Exiting the Anthropocene: Achieving personal and planetary health in the 21st century.

Planetary health provides a perspective of ecological interdependence that connects the health and vitality of individuals, communities, and Earth's natural systems. It includes the social, political, and economic ecosystems that influence both individuals and whole societies. In an era of interconnected grand challenges threatening health of all systems at all scales, planetary health provides a framework for cross-sectoral collaboration and unified systems approaches to solutions. The field of allergy is at the forefront of these efforts. Allergic conditions are a sentinel measure of environmental impact on human health in early life-illuminating how ecological changes affect immune development and predispose to a wider range of inflammatory noncommunicable diseases (NCDs). This shows how adverse macroscale ecology in the Anthropocene penetrates to the molecular level of personal and microscale ecology, including the microbial systems at the foundations of all ecosystems. It provides the basis for more integrated efforts to address widespread environmental degradation and adverse effects of maladaptive urbanization, food systems, lifestyle behaviors, and socioeconomic disadvantage. Nature-based solutions and efforts to improve nature-relatedness are crucial for restoring symbiosis, balance, and mutualism in every sense, recognizing that both personal lifestyle choices and collective structural actions are needed in tandem. Ultimately, meaningful ecological approaches will depend on placing greater emphasis on psychological and cultural dimensions such as mindfulness, values, and moral wisdom to ensure a sustainable and resilient future.

Transcendent Experiences Among Pilgrims to Lourdes: A Qualitative Investigation.

Millions of pilgrims visit Lourdes each year, often seeking revitalisation rather than miraculous cures. We sought to understand the phenomenon of transcendent experiences. We spoke with 67 pilgrims including assisted pilgrims, young volunteers and medical staff. About two in five reported a transcendent experience: some felt they had communicated or had close contact with a divine presence, while others reported a powerful experience of something intangible and otherworldly. Transcendent experiences are an important feature of pilgrimage to Lourdes and the place offers the faithful a means of connecting with the divine, with nature and with the self.

Complementary and alternative medicine use by visitors to rural Japanese family medicine clinics: results from the international complementary and alternative medicine survey.

BACKGROUND: There is growing interest in the use of complementary and alternative medicine (CAM) throughout the world, however previous research done in Japan has focused primarily on CAM use in major cities. The purpose of this study was to develop and distribute a Japanese version of the International Complementary and Alternative Medicine Questionnaire (I-CAM-Q) to assess the use of CAM among people who visit rural Japanese family medicine clinics. METHODS: Using a Japanese version of the International Complementary and Alternative Medicine Questionnaire (I-CAM-Q), a cross-sectional survey was conducted in three rural family medicine clinics. All patients and those accompanying patients who met inclusion criteria were eligible to participate. Data were entered into SPSS Statistics and analyzed for use by age, gender, and location. RESULTS: Of the 519 respondents who participated in the project, 415 participants reported CAM use in the past 12 months (80.0%). When prayer is excluded, the prevalence of CAM use drops to 77.3% in the past year, or 403 respondents. The most common forms of CAM used by respondents were pain relief pads (n = 170, 32.8%), herbal medicines/supplements (n = 167, 32.2%), and massage by self or family (n = 166, 32.0%). Female respondents, individuals with higher levels of education, and those with poorer overall health status were more likely to use CAM than respondents without these characteristics. Only 22.8% of CAM therapies used were reported to physicians by survey participants. CONCLUSIONS: These data indicate that CAM use in rural Japan is common. The results are consistent with previous studies that show that Japanese individuals are more interested in forms of CAM such as pain relief pads and massage, than in mind-body forms of CAM like relaxation and meditation. Due to the high utilization of certain CAM practices, and given that most CAM users do not disclose their CAM use to their doctors, we conclude that physicians in rural Japan would benefit by asking about CAM use during patient interviews, and by familiarizing themselves with the potential benefits and risks of commonly used CAM modalities.

Social Isolation in Older Adults: A Qualitative Study on the Social Dimensions of Group Outdoor Health Walks.

