A fundamental—and agonizing—paradox defines American public health in the 21st century. While Americans are more gravely afflicted by chronic disease than ever before, we have also never had such an array of treatments for our deadliest diseases so readily available to us. Deepening this paradox is a stunning fact: Many of the most potent and lasting treatments for our national epidemics come not from pharmaceutical labs but from changed lifestyles.
Consider a few of the following national health statistics:
- Seven out of 10 deaths among Americans each year result from chronic diseases—with heart disease, cancer, and stroke accounting for more than half of those deaths.
- Nearly half of American adults suffer from at least one chronic illness.
- One in three American adults is obese—and almost one in five children.
- Arthritis is the leading cause of disability, with nearly 19 million Americans reporting activity limitations.
- Diabetes is the leading cause of kidney failure, non-traumatic lower-extremity amputations, and blindness among American adults.
Decades of medical research attest to the preventive and curative effects of increased fitness—particularly outdoor exercise and walking-oriented lifestyles—on children and adults. And there is growing public consensus on the priority of offering children smoke-free environments in which to grow up (not to mention tobacco-free adult role models to emulate).
Indeed, leaders from both the public health and park and recreation fields make compelling arguments that custodians of our green spaces, trails and greenways, recreation facilities, community centers, and playgrounds hold the keys to our most widely accessible dispensary of national health solutions:
- Doctors really ought to prescribe parks and public recreation programs to their patients most at risk for obesity-related illnesses.
- Communities should seek to identify and address “recreation deserts” and connect residents with under-utilized recreational spaces through bike and walking trails.
- Community-led studies of public health consequences should inform and guide changes to the built environment—and parks should play key roles.
- Organizations chartered to fight chronic diseases should partner with the caretakers of local walking trails and greenways.
- And, we should all agree to keep parks tobacco-free.
In fact, each of these five common-sense approaches to improved community health is currently occurring—often with little or no funding and just a small handful of local champions. Champions like Washington, D.C.’s Dr. Robert Zarr, a park-prescribing pediatrician who believes “it’s time to move away from merely recommending ‘diet and exercise’” and exhorts his medical colleagues to “work with our communities’ and nation's natural resources to get Americans to move more outside.”
Each of these five concepts represents a distinct, growing public-health trend, and each shares a common theme: Local parks are working alongside health care professionals, nonprofits, public health specialists, and community stakeholders to prevent and treat our most devastating diseases.
And the side effects range from enhanced well-being to greater appreciation for nature to new friendships.
Trend #1: Parks are Good Medicine
“To prescribe NATURE to patients and families to encourage outside time in one of 350 green spaces/parks…”
So reads the short-term goal statement of D.C. Park Rx, an experimental partnership among Washington, D.C., pediatricians, the D.C. Department of Health, the U.S. Department of Health and Human Services, George Washington University, and several private foundations.
The program’s longer-term goals are to combat obesity and asthma, promote mental health, and foster environmental stewardship among the younger generation. D.C. Park Rx is one of a number of recent park prescription initiatives around the country based on collaboration between physicians and park agencies. Because Washington, D.C., is a city where federal lands and resources exist side by side with high percentages of low-income families and children with obesity challenges, the nation’s capital provides a unique platform for a multi-agency partnership linking public lands to public health.
Pediatrician Robert Zarr, who heads the D.C. chapter of the American Academy of Pediatrics and whose practice serves a low-income and immigrant population, is a leader of the program and a champion of the park prescription concept. Influenced by author Richard Louv’s writings (Last Child in the Woods: Saving Our Children from Nature-Deficit Disorder) and alarmed by the growing rates of childhood obesity and asthma, Zarr urges doctors to back up recommendations with practical guidance on local resources.
Zarr describes an approach to park prescriptions that blends a traditional exam with a media display. During a well-child visit, if an exam and patient survey indicate the patient could benefit from increased activity outdoors (whether due to asthma or obesity risk), Zarr says the next step is to pull up an illuminated, blown-up electronic map showing nearby parks and other public recreational facilities. Map coordinates are set according to the patient’s address, and doctor, patient, and parent(s) confer as to whether a park prescription might be appropriate.
