference 52.9 min [33.7 to 72.1]).


Study funding was provided through the Australian National Health and Medical Research Council Boosting Dementia Research Leader Fellowship (1140317) and the National Health and Medical Research Council Career Development Fellowship (1148792). Authors declared “no competing interests” in the conduct or publication of this study.  

Practice Implications & Limitations

Exposure to the natural world is increasingly recognized as a mechanism for health promotion, disease prevention, and even disease treatment.1,2 Contact with nature has been shown to positively affect biomarkers of allostatic load (ie, heart rate, blood pressure, heart rate variability, and salivary cortisol);3 measures of brain activity (ie, electroencephalogram [EEG], functional magnetic resonance imaging [fMRI]);4 and mental well-being,5 vitality,6 and quality of life.7 Presence and use of natural “green spaces” is associated with lower rates of mortality,8 cardiovascular disease,9 type 2 diabetes,10 obesity,11 depression, and anxiety.12 The health benefits of natural spaces are truly holistic and extend beyond physical and mental/emotional benefits to include enhancement of social,13 spiritual,14 and even environmental health.15

This is especially pertinent in an era of simultaneous, epidemic levels of chronic disease, increasingly indoor and sedentary lifestyles, growing social isolation, and ecological destruction.16-18 Data support the theory of biologist EO Wilson’s “biophilia hypothesis”19 that human affinity for the natural world is an intrinsic adaptation resulting from millions of years of co-evolutionary exposure with our surrounding environments.20 The dearth of contact with the natural world in modern society has been suggested to contribute to a variety of chronic physical and mental/emotional conditions known colloquially as “nature deficit disorder.”21 Recent events like the global Covid-19 pandemic have demonstrated how essential contact with nature is and how opportunities to access local green spaces benefit individuals’ and community’s physical, mental, and social health.22,23

One recent method of promoting more time in nature is the use of formal nature prescriptions by physicians and other healthcare and social service providers.24 People have shown they are more likely to engage in a lifestyle or health-behavior change when given formal prescriptions.25,26 Use of nature Rx is increasingly common as providers understand the scientific validity of empirical studies identifying the health benefits of time in nature and recognize NRx as an accepted and available professional practice.

People have shown they are more likely to engage in a lifestyle or health-behavior change when given formal prescriptions.

These methods are being increasingly adopted in countries like the UK, where the National Health Service has begun a £5.77-million ($7.06-million) “green social prescribing” program to improve health outcomes and address health inequalities.27 In Japan, people commonly visit national “forest bathing centers” to engage in physician-personalized, nature-based mindfulness nature walks known as shinrin-yoku.28 In the United States, resources like Park Rx America are facilitating the writing and inclusion of NRx in patient EHR (electronic health record) charts.29

To increase adherence/compliance and optimize health outcomes of a NRx program, it is best to adopt a patient-centered approach, integrating experience and communication between various partners (ie, healthcare, recreation, social services, transportation, etc).30 An optimal NRx includes:

  • Patient choice of activity to reflect personal interests and cultivate self-efficacy;
  • Specific “dosage” of NRx, including activity, frequency, and duration;
  • Sharing information about specific health benefits for conditions being addressed;
  • Information about local resources (eg, parks), including location, proximity, amenities, hours, and contact info;
  • Opportunities for individual or group social experience; and
  • Clinical followup and opportunities for patient accountability, input, and feedback.

Incorporation of NRx in the clinical treatment plan can be a simple and effective method of improving multiple aspects of patient health and well-being. 

Limitations of the current study include the inherent moderate-to-high risk of bias (see above); the aggregation of meta-data preventing detection and/or recommendation of potential NRx benefits for specific demographic groups based on age, sex/gender, socioeconomic status, etc; and the relatively recent inclusion and study of NRx in healthcare results in high meta-analytic heterogenicities (I2). Standardization of clinical and research protocols will allow for more uniform and reliable collection of data and detection of health-related outcomes. 