Physical distancing practices during the COVID-19 global pandemic contributed to a high degree of social isolation among older adults. To reduce loneliness and other ill effects of social isolation, public health experts recommended outdoor social gathering, with physical distancing. Adopting a case study approach, we explored how social aspects of group outdoor health walks (GOHWs) mitigate social isolation for older adults and improve individual social wellbeing. We used semi-structured interviews to understand the experiences of social isolation and social relationships in nine older (50-80 s) adults participating in a GOHW in Scotland, United Kingdom (UK). Verbatim transcripts were analysed through an iterative process of thematic analysis carried out by an interdisciplinary team of qualitative researchers from environmental psychology, medicine, and geography. Themes provide insight into the social dimensions of GOHWs, the mediating effects of social experiences, and the contribution these make to individual social wellbeing. GOHWs provide opportunities to be part of a group and attend to the needs of inexperienced or physically challenged individuals. Being part of the group walk fosters casual interpersonal interactions through spontaneous mixing during and after the walk. This programmatic structure counters loneliness, engenders pleasurable anticipation of regular contact with others, supports physical activity, and fosters group cohesion. These in turn contribute to individual social wellbeing, including expanding social networks, meaningful relationships, a sense of belonging, and acting on empathy for others. GOWHs may be beneficial for mitigation of social isolation as we emerge from the COVID-19 pandemic. Findings were used to propose a conceptual model to parse social constructs and inform selection or development of quantitative social measures for future studies of nature-based interventions such as GOHWs.

Project Earthrise: Proceedings of the Ninth Annual Conference of inVIVO Planetary Health.

The "Earthrise" photograph, taken on the 1968 Apollo 8 mission, became one of the most significant images of the 20th Century. It triggered a profound shift in environmental awareness and the potential for human unity-inspiring the first Earth Day in 1970. Taking inspiration from these events 50 years later, we initiated Project Earthrise at our 2020 annual conference of inVIVO Planetary Health. This builds on the emergent concept of planetary health, which provides a shared narrative to integrate rich and diverse approaches from all aspects of society towards shared solutions to global challenges. The acute catastrophe of the COVID-19 pandemic has drawn greater attention to many other interconnected global health, environmental, social, spiritual, and economic problems that have been underappreciated or neglected for decades. This is accelerating opportunities for greater collaborative action, as many groups now focus on the necessity of a "Great Transition". While ambitious integrative efforts have never been more important, it is imperative to apply these with mutualistic value systems as a compass, as we seek to make wiser choices. Project Earthrise is our contribution to this important process. This underscores the imperative for creative ecological solutions to challenges in all systems, on all scales with advancing global urbanization in the digital age-for personal, environmental, economic and societal health alike. At the same time, our agenda seeks to equally consider our social and spiritual ecology as it does natural ecology. Revisiting the inspiration of "Earthrise", we welcome diverse perspectives from across all dimensions of the arts and the sciences, to explore novel solutions and new normative values. Building on academic rigor, we seek to place greater value on imagination, kindness and mutualism as we address our greatest challenges, for the health of people, places and planet.

Pathways linking biodiversity to human health: A conceptual framework.

Biodiversity is a cornerstone of human health and well-being. However, while evidence of the contributions of nature to human health is rapidly building, research into how biodiversity relates to human health remains limited in important respects. In particular, a better mechanistic understanding of the range of pathways through which biodiversity can influence human health is needed. These pathways relate to both psychological and social processes as well as biophysical processes. Building on evidence from across the natural, social and health sciences, we present a conceptual framework organizing the pathways linking biodiversity to human health. Four domains of pathways-both beneficial as well as harmful-link biodiversity with human health: (i) reducing harm (e.g. provision of medicines, decreasing exposure to air and noise pollution); (ii) restoring capacities (e.g. attention restoration, stress reduction); (iii) building capacities (e.g. promoting physical activity, transcendent experiences); and (iv) causing harm (e.g. dangerous wildlife, zoonotic diseases, allergens). We discuss how to test components of the biodiversity-health framework with available analytical approaches and existing datasets. In a world with accelerating declines in biodiversity, profound land-use change, and an increase in non-communicable and zoonotic diseases globally, greater understanding of these pathways can reinforce biodiversity conservation as a strategy for the promotion of health for both people and nature. We conclude by identifying research avenues and recommendations for policy and practice to foster biodiversity-focused public health actions.

Group Outdoor Health Walks Using Activity Trackers: Measurement and Implementation Insight from a Mixed Methods Feasibility Study.