As an additional resource, Zarr offers families one-page park summaries (evaluated according to a standardized park rating tool and compiled by medical residents who visit each park). So far, he says, the map-customized prescriptions have been well received. And follow-ups one to three months after the park prescriptions show that families are indeed spending more time at the 10 to 15 parks around Zarr’s clinic.
“Many people,” he comments, “simply weren’t aware of all the parks around them.”
Zarr says the next steps are to finish rating Washington’s parks, to connect park data with patient medical records (so that doctors can easily show proximity of parks and recreational programs), and to find funds with which to formally research the impact of park prescriptions.
“The evidence is anecdotal now, but in D.C., where 40 percent of children over the age of 8 are obese…we have to give clinicians—and ultimately families—something concrete to do about it.”
Prescriptions or Scholarships?
In Oregon, where another park prescription pilot program recently concluded, Oregon State Parks outdoor recreation planner Terry Bergerson offers a cautiously optimistic perspective. The initiative found support in the Portland area, Bergerson says, because “the physical inactivity crisis was one of the top statewide issues in the 2008 Oregon Statewide Comprehensive Outdoor Recreation Plan…[and] one of the recommendations was to look at park prescriptions.”
Inspired by a New Zealand “green prescriptions” program, a 20-member group of recreation providers, health care administrators, pediatricians, and health program researchers developed a plan to target physically inactive Portland-area youth, ages 6 to 12, during well visits with their pediatricians. The ultimate goal of the Oregon park prescription plan was to encourage sign-ups for such recreational programs as swimming, dancing, or martial arts.
“It’s easier said than done,” Bergerson admits. Even though physicians’ prescriptions were sent to a park and recreation provider—who then followed up with a welcome phone call—resulting sign-ups were lower than expected.
Bergerson believes program costs created obstacles for some families. Other difficulties may have included unfamiliarity with the concept and language barriers. An unusual doctor’s prescription, followed up by a phone call from a stranger, “might have led to some confusion and sort of a feeling of being singled out,” especially for non-English-speaking parents.
Despite the hurdles that have come with the program’s newness and bare-bones funding, Bergerson says he’s never worked on a project “that had more excitement and more potential” than this pilot that spanned three park districts and linked parks and doctors in unprecedented ways. He hopes to see future versions of the program modeled more on scholarships, though, than on prescriptions:
“These families don’t have a lot of extra income. It’d be different if there were some funded programs doctors could send patients to.”
Trend #2: Tobacco-Free Parks Set a New Norm
Tobacco-free parks made headlines last year when New York City Mayor Michael Bloomberg signed legislation making all of the city’s parks, beaches, and pedestrian plazas smoke-free. While that blast of media attention (and the resulting controversy) created a new national awareness of the issue, the tobacco-free parks movement has been gaining momentum for well over a decade. And most of its successes have come not from sweeping legislation like Mayor Bloomberg’s, but from gradual consensus-building within communities.
In Minnesota, for example, where the first parks went smoke-free nearly 20 years ago, 150 communities statewide now boast tobacco-free parks. As Emily Anderson, program coordinator for the Minnesota nonprofit Tobacco-Free Youth Recreation (TFYR), points out, the majority of those communities have adopted policies—not ordinances enforceable by fines. (In some states, localities have no authority to pass ordinances banning smoking in public places. In those states, patient efforts toward local policy consensus is really the only option for achieving smoke-free parks.)
“The driving force behind a policy is really community enforcement, setting a new norm within the community that makes citizens kind of reach out to one another and say, ‘You know this isn’t allowed here,’” Anderson explains. “Tobacco use is not normal in the parks.”
Typically, those policy changes result when residents, local health advocates, TFYR members, and park employees cooperate in raising public awareness on widely approved tobacco-related issues.
First among those points of consensus, she says, is that secondhand smoke is harmful to everyone. Second is that cigarette litter comes with high costs—both in dollars and in environmental and safety hazards. Finally, there is the issue of providing healthy role models for children—and breaking the advertising-fueled connection between sporting events and tobacco use.
Most Minnesota communities that have adopted smoke-free parks report high levels of public cooperation, much to the relief of park directors who expressed concerns about enforcement difficulties, Anderson says. In fact, 70 percent of the state’s population supports tobacco bans in public parks.
