Enhancing Public Health Outcomes: A Qualitative Study of Former Participants' Experiences of the Green Prescription Program in Aotearoa New Zealand

Enhancing Public Health Outcomes: A Qualitative Study of Former Participants' Experiences of the Green Prescription Program in Aotearoa New Zealand | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Enhancing Public Health Outcomes: A Qualitative Study of Former Participants' Experiences of the Green Prescription Program in Aotearoa New Zealand Kobus Du Plooy, Beth Wishart, Damian Scarf This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6764541/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Oct, 2025 Read the published version in BMC Public Health → Version 1 posted 12 You are reading this latest preprint version Abstract Background Physical activity promotion through primary care represents a key public health strategy. New Zealand's Green Prescription (GRx) program, a nationwide primary care-based physical activity intervention, has operated for over 25 years but lacks comprehensive evaluation of participant experiences and long-term impacts. Methods This qualitative study used semi-structured interviews with 15 former GRx Otago participants (6 male, 8 female, mean age 60 years). Interviews explored experiences of the program, impacts on physical activity, mental health, and quality of life, and recommendations for improvement. Data were analyzed using Interpretive Thematic Analysis following Braun and Clarke's six-step approach. Results Six main themes emerged: barriers to engagement, general experiences, mental health experiences, physical activity experiences, quality of life experiences, and recommendations for program improvement. Most participants (14/15, 93%) reported increased physical activity levels, while 12/15 (80%) experienced mental health improvements. Key barriers included financial constraints (16 participant references), transportation difficulties (9 references), and complex medical conditions (24 references). Participants valued the program's strengths-based approach, social connections, and individually tailored support. Primary recommendations included extending program duration, enhancing in-person support, diversifying activity options, and strengthening community organization partnerships. Conclusions The GRx program demonstrates effectiveness in promoting physical activity and associated health benefits among participants. However, significant opportunities exist for enhancement through addressing identified barriers, extending support duration, and developing more comprehensive community partnerships. These findings provide evidence-based strategies for improving primary care-based physical activity interventions globally. Green Prescription physical activity public health primary care qualitative research health promotion behaviour change Background Physical activity represents one of the most cost-effective interventions for preventing and managing chronic diseases, yet global levels remain inadequate across all age groups [ 1 ]. Primary care settings offer unique opportunities for promoting physical activity, with healthcare providers positioned to reach diverse populations and provide credible, personalized advice [ 2 ]. However, successful implementation of primary care-based physical activity interventions requires understanding of participant experiences, barriers to engagement, and factors contributing to sustained behaviour change. New Zealand's Green Prescription (GRx) program, launched in 1998, represents one of the world's longest-running primary care-based physical activity interventions [ 3 ]. The program enables healthcare providers to "prescribe" physical activity by referring patients to qualified exercise professionals who provide individualized support, goal setting, and connections to community-based activities [ 4 ]. Initially focused on physical health outcomes, the program has evolved to recognize connections between physical activity, mental health, and overall quality of life [ 5 ]. Previous quantitative evaluations of GRx have demonstrated positive outcomes including increased physical activity levels, improved cardiovascular risk factors, and enhanced mental well-being over 6–12 month periods [ 6 – 11 ]. However, these studies have predominantly focused on short-term outcomes immediately following program completion, with limited exploration of participants' subjective experiences or long-term sustainability of behaviour changes. Understanding participant perspectives is crucial for optimizing program delivery and informing the development of similar interventions globally. Qualitative research can illuminate the mechanisms through which programs achieve their effects, identify barriers and facilitators to engagement, and provide insights into how interventions might be enhanced [ 12 ]. Such evidence is particularly important given the complex, multi-faceted nature of behaviour change interventions, where quantitative measures alone may not capture the full range of program impacts or participant experiences. This study sought to address these knowledge gaps by exploring the lived experiences of former GRx Otago participants through in-depth interviews. Specifically, we aimed to: (1) understand participants' overall experiences of the program; (2) examine perceived impacts on physical activity, mental health, and quality of life; (3) identify barriers and facilitators to program engagement; and (4) gather evidence-based recommendations for program improvement. Methods Study Design A qualitative descriptive approach using semi-structured interviews was selected to explore the complex, multi-dimensional experiences of former GRx participants. This methodology allows for in-depth exploration of participants' perspectives, experiences, and recommendations in their own words [ 13 ]. Setting and Context Green Prescription Otago operates as part of the national GRx program in the Otago region of New Zealand. The program receives referrals from general practitioners and other healthcare providers for patients who would benefit from increased physical activity. Participants receive individualized consultations with exercise professionals, goal setting, and support to access subsidized community-based activities over a 3–6 month period. Participants and Recruitment Former GRx Otago participants were recruited through the program database with assistance from staff. Inclusion criteria were: (1) completion of the GRx program at least 6 months prior to interview; (2) age 18 years or older; (3) ability to provide informed consent; and (4) willingness to participate in a recorded interview. Potential participants were initially contacted by GRx staff, with interested individuals providing consent for researchers to contact them directly. Data Collection Semi-structured interviews were conducted between May and August 2025 by the 1st and 2nd authors. Interview duration ranged from 13 to 42 minutes (mean 25 minutes). Ten participants were interviewed in person at the University of Otago's Department of Psychological Medicine; five participants residing in Central Otago (> 60 minutes from Dunedin) were interviewed online via secure video conferencing. All interviews followed a semi-structured guide according to which each participant was asked the following questions: What was your experience of Green Prescription? How did Green Prescription affect your physical activity levels? How did Green Prescription affect your mental health? How did Green Prescription affect your quality of life? What would you recommend to improve Green Prescription? What would attract more people who are considering to take up Green Prescription to do so? These questions were compiled with the assistance of the GRx administrators to achieve the aim of the research question by covering six core areas: Overall experience of Green Prescription Impact on physical activity levels Impact on mental health Impact on quality of life Recommendations for program improvement Suggestions for attracting new participants Additional probing questions were used to explore responses in greater depth where appropriate. All interviews were audio-recorded with participant consent and transcribed verbatim using automated transcription software, with subsequent manual verification for accuracy. Data Analysis Data were analysed using Interpretive Thematic Analysis following Braun and Clarke's six-step approach [ 14 ]. The analysis process involved: (1) familiarization with data through repeated reading of transcripts; (2) generation of initial codes through systematic coding of interesting features; (3) identification of themes by collating codes into potential themes; (4) review and refinement of themes to ensure coherent patterns; (5) definition and naming of final themes; and (6) production of the final analysis report. The research team consisted of a clinical psychologist/researcher (first author), a research assistant with qualitative research experience (second author), and another psychologist/researcher (third author). Throughout the analysis process, the team engaged in reflexive practice, acknowledging their backgrounds and potential biases, and how these might influence interpretation of the data. Ethical Considerations Ethical approval was obtained from the University of Otago Human Ethics Committee (reference H22/114). All participants provided written informed consent prior to