Green Prescribing: Communities of Boundary Practice in Transectoral Collaboration. An Actor-Oriented Approach to Environmental and Public Health Intervention.

Abstract: Green prescribing, the referral of patients to nature-based activities, has potential to bring co- benefits for psychological and physiological public health and for environmental health. Literature considers a major limitation to its effective implementation as a holistic, transectoral practice to be lack of a common language and tendency of actors involved to work within their respective paradigms, resulting in silo working and minimising realisation of potential co- benefits. Three research questions (RQs) were posed to explore how this barrier could be overcome. Qualitative analysis was undertaken to identify actors involved in practical application of green prescribing (RQ1) and information flows which exist between actors (RQ2). Interviews and grey literature formed the basis for analysis, themselves arising from two case studies situated in the United Kingdom. Data was fed into actor linkage matrices and determinants diagrams to allow its systematic analysis. Key actors originated from the health and social care sector; environmental sector; national and local governance; and the voluntary, community and social enterprise sector. User groups were additionally highlighted as key actors although were afforded little representation in extant schemes. Weak information flows typically arose between user groups and environmental and health and social care actors; between environmental actors and health and social care actors; and between local and national actors, although limited data was available on the latter. Silo working was thus apparent. A novel conceptual framework, Communities of Boundary Practice, was devised and its application to improve implementation of green prescribing considered (RQ3). Typified by flexibility, openness, inclusion of multi-level and multi-professional actors, shared knowledge generation, reflexive and iterative learning, and holistic responsiveness to feedback mechanisms, the concept provides a systems perspective on green prescribing via which relevant actors and information flows can be identified, transectoral working facilitated, organisational boundaries transgressed and effective implementation of green prescribing pursued as a common endeavour amongst actors.