Page - 270 - in Biodiversity and Health in the Face of Climate Change

270 taneously improve both human health and the health of the semi-natural environ- ment (see Box 11.2). Research over the last 20  years describes a range of nature-based activities that constitute green care and, crucially, the positive impact on health and well-being for people who may be vulnerable or socially excluded (Berget et  al. 2012). The increased interest in such innovative approaches to well-being has led to a prolifera- tion of terms used to denote nature-based work; consequently, the terms green care and nature-based interventions are often used interchangeably (Bragg and Atkins 2016). The spectrum of nature-based activities includes gardening, vistas and walk- ing, food growing, community gardens, prescribed (for example, an imposed or recommended regimen) exposure to nature, nature-based activity or structured green care activities (Green Care Coalition 2017). Thus, social prescriptions using outdoor nature-based approaches, as available within the nature, health and well- being sectors, provide one way in which health professionals with a public health role might facilitate individuals to access biodiverse greenspace. 11.4.1 Towards an  Emerging Salutogenic Paradigm? Salutogensis focuses on factors that support human health and well-being, rather than on those that cause disease (i.e. pathogenesis) (Antonovsky 1979). Predicated on the paradigm that health is a positive state of well-being rather than just “being well” and deterring ill health, salutogenesis originated through Antonovsky’s (1979) asset-based approach, which endorses the skills, attributes and resources of indi- viduals and communities to develop resilience and a sense of purpose. Hence, a salutogenic approach has influenced the move away from more medical, pathogenic models to provide a sense of coherence between health and illness. The lack of proof of causality in the evidence base for biodiversity and human well-being has straitjacketed public health policy. This is because evidence-based commissioning, the process by which health interventions are funded on the basis of their proven effectiveness, requires strong evidence that the intervention (e.g. a green-care intervention) has a causal relationship with health (i.e. disease reduc- tion). This is predicated on a medical evidence hierarchy in which a positivist para- digm prevails. Hence, commissioners may be reluctant to support services lacking experimentally-derived evidence and have been slow to embed salutogenic approaches within health-care policy. However, taking a more proactive and struc- tured approach to the use of nature-based interventions, particularly those involving biodiverse environments, has the potential to influence public health discourse and morph into an emerging salutogenic paradigm. Such interventions may be cost effective by reducing the economic burden on health-care systems; however, in order to demonstrate this, it is essential to develop evaluation methods that can adequately define these health and economic benefits. Evaluation methods need to P. A. Cook et al.