Nature prescriptions for adolescent mental health: a feasibility study

ISRCTN ISRCTN15765478
DOI https://doi.org/10.1186/ISRCTN15765478
ClinicalTrials.gov (NCT) Nil known
Clinical Trials Information System (CTIS) Nil known
Protocol serial number Nil known
Sponsor London Health Sciences Centre Research Institute
Funder Children's Health Research Institute
Submission date
23/10/2025
Registration date
03/11/2025
Last edited
03/11/2025
Recruitment status
Not yet recruiting
Overall study status
Ongoing
Condition category
Mental and Behavioural Disorders
Prospectively registered
Protocol
Statistical analysis plan
Results
Individual participant data
Record updated in last year

Plain English summary of protocol

Background and study aims
Mental health challenges affect many Canadian adolescents aged 10 to 18 years, yet few receive adequate treatment. Nature prescriptions (Nature Rx), written prescriptions to connect with nature to support health (including adult mental health), show promise, but little is known about their benefits for adolescent mental health and well-being. This study will explore the feasibility of Nature Rx for adolescents at CH-LHSC and examine their effects on mental health and wellness.

Who can participate?
Adolescents living with depression aged 10-18 years accessing outpatient services at Children's Hospital, London Health Sciences Center (CH-LHSC) can participate in the quantitative and qualitative components of the study. Caregivers and healthcare providers of these adolescents may also participate.

What does the study involve?
Adolescent participants will receive a Nature Prescription, including a conversation about nature’s benefits and the specific activities prescribed. They will receive a printed prescription, a pamphlet, videos about nature's benefits, and a toolkit with sensory items and activities. A 6-week follow-up “nudge” will be offered by a research assistant. Surveys will be conducted before the prescription and again 3 and 6 months later. Interviews will be conducted within 1 week of the prescription and again 3 and 6 months later. Caregivers and HCPs of these adolescents will participate in qualitative interviews about their perspectives and experiences of Nature Rx for adolescents.

What are the possible benefits and risks of participating?
Participants may benefit from the Nature Prescription intervention by developing tools and strategies to support their health and wellbeing. However, it is also possible that they may not receive these benefits.
Adolescents may feel uncomfortable or upset when answering questions about their mental health and wellbeing or when discussing personal experiences during interviews. Some personal information will be collected during the study. While every effort will be made to keep this information safe and confidential, there is a small risk that data could be accidentally shared. If a privacy breach occurs, the Health Sciences Research Ethics Board (HSREB) and London Health Sciences Centre will be notified within 48 hours, and institutional procedures will be followed. There may be risks in taking part in a nature prescription. Safety risks and considerations will be discussed with each adolescent and their care team. Prescribers will also follow common safety guidelines outlined in the prescribing resources to ensure the wellbeing of adolescent participants.

Where is the study run from?
The study is run from the Children's Hospital, London Health Sciences Centre (CH-LHSC) in London, Ontario. The principal investigators of this study are at Western University and CH-LHSC.

When is the study starting and how long is it expected to run for?
March 2025 to December 2026

Who is funding the study?
The Children's Health Research Institute (CHRI) (UK)

Who is the main contact?
1. Lesley Gittings, lgitting@uwoca
2. Anna Gunz, anna.gunz@lhsc.on.ca

Contact information

Dr Lesley Gittings
Public, Scientific, Principal investigator

School of Health Studies
1151 Richmond Street
London
N6A 5B9
Canada

ORCiD logo 0000-0002-0463-0478
+1 (0)519 661 4249
lgitting@uwo.ca
Dr Anna Gunz
Public, Scientific

800 Commissioners Rd E
London
N6A 5W9
Canada

ORCiD logo 0000-0003-2824-2274
+1 (0)519 685 8500 ext 58052
Anna.Gunz@lhsc.on.ca

Study information

Primary study designInterventional
Study designMixed-methods interventional feasibility study
Secondary study designFeasibility study
Scientific titleNature Rx for adolescent mental health: a feasibility study
Study objectivesFeasibility/Objective 1 (Primary Objective):
To examine the feasibility of Nature Rx as a mental health intervention to support adolescents (aged 10-18 years).

Mental Health/Objective 2:
To generate preliminary evidence on the effectiveness of Nature Rx for improving adolescent mental health outcomes (depression, anxiety- PHQ-9: Nine-symptom checklist, Generalized Anxiety Disorder 7-item scale).