Outdoor walking groups are nature-based interventions (NBIs) that promote health and wellbeing by modifying individual behaviour. The challenges of such NBIs include the motivation of inactive adults to participate and measurement issues. This feasibility study investigates a 12-week group outdoor health walk (GOHW) incorporating activity trackers and use of a holistic health and wellbeing measure, the Self-sasessment of Change (SAC) scale. A mixed methods design explored participant recruitment and retention, programme delivery, and measures of physical activity and health and wellbeing. Walker data included: pre-post questionnaires, daily step counts, and interviews. Programme delivery information included: weekly checklists, staff reflections, stakeholder meeting minutes, and a report. Thirteen adults (age 63-81, 76% female) joined and completed the activity tracker GOHW. Activity trackers motivated walkers to join and be more active but complicated programme delivery. Activity trackers allowed the quantification of physical activity and the SAC health and wellbeing measure was easy to use. By week 12, all participants met national physical activity guidelines. Clinically relevant changes on the SAC scale included: sleeping well, experiencing vibrant senses, and feeling energised, focused, joyful, calm and whole. Results illustrate the feasibility of using activity trackers to motivate engagement in and provide a measure of physical activity from GOHWs. The SAC scale offers a promising measure for nature-health research. A conceptual model is provided for the development of future large-scale studies of NBIs, such as group outdoor health walks.

Understanding public perceptions of healing: An arts-based qualitative study.

BACKGROUND: Most healing research has focussed on the views of healers, complementary and alternative medical (CAM) practitioners or medical professionals, and little is known about how the general public conceives of healing. Because healing is a complex and often abstract concept, we addressed this gap in the knowledge using creative qualitative approaches with members of the public. We aimed to elucidate the views of members of the public about their healing, to help offer a better understanding to healthcare professionals. METHODS: Our qualitative arts-based drawing method invited people to respond using crayons and paper to the question 'What does the word healing mean to you?' These drawings were followed by a short recorded interview in which people explained their image. We used convenience sampling to approach members of the public visiting a large wellbeing show and a museum. We analysed images and interviews in tandem using a focus on metaphor. RESULTS: We interviewed 59 people, including three children. Almost two thirds of participants were female. Participants' images and interviews documented three main models of the healing process: i) Healing comes from a great external force, exemplified by the sun; ii) Healing comes from other people, whether medical professionals, CAM practitioners or healers; and iii) Healing comes from within, and the individual has the ability to self-heal. People described practices and inner states that could help achieve healing. Some people depicted more than one model, demonstrating the interlinkages between the models, and some described the outcome of healing (wholeness) rather than the process. CONCLUSIONS: The drawing-based approach encouraged an intuitive way of thinking, capturing concepts that cannot easily be verbalised. Members of the public have nuanced, complex understandings of the concept of healing, and these echo historical and modern concepts of healing and healthcare. The models our participants described often interlink, suggesting an overarching framework for the way people conceive of healing. The findings may be useful both as a guide to further research and as insight that may facilitate healthcare processes.

Growing Resilience through Interaction with Nature: Can Group Walks in Nature Buffer the Effects of Stressful Life Events on Mental Health?

Nature-based activities have been used as therapeutic interventions for those experiencing stress and mental ill health. This study investigates whether group walks could be a nature-based intervention to foster resilience, by buffering the effects of recent stressful life events on mental health. An observational research design with propensity score-matched samples compared the mental health of individuals who did (Nature Group Walkers, n = 1081) or did not (Non-Group Walkers, n = 435) attend nature group walks. A sub-sample of Frequent Nature Group Walkers (at least once per week, n = 631) was also investigated. Data were analyzed using multiple regression with an interaction term. All analyses were controlled for age, gender, and recent physical activity. Results showed that neither nature group walking, nor doing this frequently, moderated the effects of stressful life events on mental health. Using a main effects model, the positive associations of group walks in nature were at a greater magnitude than the negative associations of stressful life events on depression, positive affect, and mental well-being, suggesting an 'undoing' effect of nature group walks. Group walking schemes in natural environments may be an important public health promotion intervention for mental health.

Why and How Should We Integrate Biomarkers into Complex Trials? A Discussion on Paradigms and Clinical Research Strategies.

