Advancing Equity in Green Social Prescribing: Exploring Racial and Ethnic Disparities in Access and Inclusion

Advancing Equity in Green Social Prescribing: Exploring Racial and Ethnic Disparities in Access and Inclusion | 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 Advancing Equity in Green Social Prescribing: Exploring Racial and Ethnic Disparities in Access and Inclusion Ceri R Jones, Natalie Darko, Sylvia Delpratt, Kajal Nisha Patel, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6513516/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Green Social Prescribing (GSP) aims to improve health and well-being by connecting individuals to nature-based interventions (NBIs). However, ethnic minority groups remain underrepresented in GSP despite growing evidence of its benefits. This study explores the barriers and facilitators to GSP participation among Black and Asian ethnic minority groups, applying the Environmental Justice Framework (EJF) to examine issues of distributional, procedural, and recognitional justice in access to green spaces. Methods A mixed-methods approach was used, comprising of an online survey (N=38), qualitative interviews and focus groups with participants (N=58) from diverse Black and Asian ethnicities, those from faith backgrounds and GSP programme providers. Quantitative survey responses were analysed using descriptive statistics. Qualitative data was thematically analysed and salient themes identified. Results Despite strong interest in GSP 97% of survey respondents expressed willingness to participate. Awareness was low, 95% had not been referred by healthcare professionals. Barriers included limited availability, lack of cultural representation, affordability, and safety concerns. Many participants perceived GSP as catering to white middle class groups, creating psychological barriers to participation. Participants emphasised the need for culturally tailored interventions, including multilingual materials, faith-based adaptations, gender-specific sessions, and community-led programmes. Sustainable funding, transport support, and improved safety measures were also identified as key to improving accessibility. Conclusion Findings highlight the pressing need for an equity-based approach to GSP, ensuring that ethnic minority groups have inclusive access to nature-based interventions. Increased referrals from primary care, culturally and linguistically adapted programmes, community-led initiatives, while reducing economic and transport barriers could improve participation. Future research should explore ethnicity-specific evaluation frameworks and the long-term impact of tailored GSP interventions. Social prescribing Green social prescribing Nature-based interventions Environmental justice Health inequalities Ethnic minority health racial and Ethnic disparities Public health policy Community-led interventions Social determinants of health Introduction Social prescribing is an emerging approach within primary care that seeks to improve health outcomes by linking individuals to non-clinical community-based services [ 1 ]. It has been widely recognised for its role in addressing social determinants of health, particularly among individuals with complex needs, by offering personalised support beyond conventional medical interventions [ 2 ]. Evidence suggests that social prescribing enhances mental well-being, self-efficacy, and self-management of chronic conditions while also reducing the burden on primary care services through decreased general practitioner (GP) appointments and medication use [ 3 , 4 ]. As part of the NHS Long Term Plan, social prescribing has been integrated into Primary Care Networks (PCNs), highlighting its growing importance in UK healthcare policyto address the social determinants of health [ 5 ]. Green Social Prescribing (GSP) is a specific from of social prescribing in the UK. In 2021 a two-year cross government GSP programme was launched across 7 test and learn integrated care systems (ICS) by NHS England [ 6 ]. GSP refers to the prescription of nature-based interventions (NBIs), such as green exercise, community gardening, care farming, and outdoor arts programmes, as a means of improving health and well-being. In 2021 Recent systematic reviews highlight that NBIs can contribute to improved mental health, increased physical activity, enhanced sleep quality, and reduced symptoms of anxiety and depression [ 7 , 8 ]. A recent meta-analysis suggests that nature-based interventions have a moderate-to-large effect on reducing anxiety and depression, particularly when interventions incorporate social engagement [ 9 ]. Research further indicates that while nature-based interventions can be effective in reducing mental health disparities, participation remains inequitable, particularly for individuals from ethnic minority and socio-economically deprived groups [ 10 ]. There is also emerging evidence suggesting that GSP may have additional benefits for cardiovascular health, stress reduction, and social cohesion [ 11 ]. Despite this growing evidence base, studies often have limitations in study design including small samples, and a lack of controlled trials [ 12 ]. While GSP has gained attention as a preventative and holistic approach to health, there is growing concern that ethnic minority populations remain underrepresented in social prescribing referrals and interventions [ 13 ]. Research suggests that individuals from Black, Asian, and minority ethnic groups experience disproportionately high levels of mental health inequalities, chronic disease, and socioeconomic deprivation, yet face significant barriers in accessing social prescribing programmes [ 14 ]. A national evaluation of social prescribing programmes in the UK highlighted that a lack of awareness, cultural relevance and appropriateness, and systemic barriers continue to limit engagement among ethnic minority groups [ 14 ]. Ethnic minority individuals report limited knowledge of social prescribing services, compounded by an over-reliance on biomedical models in primary care [ 2 ]. Socioeconomic disparities result in reduced availability and lower quality of green spaces in urban areas with higher ethnic minority populations [ 15 ]. In addition, experiences of racial discrimination, lack of representation, and perceived exclusion from green spaces discourage participation in GSP initiatives [ 16 ]. Costs associated with transportation, entry fees, and time constraints further limit accessibility, particularly for lower-income groups [ 17 ]. The Environmental Justice Framework (EJF) provides a useful theoretical lens for understanding disparities in access to Green Social Prescribing. Environmental justice refers to the fair distribution of environmental benefits and burdens, ensuring that all individuals regardless of race, ethnicity, or socioeconomic status have equal access to green spaces and their associated health benefits [ 18 ]. According to Rigolon et al. (2019), environmental justice in recreational settings can be examined through distributional, procedural, and recognitional justice [ 18 ]. Distributional justice relates to the unequal availability and quality of green spaces, disproportionately affecting marginalised groups and communities. Procedural justice considers the inclusivity of decision-making processes in designing and implementing GSP interventions. Recognitional justice emphasises the need to acknowledge and respect cultural identities, ensuring that interventions are accessible, meaningful, and reflective of diverse lived experiences [ 18 ]. The COVID-19 pandemic further exacerbated existing health inequalities, with evidence indicating that ethnic minority groups experienced higher rates of mental distress and reduced access to preventative health interventions [ 19 ]. Given these challenges, it is important to explore how GSP programmes can be adapted to be more inclusive and equitable for underrepresented populations. Despite the expansion of GSP within UK healthcare policy, there remains limited empirical research on the accessibility and effectiveness of these interventions for ethnic minority communities. Current evaluations of social prescribing rarely collect ethnicity-specific data, making it difficult to assess whether GSP is meeting the needs of diverse populations [ 14 ]. There is a need for research to understand how GSP can be adapted to reduce health disparities and address cultural and systemic barriers to participation. This study aims to identify the key barriers to participation in GPS interventions during the National GSP pilot among primarily Black and Asian ethnic minority groups in the UK. It also aims to explore culturally appropriate adaptations to enhance engagement, while promoting equity and accessibility in GSP initiatives. Methods The study employed a mixed-methods approach, integrating an online survey, interviews and focus group data collection to explore barriers to access in GPS among ethnic minority groups. A cross-sectional online qualitative survey was conducted, followed by semi-structured interviews and focus groups. The study was guided by the EJF framework [16]. Study Setting and Participants The study was conducted in inner-city and peri-urban areas of multiple deprivation in the Midlands, England. When GSP programmes were being implemented as part of NHS England’s National programme [6]. Participants were recruited from diverse Black and Asian ethnic minority groups, reflecting communities that are underrepresented in GSP referrals [13]. Eligibility criteria included: (1) individuals aged 18 years and above, (2) self-identifying as Black, Asian, or mixed ethnicity, (3) residing in England, and (4) been involved in, or are interested in GSP programmes. Recruitment was conducted via snowball sampling through community partnerships, and social media advertisements, with additional outreach through faith organisations and ethnic minority health networks. Posters inviting participants were distributed through local community and faith groups, social media platforms, and displayed civic buildings. The recruitment period ranged from December 2022 to June 2023 for the survey, and August 2022 to March 2023 for interviews and focus groups. Data Collection Qualitative Survey: An exploratory on-line qualitative survey was designed was developed for this study to explore understanding of GPS, accessibility and barriers to taking part, experiences of GPS and GPS intervention preferences. The full survey is available in Supplementary File 1. The survey was distributed via local community groups, social media and poster adverts in civic buildings. Participants were recruited using snowball sampling . The survey included a combination of open ended, and drop-down multiple choice exploring; i) green social prescribing availability ii) which green social prescribing interventions they would like to access iii) benefits from taking part iv) barriers to access v) how to improve inclusivity and accessibility. Interviews & Focus Groups A total of 58 participants were purposefully sampled to take part in semi-structured interviews (n=10) and focus groups (n=5). The interview and focus group schedules were developed for this study. These are provided in Supplementary File 2. Questions explored, understanding of GPS, representatives and accessibility of GPS for minority ethnic groups, cultural considerations and outcomes of GPS participation. The sample was selected to ensure diversity in age, gender, ethnicity, faith backgrounds, and included GSP and NBI intervention providers. Table 1 provides an overview of the focus groups and interview participants. Posters recruiting participants were shared via local community organisations, faith groups, and social media channels. Interviews and focus groups were conducted either in person or virtually, with all participants residing in inner-city areas of the Midlands, England. Table 1. Overview of Focus Groups and Interviews Participant Group Mode N Gender Ethnicity Age Range Duration Black Faith Focus Group (BFFG) In-person 30 Female (n=23), Male (n=7) Black African (n=15), Black African-Caribbean (n=7), Black British (n=8) 21–59 43 min Mixed Ethnicity Young People Focus Groups (MEYPFG) In-person 14 (FG1: n=8, FG2: n=6) FG1: Female (n=5), Male(n=3) FG2: Female(n=2), Male (n=4) FG1: Algerian, (n=1) Somali, (n=1) Black African(n=2), African (n=1) Indian (n=2) FG2: Black African (n=2) British Asian (n=2) Indian (n=2) British Pakistani (n=1) 18–25 FG1: 55 min FG2: 62 min Black British Focus Group (BBFG) Virtual 9 Female (n=9) Black African (n=2), Black African-Caribbean (n=7) 45–68 50 min South Asian Focus Group (SAFG) Virtual 7 Female (n=6), Male (n=1) Indian (n=4), Pakistani (n=3) 26–75 108 min Community/Faith Leaders Virtual (Interviews) 5 Female (n=4) Male (n=1) White (n=2), Dual Heritage South Asian/White (n=1), South Asian (n=1), Dual Heritage Black/White (n=1) 35–50 45–60 min GSP & NBI Providers Virtual (Interviews) 4 Female (n=4) White (n=3), South Asian (n=1) 40–64 45–60 min Service User Virtual (Interview) 1 Male (n=1) Black African 45 45–60 min Analysis Survey responses were analysed using descriptive statistics. Open-ended responses, interviews, and focus group transcripts were analysed using thematic analysis in NVivo (version 12; QSR International), following Braun and Clarke’s (2022) six-step framework [20]. Coding was conducted inductively, allowing key themes to emerge from participant narratives. To enhance consistency, two independent researchers coded the transcripts separately, and discrepancies were resolved through discussion. Ethics Ethical approval for the study was granted by the University of Leicester Psychology Department Ethics Committee. All participants were provided with a participant information sheet, detailing the study's purpose, their right to withdraw, how their data would be stored and used, and contact information for the research lead. Participants signed a consent form before taking part in the study. All identifying information was removed from transcripts, and data was stored securely in compliance with UK GDPR regulations. Results The findings from this study highlight key barriers to Green Social Prescribing (GSP) participation among ethnic minority groups, as well as potential strategies to improve inclusivity. The results are structured as follows: (1) Survey findings, presenting quantitative insights into awareness, participation, and perceived barriers; (2) Qualitative themes, drawn from interviews and focus groups. 