Co-Creating Scotland’s Blue-Green Prescribing Programme for Population and Planetary Health: Multi-Study Implementation Research Using the Knowledge-to-Action Process
Authors:   , Alejandre Julius Cesar P. 
Published: November 2024

The increasing prevalence of anxiety and depression in Scotland is associated with increasing antidepressant use, contributing to potential environmental contamination and risks to aquatic organisms. This study investigated the factors that could influence the adoption and implementation of a Blue-Green Prescribing (BGP) model in the Scottish context. BGP is a sustainable primary mental healthcare approach that aims to reduce antidepressant pollution through nature-based social prescribing (blue prescribing), and eco-directed and sustainable pharmaceutical prescribing (eco-informed prescribing). Employing analytical frameworks including the Capability, Opportunity, and Motivation – Behaviour Change Model, the Theoretical Domains Framework, and the Consolidated Framework for Implementation Research; and multiple methods embedded in the Knowledge-to-Action Process, this research is divided in four phases: 1) Knowledge Synthesis using Systematic and Scoping Reviews; 2) Knowledge Contextualisation using Stakeholders-based Policy Analysis; 3) Knowledge Adaptation using Exploratory Sequential Mixed Methods Research, and 4) Knowledge Co-creation using Participatory Double Diamond Approach with Q-Methodology. In Phase 1, 16 studies were synthesised in a systematic realist review to develop a comprehensive logic model of blue prescribing composed of programme theories on Service User Enrolment, Engagement, Adherence, Communications Protocol, and Long-term Programme Sustainability. Forty-six studies were also analysed in a scoping review that uncovered the combination of behaviour change interventions—Education, Environmental Restructuring, Enablement, Training, Persuasion, and Incentivisation— used in environmentally sustainable pharmaceutical prescribing programmes globally. Phase 2 delved into the Scottish health and environmental policy landscape and suggested supportive policy frameworks and options for BGP adoption; critical gaps in policy implementation were also identified. Forty-four interviewed stakeholders in Phase 3 identified barriers and enablers to BGP focusing on the capability, opportunity, and motivation of healthcare providers and service users. Additionally, a survey of 278 primary healthcare professionals suggested high likelihood (i.e. willingness) of implementing BGP. Phase 4 suggests a BGP logic model for Scotland co-created by 25 to 36 co-creators in a series of co-creation workshops. The logic model is composed of 12 implementation strategies categorised into four core components: 1) Accessible and Equitable Blue Space Activities for Mental Health; 2) Environmental Considerations in Quality Mental Healthcare; 3) Synergies and Collaboration for Evidence-based Blue-Green Prescribing; and 4) Socio-ecological Investment for Mental Health. This co-created BGP logic model forms a robust framework for a sustainable and transformative primary mental healthcare approach that promotes population and planetary health and could help drive Scotland’s ambition towards a Net Zero and Wellbeing Economy.