participation. Participants were assured of confidentiality and their right to withdraw from the study at any time. All data were de-identified during transcription and analysis. Results Participant Characteristics Fifteen former GRx Otago participants took part in the study (6 male, 8 female, 1 undisclosed gender; mean age 60 years, range 42–77 years). Participants had completed the GRx program between 6 months and 3 years prior to interview. Referral sources included general practitioners (n = 12), specialists (n = 2), and self-referral (n = 1). Thematic Analysis Six key themes emerged from the data analysis, encompassing 347 coded references across all interviews. Table 1 provides a comprehensive overview of themes, sub-themes, and the frequency of participant references to each area. Table 1 Summary of themes and sub-themes from participant interviews Theme & Sub-themes References 1. Barriers to engagement 1.1 Confusion due to program name 5 1.2 COVID-19 pandemic impacts 10 1.3 Accessibility and transport difficulties 9 1.4 Financial constraints 16 1.5 Medical conditions and medication effects 24 1.6 Time limitations 6 1.7 Physical and social isolation 8 2. General experiences 2.1 Mixed experiences 15 2.2 Negative experiences 1 2.2.1 Ineffective staff interactions 9 2.2.2 Long follow-up delays 3 2.3 Positive experiences 31 2.3.1 Family and peer support 44 2.3.2 Effective staff support 87 3. Mental health experiences 3.1 Mental health improvement 36 3.2 No mental health impact 3 4. Physical activity experiences 4.1 No increase in physical activity 1 4.2 Increased physical activity 27 5. Quality of life experiences 5.1 Improved quality of life 11 5.2 No change in quality of life 2 6. Recommendations for improvement 6.1 Community organization involvement 12 6.2 Program duration extension 9 6.3 Enhanced advertising and communication 34 6.4 Improved follow-up protocols 16 6.5 Better training materials 14 6.6 Activity diversification 9 6.7 Increased program awareness 15 6.8 Enhanced in-person support 23 Theme 1: Barriers to Engagement Participants identified multiple barriers that limited their engagement with the GRx program. The most frequently cited barrier was financial constraints (16 references), with participants noting that even subsidized activities could be prohibitively expensive for those on limited incomes. One participant explained: "Even with the discount, it was still quite expensive for me being on a benefit." Complex medical conditions and medication side effects represented another significant barrier (24 references), with participants describing how chronic pain, mobility limitations, and medication effects impacted their ability to engage fully with recommended activities. Transportation difficulties (9 references) were particularly challenging for participants in rural areas or those without reliable transport. The COVID-19 pandemic had a detrimental impact on program delivery (10 references), with many activities suspended or modified, reducing the social and community aspects that participants valued. Some participants (5 references) also noted confusion about the program name, with "Green Prescription" not clearly conveying the focus on physical activity and lifestyle support. Theme 2: General Experiences Most participants reported positive overall experiences with the GRx program (31 references). The quality of staff support emerged as a crucial factor, with participants particularly valuing individualized, tailored approaches to their specific circumstances and health conditions. One participant noted: "The staff member was just fantastic. She really listened to what I needed and adapted everything to suit my situation." Effective staff support encompassed multiple dimensions including accountability (12 references), empowerment (12 references), holistic care (8 references), and ongoing availability (13 references). Participants appreciated staff who focused on their capabilities rather than limitations, with one explaining: "For the first time in about two years, I felt like I could take control of some of my health... It was just so refreshing to be given advice about something that I could do, instead of being given orders about what I shouldn't do." The development of new social connections through group activities was highly valued (35 references), with many participants noting that the social aspects were as important as the physical activity itself. Family involvement and support also enhanced the program experience for some participants (9 references). Negative experiences were relatively uncommon but included ineffective staff interactions (9 references) and long delays in follow-up contact (3 references). Theme 3: Mental Health Experiences The majority of participants (12/15) reported significant mental health improvements through their involvement in the GRx program (36 references). For many, the program provided hope, structure, and purpose during challenging life periods. One participant described: "I actually remember saying to my partner before going in, 'this isn't going to work'... I was having some rather dark thoughts before I got in touch with green prescription... And that first appointment, I remember walking out and going 'There's hope'." Participants particularly valued the program's strengths-based approach, which differed markedly from previous healthcare experiences focused on limitations and restrictions. This approach appeared to enhance self-efficacy and optimism about their capacity for positive change. Three participants reported no impact on mental health, typically those with strong existing support networks or limited program engagement due to external circumstances. Theme 4: Physical Activity Experiences Nearly all participants (14/15) reported increased physical activity levels following program participation (27 references). The program helped participants discover new forms of exercise suitable for their specific circumstances, particularly important for those with physical limitations or chronic conditions. Participants appreciated learning that beneficial physical activity could take many forms, not just traditional exercise. One participant with mobility limitations explained: "Green prescription was like, exercise doesn't have to be a physical thing. You can exercise your mind. You can exercise your emotions, you can exercise your lungs and your brain and get out there and have some fresh air." Subsidized access to facilities was crucial for many participants, making regular activity financially viable. The social dimensions of group activities also enhanced motivation and enjoyment, though some participants noted challenges maintaining activity levels after formal program support ended. Theme 5: Quality of Life Experiences Most participants (13/15) reported improved quality of life following program participation (11 references). Improvements were linked to increased physical activity enhancing daily functioning, greater social engagement, and improved confidence for activities previously avoided due to physical limitations or self-consciousness. One participant described the transformation: "I used to wake up in the morning and go, 'Oh, here's another day... I'm going to be in bed. I'm going to feel useless.' Whereas now I wake up and I'm, first thing in the morning I'm like 'morning girls, let's go do this, this'... I appreciate every single day now." For participants with chronic conditions, the program provided practical tools for better health management. Regular outdoor activity was particularly valued by those affected by seasonal mood changes. Theme 6: Recommendations for Program Improvement Participants offered extensive recommendations for enhancing the GRx program, with improved advertising and communication being the most frequently mentioned area (34 references). Many felt the program was not well-known in the community and that clearer communication about its benefits could increase uptake. Enhanced in-person support was strongly recommended (23 references), particularly for participants with mental health challenges who found phone-based follow-up insufficient. Participants suggested more face-to-face interactions could build stronger relationships and provide more effective ongoing support. Extending program duration (9 references) was seen as crucial for establishing sustainable behaviour changes, with current timeframes viewed as insufficient for meaningful lifestyle modification. Participants also recommended stronger connections with community organizations (12 references) to provide pathways for continued activity after formal program completion. Other key recommendations included improved training materials better tailored to diverse needs (14 references), enhanced follow-up protocols (16 references), and diversification of activity options to accommodate different interests and abilities (9 references). Discussion This qualitative study provides valuable insights into participant experiences of New Zealand's Green Prescription program, revealing both significant benefits and opportunities for enhancement. The findings demonstrate that primary care-based physical activity interventions can achieve meaningful impacts across multiple domains of health and well-being, while also highlighting specific barriers and facilitators that influence program effectiveness. Program Effectiveness and Mechanisms The high proportion of participants reporting increased physical activity (93%) and