1) Qualitative Survey Participant Demographics A total of 38 participants completed the survey. The majority were Asian or British Asian (43%) then white (37%) or other white background (11%), mixed ethnic groups (5%) or Black British Caribbean (3%) – see Table 2. The majority were female (66%), while 33% identified as male and 3% as non-binary. The largest age group was 26-35 years (34%), followed by 18-25 years (32%), with the remaining participants distributed across older age categories. Most respondents (87%) did not report a disability, while 10% identified as having a disability. Regarding employment status, 61% were employed, 21% were self-employed, 5% were unemployed, and 8% were retired. Table 2. Ethnicity of Survey Respondents Ethnicity Category N (%) Asian or Asian British 17 (43%) Indian 14 Bangladeshi 1 Pakistani 1 Chinese 1 Black British Caribbean 1 (3%) Mixed or Multiple Ethnic Groups 2 (5%) White and Asian 2 White - British 14 (37%) Other White Backgrounds 4 (11%) Note: In this sample, the white respondents primarily represent GSP providers (27%), while the Black, Asian and mixed ethnic minority groups are primarily members of the public (73%). Green Social Prescribing Availability Green Social Prescribing (GSP) referral rates were low, with only 5% (n=2) of participants having been referred by a healthcare professional. The majority (95%, n=35) had not received a referral, primarily due to a lack of awareness about these schemes. Many participants indicated that they would have been interested in GSP if they had been informed, while others noted that they engaged in nature-based activities independently. Despite low referral rates, 97% (n=35) expressed interest in participating in future GSP programmes. Preferred Green Social Prescribing Interventions Participants identified Green Exercise (28%) and Forest Bathing (28%) as the most appealing activities, followed by Outdoor Arts and Crafts (8%), Care Farming (8%), and Community Gardening (3%). Nearly a quarter (24%) expressed interest in participating in multiple interventions (see Table 3). Table 3. Preferred GSP Activity Preferred GSP Activity N (%) Green Exercise 9 (28%) Forest Bathing 9 (28%) Outdoor Arts and Crafts 3 (8%) Care Farming 3 (8%) Community Gardens/Allotments 1 (3%) Multiple Activities 8 (24%) Perceived Benefits of Green Social Prescribing For participants who engaged in nature-based activities, improved quality of life, better mood, and increased physical activity were the most cited benefits. Other reported benefits included reduced anxiety and depression, better sleep, healthier eating habits, and improved social connections. A small number of participants also reported fewer GP visits and reduced medication use (see Table 4). Table 4. Reported Benefits Reported Benefits N Improved quality of life 11 Improved mood 11 Increased physical activity 11 Greater connection to nature 9 Better sleep 8 Healthier eating habits 8 Reduced anxiety and depression 7 Increased social connections 7 Improved management of health 7 Fewer GP visits 5 Reduced medication use 2 Barriers to Participation Nearly half of participants (47%) cited a lack of awareness as the primary barrier to GSP participation, followed by limited local availability (17%), cultural or language barriers (14%), and other challenges such as time constraints or multiple intersecting barriers (17%) see Table 5. Table 5. Barriers to Participation Barriers N (%) Lack of awareness 17 (47%) Limited local availability 6 (17%) Cultural or language barriers 5 (14%) Other (time constraints, multiple factors) 6 (17%) Improving Inclusivity and Accessibility Thematic analysis of the qualitative responses in the survey identified four key themes for enhancing inclusivity in Green Social Prescribing (GSP): (1) Funding and Affordability, (2) Cultural Sensitivity and Community Outreach, (3) Local Accessibility and Adaptations for All Abilities, and (4) Safety and Family-Friendly Environments. 1. Funding and Affordability - Participants emphasised that cost was a barrier. Providers continually sought funding and resources to improve availability and access. "We need funding and someone to organise these activities for them to work." 2. Cultural Sensitivity and Outreach - Many highlighted the need for translated materials, gender-specific sessions for religious and cultural reason, and the community partnerships to increase engagement. "Women-only sessions and translated information would encourage participation." 3. Local Accessibility and Adaptations - Transport issues and physical accessibility were common concerns, with calls for programmes closer to residential areas and adapted for different abilities. "Shared community gardens near homes would be easier to access." 4. Safety and Family-Friendly Environments - Women and parents cited safety concerns and lack of childcare as limiting factors, recommending better lighting, flexible timing, and child-friendly options. "Brighter spaces in the evenings would help women feel safer." These findings align with distributional, procedural, and recognitional justice within the Environmental Justice Framework (EJF), emphasising the need for equitable access, participatory decision-making, and cultural adaptations to encourage engagement. 2 ) Results Interviews and Focus Groups Thematic Analysis This section presents the findings from the thematic analysis of the interviews and focus groups. Eight themes are identified, 1) Lack of Awareness, (2) Systemic Discrimination, (3) Community Engagement and Co-Design, (4) Accessibility Barriers, (5) Safety Concerns, (6) Financial and Economic Barriers, (7) Cultural Adaptation, and (8) Environmental Awareness. 1. Lack of Awareness Participants highlighted a lack of awareness of GPS and a dominance of the biomedical model in healthcare settings. Many reported that GPs prioritised conventional medicine over referrals to nature-based interventions (NBIs). Many were unaware of social prescribing services, with inconsistent access to Social Prescribers and geographical variation in provision further limiting uptake.: Several participants felt that GSP was not widely promoted, making it difficult to access. "The awareness isn’t always there, and you don’t always know where to go to get that information." (SAFG, Participant 5) Participants also emphasised the need for targeted outreach and representation from South Asian and Black ethnic minority groups to increase engagement. “So, there's a capacity issue with the GPs that prescribe and there's a capacity issue with the social prescribers they link with ” (BFFG, Participant 2) “We just hear about conventional medicines from doctors and people think taking a tablet or some kind of medicine is only answer.” (SAFG, Participant 9) Participants agreed that tailored communication strategies and culturally tailored and representative marketing was needed to raise awareness and increase participation in GPS. 2. Systemic Discrimination Participants from ethnic minority groups described experiences of racial discrimination and hostility in rural green spaces, which deterred them from engaging in nature-based activities outside of urban areas. Many felt safer in inner-city parks, where they were more likely to see people from similar ethnic minority backgrounds. "It’s not always something that’s voiced, but when you enter a space and get certain looks . It tends to make you a bit uncomfortable ." (BFFG, Participant 3) “So, whatever we did was as a group and as a community and that would create problems all the time. Some people would tell us to go back where you came from.” (BFFG, Participant 4) Participants also highlighted a lack of representation of minority ethnic groups in GSP programmes and expressed a need for more visible role models from diverse backgrounds. 2.1. Domination of White "Middle-Class" Individuals Many participants felt that GSP and NBIs were dominated by white “middle class” individuals, which created barriers to engagement for people from different cultural and socioeconomic backgrounds. “Certain groups come and swamp it and make the culture white. ‘Greeny’ people, middle class, it can then be less welcoming to people who belong to other groups ” (Community Leader, Participant 4) There was a consensus that tailored interventions and diversity-friendly recruitment strategies were needed to increase participation among underrepresented groups. 3. Community Engagement and Co-Design Over half of the focus group participants had never heard of GSP, highlighting a significant gap in engagement with Black and South Asian groups. Participants emphasised the importance of faith centres, local community organisations, and cultural events as opportunities for increasing awareness. “ You could go to a church MOSC, Gurdwara Monday synagogue that would be like the community or like you know, religious side of places, and you know, if you've got these you know, big posters… with someone of that local community, so they can kind of understand and say, look, this is what's going on.” (SAFG, Participant 6) Community co-design was highlighted as an essential strategy to ensure that GSP interventions align with faith and cultural values. Participants suggested integrating GSP activities into existing cultural and religious celebrations to improve engagement. “ Putting on specific things like Eid celebrations in the garden and activities like that.” (Community Leader, Participant 4) 4. Accessibility Barriers Physical health and mobility challenges emerged as significant barriers to participation in GSP. Participants with disabilities and chronic conditions found many outdoor spaces to be inaccessible due to poor infrastructure, lack of seating, and inadequate toilet facilities. This highlights how ethnicity, socioeconomic status and (dis)ability intersect to create a further barrier to access reducing equity. “Being a wheelchair user and sometimes it is difficult like with ramps and especially like toilet facilities. So, I think that needs to be addressed.” (BFFG, Participant 6) " A couple of months ago my knee started…so I stopped walking.” BBFG, Participant 3) Participants highlighted the seasonality of outdoor activities, stating that cold weather and darker evenings often reduced motivation to engage in green exercise. “When it's dark and miserable outside, all we've got are a few aches and pains which is a bit harder to get motivated, isn't it, to get out?” (BBFC, Participant 4). 4.1. Transport and Distance Many participants reported that transport costs and travel distances restricted their ability to attend GSP programmes, particularly those based in rural or peri-urban locations. “A lot of these families don't drive. So, you know, that transport straight away puts families off, even when I'm promoting them to go to a group to meet up with other people, especially if they're isolated” (Community Leader, Participant 1) There was recognition that subsidised transport and more local, community-based initiatives could improve accessibility. 5. Safety Concerns Concerns about drug activity, youth gangs, and antisocial behaviour in urban green spaces were frequently raised, particularly by women and older participants. " Meadows is not safe, even though it's a nature route for people to walk . We do not feel safe there ." (BFFG, Participant 7) " Little packets of drugs. You can see them just passing it out in the open, so you don't take your children there ” (SAFG, Participant 1) 5.1. Public Perceptions, Race, and Gender Stereotypes Participants would limit their participation to daytime due to safety concerns. For example, Black men reported self-limiting their outdoor activity due to fears of being racially profiled This amplifies perceived inequity in access to green spaces that some ethnic minorities experience. “ If I go at night, cause the things I wear, people might conceive that I’m something else… You get what I’m saying? (laughs) I mean, obviously I'm a big… In terms of stature and I’m a black person, black male, so walking at night is not really sensible” (MEYPFG2, Participant 1) To address these concerns, participants suggested better lighting and increased community policing to make outdoor green space users feel safer. 