BACKGROUND: Research in complementary and alternative medicine (CAM) encounters a variety of challenges, such as potentially synergistic, multimodal, and complex interventions which are often dependent on the relationship between practitioner and patient, on specific settings, and on patients' individual preferences, expectations, beliefs, and motivations. Moreover, patients seeking CAM care often suffer from chronic disease conditions, and multiple symptoms and/or pathologies. On the other hand, CAM interventions are often challenged as being solely dependent on subjective and nonspecific factors without biologically based mechanisms of action. If we agree that biomarkers as outcomes are important for the understanding of CAM interventions, a hypothesis- and strategy-driven process for the selection of the most appropriate biomarkers is needed. METHODS: This paper presents the results of an expert panel on how to integrate biomarkers in whole system research of an interdisciplinary workshop on research methodology in CAM held in November 2012. RESULTS: The following main CAM research challenges were identified: (a) finding appropriate biomarkers, which are able to picture the complex pathophysiological pathways and likewise complex interventions under study; (b) integrating these biomarkers into clinical trials in CAM; and (c) identifying the biomarkers specific to the particular CAM intervention being applied. CONCLUSION: The paper provides a disease/condition/symptom- and intervention-driven strategy regarding how to identify the outcomes of interest and possible related biomarkers. The research approach presented here allows the selected biomarkers to be grounded in conventional physiology/pathophysiology as well as complementary and alternative concepts, including traditional systems of medicine. The goal is to provide researchers in the field with a framework on how to integrate biomarkers into complex trials.

Clients of UK healers: A mixed methods survey of their demography, health problems, and experiences of healing.

BACKGROUND: Healing has not been well researched, and very little is known about who goes to healers, and what they experience. METHODS: A survey of UK-based healers was undertaken with the help of The Confederation of Healing Organisations, asking healers to report on up to 20 consultations. Forms asked about the demography of healer and client, reasons for the consultation, type of healing, and outcomes. Both quantitative and qualitative data were analysed. RESULTS: 278 returned forms from 39 healers (average age 58) were analysed. Healing was described as Spiritual (69%), Reiki (15%) or Energy (10%). The clients had an average age of 57, and 76% were women. The most common reasons for consulting were mental health problems and pain. 93% of the clients reported experiencing immediate benefits. Relaxation, improved wellbeing and relief of pain were often reported. In addition, 76 (27%) had some unusual sensory experiences during the session, such as feelings of warmth, seeing coloured lights, or tingling sensations. The majority of general comments about the experience were positive, and 68% made another appointment. CONCLUSIONS: Older people, particularly older women, are the main recipients of healing in the UK, and they go for help with many problems, particularly mental health issues and pain. The majority have a positive experience, and come back for more. In addition to relief of symptoms, many have sensory experiences which could indicate that some special type of interaction was taking place between healer and healee.

Spending at least 120 minutes a week in nature is associated with good health and wellbeing.

Spending time in natural environments can benefit health and well-being, but exposure-response relationships are under-researched. We examined associations between recreational nature contact in the last seven days and self-reported health and well-being. Participants (n = 19,806) were drawn from the Monitor of Engagement with the Natural Environment Survey (2014/15-2015/16); weighted to be nationally representative. Weekly contact was categorised using 60 min blocks. Analyses controlled for residential greenspace and other neighbourhood and individual factors. Compared to no nature contact last week, the likelihood of reporting good health or high well-being became significantly greater with contact ≥120 mins (e.g. 120-179 mins: ORs [95%CIs]: Health = 1.59 [1.31-1.92]; Well-being = 1.23 [1.08-1.40]). Positive associations peaked between 200-300 mins per week with no further gain. The pattern was consistent across key groups including older adults and those with long-term health issues. It did not matter how 120 mins of contact a week was achieved (e.g. one long vs. several shorter visits/week). Prospective longitudinal and intervention studies are a critical next step in developing possible weekly nature exposure guidelines comparable to those for physical activity.

Nature-Based Interventions for Improving Health and Wellbeing: The Purpose, the People and the Outcomes.

Engagement with nature is an important part of many people's lives, and the health and wellbeing benefits of nature-based activities are becoming increasingly recognised across disciplines from city planning to medicine. Despite this, urbanisation, challenges of modern life and environmental degradation are leading to a reduction in both the quantity and the quality of nature experiences. Nature-based health interventions (NBIs) can facilitate behavioural change through a somewhat structured promotion of nature-based experiences and, in doing so, promote improved physical, mental and social health and wellbeing. We conducted a Delphi expert elicitation process with 19 experts from seven countries (all named authors on this paper) to identify the different forms that such interventions take, the potential health outcomes and the target beneficiaries. In total, 27 NBIs were identified, aiming to prevent illness, promote wellbeing and treat specific physical, mental or social health and wellbeing conditions. These interventions were broadly categorized into those that change the environment in which people live, work, learn, recreate or heal (for example, the provision of gardens in hospitals or parks in cities) and those that change behaviour (for example, engaging people through organized programmes or other activities). We also noted the range of factors (such as socioeconomic variation) that will inevitably influence the extent to which these interventions succeed. We conclude with a call for research to identify the drivers influencing the effectiveness of NBIs in enhancing health and wellbeing.