mental health improvements (80%) supports previous quantitative evaluations of the GRx program [ 6 – 11 ]. However, our qualitative approach reveals important insights into the mechanisms underlying these benefits. The program's strengths-based approach, focusing on capabilities rather than limitations, appears to be a key factor in promoting self-efficacy and positive behaviour change. This finding aligns with self-determination theory, which emphasizes the importance of autonomy, competence, and relatedness in sustaining behaviour change [ 15 ]. The social connections developed through group activities emerged as equally important as the physical activity itself, supporting research highlighting the role of social support in maintaining active lifestyles [ 16 ]. This finding suggests that the community-building aspects of physical activity interventions may be as crucial as the exercise prescription itself. Barriers and Implementation Challenges The barriers identified in this study reflect common challenges in public health program implementation. Financial constraints, despite subsidized access, remained prohibitive for some participants, highlighting the need for programs to consider the full spectrum of socioeconomic circumstances among target populations [ 17 ]. Transportation difficulties, particularly affecting rural participants, represent a significant equity issue that requires targeted solutions. The impact of complex medical conditions on program engagement underscores the need for interventions specifically designed for populations with chronic conditions and comorbidities [ 18 ]. The finding that some participants felt the program duration was insufficient for establishing sustainable behaviour change aligns with behaviour change research suggesting that longer intervention periods may be necessary for lasting lifestyle modification [ 19 ]. Implications for Program Enhancement Participants' recommendations provide a roadmap for evidence-based program improvements. The emphasis on enhanced in-person support, particularly for those with mental health challenges, suggests that while digital and phone-based interventions offer scalability, they may not be optimal for all participants [ 20 ]. A tiered approach offering different levels of support based on individual needs and preferences may optimize program effectiveness. The recommendation to strengthen connections with community organizations addresses a critical gap in sustainability planning. Creating formal pathways from structured programs to ongoing community-based activities could help bridge the "maintenance gap" that often undermines long-term behaviour change [ 21 ]. International Relevance While this study focused on a New Zealand program, the barriers and facilitators identified have international relevance. Financial constraints, transportation challenges, and the need for individualized, holistic approaches are universal considerations in public health program design [ 22 ]. The positive impacts of strengths-based approaches and social connection building are also supported by international literature on health behaviour change [ 23 ]. Strengths and Limitations This study's strengths include its focus on longer-term participant experiences (6 + months post-completion), use of established qualitative methodology, and inclusion of participants from both urban and rural settings. The research team's clinical and research expertise enhanced the depth of analysis and interpretation. However, several limitations should be noted. The sample size, while appropriate for qualitative research, may not capture the full diversity of participant experiences. Self-selection bias may have favoured participants with stronger opinions about the program. The retrospective design relies on participant recall, which may be subject to memory limitations. Additionally, the study did not include perspectives from program staff, referring healthcare providers, or individuals who declined to participate in GRx. Future Research Directions Future research should explore the optimal duration and intensity of support needed for different population groups, particularly those with complex health conditions. Comparative studies examining different delivery models (in-person vs. digital vs. hybrid) could inform evidence-based service design. Economic evaluations incorporating participant-reported outcomes would provide valuable information for policy makers and program funders. Longitudinal studies tracking participants over extended periods (2 + years) would provide insights into the sustainability of behaviour changes and identify factors associated with long-term success. Research examining the experiences of healthcare providers and program staff would provide additional perspectives on program implementation and optimization. Conclusions The Green Prescription Otago program demonstrates significant potential for promoting physical activity and associated health benefits among participants. The program's strengths-based approach, individualized support, and community connections appear to be key mechanisms underlying its effectiveness. However, meaningful opportunities exist for enhancement through addressing identified barriers, extending support duration, and developing more comprehensive community partnerships. The recommendations provided by participants offer evidence-based strategies for improving not only the GRx program but primary care-based physical activity interventions more broadly. By addressing financial barriers, enhancing in-person support, extending program duration, and strengthening community connections, such programs could achieve even greater impact on public health outcomes. The broader implications of this research extend beyond New Zealand's borders. As healthcare systems globally seek cost-effective strategies for promoting population health and preventing chronic disease, the insights gained from this study provide valuable guidance for developing and implementing successful primary care-based physical activity interventions. Declarations Ethics approval and consent to participate This study received ethical approval from the University of Otago Human Ethics Committee (reference number: H22/114). All participants provided written informed consent prior to participation. Consent for publication Not applicable. No individual participant data, images, or videos are included in this manuscript. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request, subject to ethical considerations regarding participant confidentiality. Competing interests The authors declare that they have no competing interests. Funding This research was funded by the James Hume Bequest. The funder had no role in study design, data collection, analysis, interpretation, or manuscript preparation. Authors' contributions KDP conceived and designed the study, conducted interviews, performed data analysis, and drafted the manuscript. BW conducted interviews, assisted with data analysis, and contributed to manuscript preparation. DS contributed to study design, participated in theme review and analysis, and provided feedback on the manuscript prior to his passing. All authors reviewed and approved the final manuscript. Acknowledgements We would like to thank all participants who generously shared their experiences and insights for this study. We also acknowledge the support of Green Prescription Otago staff in facilitating recruitment of former participants. Authors' information KDP is a Senior Lecturer and Clinical Psychologist in the Department of Psychological Medicine at the University of Otago, with research interests in mental health, health behaviour change, and qualitative research methods. BW is a Research Assistant in the Department of Psychological Medicine with expertise in qualitative research and health psychology. DS was a Senior Lecturer in the Department of Psychology at the University of Otago with extensive experience in behavioural research and statistical analysis. References Warburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: the evidence. CMAJ. 2006;174(6):801–9. 10.1503/cmaj.051351 . Lobelo F, Duperly J, Frank E. Physical activity habits of doctors and medical students influence their counselling practices. Br J Sports Med. 2009;43(2):89–92. 10.1136/bjsm.2008.055426 . Patel A, Schofield GM, Kolt GS, Keogh JW. General practitioners' views and experiences of counselling for physical activity through the New Zealand Green Prescription program. BMC Fam Pract. 2011;12:119. 10.1186/1471-2296-12-119 . Stanhope J, Weinstein P. What are green prescriptions? A scoping review. J Prim Health Care. 2023;15:155–61. 10.1071/HC23007 . Robinson JM, Breed MF. Green prescriptions and their co-benefits: Integrative strategies for public and environmental health. Challenges. 2019;10:9. 10.3390/challe10010009 . Hamlin MJ, Yule E, Elliot CA, Stoner L, Kathiravel Y. Long-term effectiveness of the New Zealand Green Prescription primary health care exercise initiative. Public Health. 2016;140:102–8. 10.1016/j.puhe.2016.07.014 . Kerse N, Elley CR, Robinson E, Arroll B. Is physical activity counseling effective for older people? A cluster randomized, controlled trial in primary care. J Am Geriatr Soc. 2005;53:1951–6. 10.1111/j.1532-5415.2005.00466.x . Patel A, Keogh JW, Kolt GS, Schofield GM. The long-term effects of a primary care physical activity intervention on mental health in low-active, community-dwelling older adults. Aging Ment Health. 