6. Financial and Economic Barriers GSP providers emphasised the instability of short-term funding, which created barriers to long-term sustainability. Many projects were volunteer led, leading to high turnover and inconsistent service provision. If you are constantly telling people well it’s a one-year project, then you’ve got to apply for more funding…I think that is the absolute kind of killer of it.” (GSP Provider, Participant 2) 6.1. Over-Reliance on the Voluntary Sector Participants in community and voluntary sector organisations expressed concerns about the unsustainable reliance on unpaid labour in delivering GSP initiatives. Participants called for programmes to be continued to be funded and properly resourced to ensure GSP remains accessible to those most in need. " “We weren’t paid...And we didn’t have funding. So, we did it off our own back… Yeah it’s a lot of work. Very labour intensive to deliver green activities” (Community Leader, Participant 3) 6.2. Lack of Disposable Income The cost-of-living crisis was identified as an additional barrier to participation. Many families struggled with the financial burden of transport, childcare, and other expenses related to attending GSP activities. “ That's in a local park that we can obviously promote parents go to, but again because it is kind of on the outskirts of the city, I feel there are challenges in regards to the families I work with, in regards to transport, the cost of transport” (Community Leader, Participant 1) 7. Cultural Adaptation Participants stressed the need for culturally adapted GSP programmes that respect religious beliefs and cultural practices. Muslim women, in particular, expressed a preference for gender-segregated activities. “Sometimes on a religious basis, men are not allowed. Like as a Muslim woman, I wouldn't like to mix with men freely unless it's on a professional level. If it's a professional relationship, that's fine. But I think when it comes to leisurely relationships or friendships, I would not” (SAFG, Participant 6) Younger participants also described mental health stigma in their communities, making engagement more challenging. “Y ou're really sort of struggling and also, you feel really isolated and you might not understand your experiences…there's a lot of stigma as well, especially if you're a minority” (Service User, Participant 1) 7.1 . Class, Caste, Poverty, and Social Status Participants discussed attitudes toward conservation work in their cultures, with some seeing gardening or cleaning green spaces as “low status” due to historical associations with caste and labour. In the UK and coming from an Asian background, you know we kind of we know that you know it's not promoted in our culture you know picking rubbish up is seen as derogatory…You know, I think from a young age you don't understand fully what caste means but it's only as you get older you really realise the detrimental and harmful effects of that.” (Community Leader, Participant 2) 7.2. Cultural Adaptations and a Targeted Approach GSP programmes need to be linguistically and culturally tailored, using trusted community leaders to build engagement. “ Information has to be tailored and adapted in the way that they can kind of understand it. Obviously, language information, the formatting, the simplicity of the information. Avoid using jargon. Um, you know having information available in different ways, so audio, you know, literature. I know service users who can speak the language but will not necessarily be able to read the language. It’s that, and also having champions and peer support. You know, people doing that kind of work that people can identify with, who can then communicate that information and message and specifically people that they can then relate to, and they have trust towards” (Community Worker, Participant 5) 8. Environmental Awareness: Ecological Barriers and Connectedness Weather conditions and seasonality impacted participation, with many preferring indoor alternatives during colder months. Despite this, participating in nature was described as improving their mental well-being. “Yes, I think active outdoor activities are quite successful ones. But you know the weather's not always so good. So, you have to do some indoor activities. So that might be playing pool…exercising indoors that might be doing mindfulness…at the moment it's all digital based” (Service User, Participant 1) 8.1. Ecological Connectedness Many participants, particularly younger ones, described feeling “at peace” in nature, despite limited green space access in urban areas. “I don’t know how to explain it. It’s like a different type of feeling. Because when you’re in nature, you feel closer to the earth...Yeah, I’d say being out in nature, it really helps you connect. With the earth .” (MEYPFG1, Participant 5) 8.2. Environmental Stewardship Younger participants saw participating in NBIs as a way to promote environmental activism and education, encouraging intergenerational engagement in conservation efforts. “ No-one really cared about the environment. And it ended up causing a huge impact. People finding out later-later. When it was bad enough, but I'm saying, right now we can change the game.” (MEYPFG1, Participant 5) This highlights the potential for youth-led GPS programmes focusing on environmental stewardship and conservation. Discussion This study explored the accessibility, inclusivity, and engagement of ethnic minority communities in GPS, applying the Environmental Justice Framework (EJF) to assess barriers and facilitators to participation. Findings highlight significant disparities in awareness, representation, affordability, and accessibility, reinforcing existing research indicating that ethnic minority groups remain underrepresented in social prescribing initiatives despite a strong interest in engagement [13,14]. However, this study directly addresses a key gap in the literature by actively seeking the perspectives of Black and Asian ethnic minority groups, offering a deeper understanding of the specific barriers and enablers shaping their engagement with GSP. Low awareness and inconsistent availability of GSP emerged as major barriers to participation. While nearly all participants expressed interest in engaging with GSP, most had not been referred to a programme and were often unaware of their existence. This lack of awareness aligns with research showing that social prescribing referrals in the UK remain predominantly accessed by white, middle-class populations [13]. Participants perceived a reliance on the biomedical model within general practice, where GPs prioritise medicalised interventions over social prescribing. Enhancing distributional justice within GSP requires more effective community engagement strategies, ensuring that referral pathways reach diverse populations. Raising awareness through culturally tailored outreach campaigns, increasing GP and social prescriber knowledge of GSP, and embedding initiatives within trusted community organisations may improve uptake. Existing evidence highlights the importance of co-producing interventions with community members to ensure cultural relevance and foster trust [23]. Cultural inclusivity and representation were also identified as significant barriers to engagement. Participants reported feeling unwelcome in predominantly white spaces, reinforcing findings that ethnic minority individuals often perceive outdoor spaces as exclusive or intimidating [16]. Rural racism and experiences of victimisation in green spaces can further alienate communities, creating psychological barriers to participation in GSP [15]. To promote procedural justice, initiatives should adopt culturally sensitive approaches, such as incorporating multilingual materials, gender-specific sessions, and faith-based adaptations. Participants suggested that religious festivals such as Eid and Diwali could serve as entry points for engaging ethnic minority communities with GSP, creating a more familiar and welcoming environment. Research supports the role of faith-based initiatives in promoting health equity, particularly among Black British communities, where faith is often central to health and wellness [22]. Findings further emphasise that GSP must be culturally tailored to account for religious and cultural needs. Participants described the importance of faith-based adaptations, such as incorporating prayer spaces within green environments, and ensuring activities align with cultural practices. GSP programmes that successfully integrate religious elements may foster greater engagement and long-term participation. Previous evaluations have shown that faith-centred health interventions can be highly effective in addressing health inequalities [22,23], highlighting the need for greater collaboration between healthcare providers, religious organisations, and community groups in shaping future GSP initiatives. Ensuring accessibility and affordability remains vital for promoting distributional justice in GSP. Many participants cited transport barriers, financial constraints, and inadequate infrastructure as key obstacles to participation, reinforcing evidence that individuals from African, Caribbean, and South Asian groups and communities are disproportionately affected by socioeconomic deprivation [24]. Maslow’s hierarchy of needs suggests that when basic survival needs take priority, discretionary activities such as GSP may be deprioritised [21]. Addressing financial barriers requires a commitment to subsidised transport and free entry to green spaces. These findings are consistent with previous evaluations of GSP that identified cost, language, and accessibility as key factors limiting engagement among underserved populations [7]. Sustainable funding is essential to ensure the long-term success of GSP initiatives. Current programmes rely heavily on short-term funding, creating instability in service provision. Traditional healthcare financing models are not designed to support social prescribing, and long-term funding mechanisms remain underdeveloped [25]. The closure of NHS England and its support structures, as recently announced by the Department of Health and Social Care [26] has raised concerns about the future stability of funding for GSP. However, Integrated Care Boards (ICBs) despite the challenges posed by these changes, present an opportunity to embed GSP within broader healthcare systems, by distributing funding to that which is more aligned with local population needs. However, equality monitoring data is needed to understand the demographics of those accessing services, ensuring that vulnerable and underserved communities are not left behind in the allocation of resources. Safety concerns were also highlighted as a key barrier, particularly for women and individuals living in urban areas with high crime rates. Participants described feeling unsafe in certain green spaces due to poor lighting, antisocial behaviour, and past experiences of victimisation, consistent with research on perceptions of green space safety among ethnic minority populations [27]. Improving procedural and distributional justice in GSP requires targeted safety interventions, such as enhanced lighting, community policing, and designated safe spaces within parks. Findings suggest that younger participants viewed environmental stewardship and climate activism as a pathway for engagement in GSP, reflecting broader trends in youth-led environmental movements. Involving young people in citizen science projects, such as biodiversity monitoring and conservation activities could serve as an effective strategy for increasing participation in green spaces while fostering a sense of agency and environmental responsibility [28,29]. Implications for Policy This study highlights a pressing need for policymakers to address structural and systemic barriers impacting ethnic minority communities' access to Green Social Prescribing (GSP) and nature-based interventions (NBI). Policies should prioritise sustainable funding models to ensure long-term access and continuity of services. To ensure equitable access, GSP programmes must routinely collect ethnicity data and implement ongoing monitoring and evaluation. Programmes should also be culturally and linguistically tailored and co-designed directly with ethnic minority communities. Awareness of GSP and NBI was low among ethnic minority participants in this study, despite high levels of interest. To enhance awareness and participation, promotional materials should explicitly represent these communities, clearly indicating that these programmes are inclusive and accessible beyond traditionally privileged, white, middle-class groups. As an output from this study, we have produced two culturally relevant films, featuring 1) interviews from project leaders and 2) project participants, explaining GSP and its benefits. One of these films can be accessed here: https://youtu.be/G2PQ7yFlR-k. Policymakers should further consider embedding culturally adapted GSP programmes within established community and faith-based organisations to optimise community engagement, trust, and sustained participation. Limitations While this study provides valuable insights into the barriers and facilitators of GSP for ethnic minority groups. Unlike previous GSP evaluations that fail to collect ethnicity-specific data [7], this study actively sought to engage diverse ethnic groups, incorporating perspectives from different Black and Asian ethnicities and faith communities. However, despite efforts to include a broad range of participants, some ethnic and faith groups may still be underrepresented, and findings may not be fully generalisable. Additionally, self-reported experiences may be subject to recall bias or social desirability bias. Future research could seek to capture longitudinal data on ethnic minority GSP engagement over time. A small number of participants shared that ethnicity (dis)ability and socioeconomic status intersect to create further inequity in access. Intersectional analyses could also explore how gender, disability, and socioeconomic status intersect with ethnicity and GSP participation. Conclusion This study highlights the need to ensure that ethnic minority groups have equitable access to NBIs. Findings demonstrate that while interest in GSP is high, systemic barriers related to awareness, cultural accessibility, affordability, and safety act as a barrier to participation. Addressing these barriers requires culturally tailored outreach, cultural and linguistically tailored programme design and sustainable funding that prioritise inclusion. Despite the current uncertainty, integrating GSP within ICBs social prescribing provision offers an opportunity to improve accessibility and engagement. Declarations Ethics Approval and Consent to Participate Ethical approval for this study was granted by the University of Leicester Psychology and Vision Sciences Department Ethics Committee (Ref: 35793). The study was conducted in accordance with the British