Categorized Under


  1. Jimenez MP, Deville NV, Elliott EG, et al. Associations between nature exposure and health: a review of the evidence. Int J Environ Res Public Health. 2021;18(9):4790.
  2. World Health Organization - Europe. Urban Green Spaces and Health: A Review of the Evidence. Copenhagen; 2016.
  3. Twohig-Bennett C, Jones A. The health benefits of the great outdoors: a systematic review and meta-analysis of greenspace exposure and health outcomes. Environ Res. 2018;166(June):628-637.
  4. Norwood MF, Lakhani A, Maujean A, Zeeman H, Creux O, Kendall E. Brain Activity, Underlying Mood and the Environment: A Systematic Review. Vol 65. Academic Press; 2019:101321.
  5. Houlden V, Weich S, de Albuquerque JP, Jarvis S, Rees K. The relationship between greenspace and the mental wellbeing of adults: a systematic review. PLoS One. 2018;13(9):e0203000.
  6. van den Berg MMHE, van Poppel M, van Kamp I, et al. Visiting green space is associated with mental health and vitality: a cross-sectional study in four European cities. Heal Place. 2016;38:8-15.
  7. Dyer SM, Liu E, Gnanamanickam E, et al. Associations between quality of life and outdoor access in nursing homes : a cross-sectional study. Ann Long-Term Care. 2021:1-9.
  8. Rojas-Rueda D, Nieuwenhuijsen MJ, Gascon M, Perez-Leon D, Mudu P. Green spaces and mortality: a systematic review and meta-analysis of cohort studies. Lancet Planet Heal. 2019;19(970):e469-e477.
  9. Liu X-X, Ma XL, Huang W-Z, et al. Green space and cardiovascular disease: a systematic review with meta-analysis. Environ Pollut. 2022;301:118990.
  10. Cami-Bernal F, Soriano-Moreno DR, Fernandez-Guzman D, et al. Green space exposure and type 2 diabetes mellitus incidence: a systematic review. Health Place. 2023;82:103045.
  11. Lachowycz K, Jones AP. Greenspace and obesity: a systematic review of the evidence. Obes Rev. 2011;12(501):183-189.
  12. Liu Z, Chen X, Cui H, et al. Green space exposure on depression and anxiety outcomes: a meta-analysis. Environ Res. 2023;231:116303.
  13. Huang W, Lin G. The relationship between urban green space and social health of individuals: a scoping review. Urban For Urban Green. 2023;85:127969.
  14. Naor L, Mayseless O. The therapeutic value of experiencing spirituality in nature. Spiritual Clin Pract. 2020;7(2):114-133.
  15. Barragan-Jason G, Loreau M, de Mazancourt C, Singer MC, Parmesan C. Psychological and physical connections with nature improve both human well-being and nature conservation: a systematic review of meta-analyses. Biol Conserv. 2023;277:109842.
  16. Beyer KMM, Szabo A, Hoormann K, Stolley M. Time spent outdoors, activity levels, and chronic disease among American adults. J Behav Med. 2018;41(4):494-503.
  17. O’Malley A. Nature as ally in our chronic disease epidemic. Ecopsychology. 2020;12(3):180-187.
  18. Alves S, Betrabet Gulwadi G, Nilsson P. An exploration of how biophilic attributes on campuses might support student connectedness to nature, others, and self. Front Psychol. 2022;12(793175).
  19. Wilson EO. Biophilia. Cambridge: Harvard University Press; 1984.
  20. Schiebel T, Gallinat J, Kühn S. Testing the biophilia theory: automatic approach tendencies towards nature. J Environ Psychol. 2022;79:101725.
  21. Louv R. Last Child in the Woods: Saving Our Children From Nature Deficit Disorder. Chapel Hill, North Carolina: Algonquin Press; 2005.
  22. Nigg C, Petersen E, MacIntyre T. Natural environments, psychosocial health, and health behaviors during COVID-19 – a scoping review. J Environ Psychol. 2023;88(October):102009.
  23. Lin D, Sun Y, Yang Y, Han Y, Xu C. Urban park use and self-reported physical, mental, and social health during the COVID-19 pandemic: an on-site survey in Beijing, China. Urban For Urban Green. 2023;79:127804.
  24. Kondo MC, Oyekanmi KO, Gibson A, South EC, Bocarro J, Hipp JA. Nature prescriptions for health: a review of evidence and research opportunities. Int J Environ Res Public Health. 2020;17(4213).
  25. Little M, Rosa E, Heasley C, Asif A, Dodd W, Richter A. Promoting healthy food access and nutrition in primary care: a systematic scoping review of food prescription programs. Am J Heal Promot. 2022;36(3):518-536.
  26. Lifestyle Prescriptions: A Review of the Clinical Evidence. Ottawa, Ontario; 2014.
  27. National Health Service England. Green social prescribing. National Health Service England website. Accessed April 16, 2023.
  28. Kotera Y, Richardson M, Sheffield D. Effects of shinrin-yoku (forest bathing) and nature therapy on mental health: a systematic review and meta-analysis. Int J Ment Health Addict. 2020.
  29. Park Rx America website. Accessed October 30, 2023.
  30. Lawson J, Foley H, Leach M, Feng X, Astell-Burt T, Brymer E. Towards key principles for the design and implementation of nature prescription programs. Sustain. 2023;15(12):9530.