The production of hypericins in two selected Hypericum perforatum shoot cultures is related to differences in black gland structure.

In vitro shoot cultures of Hypericum perforatum derived from wild populations grown in Armenia have a wide variation of hypericin and pseudohypericin metabolite content. We found that a germ line denoted as HP3 produces six times more hypericin and fourteen times more pseudohypericin than a second line labeled HP1. We undertook a structural comparison of the two lines (HP1 and HP3) in order to see if there are any anatomical or morphological differences that could explain the differences in production of these economically important metabolites. Analysis by LM (light microscopy), SEM (scanning electron microscopy), and TEM (transmission electron microscopy) reveals that the hypericin/pseudohypericin-containing black glands located along the margins of the leaves consist of a peripheral sheath of flattened cells surrounding a core of interior cells that are typically dead at maturity. The peripheral cells of the HP3 glands appear less flattened than those of the HP1 glands. This may indicate that the peripheral cells are involved in hypericin/pseudohypericin production. Furthermore, we find that these peripheral cells undergo a developmental transition into the gland's interior cells. The fact that the size of the peripheral cells may correlate with metabolite production adds a new hypothesis for the actual site of hypericin synthesis.

Transformational Changes in Health Status: A Qualitative Exploration of Healing Moments.

BACKGROUND AND AIMS: Dramatic self-change is a familiar concept within religious experience and is recognized within psychotherapy and some fields of nursing. However, it has been given limited consideration in wider health research, including healing research. We sought to explore the phenomenon of "healing moments". METHODS: Alternative medicine practitioners attending a continuing professional development course for healers within the UK's Holistic Health Show were shown a 10min video clip showing two of the authors discussing healing moments. Sixty-nine (69) of the practitioners then provided "short stories" outlining their own experiences of such moments. Both the video and the short stories were analyzed qualitatively using a thematic approach. We sought to evaluate holistic practitioners' perceptions of the concept of healing moments. RESULTS: The concept of healing moments was widely accepted by the 69 participants. An overarching theme of transformational change described personal shifts that ranged from the sudden and quasimiraculous to transient but much-needed improvements in health and wellbeing. Three subordinate themes of connectivity, quiescence and control were identified. Connectivity described intense connections, experienced through touch, empathy and love, which could provide reciprocal benefits for healers as well as clients. Quiescence captured the quiet, calm atmosphere that pervaded many healing episodes. The contrasting aspects of control encompassed healers relinquishing control to channel healing, and clients seizing control to become empowered in their own healing process. CONCLUSION: Healing moments are a recognized and distinct concept within healing, although they remain under-explored in the literature. Our findings suggest that such experiences are common among alternative medicine practitioners. The concepts we uncovered can inform future research.

Healing journey: a qualitative analysis of the healing experiences of Americans suffering from trauma and illness.

OBJECTIVES: To elucidate pathways to healing for people having suffered injury to the integrity of their function as a human being. METHODS: A team of physician-analysts conducted thematic analyses of in-depth interviews of 23 patients who experienced healing, as identified by six primary care physicians purposefully selected as exemplary healers. RESULTS: People in the sample experienced healing journeys that spanned a spectrum from overcoming unspeakable trauma and then becoming healers themselves to everyday heroes functioning well despite ongoing serious health challenges.The degree and quality of suffering experienced by each individual is framed by contextual factors that include personal characteristics, timing of their initial or ongoing wounding in the developmental life cycle and prior and current relationships.In the healing journey, bridges from suffering are developed to healing resources/skills and connections to helpers outside themselves. These bridges often evolve in fits and starts and involve persistence and developing a sense of safety and trust.From the iteration between suffering and developing resources and connections, a new state emerges that involves hope, self-acceptance and helping others. Over time, this leads to healing that includes a sense of integrity and flourishing in the pursuit of meaningful goals and purpose. CONCLUSION: Moving from being wounded, through suffering to healing, is possible. It is facilitated by developing safe, trusting relationships and by positive reframing that moves through the weight of responsibility to the ability to respond.

Isoflavone levels in five soybean (Glycine max) genotypes are altered by phytochrome-mediated light treatments.