Psychological Society’s Code of Human Research Ethics (2014) and the ethical principles outlined in the Declaration of Helsinki. All participants provided informed consent prior to participation, and all data were anonymised to maintain confidentiality. Consent for Publication Not applicable. Availability of Data and Materials The datasets generated and analysed during the current study are not publicly available due to confidentiality agreements with participants but are available from the corresponding author on reasonable request. Competing interests No competing interests. Funding This study was funded by the National Institute for Health and Care Research (NIHR) Policy Research Programme (PRP). The funder had no role in the study design, data collection, analysis, interpretation, or manuscript writing. Authors’ Contributions Dr. Ceri R. Jones was the Principal Investigator, conceptualised the study, led data collection and analysis, and drafted the main manuscript. Dr. Sylvia Delpratt and Ms. Kajal Nisha Patel conducted the focus groups, interviews, and thematic analysis. Dr. Natalie Darko, as a co-investigator, contributed to the study conceptualisation, study delivery, interpretation, and manuscript revisions. Dr. Ffion Curtis is a co-investigator and contributed to manuscript revisions. All authors read and approved the final manuscript. Acknowledgments The authors would like to thank all participants, community organisations, and faith groups who contributed to this research. We also acknowledge the support of the National Institute for Health and Care Research (NIHR) Policy Research Programme (PRP). This research was also supported by the National Institute for Health Research (NIHR) Applied Research Collaborative (ARC) East Midlands the Centre for Ethnic Health Research, and NIHR Leicester Biomedical Research Centre. References Bickerdike L, Booth A, Wilson PM, Farley K, Wright K. Social prescribing: Less rhetoric and more reality. A systematic review of the evidence. BMJ Open. 2017;7(4):e013384. Wildman JM, Moffatt S, Penn L, O'Brien N, Steer M, Hill C. Link workers’ perspectives on social prescribing: A qualitative follow-up study of the pathways linking primary care to the voluntary sector. BMC Public Health. 2019;19(1):1-13. Carrier J, Newbury S. Social prescribing: a review of community referral schemes. London J Prim Care. 2016;8(6):108–12. Lynch M, Jones S. Social prescribing for primary care patients: A mixed-methods evaluation. Br J Gen Pract. 2019;69(685):e487–e494. NHS England. NHS Long Term Plan. NHS England; 2023. Available from: https://www.longtermplan.nhs.uk/ NHS England. Green Social Prescribing [Internet]. NHS England; [cited 2025 Mar 20]. Available from: https://www.england.nhs.uk/personalisedcare/social-prescribing/green-social-prescribing/ Haywood C, Simpson D, Lovell R, Sandhu J, Kersey E, Richardson M, et al. National Evaluation of the Preventing and Tackling Mental Ill Health through Green Social Prescribing Programme. Defra; 2023. Sandhu J, Li Y, Hunter R. Nature-based interventions for mental health: A systematic review of economic evaluations. Environ Res. 2022;214:114054. Coventry PA, Gilbody S, Wainwright K, White R, McMillan D. Nature-based interventions for improving mental health: Systematic review and meta-analysis of randomised controlled trials. J R Soc Promot Health. 2023;17579139231170768. Available from: https://doi.org/10.1177/17579139231170768 Robinson JM, Brindley P, Cameron R, MacKerron G, Dallimer M. Nature-based social prescribing for mental health: A systematic review of barriers and enablers. Int J Environ Res Public Health. 2023;20(1):745. Marselle MR, Warber SL, Irvine KN, de Bell S, Ciravegna F, Ambrose-Oji B, et al. Examining group walks in nature and multiple health outcomes: A large-scale study. Int J Environ Res Public Health. 2021;18(3):1396. Allen J, Lanphear B. Nature contact and human health: A research agenda. Environ Health Perspect. 2015;123(10):925-31. Gupta A. Social prescribing and ethnic minority communities: Barriers and facilitators. J Public Health (Oxf). 2021;43(3):514-20. Haywood C, Lovell R, Simpson D, Kersey E, Sandhu J, Richardson M, et al. Understanding ethnic disparities in green social prescribing: Findings from a national evaluation. Soc Sci Med. 2023;322:115899. Robinson J, Breed M. Ethnic disparities in urban green space access and social prescribing participation. Urban For Urban Green. 2022;75:127690. Chakraborti N, Garland J. Rural racism and racialized identities in rural Britain. Routledge; 2013. Boyd C, Clarke D, Barnett R. Economic barriers to social prescribing participation among low-income communities. Health Soc Care Community. 2018;26(5):745-55. Rigolon A, Fernandez M, Harris B, Stewart W. An ecological model of environmental justice for recreation. Leis Sci. 2019;1–22. Available from: https://doi.org/10.1080/01490400.2019.1673907. Otu A, Ahinkorah BO, Ameyaw EK, Seidu AA, Yaya S. COVID-19 pandemic: Can we handle the disparity between wealthier and poorer countries? Eur J Med Res. 2020;25(1):51. Braun V, Clarke V. Thematic analysis: A practical guide. SAGE Publications ; 2022. Maslow AH. A theory of human motivation. Psychol Rev. 1943;50(4):370-96. Codjoe L, Byrne M, Langer S, Wildschut T, Sedikides C, Muir K, et al. Faith, identity, and mental health in Black British communities: A qualitative exploration. J Racial Ethn Health Disparities. 2019;6(1):203-12. Stickley T, Eades M. Faith and community mental health resilience: The role of places of worship as spaces of wellbeing. Health Place. 2013;19:90-5. Social Metrics Commission. Measuring poverty 2020: A report of the Social Metrics Commission. 2020. Available from: https://socialmetricscommission.org.uk/ Sandhu J, Patel S, Cole J, Reeves D, Gilbody S. Financial sustainability in social prescribing: Challenges and opportunities. BMC Health Serv Res. 2022;22(1):1137. Department of Health and Social Care. World's largest quango scrapped under reforms to put patients first [Internet]. 2025 Mar 13 [cited 2025 Mar 17]. Available from: https://www.gov.uk/government/news/worlds-largest-quango-scrapped-under-reforms-to-put-patients-first Marselle MR, Irvine KN, Warber SL. Walking for well-being: Are group walks in certain types of natural environments better for well-being than group walks in urban environments? Int J Environ Res Public Health. 2015;12(6):1688-99. Bonney R, Shirk J, Phillips T, Wiggins A, Ballard H, Miller-Rushing A, et al. Citizen science: A developing tool for expanding science knowledge and scientific literacy. BioScience. 2016;66(6):508-21. McKinley DC, Miller-Rushing AJ, Ballard HL, Bonney R, Brown H, Evans DM, et al. Citizen science can improve conservation science, natural resource management, and environmental protection. Biol Conserv. 2017;208:15-28. Additional Declarations No competing interests reported. Supplementary Files GreenSocialPrescribingSurvey.pdf SuplimentaryFileGreenSocialPrescribingInterviewandFocusGroupQuestions.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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It has been widely recognised for its role in addressing social determinants of health, particularly among individuals with complex needs, by offering personalised support beyond conventional medical interventions [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Evidence suggests that social prescribing enhances mental well-being, self-efficacy, and self-management of chronic conditions while also reducing the burden on primary care services through decreased general practitioner (GP) appointments and medication use [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. As part of the NHS Long Term Plan, social prescribing has been integrated into Primary Care Networks (PCNs), highlighting its growing importance in UK healthcare policyto address the social determinants of health [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGreen Social Prescribing (GSP) is a specific from of social prescribing in the UK. In 2021 a two-year cross government GSP programme was launched across 7 test and learn integrated care systems (ICS) by NHS England [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. GSP refers to the prescription of nature-based interventions (NBIs), such as green exercise, community gardening, care farming, and outdoor arts programmes, as a means of improving health and well-being. In 2021 Recent systematic reviews highlight that NBIs can contribute to improved mental health, increased physical activity, enhanced sleep quality, and reduced symptoms of anxiety and depression [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. A recent meta-analysis suggests that nature-based interventions have a moderate-to-large effect on reducing anxiety and depression, particularly when interventions incorporate social engagement [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Research further indicates that while nature-based interventions can be effective in reducing mental health disparities, participation remains inequitable, particularly for individuals from ethnic minority and socio-economically deprived groups [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. There is also emerging evidence suggesting that GSP may have additional benefits for cardiovascular health, stress reduction, and social cohesion [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Despite this growing evidence base, studies often have limitations in study design including small samples, and a lack of controlled trials [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile GSP has gained attention as a preventative and holistic approach to health, there is growing concern that ethnic minority populations remain underrepresented in social prescribing referrals and interventions [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Research suggests that individuals from Black, Asian, and minority ethnic groups experience disproportionately high levels of mental health inequalities, chronic disease, and socioeconomic deprivation, yet face significant barriers in accessing social prescribing programmes [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. A national evaluation of social prescribing programmes in the UK highlighted that a lack of awareness, cultural relevance and appropriateness, and systemic barriers continue to limit engagement among ethnic minority groups [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Ethnic minority individuals report limited knowledge of social prescribing services, compounded by an over-reliance on biomedical models in primary care [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Socioeconomic disparities result in reduced availability and lower quality of green spaces in urban areas with higher ethnic minority populations [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In addition, experiences of racial discrimination, lack of representation, and perceived exclusion from green spaces discourage participation in GSP initiatives [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Costs associated with transportation, entry fees, and time constraints further limit accessibility, particularly for lower-income groups [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Environmental Justice Framework (EJF) provides a useful theoretical lens for understanding disparities in access to Green Social Prescribing. Environmental justice refers to the fair distribution of environmental benefits and burdens, ensuring that all individuals regardless of race, ethnicity, or socioeconomic status have equal access to green spaces and their associated health benefits [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. According to Rigolon et al. (2019), environmental justice in recreational settings can be examined through distributional, procedural, and recognitional justice [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Distributional justice relates to the unequal availability and quality of green spaces, disproportionately affecting marginalised groups and communities. Procedural justice considers the inclusivity of decision-making processes in designing and implementing GSP interventions. Recognitional justice emphasises the need to acknowledge and respect cultural identities, ensuring that interventions are accessible, meaningful, and reflective of diverse lived experiences [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe COVID-19 pandemic further exacerbated existing health inequalities, with evidence indicating that ethnic minority groups experienced higher rates of mental distress and reduced access to preventative health interventions [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Given these challenges, it is important to explore how GSP programmes can be adapted to be more inclusive and equitable for underrepresented populations. Despite the expansion of GSP within UK healthcare policy, there remains limited empirical research on the accessibility and effectiveness of these interventions for ethnic minority communities. Current evaluations of social prescribing rarely collect ethnicity-specific data, making it difficult to assess whether GSP is meeting the needs of diverse populations [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. There is a need for research to understand how GSP can be adapted to reduce health disparities and address cultural and systemic barriers to participation.\u003c/p\u003e \u003cp\u003eThis study aims to identify the key barriers to participation in GPS interventions during the National GSP pilot among primarily Black and Asian ethnic minority groups in the UK. It also aims to explore culturally appropriate adaptations to enhance engagement, while promoting equity and accessibility in GSP initiatives.