INTEGRARE LE INIZIATIVE DI GREEN CARE NEI SISTEMI SANITARI TRADIZIONALI: Analisi di caso studio nel Nord-Est Italia e nelle Alpi per la validazione di un quadro di governance innovativo

Urbanisation is one of the defining trends of the twenty-first century, with most of the world’s population residing in cities and the European urban population projected to exceed 83% by 2050. While urbanisation drives economic development and access to services, it also increases health risks, including physical inactivity, psychosocial stress, and exposure to environmental hazards such as air pollution, noise, and heat. At the same time, urban expansion causes loss and fragmentation of green and blue spaces, reducing opportunities for restorative contact with nature. Yet extensive evidence shows that exposure to natural environments supports psychological restoration, fosters social cohesion, and enhances physical and mental health. The COVID-19 pandemic, alongside recurrent climatic, economic, and geopolitical crises, has heightened awareness of nature’s role in resilience, well-being, and sustainable urban living. Against this backdrop, Europe faces a rising prevalence of chronic non-communicable diseases and mental health disorders, placing pressure on healthcare systems and underscoring the urgent need for preventive, health-promoting strategies. Green Care Initiatives (GCIs)—or Nature-based Health Initiatives (NbHIs)—have emerged as promising responses, intentionally using natural settings to generate physical, psychological, and social benefits. However, despite growing literature on their biomedical and psychological effects, little is known about their governance: how actor networks are structured, how intersectoral collaborations and participatory decision-making are sustained, and how diverse outcomes—health, social, and environmental—can be systematically assessed and communicated to decision-makers. This dissertation addresses these gaps by conceptualising, operationalising, and validating a governance framework to guide collaborative decision-making, intersectoral partnerships, and outcome evaluation in GCIs/NbHIs. The research was conducted in three phases. First, a systematised literature review and thematic synthesis identified four core governance dimensions—organisational structure, nature–health knowledge, legitimacy, and decentralisation—that provided the theoretical foundation. Second, these constructs were operationalised through 152 indicators, collected in a multi-case study of three NbHIs in North-Eastern Italy, combining 20 expert interviews with an online questionnaire of 27 forest bathing participants. Indicators were normalised and aggregated into 37 composite indicators, grouped into four dimension-level indices, and then combined into a governance composite index under two scenarios: unweighted and expert-weighted. Finally, the third phase applied framework-guided thematic analysis of expert interviews and free-text comments to test interpretability and empirical robustness. The qualitative validation confirmed the relevance of the four dimensions, refined their formulation, and generated additional insights by triangulating expert perspectives. The main outcome is a governance assessment tool—the first of its kind for GCIs/NbHIs—which translates qualitative perceptions into quantitative scores, enabling comparability, communication, and policy uptake. The tool captures health, social, environmental, and institutional dimensions of GCIs, supporting comprehensive evaluation of their contribution to social innovation and territorial development.