Title: Exploring racial and ethnic disparities in green social prescribing interventions and ‘what will work for whom in which contexts’ to improve the accessibility of green social prescribing programmes: Evidence based guidance for commissioners and policy makers
Funder: Department of Health and Social Care

Abstract: Green social prescribing links people to nature-based interventions (NBIs). Engagement in NBIs has been linked to improved physical and mental health outcomes (Howarth et al., 2018). Minority ethnic groups are more likely to live in poverty that their white counterparts (SMC, 2020). The positive relationships between NBI and health outcomes is stronger for those from socio-economically deprived communities than those of higher socio-economic status (Mitchell & Popham, 2008). Nature is accessed less frequently by minority ethnic populations due to lack availability, safety fears and lack of transport (Boyd, et al., 2018). These groups are underrepresented in social prescribing referrals (Gupta, 2021). This is due to language barriers and poor understanding of cultural or religious needs by providers (Wildman et al., 2019). Aim: To understand 'what works for whom in what contexts' for minoritised ethnic communities in relation to green social prescribing schemes to provide evidence based guidance for commissioners and policy makers to improve equitable access. Methods: WPK1: Stakeholder Reference Group & Survey: The SHRG will be convened with representatives from i) policy makers ii) commissioners and healthcare providers iii) NBI providers and iv) minoritised ethnic groups. The SHRG will act as a core reference group throughout the study, offering expert guidance and to inform the development of recommendations for the commissioning of social prescribing and NBIs to be more inclusive for minoritised ethnic groups as part of wider society (WPK4). Survey: A survey using a non-probability design, will be distributed to purposefully sampled (n=100) policy makers, commissioners, providers and minority ethnic community online via local/national networks. Questions will explore i) which NBIs are currently tailored for minoritised ethnic groups ii) intervention components, iii) intersectionality and inter-ethnicity considerations iv) contextual factors and mechanisms that influence participation, v) mental health outcomes and measures and vi) referral routes. WPK2: Realist Programme Theory: Relevant literature on NBIs and ethnic diversity will be rapidly reviewed. Findings will be synthesised with the survey results to develop context, mechanism, outcomes statements (C-M-Os) on ethnic disparities in green social prescribing intervention and what will work for whom in which contexts to improve accessibility. Refinement of Programme Theory: The C-M-Os will be revised and refined with co-design events of purposefully sampled stakeholders (i) commissioners/policy makers (n=5), (ii) social prescribers (n=5), (iii) NBI providers (n=5) and (iv) and minoritised ethnic groups (n=10). The C-M-Os will be further tested, refined, confirmed/refuted through semi-structured interviews with participants purposefully sampled from i) diverse ethnic groups (n=10), ii) Faith leaders/community organisations (n=10), iii) social prescribers (n=5) iv) GP's/healthcare professionals (n=5), v) commissioners/policy makers (n=5). WPK3: Outcome Measures: Routinely collected data sources will be identified and examined to make recommendations to commissioners on what is typically collected and what data needs to be collected in the future to effectively evaluate the outcomes of NBIs for minoritised ethnic groups. WPK4: Study Protocol: The SHRG will be reconvened to appraise the evidence gathered and develop key principles and recommendations commissioners when commissioning green social prescribing to be inclusive and equitable for minoritised ethnic groups.

Lay abstract: Green social prescribing links people to a range of nature-based activities; green exercise, local walking schemes, community gardening, food-growing projects and outdoor arts activities. There is evidence to suggest nature-based activities are good for people s health and wellbeing. People who access these activities eat more fruit and vegetables, have a healthier weight and have improved mental health and quality of life. Research suggests that people living in the poorest areas have less access to outdoor green space but when they are able to access good quality outdoor green space the benefits to their mental health are greater than those people from wealthier areas. Non-white ethnic minorities are more likely to live in the poorest areas and are more likely to experience poorer mental health. People from minority ethnic groups are less likely to be referred to green social prescribing and access nature-based activities. They may be further disadvantaged due to lack of transport, safety concerns and fears of discrimination and racism. There may be further barriers due to lack of understanding of cultural or religious needs when designing activities. In order to encourage referrals and engagement from minority ethnic groups green social prescribing programmes need to be designed with these communities to encourage equal access. Aims To provide guidance on how to improve opportunities to access and engage with nature based interventions for minority ethnic communities to support people s health and wellbeing. Methodology A group of experts from healthcare, commissioning policy and representatives from the local community will be brought together to form a study reference group to oversee the study and help develop guidance for the commissioners of nature-based interventions to be more diversity friendly and inclusive for minority groups. The study will seek views of professionals and the community through: Surveys: Social prescribing networks, policy makers, commissioners and healthcare providers will be surveyed to understand the green social prescribing programmes currently available, how they are tailored to improve referrals and engagement from ethnic minority groups. A second survey will be sent to the ethnic minority community and faith organisations to gather feedback on how these can be tailored to improve access. Stakeholder Consultations: Group events and interviews will be undertaken to get feedback from policy, healthcare professionals and the ethnic minority community to understand how these programmes work and can be adapted to engage this community to support their health and wellbeing. Data Review: Available data sources will be reviewed to identify what is typically collected to inform what data needs to be collected for future evaluations. The findings will be reviewed by the study reference group and guidance will be developed to improve opportunities for the ethnic minority community to access and engage with nature-based interventions.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;7.1 INDIVIDUAL CARE NEEDS
Health categories: GENERIC HEALTH RELEVANCE