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe study employed a mixed-methods approach, integrating an online survey, interviews and focus group data collection to explore barriers to access in GPS among ethnic minority groups. A cross-sectional online qualitative survey was conducted, followed by semi-structured interviews and focus groups. The study was guided by the EJF framework\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e[16].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Setting and Participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in inner-city and peri-urban areas of multiple deprivation in the Midlands, England. When GSP programmes were being implemented as part of NHS England\u0026rsquo;s National programme [6]. Participants were recruited from diverse Black and Asian ethnic minority groups, reflecting communities that are underrepresented in GSP referrals [13]. Eligibility criteria included: (1) individuals aged 18 years and above, (2) self-identifying as Black, Asian, or mixed ethnicity, (3) residing in England, and (4) been involved in,\u0026nbsp;or are interested in GSP programmes.\u003c/p\u003e\n\u003cp\u003eRecruitment was conducted via snowball sampling through community partnerships, and social media advertisements, with additional outreach through faith organisations and ethnic minority health networks. Posters inviting participants were distributed through\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003elocal community and faith groups, social media platforms, and displayed civic buildings. The recruitment period ranged from December 2022 to June 2023 for the survey, and August 2022 to March 2023\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003efor interviews and focus groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative Survey:\u003c/strong\u003e An exploratory on-line qualitative survey was designed was developed for this study to explore understanding of GPS, accessibility and barriers to taking part, experiences of GPS and GPS intervention preferences. The full survey is available in Supplementary File 1. The survey\u0026nbsp;was distributed via local community groups, social media and poster adverts in civic buildings. Participants were recruited using snowball sampling\u003cstrong\u003e.\u003c/strong\u003e The survey included a combination of open ended, and drop-down multiple choice exploring; i) green social prescribing availability ii) which green social prescribing interventions they would like to access iii) benefits from taking part iv) barriers to access v) how to improve inclusivity and accessibility.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInterviews \u0026amp; Focus Groups\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 58 participants were purposefully sampled to take part in semi-structured interviews (n=10) and focus groups (n=5).\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe interview and focus group schedules were developed for this study. These are provided in Supplementary File 2.\u0026nbsp;Questions explored,\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eunderstanding of GPS, representatives and accessibility of GPS for minority ethnic groups, cultural considerations and outcomes of GPS participation.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe sample was selected to ensure diversity in\u0026nbsp;age, gender, ethnicity, faith backgrounds, and included GSP and NBI intervention providers. Table 1 provides an overview of the focus groups and interview participants. Posters recruiting participants were shared via local community organisations, faith groups, and social media channels. Interviews and focus groups were conducted either in person or virtually, with all participants residing in\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003einner-city areas of the Midlands, England.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1. Overview of Focus Groups and Interviews\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"601\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipant Group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMode\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge Range\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBlack Faith Focus Group (BFFG)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eIn-person\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eFemale (n=23), Male (n=7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003eBlack African (n=15),\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBlack African-Caribbean (n=7), Black British (n=8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e21\u0026ndash;59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e43 min\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMixed Ethnicity Young People Focus Groups (MEYPFG)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eIn-person\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e14\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(FG1: n=8,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFG2: n=6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eFG1:\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFemale (n=5),\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMale(n=3)\u0026nbsp;\u003cbr\u003e\u0026nbsp;FG2:\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFemale(n=2), Male (n=4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003eFG1:\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAlgerian, (n=1)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSomali, (n=1)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBlack African(n=2),\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAfrican (n=1) Indian (n=2)\u0026nbsp;\u003cbr\u003eFG2:\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBlack African (n=2)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBritish Asian (n=2)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eIndian (n=2)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBritish Pakistani (n=1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e18\u0026ndash;25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003eFG1:\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e55 min\u0026nbsp;\u003cbr\u003e\u0026nbsp;FG2: 62 min\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBlack British Focus Group (BBFG)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eVirtual\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eFemale (n=9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003eBlack African (n=2), Black\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAfrican-Caribbean (n=7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e45\u0026ndash;68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e50 min\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSouth Asian Focus Group (SAFG)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eVirtual\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eFemale (n=6), Male (n=1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003eIndian (n=4), Pakistani (n=3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e26\u0026ndash;75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e108 min\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunity/Faith Leaders\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eVirtual (Interviews)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eFemale (n=4)\u003c/p\u003e\n \u003cp\u003eMale (n=1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003eWhite (n=2),\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDual Heritage South Asian/White (n=1), South Asian (n=1), Dual Heritage Black/White (n=1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e35\u0026ndash;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e45\u0026ndash;60 min\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGSP \u0026amp; NBI Providers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eVirtual (Interviews)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eFemale (n=4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003eWhite (n=3),\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSouth Asian (n=1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e40\u0026ndash;64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e45\u0026ndash;60 min\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eService User\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eVirtual (Interview)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eMale (n=1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003eBlack African\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e45\u0026ndash;60 min\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSurvey responses were analysed using descriptive statistics. Open-ended responses, interviews, and focus group transcripts were analysed using thematic analysis in NVivo (version 12; QSR International), following Braun and Clarke\u0026rsquo;s (2022) six-step framework [20]. Coding was conducted inductively, allowing key themes to emerge from participant narratives. To enhance consistency, two independent researchers coded the transcripts separately, and discrepancies were resolved through discussion.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for the study was granted by the University of Leicester Psychology Department Ethics Committee. All participants were provided with a participant information sheet, detailing the study\u0026apos;s purpose, their right to withdraw, how their data would be stored and used, and contact information for the research lead. Participants signed a consent form before taking part in the study. All identifying information was removed from transcripts, and data was stored securely in compliance with UK GDPR regulations.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe findings from this study highlight key barriers to Green Social Prescribing (GSP) participation\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eamong ethnic minority groups, as well as potential strategies to improve inclusivity. The results are structured as follows: (1) Survey findings, presenting quantitative insights into awareness, participation, and perceived barriers; (2) Qualitative themes, drawn from interviews and focus groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1) Qualitative Survey\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipant Demographics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 38 participants completed the survey. The majority were Asian or British Asian (43%) then white (37%) or other white background (11%), mixed ethnic groups (5%) or Black British Caribbean (3%) \u0026ndash; see Table 2. The majority were female (66%), while 33% identified as male and 3% as non-binary. The largest age group was 26-35 years (34%), followed by 18-25 years (32%), with the remaining participants distributed across older age categories. Most respondents (87%) did not report a disability, while 10% identified as having a disability. Regarding employment status, 61% were employed, 21% were self-employed, 5% were unemployed, and 8% were retired.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2. Ethnicity of Survey Respondents\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"303\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 237px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity Category\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 237px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAsian or Asian British\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e17 (43%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 237px;\"\u003e\n \u003cp\u003eIndian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 237px;\"\u003e\n \u003cp\u003e\u0026nbsp;Bangladeshi\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 237px;\"\u003e\n \u003cp\u003e\u0026nbsp;Pakistani\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 237px;\"\u003e\n \u003cp\u003e\u0026nbsp;Chinese\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 237px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBlack British Caribbean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 237px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMixed or Multiple Ethnic Groups\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e2 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 237px;\"\u003e\n \u003cp\u003e\u0026nbsp;White and Asian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 237px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhite - British\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e14 (37%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 237px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOther White Backgrounds\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e4 (11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote: In this sample, the white respondents primarily represent GSP providers (27%), while the Black, Asian and mixed ethnic minority groups are primarily members of the public (73%).