Park Prescription programs are initiatives designed in collaboration among public land agencies, healthcare providers, and community partners to encourage people to utilize parks, trails, and open space for the purpose of improving individual and community health. National Geographic just wrote about Park Prescription programs and these programs have been recognized by the Surgeon General’s Office, the National Park Service, and the American Public Health Association as important tools to promote wellbeing.
This is all to say that Park Prescription programs have really flourished in the United States. One question still remains: “How do I build my own Park Prescription program?”
That’s the question that the Institute always receives. As the convener of the Healthy Parks Healthy People: Bay Area collaborative and the National ParkRx Initiative, it makes sense that we get fielded this question. Answering this question has been our guiding light for the past few years. We’ve led workshops, hosted webinars, and written reports, all in pursuit of finding out what makes a Park Prescription program work.
After years of observing programs, especially those in the Bay Area, we have created a Park Prescription program toolkit to guide the process of creating a program. This toolkit is a "program-in-a-box," curating examples, templates, and guidance for those interested in implementing Park Prescription programs. We know that there are a myriad of agencies interested in building these programs, so this toolkit was created with sector-specific guidance for clinicians, public health providers, community service providers, and parks staff.
I hope that this resource makes it easier for you to serve your community!
Catalyzing Change by Rhianna Mendez
It has been a little over two months since I began my fellowship and was tasked with detailing the story of the Healthy Parks Healthy People: Bay Area collaborative. As I continue to interview stakeholders and partners from the world of parks, public health, and community based organizations, I am amazed by the many leaders in the bay area who catalyze change. Healthy Parks Healthy People lives within the individuals who work around hectic schedules to impact the lives of others. Healthy Parks Healthy People lives within the communities it reaches. I have been seeking out promising practices and potential lessons learned and along the way I have uncovered refreshing narratives filled with enthusiasm. The collaborative continues to grow and evolve after three years and I know all involved are excited to see what the next three years have to bring.
As First Saturdays continue to thrive with consistency and Park Prescriptions begin to take root, many are looking forward to larger systematic changes. Of particular interest is a change in the way we structure medical care. This concept, of course, is nothing new but there has never been a time where so many sectors are chipping away at an over-haul. There has been recent success in changing the way we bill a doctor’s time that allows for a conversation instead of just a diagnosis or prescription. One example revolves around palliative care and end-of-life discussions between doctors and patients. A very contentious topic in 2009 has now seen wider appeal as society begins to rethink the time doctors spend with us. The time is ripe for change and the collaborative will use this momentum to continue to impact lives locally and forge change nationally.
Visualizing The History of Fort Baker by Sophia Choi
It has been a little over two months since I took on the role as the Urban Fellow at the Institute. An important part of my project on post-to-park conversions has been looking back at the history of how Fort Baker and Crissy Field in the Bay Area, and Governors Island in New York, have developed into such wonderful public parks in urban areas.
One of the first steps in my search for lessons learned from the transformations of these urban parks was visiting Golden Gate’s park archive, located in the Presidio of San Francisco. The military building turned gold mine of photos, plans, and letters, was overwhelmingly abundant – in the best way. My first visit to the archives was a bit daunting, but the archival curator, Amanda, was extremely helpful in guiding me through millions of archived material on the Golden Gate National Parks.
Not knowing what exactly I was looking for, Amanda suggested I start from a large binder of photos and plates of Fort Baker. As I flipped through, page-by-page, I was amazed to find that the black and white images of military infrastructure looked exactly the same as how the buildings look now; the look of the building that used to be the home of military officers but now houses the Institute had not changed since its history.
Officer housing during military occupation at Fort Baker - Golden Gate NRA Park Archives & Record Center
Literature and document research has been crucial to gaining insight and learning from the transformation at Fort Baker. These photos showed a critical transition from a dilapidated military post to a thriving public place of nature and respite, all the while preserving the sites specific cultural landscape.
I felt a sense of nostalgia, tracing the steps of the park history vicariously through these photos. Being able to visualize and see Fort Baker’s history was impactful in my research both emotionally and intellectually. I was reminded of the importance of telling a unique story of a place, and how that story can create a more profound connection between people and their parks.
Here at the Institute, we are BIG believers in collaboration. As a small but mighty team, we realize that to have the biggest possible impact and to create the change we want to see, we need to seek out, engage, and support other organizations to achieve our collective goals.