The objective of the present study was to determine whether concentrations of different isoflavones (puerarin, genistein, genistin, daidzein, and daidzin) in shoots and roots of five selected soybean genotypes would respond the same or differently to red (650 nm peak transmittance) and far-red (750 nm peak transmittance) light treatments given under controlled environments. Levels of isoflavones (mg g(-1) dry weight biomass) present in seeds, control roots, and shoots and 10 day light-treated seedlings (light, dark, red, and far-red wavelengths) of soybean (Glycine max) were determined by high-performance liquid chromatography analysis in comparison with known isoflavone standards. Seeds of the five soybean genotypes studied consistently stored most of their isoflavones as glucosyl conjugates (e.g., daidzin, genistin, and puerarin). For the five soybean genotypes, isoflavone levels were lower in the seeds as compared with roots plus shoots of control, time zero (first true leaf stage) seedlings. Following 10 days of the respective light treatments, we found that (i) isoflavone levels were enhanced in dark-grown plants over light-grown plants for three of the five genotypes (a new finding) and the reverse occurred for a single genotype (a typical response of legumes) and (ii) generally, far-red end of day (EOD) light treatment enhanced total isoflavone levels in roots plus shoots over red EOD light treatment. Results from the present study show that phytochrome does appear to play a role in regulating isoflavone levels in developing soybean seedlings and that this influence by red/far-red-mediated phytochrome reactions is strongly dependent on the genotypes selected for study.

The Online Dissemination of Nature-Health Concepts: Lessons from Sentiment Analysis of Social Media Relating to "Nature-Deficit Disorder".

Evidence continues to grow supporting the idea that restorative environments, green exercise, and nature-based activities positively impact human health. Nature-deficit disorder, a journalistic term proposed to describe the ill effects of people's alienation from nature, is not yet formally recognized as a medical diagnosis. However, over the past decade, the phrase has been enthusiastically taken up by some segments of the lay public. Social media, such as Twitter, with its opportunities to gather "big data" related to public opinions, offers a medium for exploring the discourse and dissemination around nature-deficit disorder and other nature-health concepts. In this paper, we report our experience of collecting more than 175,000 tweets, applying sentiment analysis to measure positive, neutral or negative feelings, and preliminarily mapping the impact on dissemination. Sentiment analysis is currently used to investigate the repercussions of events in social networks, scrutinize opinions about products and services, and understand various aspects of the communication in Web-based communities. Based on a comparison of nature-deficit-disorder "hashtags" and more generic nature hashtags, we make recommendations for the better dissemination of public health messages through changes to the framing of messages. We show the potential of Twitter to aid in better understanding the impact of the natural environment on human health and wellbeing.

What approaches to social prescribing work, for whom, and in what circumstances? A protocol for a realist review.

BACKGROUND: The use of non-drug, non-health-service interventions has been proposed as a cost-effective alternative to help those with long-term conditions manage their illness and improve their health and well-being. Interventions typically involve accessing activities run by the third sector or community agencies and may also be described as non-medical referral, community referral or social prescribing. To be effective, patients need to be "transferred" from the primary care setting into the community and to maintain their participation in activities. However, it is not currently known how and why these approaches enable which people under what circumstances to reach community services that may benefit their health and well-being. METHODS: Database searches and extensive searching of grey sources will be carried out in an attempt to find evidence associated with referral and retention in social prescribing. After initial scoping searches, two main phases of searching will be conducted: (a) will focus on the identification of programme theories to illustrate how approaches to social prescribing work for different people and in different contexts and (b) will consist of targeted searches to locate evidence to refine these candidate theories into configurations of the contexts in which populations and the main mechanisms outcomes are achieved. Inclusion criteria will initially be broad in order to develop a clear picture of the ways in which social prescriptions might operate but may iteratively become more focused in response to initially identified evidence, for example, in terms of the population group. An expert advisory group consisting of professionals working in a range of organisations involved in social prescribing will be convened to check the approaches in the review and provide real-life experience of social prescribing. Findings from the review will be disseminated to commissioners, published in a peer-reviewed journal and used to help refine an intervention model for an outdoor nature-based group intervention. DISCUSSION: This realist review will explore why mechanisms of social prescribing work, for what groups of people and their impact on enrolment, attendance and adherence to programmes. The use of realist approaches to detail the social prescribing process is novel and will offer insights into effective transfer of patients. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016039491.