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGreen Social Prescribing Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGreen Social Prescribing (GSP) referral rates were low, with only 5%\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e(n=2) of participants having been referred by a healthcare professional. The majority (95%, n=35) had not received a referral, primarily due to a lack of awareness about these schemes. Many participants indicated that they would have been interested in GSP if they had been informed, while others noted that they engaged in nature-based activities independently. Despite low referral rates, 97% (n=35) expressed interest in participating in future GSP programmes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePreferred Green Social Prescribing Interventions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants identified Green Exercise (28%) and Forest Bathing (28%) as the most appealing activities, followed by Outdoor Arts and Crafts (8%), Care Farming (8%), and Community Gardening (3%). Nearly a quarter (24%) expressed interest in participating in multiple interventions (see Table 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3. Preferred GSP Activity\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"274\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreferred GSP Activity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 216px;\"\u003e\n \u003cp\u003eGreen Exercise\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e9 (28%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 216px;\"\u003e\n \u003cp\u003eForest Bathing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e9 (28%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 216px;\"\u003e\n \u003cp\u003eOutdoor Arts and Crafts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e3 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 216px;\"\u003e\n \u003cp\u003eCare Farming\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e3 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 216px;\"\u003e\n \u003cp\u003eCommunity Gardens/Allotments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e1 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 216px;\"\u003e\n \u003cp\u003eMultiple Activities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e8 (24%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003ePerceived Benefits of Green Social Prescribing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor participants who engaged in nature-based activities, improved quality of life, better\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003emood, and increased physical activity were the most cited benefits. Other reported benefits included reduced anxiety and depression, better sleep, healthier eating habits,\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eand improved social connections. A small number of participants also reported fewer GP visits and reduced medication use (see Table 4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 4. Reported Benefits\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"263\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReported Benefits\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eImproved quality of life\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eImproved mood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eIncreased physical activity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eGreater connection to nature\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eBetter sleep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eHealthier eating habits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eReduced anxiety and depression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eIncreased social connections\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eImproved management of health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eFewer GP visits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003eReduced medication use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eBarriers to Participation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNearly half of participants (47%) cited a lack of awareness as the primary barrier to GSP participation, followed by limited local availability (17%), cultural or language barriers\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e(14%), and other challenges such as time constraints or multiple intersecting barriers (17%) see Table 5.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 5. Barriers to Participation\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"334\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 268px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBarriers\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 268px;\"\u003e\n \u003cp\u003eLack of awareness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e17 (47%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 268px;\"\u003e\n \u003cp\u003eLimited local availability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e6 (17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 268px;\"\u003e\n \u003cp\u003eCultural or language barriers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e5 (14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 268px;\"\u003e\n \u003cp\u003eOther (time constraints, multiple factors)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e6 (17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eImproving Inclusivity and Accessibility\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThematic analysis of the qualitative responses in the survey identified four key themes for enhancing inclusivity in Green Social Prescribing (GSP): (1) Funding and Affordability, (2)\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eCultural Sensitivity and Community Outreach, (3) Local Accessibility and Adaptations for All Abilities, and (4) Safety and Family-Friendly Environments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1. Funding and Affordability -\u0026nbsp;\u003c/strong\u003eParticipants emphasised that cost was a barrier. Providers continually sought funding and resources to improve availability and access.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;We need funding and someone to organise these activities for them to work.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. Cultural Sensitivity and Outreach\u003c/strong\u003e - Many highlighted the need for translated materials, gender-specific sessions for religious and cultural reason, and the community partnerships to increase engagement.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Women-only sessions and translated information would encourage participation.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Local Accessibility and Adaptations\u003c/strong\u003e - Transport issues and physical accessibility were common concerns, with calls for programmes closer to residential areas and adapted for different abilities.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Shared community gardens near homes would be easier to access.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4. Safety and Family-Friendly Environments\u003c/strong\u003e - Women and parents cited safety concerns and lack of childcare as limiting factors, recommending better lighting, flexible timing, and child-friendly options.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Brighter spaces in the evenings would help women feel safer.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThese findings align with distributional, procedural, and recognitional justice within the Environmental Justice Framework (EJF), emphasising the need for equitable access, participatory decision-making, and cultural adaptations to encourage engagement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2 ) Results Interviews and Focus Groups\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThematic Analysis\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis section presents the findings from the thematic analysis of the interviews and focus groups. Eight themes are identified, 1) Lack of Awareness, (2) Systemic Discrimination, (3) Community Engagement and Co-Design, (4) Accessibility Barriers, (5) Safety Concerns, (6) Financial and Economic Barriers, (7) Cultural Adaptation, and (8) Environmental Awareness.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.\u003cstrong\u003e\u0026nbsp;Lack of Awareness\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants highlighted a lack of awareness of GPS and a dominance of the biomedical model in healthcare settings. Many reported that GPs prioritised conventional medicine over referrals to nature-based interventions (NBIs). Many were unaware of social prescribing services, with inconsistent access to Social Prescribers and geographical variation in provision further limiting uptake.: Several participants felt that GSP was not widely promoted, making it difficult to access.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;The awareness isn\u0026rsquo;t always there, and you don\u0026rsquo;t always know where to go to get that information.\u0026quot; (SAFG, Participant 5)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants also emphasised the need for targeted outreach and representation from South Asian and Black ethnic minority groups to increase engagement.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;So, there\u0026apos;s a capacity issue with the GPs that prescribe and there\u0026apos;s a capacity issue with the social prescribers they link with\u003c/em\u003e\u003cem\u003e\u0026rdquo;\u003c/em\u003e (BFFG, Participant 2)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We just hear about conventional medicines from doctors and people think taking a tablet or some kind of medicine is only answer.\u0026rdquo;\u003c/em\u003e (SAFG, Participant 9)\u003c/p\u003e\n\u003cp\u003eParticipants agreed that tailored communication strategies and culturally tailored and representative marketing was\u0026nbsp;needed to raise\u0026nbsp;awareness and increase participation in GPS.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2. \u003cstrong\u003eSystemic Discrimination\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants from ethnic minority groups described experiences of racial discrimination and hostility in rural green spaces, which deterred them from engaging in nature-based activities outside of urban areas. Many felt safer in inner-city parks, where they were more likely to see people from similar ethnic minority backgrounds.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;It\u0026rsquo;s not always something that\u0026rsquo;s voiced, but when you enter a space and get certain looks\u003c/em\u003e\u003cem\u003e. It tends to make you a bit uncomfortable\u003c/em\u003e\u003cem\u003e.\u0026quot;\u003c/em\u003e (BFFG, Participant 3)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;So, whatever we did was as a group and as a community and that would create problems all the time. Some people would tell us to go back where you came from.\u0026rdquo;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e (BFFG, Participant 4)\u003c/p\u003e\n\u003cp\u003eParticipants also highlighted a lack of representation of minority ethnic groups in GSP\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eprogrammes and expressed a need for more visible role models from diverse backgrounds.\u003c/p\u003e\n\u003cp\u003e2.1.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cem\u003eDomination of White \u0026quot;Middle-Class\u0026quot; Individuals\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMany participants felt that GSP and NBIs were dominated by white \u003cem\u003e\u0026ldquo;middle class\u0026rdquo;\u0026nbsp;\u003c/em\u003eindividuals, which created barriers to engagement for people from different cultural and socioeconomic backgrounds.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Certain groups come and swamp it and make the culture white. \u0026lsquo;Greeny\u0026rsquo; people, middle class, it can then be less welcoming to people who belong to other groups\u003c/em\u003e\u003cem\u003e\u0026rdquo;\u003c/em\u003e (Community Leader, Participant 4)\u003c/p\u003e\n\u003cp\u003eThere was a consensus that tailored interventions and diversity-friendly recruitment strategies were needed to increase participation among underrepresented groups.\u003c/p\u003e\n\u003cp\u003e3. \u003cstrong\u003eCommunity Engagement and Co-Design\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOver half of the focus group participants had never heard of GSP, highlighting a significant gap in engagement\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ewith Black and South Asian groups. Participants emphasised the importance of faith centres, local community organisations, and cultural events as opportunities for increasing awareness.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eYou could go to a church MOSC, Gurdwara Monday synagogue that would be like the community or like you know, religious side of places, and you know, if you\u0026apos;ve got these you know, big posters\u0026hellip; with someone of that local community, so they can kind of understand and say, look, this is what\u0026apos;s going on.\u0026rdquo;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e(SAFG, Participant 6)\u003c/p\u003e\n\u003cp\u003eCommunity co-design was highlighted as an essential strategy to ensure that GSP\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003einterventions align with faith and cultural values. Participants suggested integrating GSP activities into existing cultural and religious celebrations\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eto improve engagement.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003ePutting on specific things like Eid celebrations in the garden and activities like that.\u0026rdquo;\u003c/em\u003e (Community Leader, Participant 4)\u003c/p\u003e\n\u003cp\u003e4. \u003cstrong\u003eAccessibility Barriers\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePhysical health and mobility challenges emerged as significant barriers to participation in GSP. Participants with disabilities and chronic conditions found many outdoor spaces to be inaccessible due to poor infrastructure, lack of seating, and inadequate toilet facilities. This highlights\u0026nbsp;how ethnicity, socioeconomic status and (dis)ability intersect to create a further barrier to access reducing equity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Being a wheelchair user and sometimes it is difficult like with ramps and especially like toilet facilities. So, I think that needs to be addressed.\u0026rdquo;\u0026nbsp;\u003c/em\u003e (BFFG, Participant 6)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;\u003c/em\u003eA\u0026nbsp;\u003cem\u003ecouple of months ago my knee started\u0026hellip;so I stopped walking.