Contextual Factors and Programme Theories Associated with Implementing Blue Prescription Programmes: A Systematic Realist Review

Table 3

Characteristics of blue prescription programmes.

Authors, year, country	Service users	Health and wellbeing status	Inputs				Activities			Health, wellbeing and other outcomes
			Facility providing prescription or referral	Prescriber or referrer	Frequency and duration	Timescale	Referral pathway	Programme format	Type of blue space activity
Bennett et al., 2014, USA [59]	28 veterans, aged 22–50 years	PTSD, TBI, and hearing impairment	Veteran hospital	Recreational therapist	4 sessions, 4 hours each	4 days	Signposting	Structured fly-fishing, stretching, and breathing exercises, campfire, and games	Fly-fishing	Self-confidence, social and nature reconnection, overcoming fears
Cavanaugh and Rademacher, 2014, UK [66]	11 student campers, aged 10–16 years	ASD	Specialised school	Psychologist	7 sessions (estimated), unspecified duration	7 weeks (estimated)	Holistic link worker	Structured pre-post surf camp, family socials, group activities, two-day surf camp (i.e., arts and crafts, frame decoration, paddle relay, sandcastle building, and t-shirt signing)	Surfing	Social competence (assertion, responsibility, and engagement); social skills (ownership of behaviour)
de Matos et al., 2017, Portugal [67]	48 adolescents, aged 10–16 years	Psychosocial problem and vulnerability	Foster care homes	Social worker and adolescent educators	8 sessions, 4 hours each	3 months (estimated)	Direct referral	Structured group surfing and psychoeducational activities	Surfing	Perseverance, problem solving, time management, social competencies, interpersonal relationship, emotional regulation, improved peer interaction, surfing skills, and sea safety
Dustin et al., 2011, USA [60]	13 veterans, unspecified age	PTSD	Veteran hospital	Therapeutic recreation specialist, nurse, psychologist, social worker	Whole day camping for 4 days	4 days	Direct referral	Structured boating (floating), hiking, campfire, and socials	Combined river running, kayaking and paddling	Reduced PTSD symptomology, feeling present, self-efficacy, less dependence on medications
Fleischmann et al., 2011, USA [61]	One adult, aged 21 years	Polytrauma, TBI, and mild depression	Veteran hospital	Exercise physiologist	24 sessions, 3 hours each	6 months	Holistic link worker	Structured group surf therapy and yoga for strength training, balance rehabilitation, and hydrotherapy	Surfing	Improved mobility (walking, balancing, vestibular function, muscular strength, and aerobic endurance); relief from TBI; reduced narcotic intake
Godfrey et al., 2015, UK [68]	121 young people, aged 8–18 years	Depression, anxiety, social exclusion, obesity, and sensory problems	GP surgery, educational facility, and social care institution	GP, nurse, psychologist; and social and child support service specialist	6 sessions, unspecified duration	6 weeks	Direct referral	Structured group surfing	Surfing	Robust positive functioning, self-esteem, emotional wellbeing, vitality, friendship and social trust, fitness, and physical activity
Hignett et al., 2017, UK [69]	58 young people, aged 13–16 years	Aggressive behaviours, and social, emotional, and behavioural problems	Short stay schools or pupil referral units	Teachers trained in assessing social, emotional, and behavioural status of children using a tool developed by the local council	Unspecified	12 weeks	Direct referral	Structured surfing and environmental awareness activities (e.g., beach cleaning)	Surfing	Physical fitness (drop in resting heart rate); personal and interpersonal wellbeing; social connectedness; positive attitude; and environmental awareness and knowledge
James et al., 2017, USA [70]	Unspecified number of children, aged 2–13 years	Overweight and obesity	Community health clinic/centre	Paediatrician	Weekly sessions, unspecified duration	Unspecified	Holistic link worker	Unstructured physical activities outdoors (e.g., nature walks, unstructured playtime at the beach)	Play activities	Physical activity and weight loss