2013;17:766–72. 10.1080/13607863.2013.781118 . Kolt GS, Schofield GM, Kerse N, Garrett N, Ashton T, Patel A. Healthy Steps trial: pedometer-based advice and physical activity for low-active older adults. Ann Fam Med. 2012;10:206–12. 10.1370/afm.1345 . Lawton BA, Rose SB, Elley CR, Dowell AC, Fenton A, Moyes SA. Exercise on prescription for women aged 40–74 recruited through primary care: two year randomised controlled trial. BMJ. 2008;337:a2509. 10.1136/bmj.a2509 . Sinclair KM, Hamlin MJ. Self-reported health benefits in patients recruited into New Zealand's 'Green Prescription' primary health care program. Southeast Asian J Trop Med Public Health. 2007;38:1158–67. PMID: 18613560. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008;337:a1655. 10.1136/bmj.a1655 . Sandelowski M. What's in a name? Qualitative description revisited. Res Nurs Health. 2010;33:77–84. 10.1002/nur.20362 . Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77–101. 10.1191/1478088706qp063oa . Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol. 2000;55:68–78. 10.1037//0003-066x.55.1.68 . Thoits PA. Mechanisms linking social ties and support to physical and mental health. J Health Soc Behav. 2011;52:145–61. 10.1177/0022146510395592 . Bethancourt HJ, Rosenberg DE, Beatty T, Arterburn DE. Barriers to and facilitators of physical activity program use among older adults. Clin Med Res. 2014;12:10–20. 10.3121/cmr.2013.1171 . Mulligan H, Treharne GJ, Hale LA, Smith C. Combining self-help and professional help to minimize barriers to physical activity in persons with multiple sclerosis: a trial of the Blue Prescription approach in New Zealand. J Neurol Phys Ther. 2013;37:51–7. 10.1097/NPT.0b013e318292799e . Fjeldsoe B, Neuhaus M, Winkler E, Eakin E. Systematic review of maintenance of behaviour change following physical activity and dietary interventions. Health Psychol. 2011;30:99–109. 10.1037/a0021974 . Cadmus-Bertram LA, Marcus BH, Patterson RE, Parker BA, Morey BL. Randomized trial of a Fitbit-based physical activity intervention for women. Am J Prev Med. 2015;49:414–8. 10.1016/j.amepre.2015.01.020 . Kwasnicka D, Dombrowski SU, White M, Sniehotta F. Theoretical explanations for maintenance of behaviour change: a systematic review of behaviour theories. Health Psychol Rev. 2016;10:277–96. 10.1080/17437199.2016.1151372 . Adewuyi FA, Knobel P, Gogna P, Dadvand P. Health effects of green prescription: a systematic review of randomized controlled trials. Environ Res. 2023;236:116844. 10.1016/j.envres.2023.116844 . Michie S, Abraham C, Whittington C, McAteer J, Gupta S. Effective techniques in healthy eating and physical activity interventions: a meta-regression. Health Psychol. 2009;28:690–701. 10.1037/a0016136 . Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6764541","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":465784114,"identity":"bcaf50ed-cae9-434a-a0f3-453faa495dd2","order_by":0,"name":"Kobus Du Plooy","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABD0lEQVRIiWNgGAWjYBACCQYeEMXMwMAOoitI0sIMos8ABUjTwthGhBbJ9t5jkj8YrBO3MzMffMw7z6aOv3/xAYYfNQx58g3YtUjznEuT5mFIT9zZzJZszLstTULixrMExp5jDMWMOLTISeSYSTMwHE7ccJjHTJp322EJhhtnDBh4GxgSm3E4DKQF6DCYljmHJeSBWhj/ArW04dAiDdQiwQPX0nBYwuB8jwEzyJYeXN7vOZdszWOQbgzyi+GcY2mSG2+wJRyWOSaROAOHFonjvQdv/qiwlt3O3nzwwZsaG36584cPPgQyEufj8D4EGIARAxM4jiQSGA4wEBE/YC2MP0As/gOEVY+CUTAKRsGIAgCdHFMoohPfUgAAAABJRU5ErkJggg==","orcid":"","institution":"University of Otago","correspondingAuthor":true,"prefix":"","firstName":"Kobus","middleName":"","lastName":"Du Plooy","suffix":""},{"id":465784115,"identity":"e54b8b56-e8ba-4811-a1bd-5858721ab9df","order_by":1,"name":"Beth Wishart","email":"","orcid":"","institution":"University of Otago","correspondingAuthor":false,"prefix":"","firstName":"Beth","middleName":"","lastName":"Wishart","suffix":""},{"id":465784116,"identity":"ea4b6b23-6df1-45a0-8a63-fe800d7cbc05","order_by":2,"name":"Damian Scarf","email":"","orcid":"","institution":"University of Otago","correspondingAuthor":false,"prefix":"","firstName":"Damian","middleName":"","lastName":"Scarf","suffix":""}],"badges":[],"createdAt":"2025-05-28 05:53:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6764541/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6764541/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-025-24524-z","type":"published","date":"2025-10-01T15:57:20+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":92884450,"identity":"b9a4712e-bd2a-41ab-b9c8-118136776911","added_by":"auto","created_at":"2025-10-06 16:13:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":856591,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6764541/v1/7aeeb465-f2a0-4acb-a669-02b20eec6687.pdf"},{"id":83994999,"identity":"8c5f2ee3-4473-44f4-aad2-fab88f252a00","added_by":"auto","created_at":"2025-06-05 13:22:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":103937,"visible":true,"origin":"","legend":"","description":"","filename":"Semistructuredinterviewquestions.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6764541/v1/eb616ffa22074bd69116a3cc.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Enhancing Public Health Outcomes: A Qualitative Study of Former Participants' Experiences of the Green Prescription Program in Aotearoa New Zealand","fulltext":[{"header":"Background","content":"\u003cp\u003ePhysical activity represents one of the most cost-effective interventions for preventing and managing chronic diseases, yet global levels remain inadequate across all age groups [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Primary care settings offer unique opportunities for promoting physical activity, with healthcare providers positioned to reach diverse populations and provide credible, personalized advice [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, successful implementation of primary care-based physical activity interventions requires understanding of participant experiences, barriers to engagement, and factors contributing to sustained behaviour change.\u003c/p\u003e \u003cp\u003eNew Zealand's Green Prescription (GRx) program, launched in 1998, represents one of the world's longest-running primary care-based physical activity interventions [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The program enables healthcare providers to \"prescribe\" physical activity by referring patients to qualified exercise professionals who provide individualized support, goal setting, and connections to community-based activities [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Initially focused on physical health outcomes, the program has evolved to recognize connections between physical activity, mental health, and overall quality of life [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrevious quantitative evaluations of GRx have demonstrated positive outcomes including increased physical activity levels, improved cardiovascular risk factors, and enhanced mental well-being over 6\u0026ndash;12 month periods [\u003cspan additionalcitationids=\"CR7 CR8 CR9 CR10\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, these studies have predominantly focused on short-term outcomes immediately following program completion, with limited exploration of participants' subjective experiences or long-term sustainability of behaviour changes.\u003c/p\u003e \u003cp\u003eUnderstanding participant perspectives is crucial for optimizing program delivery and informing the development of similar interventions globally. Qualitative research can illuminate the mechanisms through which programs achieve their effects, identify barriers and facilitators to engagement, and provide insights into how interventions might be enhanced [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Such evidence is particularly important given the complex, multi-faceted nature of behaviour change interventions, where quantitative measures alone may not capture the full range of program impacts or participant experiences.\u003c/p\u003e \u003cp\u003eThis study sought to address these knowledge gaps by exploring the lived experiences of former GRx Otago participants through in-depth interviews. Specifically, we aimed to: (1) understand participants' overall experiences of the program; (2) examine perceived impacts on physical activity, mental health, and quality of life; (3) identify barriers and facilitators to program engagement; and (4) gather evidence-based recommendations for program improvement.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003e A qualitative descriptive approach using semi-structured interviews was selected to explore the complex, multi-dimensional experiences of former GRx participants. This methodology allows for in-depth exploration of participants' perspectives, experiences, and recommendations in their own words [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSetting and Context\u003c/h3\u003e\n\u003cp\u003eGreen Prescription Otago operates as part of the national GRx program in the Otago region of New Zealand. The program receives referrals from general practitioners and other healthcare providers for patients who would benefit from increased physical activity. Participants receive individualized consultations with exercise professionals, goal setting, and support to access subsidized community-based activities over a 3\u0026ndash;6 month period.