Park Prescriptions in Practice

August 1, 2014, Department, by Nooshin Razani, M.D., MPH; Curtis Chan, M.D., MPH; and Kristin Wheeler

As part of Healthy Parks Healthy People: Bay Area, East Bay Regional Park District and UCSF Benioff Children’s Hospital Oakland partner to take patients into nature for health.In a busy urban health clinic, I am a primary care provider to countless children and their families who are experiencing physical and mental health epidemics. Junior, for example, is a 10-year-old struggling with extreme obesity. His parents are eager to serve more nutritious food, but have found it challenging to be more physically active and to involve the whole family in lifestyle changes.

Nationally, approximately 20 percent of children and adolescents and more than one third of adults are obese. An increasing number of children and adults are being treated for serious mental health conditions. Yet health research confirms that being outdoors leads to increased physical activity as well as improved eyesight and sleep quality. Experiencing nature reduces aggression, anger, fatigue, sadness, stress and anxiety, and it improves attention and cognition. 

Parks are critical to community health, as they are low-cost, readily available and sometimes the only nature accessible to families. Spending time in parks also encourages families to get outside and meet others, leading to less loneliness and more community cohesion. I have recommended park visits for Junior, yet the family has had difficulty getting there.

I asked Junior’s mother what we should do as Junior’s weight increases. She and her husband both work two jobs and Junior’s school only has P.E. every other week for one hour. After school, Junior goes to a homework club and eats fast food on the way home. In the evenings, they can’t leave the apartment because of neighborhood violence. On Saturdays, the parents work their second jobs. Sundays are for cleaning and errands. There is seldom time for family activities. 

It would take extraordinary arrangements to bring Junior to physical activity programs. His mother knows that being sedentary and socially isolated affects her family’s health and that parks are part of the solution, but she is stuck. As her family’s healthcare provider, I also feel stuck.

Lifestyle change is difficult to address in a clinical visit. The highest-need patients often have the least access to parks and nature. This is why public health departments and healthcare systems seek parks when tackling significant health problems. Increasing use of parks helps prevent disease while fostering the next generation of park supporters. 

Innovators have forged alliances to form a movement to bring parks and health together.

National Park Prescriptions 

In 2012, the Institute at the Golden Gate partnered with NRPA and the U.S. Centers for Disease Control and Prevention (CDC) to identify successes and areas for improvement. They found more than 50 programs nationwide connecting people to the outdoors for health, implemented by many agencies. Partners range from individuals to small private practices, large hospitals and health insurance agencies. A variety of governmental and nongovernmental agencies support these efforts.

The central question is how parks and healthcare providers can collaborate to refer patients to parks and to support park prescription alliances. 

Case Study — Healthy Parks Healthy People: Bay Area 

Healthy Parks Healthy People: Bay Area (HPHP: Bay Area) represents a coalition of more than 40 parks, community and health agencies whose mission is to improve the well-being of Bay Area residents through regular use of parks and public lands. 

The process started with community assessment through interviews with patients, healthcare providers and park administrators and continued with monthly cross-agency meetings. Based on these, the parks in all nine San Francisco Bay Area counties agreed to hold a Healthy Nature Walk on the first Saturday of every month. This collaboration has created programs that introduce high health needs populations to nature, encourage physical activity and foster social connections. In the last year alone, more than 35 park sites throughout the Bay Area have offered Healthy Parks, Healthy People programming — engaging hundreds of new park users.

Through trial and error, we have learned some lessons:

1) Prevention starts outside the clinic walls. 

A physician’s recommendation does not address barriers in access, time and resources. Our collaborative is as interested in making sure parks are accessible to under-represented communities as we are in training doctors to give park prescriptions. 

Parks don’t need to wait for health partners. When parks attract new users with physical activity and social connection, and make themselves accessible to people, they are serving the public health. 

2) Parks can be reliable health resources. Empower clinicians and patients to use parks by making it easy to know where, when and what.

Clinicians are busy. Staff turnover is high and opportunities to train are few and far between. When reaching out to clinics, it is important that parks offer reliable and consistent programming, and that it have some value besides a park visit. In our case, HPHP: Bay Area partners have signed a memorandum of understanding agreeing to standardization for health programming, including consistent language, a survey at the beginning of the event, a stretch, a simple walk and inclusive activities.

Basic standardization in health branding across park agencies is key in encouraging providers to prescribe parks and encouraging patients to fulfill their park prescriptions. Healthy Nature Walks that are consistent across nine counties means I can tell a family to “Go to a local HPHP event” without having to sift through websites. Health clinics need information that is consistently available for patients regardless of where they live. While there is basic standardization, individual parks use local talents to engage high-needs communities in nature. Examples include parks with community-based outreach for Latino populations, birding, yoga and health fairs. Culturally appropriate programming, such as relaxation and social connectivity, gives a specific reason for healthcare providers to make recommendations to patients with critical health and social needs. 

Once consistent programming was in place, health partners became eager to join. The San Francisco Department of Public Health saw these efforts and committed to training clinical staff on the health benefits of nature and parks.

3) Community leaders are enthusiastic in helping align parks and health. 

Community leaders are invaluable partners to have in deciding where, when and how to get patients to parks. It is important that the healthcare provider knows where local parks are and which are acceptable. One of the most useful tools created by our HPHP: Bay Area collaborative is a map of neighborhood green spaces, with parks selected through feedback from community members. The map also lists availability of bathrooms and other amenities, such as public transit routes. This makes it easier for me to address barriers to being outdoors. Community organizations, agency directors, medical groups, foundations, media and elected officials can also promote efforts such as the Healthy Nature Saturdays. 

4) Clinicians are looking for a “warm handoff.”

Healthcare providers appreciate the wealth of knowledge, talent, enthusiasm and resources that parks have in engaging people in nature. When our collaborative trained healthcare providers, we found that they love meeting park staff and telling patients about that experience. In encouraging a family like Junior’s to invest the time and resources necessary to spend half a day in nature, it makes all the difference if I can say: “This is the naturalist who will meet you there; this is what you will do, and here’s how long it will take. Tell her I say hi.”

5) Alliances and programming will influence systems change and policy development.

When park agencies collaborate with healthcare providers to offer seamless information and programming for community members, this creates a powerful movement. This relationship-building between parks staff, healthcare providers and community members allows agencies to designate staff and resources to achieve this mutual goal. As healthcare systems join this movement, we hope our initiative can be a catalyst for broad policy change that advances measurable recreational models to support the physical and mental health of our population.

Since my involvement in HPHP: Bay Area, I feel more confident that I have the tools to engage patients in nature and the outdoors. I now have a specific resource to give patients in order to get to parks, and I know they will receive a warm welcome. 

I hope to see you, and my patients, in the parks!

Learn more about the Healthy Parks Healthy People: Bay Area collaborative (HPHP: Bay Area).

Curtis Chan, M.D., MPH, is the Medical Director of Maternal, Child and Adolescent Health at the San Francisco Department of Public Health. Nooshin Razani, M.D., MPH, is a Pediatrician at UCSF Benioff Children’s Hospital in Oakland and Senior Health Fellow at the Institute at the Golden Gate. Kristin Wheeler is the Health Program Manager at the Institute at the Golden Gate.