Wellbeing/Objective 3:
To generate preliminary evidence on the effectiveness of Nature Rx on adolescent well-being and additional health-related measures (i.e., BMI, hemoglobin A1C, heart rate variability; survey measures of Acceptability of Intervention Measure, Intervention Appropriateness Measure, and Feasibility of Intervention Measure, Adolescent Wellbeing, Child and Youth Resilience Measure-Revised, The Hogg Eco-Anxiety Scale, Brief Screener for Tobacco, Alcohol, and other Drugs, Pediatric ACEs and Related Life Events Screener, HOPE Scale-Short Form, Generalized Self-Efficacy Scale, Mindful Self-Care Scale, Self-Compassion Scale Short Form, Child and Adolescent Mindfulness Measure, The Social Connectedness Scale, Youth Quality of Life Scale, Connectedness to Nature Scale (Children's Version).
Ethics approval(s)

Submitted 04/03/2025, Western University Health Sciences Research Ethics Board (HSREB) (Western Research Room 5150, Support Services Building Western University, London, N6G 1G9, Canada; +1 (0)519 661 3036; ethics@uwo.ca), ref: 126829

Health condition(s) or problem(s) studiedAdolescent mental health outcomes (depression, anxiety), adolescent well-being, and additional health-related measures
InterventionParticipants will be screened for moderate depression (based on the PHQ-9) at baseline survey. Following enrolment and the baseline survey, participants will receive a Nature Rx in an individual guided conversation with their HCP. Patient participants will receive a nature prescription from their healthcare provider (a formal plan for connecting nature). This Nature Rx conversation will include: the health and well-being benefits of connecting with nature, and a tailored discussion about the frequency, location and activities of their prescription, based on individual interests, needs, health status and geographical environment/access. HCPs will receive a Nature Prescribing toolkit, containing items such as a pamphlet to provide to patients in the intervention, a Nature Rx script and template, and Nature Rx case studies. Alongside the conversation, participants will receive (1) their printed Nature Rx Script, including the details above; (2) written (online, printed handout) resources summarizing the evidence on the health benefits of nature, which include a QR code link to three brief video summaries (i. The benefits of nature; ii. What is a nature Rx?; iii. Nature Rx ‘how to’); (3) an Adolescent Nature Rx Sensory toolkit). Sensory toolkit items include a Nature journal (including somatic and embodied prompts, colouring activities and a Nature Rx logbook) with nature-based mindfulness activities, and a small indoor plant (optional, real or artificial - sight and touch), QR code nature playlist, a scent package.
Intervention typeBehavioural
Primary outcome measure(s)

The acceptability and feasibility of Nature Rx as an adolescent (aged 10-18 years) mental health intervention, measured using:
1. Enrolment, recorded as the number of eligible participants who consent to participate at baseline
2. HCP completion: the number of patients who healthcare providers are able to prescribe nature to and follow-up with, measured at baseline and follow-up at 3 and 6 months
3. Recruitment rate recorded as the number of eligible participants who consent to participate who remain in the study until the end of follow up at 6 months
4. Adherence to Nature Rx (≥75%) assessed using the number of participants who consent to participate who adhere to their nature prescription at 3- and 6-month follow-ups, and RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) measured at 3 and 6 months
5. The researchers will qualitatively explore acceptability, barriers and facilitators using in-depth semi-structured interviews (adolescents, caregivers, healthcare provider), photo elicitation and narrative interviewing methods (adolescents). Adolescents will be interviewed at three timepoints (T1 - baseline, T2, T3). Caregiver and healthcare provider interviews will happen at one timepoint (T3).

Key secondary outcome measure(s)