\u0026rdquo;\u0026nbsp;\u003c/em\u003eBBFG, Participant 3)\u003c/p\u003e\n\u003cp\u003eParticipants highlighted the seasonality of outdoor activities, stating that cold weather and darker evenings often reduced motivation to engage in green exercise.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;When it\u0026apos;s dark and miserable outside, all we\u0026apos;ve got are a few aches and pains which is a bit harder to get motivated, isn\u0026apos;t it, to get out?\u0026rdquo;\u0026nbsp;\u003c/em\u003e(BBFC, Participant 4).\u003c/p\u003e\n\u003cp\u003e4.1. \u003cem\u003eTransport and Distance\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMany participants reported that transport costs and travel\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003edistances restricted their ability to attend GSP programmes, particularly those based in rural or peri-urban locations.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;A lot of these families don\u0026apos;t drive. So, you know, that transport straight away puts families off, even when I\u0026apos;m promoting them to go to a group to meet up with other people, especially if they\u0026apos;re isolated\u0026rdquo;\u003c/em\u003e (Community Leader, Participant 1)\u003c/p\u003e\n\u003cp\u003eThere was recognition that subsidised transport and more local, community-based initiatives could improve accessibility.\u003c/p\u003e\n\u003cp\u003e5. \u003cstrong\u003eSafety Concerns\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConcerns about drug activity, youth gangs, and antisocial behaviour in urban green spaces were frequently raised, particularly by women and older participants.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;\u003c/em\u003e\u003cem\u003e\u0026nbsp;Meadows is not safe, even though it\u0026apos;s a nature route for people to walk\u003c/em\u003e\u003cem\u003e. We do not feel safe there\u003c/em\u003e\u003cem\u003e.\u0026quot;\u003c/em\u003e (BFFG, Participant 7)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;\u003c/em\u003e\u003cem\u003e\u0026nbsp;Little packets of drugs. You can see them just passing it out in the open, so you don\u0026apos;t take your children there\u003c/em\u003e\u003cem\u003e\u0026rdquo;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e(SAFG, Participant 1)\u003c/p\u003e\n\u003cp\u003e5.1. \u003cem\u003ePublic Perceptions, Race, and Gender Stereotypes\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants would limit their participation to daytime due to safety concerns. For example, Black men reported self-limiting their outdoor activity due to fears of being racially profiled This amplifies perceived inequity in access to green spaces that some ethnic minorities experience.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cem\u003eIf I go at night, cause the things I wear, people might conceive that I\u0026rsquo;m something else\u0026hellip; You get what I\u0026rsquo;m saying? (laughs) I mean, obviously I\u0026apos;m a big\u0026hellip; In terms of stature and I\u0026rsquo;m a black person, black male, so walking at night is not really sensible\u0026rdquo;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e(MEYPFG2, Participant 1)\u003c/p\u003e\n\u003cp\u003eTo address these concerns, participants suggested better lighting and increased community policing to make outdoor green space users feel safer.\u003c/p\u003e\n\u003cp\u003e6. \u003cstrong\u003eFinancial and Economic Barriers\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGSP providers emphasised the instability of short-term funding, which created barriers to long-term sustainability. Many projects were volunteer led, leading to high turnover and inconsistent service provision.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIf you are constantly telling people well it\u0026rsquo;s a one-year project, then you\u0026rsquo;ve got to apply for more funding\u0026hellip;I think that is the absolute kind of killer of it.\u0026rdquo;\u003c/em\u003e (GSP Provider, Participant 2)\u003c/p\u003e\n\u003cp\u003e6.1. \u003cem\u003eOver-Reliance on the Voluntary Sector\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants in community and voluntary sector organisations expressed concerns about the unsustainable reliance on unpaid labour in delivering GSP initiatives. Participants called for programmes to be continued to be funded and properly resourced\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eto ensure GSP remains accessible to those most in need.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;\u003c/em\u003e\u003cem\u003e\u0026ldquo;We weren\u0026rsquo;t paid...And we didn\u0026rsquo;t have funding. So, we did it off our own back\u0026hellip;\u003c/em\u003e\u003cem\u003eYeah it\u0026rsquo;s a lot of work. Very labour intensive to deliver green activities\u0026rdquo;\u003c/em\u003e (Community Leader, Participant 3)\u003c/p\u003e\n\u003cp\u003e6.2. \u003cem\u003eLack of Disposable Income\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe cost-of-living crisis was identified as an additional barrier to participation. Many families struggled with the financial burden of transport, childcare, and other expenses related to attending GSP activities.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eThat\u0026apos;s in a local park that we can obviously promote parents go to, but again because it is kind of on the outskirts of the city, I feel there are challenges in regards to the families I work with, in regards to transport, the cost of transport\u0026rdquo;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e(Community Leader, Participant 1)\u003c/p\u003e\n\u003cp\u003e7. \u003cstrong\u003eCultural\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAdaptation\u003c/strong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants stressed the need for culturally adapted GSP programmes that respect religious beliefs and cultural practices. Muslim women, in particular, expressed a preference for gender-segregated activities.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Sometimes on a religious basis, men are not allowed. Like as a Muslim woman, I wouldn\u0026apos;t like to mix with men freely unless it\u0026apos;s on a professional level. If it\u0026apos;s a professional relationship, that\u0026apos;s fine. But I think when it comes to leisurely relationships or friendships, I would not\u0026rdquo;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e(SAFG, Participant 6)\u003c/p\u003e\n\u003cp\u003eYounger participants also described mental health stigma in their communities, making engagement more challenging.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Y\u003c/em\u003e\u003cem\u003eou\u0026apos;re really sort of struggling and also, you feel really isolated and you might not understand your experiences\u0026hellip;there\u0026apos;s a lot of stigma as well, especially if you\u0026apos;re a minority\u0026rdquo;\u003c/em\u003e (Service User, Participant 1)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e7.1\u003c/em\u003e\u003cem\u003e.\u003c/em\u003e\u003cem\u003e\u0026nbsp;Class, Caste, Poverty, and Social Status\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants discussed attitudes toward conservation work in their cultures, with some seeing gardening or cleaning green spaces as \u0026ldquo;low status\u0026rdquo; due to historical associations with caste and labour.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIn the UK and coming from an Asian background, you know we kind of we know that you know it\u0026apos;s not promoted in our culture you know picking rubbish up is seen as derogatory\u0026hellip;You know, I think from a young age you don\u0026apos;t understand fully what caste means but it\u0026apos;s only as you get older you really realise the detrimental and harmful effects of that.\u0026rdquo;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e(Community Leader, Participant 2)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e7.2. Cultural Adaptations and a Targeted Approach\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eGSP programmes need to be linguistically and culturally tailored, using trusted community leaders to build engagement.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026ldquo;\u003cem\u003eInformation has to be tailored and adapted in the way that they can kind of understand it. Obviously, language information, the formatting, the simplicity of the information. Avoid using jargon. Um, you know having information available in different ways, so audio, you know, literature. I know service users who can speak the language but will not necessarily be able to read the language. It\u0026rsquo;s that, and also having champions and peer support. You know, people doing that kind of work that people can identify with, who can then communicate that information and message and specifically people that they can then relate to, and they have trust towards\u0026rdquo;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e(Community Worker, Participant 5)\u003c/p\u003e\n\u003cp\u003e8.\u003cstrong\u003e\u0026nbsp;Environmental Awareness: Ecological Barriers and Connectedness\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWeather conditions and seasonality impacted participation, with many preferring indoor alternatives during colder months. Despite this,\u0026nbsp;participating in nature was described as improving their mental well-being.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Yes, I think active outdoor activities are quite successful ones. But you know the weather\u0026apos;s not always so good. So, you have to do some indoor activities. So that might be playing pool\u0026hellip;exercising indoors that might be doing mindfulness\u0026hellip;at the moment it\u0026apos;s all digital based\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Service User, Participant 1)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e8.1. Ecological Connectedness\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMany participants, particularly younger ones, described feeling \u0026ldquo;at peace\u0026rdquo; in nature, despite limited green space access in urban areas.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t know how to explain it. It\u0026rsquo;s like a different type of feeling. Because when you\u0026rsquo;re in nature, you feel closer to the earth...Yeah, I\u0026rsquo;d say being out in nature, it really helps you connect. With the earth\u003c/em\u003e\u003cem\u003e.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(MEYPFG1, Participant 5)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e8.2. Environmental Stewardship\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eYounger participants saw participating in NBIs as a way to promote environmental activism and education, encouraging intergenerational engagement in conservation efforts.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cem\u003eNo-one really cared about the environment. And it ended up causing a huge impact. People finding out later-later. When it was bad enough, but I\u0026apos;m saying, right now we can change the game.\u0026rdquo;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e(MEYPFG1, Participant 5)\u003c/p\u003e\n\u003cp\u003eThis highlights the potential for youth-led GPS\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eprogrammes focusing on environmental stewardship and conservation.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study explored the accessibility, inclusivity, and engagement of ethnic minority communities in GPS, applying the Environmental Justice Framework (EJF) to assess barriers and facilitators to participation. Findings highlight significant disparities in awareness, representation, affordability, and accessibility, reinforcing existing research indicating that ethnic minority groups remain underrepresented in social prescribing initiatives despite a strong interest in engagement [13,14]. However, this study directly addresses a key gap in the literature by actively seeking the perspectives of Black and Asian ethnic minority groups, offering a deeper understanding of the specific barriers and enablers shaping their engagement with GSP.\u003c/p\u003e\n\u003cp\u003eLow awareness and inconsistent availability of GSP emerged as major barriers to participation. While nearly all participants expressed interest in engaging with GSP, most had not been referred to a programme and were often unaware of their existence. This lack of awareness aligns with research showing that social prescribing referrals in the UK remain predominantly accessed by white, middle-class populations [13]. Participants perceived a reliance on the biomedical model within general practice, where GPs prioritise medicalised interventions over social prescribing. Enhancing distributional justice within GSP requires more effective community engagement strategies, ensuring that referral pathways reach diverse populations. Raising awareness through culturally tailored outreach campaigns, increasing GP and social prescriber knowledge of GSP, and embedding initiatives within trusted community organisations may improve uptake. Existing evidence highlights the importance of co-producing interventions with community members to ensure cultural relevance and foster trust [23].\u003c/p\u003e\n\u003cp\u003eCultural inclusivity and representation were also identified as significant barriers to engagement. Participants reported feeling unwelcome in predominantly white spaces, reinforcing findings that ethnic minority individuals often perceive outdoor spaces as exclusive or intimidating [16]. Rural racism and experiences of victimisation in green spaces can further alienate communities, creating psychological barriers to participation in GSP [15]. To promote procedural justice, initiatives should adopt culturally sensitive approaches, such as incorporating multilingual materials, gender-specific sessions, and faith-based adaptations. Participants suggested that religious festivals such as Eid and Diwali could serve as entry points for engaging ethnic minority communities with GSP, creating a more familiar and welcoming environment. Research supports the role of faith-based initiatives in promoting health equity, particularly among Black British communities, where faith is often central to health and wellness [22].