\u003c/p\u003e\n\u003ch3\u003eParticipants and Recruitment\u003c/h3\u003e\n\u003cp\u003eFormer GRx Otago participants were recruited through the program database with assistance from staff. Inclusion criteria were: (1) completion of the GRx program at least 6 months prior to interview; (2) age 18 years or older; (3) ability to provide informed consent; and (4) willingness to participate in a recorded interview. Potential participants were initially contacted by GRx staff, with interested individuals providing consent for researchers to contact them directly.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eSemi-structured interviews were conducted between May and August 2025 by the 1st and 2nd authors. Interview duration ranged from 13 to 42 minutes (mean 25 minutes). Ten participants were interviewed in person at the University of Otago's Department of Psychological Medicine; five participants residing in Central Otago (\u0026gt;\u0026thinsp;60 minutes from Dunedin) were interviewed online via secure video conferencing. All interviews followed a semi-structured guide according to which each participant was asked the following questions:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat was your experience of Green Prescription?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHow did Green Prescription affect your physical activity levels?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHow did Green Prescription affect your mental health?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHow did Green Prescription affect your quality of life?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat would you recommend to improve Green Prescription?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat would attract more people who are considering to take up Green Prescription to do so?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThese questions were compiled with the assistance of the GRx administrators to achieve the aim of the research question by covering six core areas:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eOverall experience of Green Prescription\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eImpact on physical activity levels\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eImpact on mental health\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eImpact on quality of life\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eRecommendations for program improvement\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSuggestions for attracting new participants\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eAdditional probing questions were used to explore responses in greater depth where appropriate. All interviews were audio-recorded with participant consent and transcribed verbatim using automated transcription software, with subsequent manual verification for accuracy.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eData were analysed using Interpretive Thematic Analysis following Braun and Clarke's six-step approach [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The analysis process involved: (1) familiarization with data through repeated reading of transcripts; (2) generation of initial codes through systematic coding of interesting features; (3) identification of themes by collating codes into potential themes; (4) review and refinement of themes to ensure coherent patterns; (5) definition and naming of final themes; and (6) production of the final analysis report.\u003c/p\u003e \u003cp\u003eThe research team consisted of a clinical psychologist/researcher (first author), a research assistant with qualitative research experience (second author), and another psychologist/researcher (third author). Throughout the analysis process, the team engaged in reflexive practice, acknowledging their backgrounds and potential biases, and how these might influence interpretation of the data.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthical Considerations\u003c/h2\u003e \u003cp\u003e Ethical approval was obtained from the University of Otago Human Ethics Committee (reference H22/114). All participants provided written informed consent prior to participation. Participants were assured of confidentiality and their right to withdraw from the study at any time. All data were de-identified during transcription and analysis.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eParticipant Characteristics\u003c/h2\u003e \u003cp\u003eFifteen former GRx Otago participants took part in the study (6 male, 8 female, 1 undisclosed gender; mean age 60 years, range 42\u0026ndash;77 years). Participants had completed the GRx program between 6 months and 3 years prior to interview. Referral sources included general practitioners (n\u0026thinsp;=\u0026thinsp;12), specialists (n\u0026thinsp;=\u0026thinsp;2), and self-referral (n\u0026thinsp;=\u0026thinsp;1).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eThematic Analysis\u003c/h2\u003e \u003cp\u003eSix key themes emerged from the data analysis, encompassing 347 coded references across all interviews. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e provides a comprehensive overview of themes, sub-themes, and the frequency of participant references to each area.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of themes and sub-themes from participant interviews\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme \u0026amp; Sub-themes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReferences\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Barriers to engagement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.1 Confusion due to program name\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.2 COVID-19 pandemic impacts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.3 Accessibility and transport difficulties\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.4 Financial constraints\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.5 Medical conditions and medication effects\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.6 Time limitations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.7 Physical and social isolation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2. General experiences\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.1 Mixed experiences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.2 Negative experiences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.2.1 Ineffective staff interactions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.2.2 Long follow-up delays\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.3 Positive experiences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.3.1 Family and peer support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.3.2 Effective staff support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e3. Mental health experiences\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.1 Mental health improvement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.2 No mental health impact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e4. Physical activity experiences\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4.1 No increase in physical activity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4.2 Increased physical activity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e5. Quality of life experiences\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5.1 Improved quality of life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5.2 No change in quality of life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e6. Recommendations for improvement\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6.1 Community organization involvement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6.2 Program duration extension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6.3 Enhanced advertising and communication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6.4 Improved follow-up protocols\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6.5 Better training materials\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6.6 Activity diversification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6.7 Increased program awareness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6.8 Enhanced in-person support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1: Barriers to Engagement\u003c/h2\u003e \u003cp\u003eParticipants identified multiple barriers that limited their engagement with the GRx program. The most frequently cited barrier was financial constraints (16 references), with participants noting that even subsidized activities could be prohibitively expensive for those on limited incomes. One participant explained: \u003cem\u003e\"Even with the discount, it was still quite expensive for me being on a benefit.\"\u003c/em\u003e\u003c/p\u003e \u003cp\u003eComplex medical conditions and medication side effects represented another significant barrier (24 references), with participants describing how chronic pain, mobility limitations, and medication effects impacted their ability to engage fully with recommended activities. Transportation difficulties (9 references) were particularly challenging for participants in rural areas or those without reliable transport.\u003c/p\u003e \u003cp\u003eThe COVID-19 pandemic had a detrimental impact on program delivery (10 references), with many activities suspended or modified, reducing the social and community aspects that participants valued. Some participants (5 references) also noted confusion about the program name, with \"Green Prescription\" not clearly conveying the focus on physical activity and lifestyle support.