Strengths and limitations
ADVERSE EVENTS, ADVERSE EFFECTS, DISEASE
This is a non-randomized pilot study in a real life, primary care setting and should be interpretated as such. Some aspects can be regarded both as strengths and limitations. First, inclusion was not based on a specific disease or diagnosis, but a common need for general health improvement. This strategic choice is based on the knowledge that primary care patients seek help for various health problems and symptoms, and frequent attenders commonly suffer from symptoms that might not be due to a specific diagnosis (Second, some methodological limitations need to be noted. All participants live in an area with abundant green and blue spaces, therefore, it is likely that the participants in the Sports-group also spent active time outdoors. Sleep was assessed by wrist-worn accelerometers that are considered acceptable for use in population studies or community-based interventions, and they compare rather well with polysomnography, which is considered the gold standard measure of sleep (Third, the follow-up time is short. The social restrictions following the outbreak of the COVID-19 pandemic ended this study early, therefore, we were able to recruit approximately half of the planned number of participants. A six-month follow-up questionnaire was initially planned, but as the COVID-19 pandemic occupied professionals, it simply was not possible to fulfill this part of the study. Also, we were not able to analyze how participation in the intervention affected the use of health care services. Research in primary care faces pragmatic challenges and needs stronger structure in Finland. Digital tools could facilitate communication between participants and instructors as well as providing a platform for follow-up when developing social prescribing programs. However, consideration of the target groups’ ability to use technical devices is important. The national Sustainable Growth Program in Finland is part of the NextGenerationEU program, aiming to support growth that is ecologically, socially and economically sustainable (Fourth, this was not a randomized controlled trial. The concept of Health Forest started out as a trial, and the study protocol evolved from these experiences. As the project had gained public interest before the study, positive perception may impact the results in favor of the Nature-group, also among the referring health professionals. Even so, the activities for the Sports-group were planned carefully to represent the current best practice. Primary care clients committed to both social prescribing schemes, and no adverse effects nor adverse events occurred. We found no difference in season, and this being found the Nature-groups can be organized all year round also in Nordic countries. Based on the encouraging results we hope to see more preventive projects utilizing nature and research addressing how nature can be used as a treatment. In future research, the use of cluster randomization is a way to provide a more robust study design. In bigger studies, inclusion of health data such as diagnosis and medication could help us understand more about the conditions to which nature-based social prescribing is best of help, and by including information health metrics we might also learn whether nature-based interventions can reduce demand on health and social service.The programs used in this study can be adapted to different target groups and locations, and we consider the practical approach as the biggest strength of this field-study.