One key to the widespread public support has been the leadership of youth in the tobacco-free movement. Anderson recounts youth-led cleanups that have culminated in park displays featuring enormous jars of cigarette litter. Communities can agree that the gallons and gallons of discarded butts have no place in parks—and that their youngest members shouldn’t have to demonstrate that point.
Trend #3: Community Walking Programs Gain Speed
“Couch potatoes can do this. The only requirement is that you can stand for 10 minutes without pain.”
This is how Jeannine Galloway of the Arthritis Foundation describes the criteria for her organization’s program to get arthritis sufferers of all fitness levels out walking. “Walk with Ease,” like other structured walking programs sponsored by such national nonprofits as the American Heart Association and the American Association of Retired Persons, centers on inclusiveness, consistency, social interaction, and the celebration of small fitness gains.
The many health benefits of walking are certainly not new discoveries. Parks have long offered community-based walking programs, and building and connecting trails and greenways have become top priorities for regional planning boards throughout the country. Moreover, walking has been on the rise among Americans. According to the U.S. Centers for Disease Control and Prevention, the percentage of people who report walking at least once for 10 minutes or more in the previous week rose from 56 percent in 2005 to 62 percent in 2010.
What programs like the Arthritis Foundation’s Walk with Ease initiative provide that localities cannot is investments in nationwide program development, commissioned research, member education, and best practices insights. Furthermore, nonprofits specializing in a particular type of chronic illness provide programs designed for people suffering with disease-specific limitations.
In Walk with Ease, six-week group classes led by certified instructors include discussion topics relevant to arthritis management. An individual program is also available in the form of a workbook that guides participants through the walking plan. Because the program depends on safe, convenient walking routes, the Arthritis Foundation is eager to partner with park systems and workplaces.
Galloway says the content and strategies are based on research and tested programs in exercise science, behavior change, and arthritis management. And studies among program participants have shown improvements in balance, strength, walking pace, and pain reduction.
Best of all, Galloway remarks, there’s a “built-in synergy” between the expanding trails and greenways in our country and the population’s growing need for low-impact exercise programs.
The National Recreation and Park Association will be responsible for implementing the Arthritis Foundation Exercise Program (AFEP) and Walk With Ease (WWE) intervention in 30 park and recreation agencies selected through a competitive RFA process. This will be conducted in two phases. The programs will initially be piloted in 15 agencies in the first phase and then pilot in the remaining 15 agencies in the second phase with a total reach of at least 1,500 persons with arthritis. NRPA will collect data from participating agencies on a semi-annual basis to demonstrate overall program success. NRPA will also disseminate successes from the studies by producing resources and materials that highlight key successes, challenges, and lessons learned from grantees. A best-practices document and a webinar will be produced that encourage replication of the interventions by other park and recreation agencies.
Trend #4: Weighing the Pros and Cons: Health Impact Assessments
See your doctor before beginning this program.
It’s the standard advice accompanying any new self-improvement regimen. A Health Impact Assessment (HIA) might be considered the community health equivalent of “seeing your doctor first.” It is a structured discovery-and-reporting tool for maximizing the potential health benefits—and lessening the risks—of changes to the built environment.
The HIA process generates a collage of health recommendations from across a community. Typically, local government officials, residents, and health, economic, and environmental groups form the representative core. Participants identify project specifics and relevant health issues, develop concrete recommendations, report to decision-makers, and monitor and evaluate actions taken.
Kara Vonasek-Blankner, an Arlington, Virginia, volunteer leader under the CDC’s ACHIEVE (Action Communities for Health, Innovation, and EnVironmental ChangE) grant to her city, describes the HIA as “a great tool for engaging community members and bringing critical information to policymakers at timely intervention points.”
What do park agencies bring to HIAs? While roles vary and park input might range from operations insights to public-outreach strategies, Vonasek-Blankner illustrates this with a walking-trail discussion: “During stakeholder input meetings, [park leaders] might say, ‘Of course, this trail is good for health—and sure, we can build it there. But unless we install lighting, increase entrance and exit points, and increase patrols, it won’t get the use we’re hoping for.’”