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: General Experiences\u003c/h2\u003e \u003cp\u003eMost participants reported positive overall experiences with the GRx program (31 references). The quality of staff support emerged as a crucial factor, with participants particularly valuing individualized, tailored approaches to their specific circumstances and health conditions. One participant noted: \u003cem\u003e\"The staff member was just fantastic. She really listened to what I needed and adapted everything to suit my situation.\"\u003c/em\u003e\u003c/p\u003e \u003cp\u003eEffective staff support encompassed multiple dimensions including accountability (12 references), empowerment (12 references), holistic care (8 references), and ongoing availability (13 references). Participants appreciated staff who focused on their capabilities rather than limitations, with one explaining: \u003cem\u003e\"For the first time in about two years, I felt like I could take control of some of my health... It was just so refreshing to be given advice about something that I could do, instead of being given orders about what I shouldn't do.\"\u003c/em\u003e\u003c/p\u003e \u003cp\u003e The development of new social connections through group activities was highly valued (35 references), with many participants noting that the social aspects were as important as the physical activity itself. Family involvement and support also enhanced the program experience for some participants (9 references).\u003c/p\u003e \u003cp\u003eNegative experiences were relatively uncommon but included ineffective staff interactions (9 references) and long delays in follow-up contact (3 references).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eTheme 3: Mental Health Experiences\u003c/h2\u003e \u003cp\u003eThe majority of participants (12/15) reported significant mental health improvements through their involvement in the GRx program (36 references). For many, the program provided hope, structure, and purpose during challenging life periods. One participant described: \u003cem\u003e\"I actually remember saying to my partner before going in, 'this isn't going to work'... I was having some rather dark thoughts before I got in touch with green prescription... And that first appointment, I remember walking out and going 'There's hope'.\"\u003c/em\u003e\u003c/p\u003e \u003cp\u003eParticipants particularly valued the program's strengths-based approach, which differed markedly from previous healthcare experiences focused on limitations and restrictions. This approach appeared to enhance self-efficacy and optimism about their capacity for positive change.\u003c/p\u003e \u003cp\u003eThree participants reported no impact on mental health, typically those with strong existing support networks or limited program engagement due to external circumstances.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eTheme 4: Physical Activity Experiences\u003c/h2\u003e \u003cp\u003eNearly all participants (14/15) reported increased physical activity levels following program participation (27 references). The program helped participants discover new forms of exercise suitable for their specific circumstances, particularly important for those with physical limitations or chronic conditions.\u003c/p\u003e \u003cp\u003eParticipants appreciated learning that beneficial physical activity could take many forms, not just traditional exercise. One participant with mobility limitations explained: \u003cem\u003e\"Green prescription was like, exercise doesn't have to be a physical thing. You can exercise your mind. You can exercise your emotions, you can exercise your lungs and your brain and get out there and have some fresh air.\"\u003c/em\u003e\u003c/p\u003e \u003cp\u003eSubsidized access to facilities was crucial for many participants, making regular activity financially viable. The social dimensions of group activities also enhanced motivation and enjoyment, though some participants noted challenges maintaining activity levels after formal program support ended.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eTheme 5: Quality of Life Experiences\u003c/h2\u003e \u003cp\u003eMost participants (13/15) reported improved quality of life following program participation (11 references). Improvements were linked to increased physical activity enhancing daily functioning, greater social engagement, and improved confidence for activities previously avoided due to physical limitations or self-consciousness.\u003c/p\u003e \u003cp\u003eOne participant described the transformation: \u003cem\u003e\"I used to wake up in the morning and go, 'Oh, here's another day... I'm going to be in bed. I'm going to feel useless.' Whereas now I wake up and I'm, first thing in the morning I'm like 'morning girls, let's go do this, this'... I appreciate every single day now.\"\u003c/em\u003e\u003c/p\u003e \u003cp\u003eFor participants with chronic conditions, the program provided practical tools for better health management. Regular outdoor activity was particularly valued by those affected by seasonal mood changes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eTheme 6: Recommendations for Program Improvement\u003c/h2\u003e \u003cp\u003e Participants offered extensive recommendations for enhancing the GRx program, with improved advertising and communication being the most frequently mentioned area (34 references). Many felt the program was not well-known in the community and that clearer communication about its benefits could increase uptake.\u003c/p\u003e \u003cp\u003eEnhanced in-person support was strongly recommended (23 references), particularly for participants with mental health challenges who found phone-based follow-up insufficient. Participants suggested more face-to-face interactions could build stronger relationships and provide more effective ongoing support.\u003c/p\u003e \u003cp\u003eExtending program duration (9 references) was seen as crucial for establishing sustainable behaviour changes, with current timeframes viewed as insufficient for meaningful lifestyle modification. Participants also recommended stronger connections with community organizations (12 references) to provide pathways for continued activity after formal program completion.\u003c/p\u003e \u003cp\u003eOther key recommendations included improved training materials better tailored to diverse needs (14 references), enhanced follow-up protocols (16 references), and diversification of activity options to accommodate different interests and abilities (9 references).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis qualitative study provides valuable insights into participant experiences of New Zealand's Green Prescription program, revealing both significant benefits and opportunities for enhancement. The findings demonstrate that primary care-based physical activity interventions can achieve meaningful impacts across multiple domains of health and well-being, while also highlighting specific barriers and facilitators that influence program effectiveness.\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eProgram Effectiveness and Mechanisms\u003c/h2\u003e \u003cp\u003eThe high proportion of participants reporting increased physical activity (93%) and mental health improvements (80%) supports previous quantitative evaluations of the GRx program [\u003cspan additionalcitationids=\"CR7 CR8 CR9 CR10\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, our qualitative approach reveals important insights into the mechanisms underlying these benefits. The program's strengths-based approach, focusing on capabilities rather than limitations, appears to be a key factor in promoting self-efficacy and positive behaviour change. This finding aligns with self-determination theory, which emphasizes the importance of autonomy, competence, and relatedness in sustaining behaviour change [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe social connections developed through group activities emerged as equally important as the physical activity itself, supporting research highlighting the role of social support in maintaining active lifestyles [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This finding suggests that the community-building aspects of physical activity interventions may be as crucial as the exercise prescription itself.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eBarriers and Implementation Challenges\u003c/h2\u003e \u003cp\u003eThe barriers identified in this study reflect common challenges in public health program implementation. Financial constraints, despite subsidized access, remained prohibitive for some participants, highlighting the need for programs to consider the full spectrum of socioeconomic circumstances among target populations [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Transportation difficulties, particularly affecting rural participants, represent a significant equity issue that requires targeted solutions.