Lopes, 2015, Portugal [62]	321 children and adults, aged 8–66 years	Mobility and visual impairment, cognitive disabilities	Rehabilitation centres and foster care homes	Therapist and social worker	10 surfing sessions, unspecified duration	1 year	Direct referral	Structured adapted surfing encompassing activities of daily living, education, work, play and leisure, and social participation	Surfing	Social skills and inclusion, mental wellbeing, physical activity, and health and environmental awareness
Maund et al., 2009, UK [63]	16 adults, aged 65–85 years	Anxiety and depression	Community wellbeing service	Mental health support worker	6 sessions, unspecified duration	6 weeks	Link worker	Structured guided nature walks, introduction to wetland reserve, feeding and identifying bird species, canoeing, and free time in nature	Combined nature and river walk, bird and otter watching, and canoeing	Improved mental and physical health; social inclusion; nature connection
Mowatt & Bennett, 2011, USA [64]	67 veterans, unspecified age	PTSD	Veteran hospital	Recreational therapist	Whole day for 2 days	2 days	Signposting	Unstructured fly-fishing	Fly-fishing	Being at the present state, relaxed, and retrospective reconciliation
Pereira et al., 2020 Portugal [71].	89 youth, aged 7–17 years	High risk of mental health conditions (e.g., anxiety, depression, low self-esteem, and social disconnection)	Residential childcare centre	Residential care worker	Weekly sessions, 3 hours each	1 school year	Direct referral	Structured surfing and psychoeducation composed of sharing and recapitulation (initial circle), theme-related group activity or reflection on socioemotional skills (group dynamic), surfing (surf dynamic), and another sharing and reflection (final circle)	Surfing	Significant reduction in total emotional and behavioural problems and significant increase in prosocial behaviour and quality of life (care worker reported outcomes).; No significant effects on depression, anxiety, self-esteem, emotion regulation, social connectedness, sleep quality, and physical activity (child reported outcomes)
Razani et al., 2018, USA [72]	78 children, average age of 8 years	Poor mental health, loneliness, and psychological stress	Primary care clinic	Paediatrician	Unspecified	3 weeks	Signposting and link worker	Mix of independent and supported park prescription (e.g., group nature outings and play activities at the bayfront and lake)	Play activities	Decrease in stress, improvement in loneliness and physical activity, nature affinity, and frequent park visit
Rogers et al., 2014, USA [73]	14 veterans, aged 24–30 years	PTSD and depression	Primary care clinic	Physician	5 sessions, 4 hours each	5 weeks	Holistic link worker	Structured one-to-one surfing lesson and collaborative socialisation	Surfing	Lower PTSD symptom severity
Vella et al., 2013, USA [74]	74 veterans, unspecified age	PTSD, TBI, major depressive disorder, and anxiety	Veteran hospital	Recreational therapist	4 sessions,; 4 hours each	2 days	Direct referral	Structured fly-fishing, socials, games, and entertainment	Fly-fishing	Sustained reduction in symptoms of depression, anxiety, and somatic stress; increased sleep quality and efficiency; improvement in mood profiles (e.g., attentiveness, serenity, self-assuredness, joviality, and positive affect); and decreased feelings of guilt, hostility, fear, sadness, and negative affect
White et al., 2016, UK [65]	11 adults, aged 26–61 years	Alcohol and drug use	Rehabilitation clinic	Medical professionals specialising in drug and alcohol dependency	Whole day for 5 days	5 days	Direct referral	Structured day-to-day sailing functions and group activities and socialisation (e.g., hosting sails, lifting anchors, cooking, cleaning, navigation, steering, keeping watch, and attending social meetings)	Sailing	Self-insight, perseverance, and inner strength; social skills; increased confidence; abstinence to substance abuse; and positive future framing

PTSD: post-traumatic stress disorder; TBI: traumatic brain injury; ASD: autism spectrum disorder; GP: general practitioner.