\u003c/p\u003e\n\u003cp\u003eFindings further emphasise that GSP must be culturally tailored to account for religious and cultural needs. Participants described the importance of faith-based adaptations, such as incorporating prayer spaces within green environments, and ensuring activities align with cultural practices. GSP programmes that successfully integrate religious elements may foster greater engagement and long-term participation. Previous evaluations have shown that faith-centred health interventions can be highly effective in addressing health inequalities [22,23], highlighting the need for greater collaboration between healthcare providers, religious organisations, and community groups in shaping future GSP initiatives.\u003c/p\u003e\n\u003cp\u003eEnsuring accessibility and affordability remains vital for promoting distributional justice in GSP. Many participants cited transport barriers, financial constraints, and inadequate infrastructure as key obstacles to participation, reinforcing evidence that individuals from African, Caribbean, and South Asian groups and communities are disproportionately affected by socioeconomic deprivation [24]. Maslow\u0026rsquo;s hierarchy of needs suggests that when basic survival needs take priority, discretionary activities such as GSP may be deprioritised [21]. Addressing financial barriers requires a commitment to subsidised transport and free entry to green spaces. These findings are consistent with previous evaluations of GSP that identified cost, language, and accessibility as key factors limiting engagement among underserved populations [7].\u003c/p\u003e\n\u003cp\u003eSustainable funding is essential to ensure the long-term success of GSP initiatives. Current programmes rely heavily on short-term funding, creating instability in service provision. Traditional healthcare financing models are not designed to support social prescribing, and long-term funding mechanisms remain underdeveloped [25]. The closure of NHS England and its support structures, as recently announced by the Department of Health and Social Care [26] has raised concerns about the future stability of funding for GSP. However, Integrated Care Boards (ICBs) despite the challenges posed by these changes, present an opportunity to embed GSP within broader healthcare systems, by distributing funding to that which is more aligned with local population needs. However, equality monitoring data is needed to understand the demographics of those accessing services, ensuring that vulnerable and underserved communities are not left behind in the allocation of resources.\u003c/p\u003e\n\u003cp\u003eSafety concerns were also highlighted as a key barrier, particularly for women and individuals living in urban areas with high crime rates. Participants described feeling unsafe in certain green spaces due to poor lighting, antisocial behaviour, and past experiences of victimisation, consistent with research on perceptions of green space safety among ethnic minority populations [27]. Improving procedural and distributional justice in GSP requires targeted safety interventions, such as enhanced lighting, community policing, and designated safe spaces within parks.\u003c/p\u003e\n\u003cp\u003eFindings suggest that younger participants viewed environmental stewardship and climate activism as a pathway for engagement in GSP, reflecting broader trends in youth-led environmental movements. Involving young people in citizen science projects, such as biodiversity monitoring and conservation activities could serve as an effective strategy for increasing participation in green spaces while fostering a sense of agency and environmental responsibility [28,29].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications for Policy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study highlights a pressing need for policymakers to address structural and systemic barriers impacting ethnic minority communities\u0026apos; access to Green Social Prescribing (GSP) and nature-based interventions (NBI). Policies should prioritise sustainable funding models to ensure long-term access and continuity of services. To ensure equitable access, GSP programmes must routinely collect ethnicity data and implement ongoing monitoring and evaluation. Programmes should also be culturally and linguistically tailored and co-designed directly with ethnic minority communities. Awareness of GSP and NBI was low among ethnic minority participants in this study, despite high levels of interest. To enhance awareness and participation, promotional materials should explicitly represent these communities, clearly indicating that these programmes are inclusive and accessible beyond traditionally privileged, white, middle-class groups. As an output from this study, we have produced two culturally relevant films, featuring 1) interviews from project leaders and 2) project participants, explaining GSP and its benefits. One of these films can be accessed here: https://youtu.be/G2PQ7yFlR-k. Policymakers should further consider embedding culturally adapted GSP programmes within established community and faith-based organisations to optimise community engagement, trust, and sustained participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhile this study provides valuable insights into the barriers and facilitators of GSP for ethnic minority groups. Unlike previous GSP evaluations that fail to collect ethnicity-specific data [7], this study actively sought to engage diverse ethnic groups, incorporating perspectives from different Black and Asian ethnicities and faith communities. However, despite efforts to include a broad range of participants, some ethnic and faith groups may still be underrepresented, and findings may not be fully generalisable.\u003c/p\u003e\n\u003cp\u003eAdditionally, self-reported experiences may be subject to recall bias or social desirability bias. Future research could seek to capture longitudinal data on ethnic minority GSP engagement over time. A small number of participants shared that ethnicity (dis)ability and socioeconomic status intersect to create further inequity in access. Intersectional analyses could also explore how gender, disability, and socioeconomic status intersect with ethnicity and GSP participation.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights the need to ensure that ethnic minority groups have equitable access to NBIs. Findings demonstrate that while interest in GSP is high, systemic barriers related to awareness, cultural accessibility, affordability, and safety act as a barrier to participation. Addressing these barriers requires culturally tailored outreach, cultural and linguistically tailored programme design and sustainable funding that prioritise inclusion. Despite the current uncertainty, integrating GSP within ICBs social prescribing provision offers an opportunity to improve accessibility and engagement.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was granted by the University of Leicester Psychology and Vision Sciences Department Ethics Committee (Ref: 35793). The study was conducted in accordance with the British Psychological Society\u0026rsquo;s Code of Human Research Ethics (2014) and the ethical principles outlined in the Declaration of Helsinki. All participants provided informed consent prior to participation, and all data were anonymised to maintain confidentiality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are not publicly available due to confidentiality agreements with participants but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by the National Institute for Health and Care Research (NIHR) Policy Research Programme (PRP). The funder had no role in the study design, data collection, analysis, interpretation, or manuscript writing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDr. Ceri R. Jones was the Principal Investigator, conceptualised the study, led data collection and analysis, and drafted the main manuscript. Dr. Sylvia Delpratt and Ms. Kajal Nisha Patel conducted the focus groups, interviews, and thematic analysis. Dr. Natalie Darko, as a co-investigator, contributed to the study conceptualisation, study delivery, interpretation, and manuscript revisions. Dr. Ffion Curtis is a co-investigator and contributed to manuscript revisions. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all participants, community organisations, and faith groups who contributed to this research. We also acknowledge the support of the National Institute for Health and Care Research (NIHR) Policy Research Programme (PRP). This research was also supported by the National Institute for Health Research (NIHR) Applied Research Collaborative (ARC) East Midlands the Centre for Ethnic Health Research, and NIHR Leicester Biomedical Research Centre.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col start=\"1\" type=\"1\"\u003e\n\u003cli\u003eBickerdike L, Booth A, Wilson PM, Farley K, Wright K. Social prescribing: Less rhetoric and more reality. A systematic review of the evidence. \u003cem\u003eBMJ Open.\u003c/em\u003e 2017;7(4):e013384. \u003c/li\u003e\n\u003cli\u003eWildman JM, Moffatt S, Penn L, O\u0026apos;Brien N, Steer M, Hill C. 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Walking for well-being: Are group walks in certain types of natural environments better for well-being than group walks in urban environments? \u003cem\u003eInt J Environ Res Public Health.\u003c/em\u003e 2015;12(6):1688-99. \u003c/li\u003e\n\u003cli\u003eBonney R, Shirk J, Phillips T, Wiggins A, Ballard H, Miller-Rushing A, et al. Citizen science: A developing tool for expanding science knowledge and scientific literacy. \u003cem\u003eBioScience.\u003c/em\u003e 2016;66(6):508-21. \u003c/li\u003e\n\u003cli\u003eMcKinley DC, Miller-Rushing AJ, Ballard HL, Bonney R, Brown H, Evans DM, et al. Citizen science can improve conservation science, natural resource management, and environmental protection. \u003cem\u003eBiol Conserv.\u003c/em\u003e 2017;208:15-28.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Social prescribing, Green social prescribing, Nature-based interventions, Environmental justice, Health inequalities, Ethnic minority health, racial and Ethnic disparities, Public health policy, Community-led interventions, Social determinants of health","lastPublishedDoi":"10.21203/rs.3.rs-6513516/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6513516/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGreen Social Prescribing (GSP) aims to improve health and well-being by connecting individuals to nature-based interventions (NBIs). However, ethnic minority groups remain underrepresented in GSP despite growing evidence of its benefits. This study explores the barriers and facilitators to GSP participation among Black and Asian ethnic minority groups, applying the Environmental Justice Framework (EJF) to examine issues of distributional, procedural, and recognitional justice in access to green spaces.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA mixed-methods approach was used, comprising of \u0026nbsp;an online survey (N=38), qualitative interviews and focus groups with participants (N=58) from diverse Black and Asian ethnicities, those from faith backgrounds and GSP programme providers. Quantitative survey responses were analysed using descriptive statistics. Qualitative data was thematically analysed and salient themes identified.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite strong interest in GSP 97% of survey respondents expressed willingness to participate. Awareness was low, 95% had not been referred by healthcare professionals. Barriers included limited availability, lack of cultural representation, affordability, and safety concerns. Many participants perceived GSP as catering to white middle class groups, creating psychological barriers to participation. Participants emphasised the need for culturally tailored interventions, including multilingual materials, faith-based adaptations,\u003cstrong\u003e \u003c/strong\u003egender-specific sessions,\u003cstrong\u003e \u003c/strong\u003eand community-led programmes. Sustainable funding, transport support, and improved safety measures were also identified as key to improving accessibility.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFindings highlight the pressing need for an equity-based approach to GSP, ensuring that ethnic minority groups have inclusive access to nature-based\u003cstrong\u003e \u003c/strong\u003einterventions. Increased referrals from primary care, culturally and linguistically adapted programmes, community-led initiatives, while reducing economic and transport barriers could improve participation. Future research should explore ethnicity-specific evaluation frameworks and the long-term impact of tailored GSP interventions.\u003c/p\u003e","manuscriptTitle":"Advancing Equity in Green Social Prescribing: Exploring Racial and Ethnic Disparities in Access and Inclusion","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-09 06:17:34","doi":"10.21203/rs.3.rs-6513516/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ba9d7f32-87f4-4ea4-b296-3f353533e951","owner":[],"postedDate":"May 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-12T18:23:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-09 06:17:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6513516","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6513516","identity":"rs-6513516","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}