\u003c/p\u003e \u003cp\u003eThe impact of complex medical conditions on program engagement underscores the need for interventions specifically designed for populations with chronic conditions and comorbidities [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The finding that some participants felt the program duration was insufficient for establishing sustainable behaviour change aligns with behaviour change research suggesting that longer intervention periods may be necessary for lasting lifestyle modification [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eImplications for Program Enhancement\u003c/h2\u003e \u003cp\u003eParticipants' recommendations provide a roadmap for evidence-based program improvements. The emphasis on enhanced in-person support, particularly for those with mental health challenges, suggests that while digital and phone-based interventions offer scalability, they may not be optimal for all participants [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. A tiered approach offering different levels of support based on individual needs and preferences may optimize program effectiveness.\u003c/p\u003e \u003cp\u003eThe recommendation to strengthen connections with community organizations addresses a critical gap in sustainability planning. Creating formal pathways from structured programs to ongoing community-based activities could help bridge the \"maintenance gap\" that often undermines long-term behaviour change [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eInternational Relevance\u003c/h2\u003e \u003cp\u003eWhile this study focused on a New Zealand program, the barriers and facilitators identified have international relevance. Financial constraints, transportation challenges, and the need for individualized, holistic approaches are universal considerations in public health program design [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The positive impacts of strengths-based approaches and social connection building are also supported by international literature on health behaviour change [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eThis study's strengths include its focus on longer-term participant experiences (6\u0026thinsp;+\u0026thinsp;months post-completion), use of established qualitative methodology, and inclusion of participants from both urban and rural settings. The research team's clinical and research expertise enhanced the depth of analysis and interpretation.\u003c/p\u003e \u003cp\u003eHowever, several limitations should be noted. The sample size, while appropriate for qualitative research, may not capture the full diversity of participant experiences. Self-selection bias may have favoured participants with stronger opinions about the program. The retrospective design relies on participant recall, which may be subject to memory limitations. Additionally, the study did not include perspectives from program staff, referring healthcare providers, or individuals who declined to participate in GRx.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eFuture Research Directions\u003c/h2\u003e \u003cp\u003eFuture research should explore the optimal duration and intensity of support needed for different population groups, particularly those with complex health conditions. Comparative studies examining different delivery models (in-person vs. digital vs. hybrid) could inform evidence-based service design. Economic evaluations incorporating participant-reported outcomes would provide valuable information for policy makers and program funders.\u003c/p\u003e \u003cp\u003eLongitudinal studies tracking participants over extended periods (2\u0026thinsp;+\u0026thinsp;years) would provide insights into the sustainability of behaviour changes and identify factors associated with long-term success. Research examining the experiences of healthcare providers and program staff would provide additional perspectives on program implementation and optimization.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe Green Prescription Otago program demonstrates significant potential for promoting physical activity and associated health benefits among participants. The program's strengths-based approach, individualized support, and community connections appear to be key mechanisms underlying its effectiveness. However, meaningful opportunities exist for enhancement through addressing identified barriers, extending support duration, and developing more comprehensive community partnerships.\u003c/p\u003e \u003cp\u003eThe recommendations provided by participants offer evidence-based strategies for improving not only the GRx program but primary care-based physical activity interventions more broadly. By addressing financial barriers, enhancing in-person support, extending program duration, and strengthening community connections, such programs could achieve even greater impact on public health outcomes.\u003c/p\u003e \u003cp\u003eThe broader implications of this research extend beyond New Zealand's borders. As healthcare systems globally seek cost-effective strategies for promoting population health and preventing chronic disease, the insights gained from this study provide valuable guidance for developing and implementing successful primary care-based physical activity interventions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received ethical approval from the University of Otago Human Ethics Committee (reference number: H22/114). All participants provided written informed consent prior to participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. No individual participant data, images, or videos are included in this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request, subject to ethical considerations regarding participant confidentiality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded by the James Hume Bequest. The funder had no role in study design, data collection, analysis, interpretation, or manuscript preparation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKDP conceived and designed the study, conducted interviews, performed data analysis, and drafted the manuscript. BW conducted interviews, assisted with data analysis, and contributed to manuscript preparation. DS contributed to study design, participated in theme review and analysis, and provided feedback on the manuscript prior to his passing. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank all participants who generously shared their experiences and insights for this study. We also acknowledge the support of Green Prescription Otago staff in facilitating recruitment of former participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKDP is a Senior Lecturer and Clinical Psychologist in the Department of Psychological Medicine at the University of Otago, with research interests in mental health, health behaviour change, and qualitative research methods. BW is a Research Assistant in the Department of Psychological Medicine with expertise in qualitative research and health psychology. DS was a Senior Lecturer in the Department of Psychology at the University of Otago with extensive experience in behavioural research and statistical analysis.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWarburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: the evidence. CMAJ. 2006;174(6):801\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1503/cmaj.051351\u003c/span\u003e\u003cspan address=\"10.1503/cmaj.051351\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLobelo F, Duperly J, Frank E. Physical activity habits of doctors and medical students influence their counselling practices. Br J Sports Med. 2009;43(2):89\u0026ndash;92. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bjsm.2008.055426\u003c/span\u003e\u003cspan address=\"10.1136/bjsm.2008.055426\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel A, Schofield GM, Kolt GS, Keogh JW. General practitioners' views and experiences of counselling for physical activity through the New Zealand Green Prescription program. BMC Fam Pract. 2011;12:119. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1471-2296-12-119\u003c/span\u003e\u003cspan address=\"10.1186/1471-2296-12-119\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStanhope J, Weinstein P. What are green prescriptions? A scoping review. J Prim Health Care. 2023;15:155\u0026ndash;61. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1071/HC23007\u003c/span\u003e\u003cspan address=\"10.1071/HC23007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRobinson JM, Breed MF. Green prescriptions and their co-benefits: Integrative strategies for public and environmental health. Challenges. 2019;10:9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/challe10010009\u003c/span\u003e\u003cspan address=\"10.3390/challe10010009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHamlin MJ, Yule E, Elliot CA, Stoner L, Kathiravel Y. Long-term effectiveness of the New Zealand Green Prescription primary health care exercise initiative. Public Health. 2016;140:102\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.puhe.2016.07.014\u003c/span\u003e\u003cspan address=\"10.1016/j.puhe.2016.07.014\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKerse N, Elley CR, Robinson E, Arroll B. Is physical activity counseling effective for older people? A cluster randomized, controlled trial in primary care. J Am Geriatr Soc. 2005;53:1951\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1532-5415.2005.00466.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1532-5415.2005.00466.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel A, Keogh JW, Kolt GS, Schofield GM. The long-term effects of a primary care physical activity intervention on mental health in low-active, community-dwelling older adults. Aging Ment Health. 2013;17:766\u0026ndash;72. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/13607863.2013.781118\u003c/span\u003e\u003cspan address=\"10.1080/13607863.2013.781118\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKolt GS, Schofield GM, Kerse N, Garrett N, Ashton T, Patel A. Healthy Steps trial: pedometer-based advice and physical activity for low-active older adults. Ann Fam Med. 2012;10:206\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1370/afm.1345\u003c/span\u003e\u003cspan address=\"10.1370/afm.1345\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLawton BA, Rose SB, Elley CR, Dowell AC, Fenton A, Moyes SA. Exercise on prescription for women aged 40\u0026ndash;74 recruited through primary care: two year randomised controlled trial. BMJ. 2008;337:a2509. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmj.a2509\u003c/span\u003e\u003cspan address=\"10.1136/bmj.a2509\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSinclair KM, Hamlin MJ. Self-reported health benefits in patients recruited into New Zealand's 'Green Prescription' primary health care program. Southeast Asian J Trop Med Public Health. 2007;38:1158\u0026ndash;67. PMID: 18613560.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCraig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008;337:a1655. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmj.a1655\u003c/span\u003e\u003cspan address=\"10.1136/bmj.a1655\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSandelowski M. What's in a name? Qualitative description revisited. Res Nurs Health. 2010;33:77\u0026ndash;84. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/nur.20362\u003c/span\u003e\u003cspan address=\"10.1002/nur.20362\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77\u0026ndash;101. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1191/1478088706qp063oa\u003c/span\u003e\u003cspan address=\"10.1191/1478088706qp063oa\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRyan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol. 2000;55:68\u0026ndash;78. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1037//0003-066x.55.1.68\u003c/span\u003e\u003cspan address=\"10.1037//0003-066x.55.1.68\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThoits PA. Mechanisms linking social ties and support to physical and mental health. J Health Soc Behav. 2011;52:145\u0026ndash;61. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0022146510395592\u003c/span\u003e\u003cspan address=\"10.1177/0022146510395592\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBethancourt HJ, Rosenberg DE, Beatty T, Arterburn DE. Barriers to and facilitators of physical activity program use among older adults. Clin Med Res. 2014;12:10\u0026ndash;20. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3121/cmr.2013.1171\u003c/span\u003e\u003cspan address=\"10.3121/cmr.2013.1171\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMulligan H, Treharne GJ, Hale LA, Smith C. Combining self-help and professional help to minimize barriers to physical activity in persons with multiple sclerosis: a trial of the Blue Prescription approach in New Zealand. J Neurol Phys Ther. 2013;37:51\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/NPT.0b013e318292799e\u003c/span\u003e\u003cspan address=\"10.1097/NPT.0b013e318292799e\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFjeldsoe B, Neuhaus M, Winkler E, Eakin E. Systematic review of maintenance of behaviour change following physical activity and dietary interventions. Health Psychol. 2011;30:99\u0026ndash;109. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1037/a0021974\u003c/span\u003e\u003cspan address=\"10.1037/a0021974\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCadmus-Bertram LA, Marcus BH, Patterson RE, Parker BA, Morey BL. Randomized trial of a Fitbit-based physical activity intervention for women. Am J Prev Med. 2015;49:414\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.amepre.2015.01.020\u003c/span\u003e\u003cspan address=\"10.1016/j.amepre.2015.01.020\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKwasnicka D, Dombrowski SU, White M, Sniehotta F. Theoretical explanations for maintenance of behaviour change: a systematic review of behaviour theories. Health Psychol Rev. 2016;10:277\u0026ndash;96. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/17437199.2016.1151372\u003c/span\u003e\u003cspan address=\"10.1080/17437199.2016.1151372\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdewuyi FA, Knobel P, Gogna P, Dadvand P. Health effects of green prescription: a systematic review of randomized controlled trials. Environ Res. 2023;236:116844. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.envres.2023.116844\u003c/span\u003e\u003cspan address=\"10.1016/j.envres.2023.116844\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMichie S, Abraham C, Whittington C, McAteer J, Gupta S. Effective techniques in healthy eating and physical activity interventions: a meta-regression. Health Psychol. 2009;28:690\u0026ndash;701. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1037/a0016136\u003c/span\u003e\u003cspan address=\"10.1037/a0016136\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Green Prescription, physical activity, public health, primary care, qualitative research, health promotion, behaviour change","lastPublishedDoi":"10.21203/rs.3.rs-6764541/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6764541/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePhysical activity promotion through primary care represents a key public health strategy. New Zealand's Green Prescription (GRx) program, a nationwide primary care-based physical activity intervention, has operated for over 25 years but lacks comprehensive evaluation of participant experiences and long-term impacts.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis qualitative study used semi-structured interviews with 15 former GRx Otago participants (6 male, 8 female, mean age 60 years). Interviews explored experiences of the program, impacts on physical activity, mental health, and quality of life, and recommendations for improvement. Data were analyzed using Interpretive Thematic Analysis following Braun and Clarke's six-step approach.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSix main themes emerged: barriers to engagement, general experiences, mental health experiences, physical activity experiences, quality of life experiences, and recommendations for program improvement. Most participants (14/15, 93%) reported increased physical activity levels, while 12/15 (80%) experienced mental health improvements. Key barriers included financial constraints (16 participant references), transportation difficulties (9 references), and complex medical conditions (24 references). Participants valued the program's strengths-based approach, social connections, and individually tailored support. Primary recommendations included extending program duration, enhancing in-person support, diversifying activity options, and strengthening community organization partnerships.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe GRx program demonstrates effectiveness in promoting physical activity and associated health benefits among participants. However, significant opportunities exist for enhancement through addressing identified barriers, extending support duration, and developing more comprehensive community partnerships. These findings provide evidence-based strategies for improving primary care-based physical activity interventions globally.\u003c/p\u003e","manuscriptTitle":"Enhancing Public Health Outcomes: A Qualitative Study of Former Participants' Experiences of the Green Prescription Program in Aotearoa New Zealand","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-05 13:22:03","doi":"10.21203/rs.3.rs-6764541/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-07T06:36:43+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-03T16:16:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-03T15:41:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"314427926778027136031938351756278115670","date":"2025-07-01T08:13:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"75126302618792968749969301136675975149","date":"2025-06-30T20:14:03+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-20T13:50:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"334909695083669818099347134685874856541","date":"2025-06-12T18:43:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"91571247137009283487197370290466919621","date":"2025-06-12T11:46:53+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-02T12:04:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-02T08:16:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-01T01:56:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-06-01T01:53:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"04db518d-eab7-4004-b5ff-b917fb96af6c","owner":[],"postedDate":"June 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-06T16:08:55+00:00","versionOfRecord":{"articleIdentity":"rs-6764541","link":"https://doi.org/10.1186/s12889-025-24524-z","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-10-01 15:57:20","publishedOnDateReadable":"October 1st, 2025"},"versionCreatedAt":"2025-06-05 13:22:03","video":"","vorDoi":"10.1186/s12889-025-24524-z","vorDoiUrl":"https://doi.org/10.1186/s12889-025-24524-z","workflowStages":[]},"version":"v1","identity":"rs-6764541","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6764541","identity":"rs-6764541","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}