Sharon Pfleger

The clinical case discusses a patient taking part in wild swimming but succumbing to sickness and diarrhoea due to water pollution from sewage discharge. Human health is dependent on access to clean water but also other aquatic systems (coastal, ocean, etc.) functioning well. The introduction starts with a review of the historic (life started in the oceans), geographic (nearly three-quarters of the planet is covered in water, with most being in oceans), and current state (three billion people depend on waterways for their livelihoods) of water. The chapter progresses with an examination of the interaction between health care and water systems, including the impact through health-care transportation and supply chains, the importance of “blue carbon”, and food availability through fishing. The health benefits of healthy blue spaces are emphasised. The harm from health care includes greenhouse gas emissions, which contribute to ocean acidification, biodiversity and species loss, and water pollution. Pharmaceuticals are partially dependent on water systems for marine-derived compounds but also responsible for pollution from pharmaceutical compounds. Currently, only two rivers in the world have no recorded pharmaceutical pollution. How medicines reach the environment is explored. Actions (whether reducing medication supplied or informing patients of correct disposal) are considered. Other issues – antimicrobial resistance and plastic pollution are discussed. Positive actions of nature recovery and nature connection are explored.

Humans are consuming more pharmaceuticals than ever before [ 1] as a result of ageing populations, and technological innovation transforming the treatment of ageing-related and chronic diseases [ 2]. Moreover, climate-related environmental changes are associated with a rise in the incidence of certain chronic diseases [ 3], which ultimately will lead to further medicines use. Healthcare is a key contributor to the climate crisis emitting 4.4% of global net emissions [ 4]. Medicines are estimated to account for 25% of NHS carbon emissions in the UK [ 5] so any increase in their use may worsen atmospheric warming [ 6].

Antimicrobial resistance (AMR) is a vital One Health issue; the rational use of antimicrobials is essential to preserve their efficacy. Veterinarians cite pressure from pet owners as a contributor to antimicrobial prescription. Engaging pet owners in antimicrobial stewardship could reduce this pressure. A short educational animation could facilitate communication of this message. The impact of the animation on participant’s opinions relating to antimicrobial prescribing and awareness of AMR was assessed via a randomized controlled trial. A survey was created based on the health belief model. Owners attending six UK veterinary centres were randomized to the intervention or control group (ratio 1:1). All owners completed an agreement level survey of two questions followed by 18 statements scored using a Likert agreement scale. The control group responded without interruption, whereas the animation group was shown the animation after answering the first two questions and five statements. In total, 647 owners participated in the study; 350 complete responses were analysed. Responses to 10 of 13 statements asked after the animation were significantly different (all P < 0.050) between groups, whereas there was no significant difference between groups in response to any of the statements asked before the animation. The animation group were more likely to agree that lower antimicrobial use would help maintain future efficacy (P < 0.001) and that requesting antimicrobials from their vet could increase unnecessary use (P < 0.001). The animation group were more likely to disagree that they would expect antimicrobials if their pet had diarrhoea (P = 0.048). Pet owners that watched a short AMR engagement animation displayed greater awareness of the impact of AMR and were more likely to support measures in line with antimicrobial stewardship. This behavioural-nudge resource could support owners towards contributing to a multi-faceted approach to AMR.

In 2021, the United Nations (UN) called on the world to ‘Make peace with nature’ saying that the inter-connected climate, biodiversity, and pollution emergencies (hereafter termed climate change) are threatening the human well-being of current and future generations [ 1]. The same year, the International Pharmaceutical Federation (FIP) in its letter ‘Pharmacy stands up to climate change’ to the Conference of the Parties (COP26), recognized COP26 and the 2021 UN Climate Change Conference as a ‘pivotal moment in the fight against climate change’ and voiced its full support [ 2]. FIP joined the global health community and worldwide partners, alongside the World Health Professions Alliance and the World Health Organization (WHO) in signing the #HealthyClimate Prescription letter [ 3]. FIP stated that ‘pharmacists are fully recognized by the UN as essential agents of sustainable development and key to achieving the health targets under Sustainable Development Goal (SDG) 3- ensure healthy lives and promote well-being for all at all ages’ [ 2]. I believe that pharmacy can and must play a role in several other SDGs including SDG4—Quality Education, SDG5—Gender Equality, SDG6—Clean Water and Sanitation, SDG10—Reduced Inequalities, SDG11—Sustainable Cities and Communities, SDG12—Responsible Consumption and Production, SDG13—Climate Action, SDG14—Life Below Water, SDG15—Life on Land and SDG16—Peace, Justice and Strong Institutions and finally SDG17—Partnerships for Goals. The Royal Pharmaceutical Society of Great Britain also formally recognized the scale and importance by publishing a climate declaration and sustainability policies [ 4, 5]. It was an acknowledgement that far from being simply an environmental issue, climate change is actually the most significant public health threat that modern society has ever faced [ 6].There is now an increasing opportunity for pharmacists to become involved and share good practices in groups such as Healthcare without Harm’s Pharmacists for Greener Healthcare network and Global Green and Healthy Hospitals initiative and Pharmacy Declares in the UK [ 7–9].

Nature-based social prescribing such as “blue prescription” promotes public health and health improvement of individuals with long-term health conditions. However, there is limited evidence explaining the relationship of contexts, mechanisms, and outcomes of implementing blue prescription programmes (BPPs) in health and social care settings that could inform policy and practice. We conducted a systematic realist review by searching PubMed, Web of Science, PsycInfo, Scopus, MEDLINE, and CINAHL for articles published in English between January 2000 and June 2022 about health and social care professionals providing referral to or prescription of blue space activities (e.g., swimming, fishing, surfing, etc.) with health-related outcomes. Components and descriptions of BPP implementation were extracted and used to develop themes of contextual factors used to develop programme theories and a logic model demonstrating the mechanisms of BPP implementation. Sixteen studies with adequate to strong quality were included from 8,619 records. After participating in BPPs referred to or prescribed by health and social care professionals, service users had improvements in their physical, cognitive (mental), social health, and proenvironmental knowledge. Service user-related contextual factors were referral information, free equipment, transportation, social support, blue space environments, and skills of service providers. Programme-related contextual factors were communication, multistakeholder collaboration, financing, and adequate service providers. Programme theories on service user enrolment, engagement, adherence, communication protocols, and programme sustainability explain the mechanisms of BPP implementation. BPPs could promote health and wellbeing if contextual factors and programme theories associated with service users’ characteristics and programme delivery are considered in the design, delivery, and evaluation of BPPs. Our study was registered with PROSPERO (CRD42020170660).

Pharmacy Practice is a free full-text journal with a scope on the practice of pharmacy. Pharmacy Practice covers pharmaceutical care, social pharmacy, pharmacy education, process and outcome research, health promotion and education, health informatics, pharmacoepidemiology