Preliminary evidence on the effectiveness of Nature Rx for improving adolescent mental health outcomes (depression, anxiety) and wellbeing outcomes:
1. Depression measured using the Patient Health Questionnaire for Adolescents (PHQ-9) at T1, T2 and T3 (baseline, 3 months, 6 months).
2. Anxiety measured using the Severity Measure for Generalized Anxiety Disorder for Children 11-17 at T1, T2 and T3 (baseline, 3 months, 6 months).
3. Wellbeing measured using the Adolescent Wellbeing Scale for Young People Aged 11 to 16 at T1, T2 and T3 (baseline, 3 months, 6 months).
4. Quality of life measured using the Youth Quality of Life Scale at T1, T2 and T3 (baseline, 3 months, 6 months).
5. Child and youth resilience measured using the Child & Youth Resilience Measure-Revised (CYRM-R)at T1, T2 and T3 (baseline, 3 months, 6 months).
6. Connectedness to nature measured using the connectedness to nature scale at T1, T2 and T3 (baseline, 3 months, 6 months).
7. Ecodistress measured using the Hogg Eco-Anxiety Scale (HEAS-13) at T1, T2 and T3 (baseline, 3 months, 6 months).
8. Substance use measured using a brief screener for tobacco, alcohol, and other drugs measure at T1, T2 and T3 (baseline, 3 months, 6 months).
9. Paediatric ACEs and related life events measured using PEARLS T1, T2 and T3 (baseline, 3 months, 6 months).
10. Hope measured using the HOPE Scale-Short Form T1, T2 and T3 (baseline, 3 months, 6 months).
11. Self-efficacy measured using the Generalised Self-efficacy Scale at T1, T2 and T3 (baseline, 3 months, 6 months).
12. Mindful self-care measured using the Mindful Self-Care Scale atT1, T2 and T3 (baseline, 3 months, 6 months).
13. Self-compassion measured using the Self-Compassion Scale Short Form 0 (SCS-SF) atT1, T2 and T3 (baseline, 3 months, 6 months).
14. Mindfulness measured using the Child and Adolescent Mindfulness Measure (CAMM) at T1, T2 and T3 (baseline, 3 months, 6 months).
15. Social connectedness measured using the Social Connectedness Scale at T1, T2 and T3 (baseline, 3 months, 6 months).
16. Nature connectedness measured using the Connectedness to Nature Scale: Children's Version at T1, T2 and T3 (baseline, 3 months, 6 months).
17. Sleep measured using the Adolescent Sleep Wake Scale (ASWS)- short and sleep pattern/duration items from the Children’s Report of Sleep Patterns (CRSP) at T1, T2 and T3 (baseline, 3 months, 6 months).
18. Pro-environmental behaviours measured using the Social Pro-Environmental Behaviors Scale for Adolescents (s-PEBS-A) at T1, T2 and T3 (baseline, 3 months, 6 months).

Completion date31/12/2026

Eligibility

Participant type(s)Health professional, Patient, Other
Age groupMixed
Lower age limit10 Years
Upper age limit18 Years
SexAll
Target sample size at registration100
Key inclusion criteriaAdolescent eligibility:
Inclusion criteria for quantitative survey include:
1. At recruitment stage, a list of adolescents with a depression diagnosis based on PHQ-9A with HCP at CH-LHSC OR depression diagnosis based on clinic procedures will be provided to the study team
2. Screen for depression (using PHQ-9A, with a validated cutoff score of 10) on quantitative survey by study team
3. Aged 10-18 years
4. Ability to participate in English
5. Are able to provide informed consent (as determined by the recommending HCP)

Inclusion criteria for adolescent qualitative patients include:
1. Adolescent patients who have participated in the quantitative survey and intervention (i.e., inclusion criteria as above apply)
2. Informed patient consent

Healthcare providers:
Inclusion criteria include:
1. Health provider at CH-LHSC
2. Prescribed nature to an adolescent participant
3. Ability to participate in English
4. Informed consent

Caregivers:
Inclusion criteria include:
1. A caregiver of a patient who participated in the intervention
2. Ability to participate in English
3. Provide informed consent to participate
4. Patient (their child) provided consent for their participation
Key exclusion criteriaAdolescent eligibility:
Exclusion criteria for quantitative survey:
1. Did not screen for depression (using PHQ-9A, with a validated cutoff score of 10) by a HCP at CH-LHSC AND has not received depression diagnosis by a CH-LHSC HCP
2. Are not between the ages of 10-18 years
3. Are unable to participate in English
4. Informed patient consent is not obtained

Exclusion criteria for qualitative patients:
1. Adolescent patients did not in the quantitative survey and intervention (i.e., inclusion criteria as above apply)
2. Informed patient consent not obtained

Healthcare Providers:
Exclusion criteria include:
1. Is not a health provider at CH-LHSC
2. Did not prescribe nature to an adolescent participant in this study
3. Are unable to participate in English
4. Informed consent is not obtained

Caregivers:
Exclusion criteria include:
1. Not a caregiver of a patient who participated in the intervention
2. Are unable to participate in English
3. Do not provide informed consent to participate
4. Patient (their child) did not provide consent for their participation
Date of first enrolment01/12/2025
Date of final enrolment01/09/2026

Locations

Countries of recruitment

  • Canada

Study participating centre

Children's Hospital, London Health Sciences Centre
800 Commissioners Rd E
London
N6A 5W9
Canada

Results and Publications

Individual participant data (IPD) Intention to shareYes
IPD sharing plan summaryStored in non-publicly available repository
IPD sharing planThe datasets generated during the current study will be stored in a non-publicly available repository at Western University. De-identified data may be accessed and analysed by members of the project team. Consent from participants will not be sought for sharing raw data publicly. Data will not be made available, given the potential for unintentional participant identification, and the possibility of data being engaged without adequate contextualising information.

Editorial Notes

23/10/2025: Study's existence confirmed by the Children's Health Research Institute.

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