Bike Plan as Community Health Conversation
Planners Don Kostelec and Chris Danley have facilitated exactly those kinds of discussions. The park and recreation departments of North Carolina’s Haywood and Buncombe Counties hired the two consultants to manage their respective HIAs for improving biking and walking infrastructure.
In Haywood County, where the park and recreation agency sought to develop a comprehensive bike plan in 2011, HIA participants included representatives from the county health department, the local school district, a regional air-quality office, the social services department, the sustainability office of the local community college, and a bike advocacy group. Kostelec relates a discussion in which the county social services director commented that he could reimburse expenses for a client’s vehicle repairs but not for a bicycle.
“Right there, we had identified a policy barrier—and one that was not just about physical health but…about mental health and autonomy.”
In other discussions that identified trail-adjacent parking facilities and bike racks as needs, community college representatives offered resources. In one instance, the college provided parking facilities as part of a “park and pedal” trail access solution. And in another, the college’s metal shop provided bike racks as a student project.
But the most dramatic example of how the health conversation steered Haywood County’s bike plan came in the form of data the school district provided—data Danley says ended up being “pivotal in prioritizing improvements.”
“One elementary school had gone in a five-year time span from 19 percent of its students with a BMI [body mass index] of overweight or obese to 40 percent,” Kostelec says. “When we started to cross-tabulate that with other Census data that are indicators of poor health, such as lower income, rental housing, and density, [that area] flagged across the board. That’s when we said, 'Okay, we’ve found health priority number one.'”
The consultants are now applying lessons learned from Haywood County to an HIA for an ambitious greenways and trails master plan in adjacent Buncombe County. Kostelec says they often hear from park and recreation departments the frustration that “if I build that park or I build that greenway, that doesn’t cure diabetes.” But from the consultants’ perspective, an HIA lends structure to the kind of holistic project that can help cure and prevent chronic illnesses—while enriching a local culture of health.
Trend #5: Turning Recreation Deserts into Community Oases
As U.S. obesity rates accelerate—particularly among those with limited access to recreational opportunities—the drive to eliminate “recreation deserts” has also gained momentum. Addressing this notion of recreational impoverishment is, perhaps, where public health priority most tangibly intersects with social equity ethics.
The term “recreation desert” may bring to mind visions of a dilapidated playground half-hidden in a maze of elevated on-ramps. Or perhaps a tenement-dotted urban grid where only a few stubborn blades of grass sprout between sidewalk cracks. While haphazard urban planning and freeway-bisected suburbs are often to blame for recreation-deprived areas, identifying and improving these impoverished spaces is a complex undertaking that demands insight into more than green spaces, facilities, and mapped distances.
“It’s just as much about the people using the spaces,” Bill Beckner, NRPA's senior research manager, explains, “and how they get there and whether they perceive them as being safe and welcoming.”
In a creative partnership between parks and academia, the City of Allentown (Pennsylvania) Parks and Recreation sought to better understand its users. With funding from the Pennsylvania Recreation and Park Society, the city worked with Penn State University to connect the city into a recreational destination.
Greg A. Weitzel is Allentown’s former park and recreation director and presently parks director for the City of Idaho Falls, Idaho. He says aging infrastructure and safe-access problems presented known obstacles to residents. And he and his colleagues wanted to eliminate those obstacles while also gaining insight into the many factors influencing use.
Penn State’s Andrew Mowen conducted a pre- and post-renovation study of Allentown’s Cedar Creek Parkway, a linear park connecting the eastside and westside neighborhoods of Allentown, to determine what improvements mattered most to residents. The following attractions were the most commonly cited in Mowen’s study:
- A large destination playground with universal accessibility and multigenerational appeal (including fitness trail)
- Paved access trail
- Cleanliness of supporting facilities, such as restrooms and water fountains
- Installation of a rose garden.
Clearly, these kinds of renovations (not to mention the many less visible to the public) require a substantial investment in master-planning and dollars. Weitzel, known for championing thoughtful, built-environment approaches to increased recreational access, says the study—and his own years of experience—point to one overarching conclusion.
“Park departments simply can’t do it alone. You’ve just got to have the political will—the support of the entire community—to make these kinds of changes.”
Maureen Hannan is a Virginia-based freelance writer and former staff editor with Parks & Recreation.