As such, a number of our programs focus on supporting collaborative efforts. Healthy Parks Healthy People: Bay Area and the Bay Area Climate Literacy Collaborative are two such projects. In both, the Institute plays the “backbone” role; supporting the collaborative through coordination, holding the vision, and ensuring that the group is functioning effectively in the pursuit of its goals.
Through both of these initiatives, we at the Institute have learned a lot about supporting multi-group collaborations (HPHP: Bay Area has over 40 members while our younger Climate Collaborative has over 20). By keeping an open mind and constantly striving to learn from those around us and our mistakes, we’ve picked up a number of tips and tricks along the way. This week, we thought we’d combine our collective knowledge and share our top pieces of advice for building effective collaboratives.
Kristin: The first step is always the hardest. Stop thinking about it and just do it.
Easier said than done right? Bringing together a group of individuals or organizations for the first time can strike fear in even the most seasoned collaborator. After ten years of community organizing and coalition building I’ve made my fair share of mistakes, stumbled over a few hurdles, and certainly learned some valuable lessons. Some of the biggest, and translatable, lessons I’ve learned for getting an effective collaborative off the ground are:
If you go in knowing the collaborative is a process not a project you’re already ahead of the game. Just don’t let perfect be the enemy of good. Have you had enough metaphors? Great. Get out there and do it and don’t forget to report back on your lessons learned.
Oksana: Manage structure without managing content.
Supporting collaborative initiatives is exciting work but requires unique skills, separate from those of collaborative members. One such skill that I have found to be incredibly helpful is the ability to manage structure without taking over managing the content coming out of the collaborative. For example, I may present on some best practices for drafting mission statements but will follow it with an opportunity for the collaborative members to use these tools to craft their own mission statement. Collaborative members must have the opportunity to share their thoughts, have their questions taken seriously, and make the ultimate decisions on the direction of the work, as they are the driving force behind the collaborative’s success. As the facilitator, I am best able to provide coordination and backbone support—setting the agenda, providing logistical support, keeping meetings on track, and jumping in if meetings are diverging dramatically from the agenda. However, the vision, goals, and activities of the group are decided by its members. Providing space for their input is crucial to creating a successful group where all members feel like they have buy-in.
Donna: Humility is crucial.
Humility is a crucial mindset to have when in a backbone position because it is the main bridge between a theory of change and its practice. As a backbone, it is often the case that you are not a practitioner in your topic of interest; for example, as a backbone to the Healthy Parks Healthy People: Bay Area collaborative, the Institute neither leads park programs nor prescribes time in parks. While being a backbone organization allows you to dive deep into the needs and future goals of your collaborative, this theory of change is colored by your role as a non-practitioner with a different set of agency constraints. When a collaborative’s practitioners implement these goals, they will necessarily adapt them to fit their own agency constraints. Humility and keeping an open mind is important when drafting these goals, but it is especially important considering that implementing these goals may look very different from the theory of change. Understanding the crucial role that humility plays in collaborative efforts ensures that there is flexibility and feedback when charting the course forward.
Catherine: Have patience!
Kristin’s sage advice that collaboration is a process, not a project, is something that has stuck with me since we first started thinking about forming a regional climate literacy collaborative. If I have learned one thing since then, it’s that processes take time! This is especially true when you want to ensure that all of your partners feel ownership of the process and are inspired by the results. In today’s grant-driven, output-oriented world, it can be scary and challenging to dedicate the time that it takes to make sure you have the right people at the table, that they’re all on the same page, and that they all feel connected to you, to each other, and to the work. While walking through the process can seem slow, creating a strong foundation is critical to the overall success and sustainability of the collaborative.
At this point, is it safe to assume that the term “social determinants of health” is readily understood? What about “social determinants of park use?” Can we also work towards consensus that these two terms describe the same barriers, for both health and parks?
Social determinants of health (SDH) are factors outside of an individual’s genetic makeup that influence a person’s entire health. SDH focus less on DNA factors, but more on the societal, community factors that determine access, amount, and quality of prevention and treatment a person receives. Not having health insurance covering the cost of treating an overactive thyroid problem is an SDH. Not being able to find a therapist who speaks the same language as you is an SDH.
As parks inventory their programs and activities to figure out how to bring more residents to the great outdoors, they are finding more and more that there are a set of barriers that create social determinants of park use (SDPH). Uncoincidentally, these barriers look very much like SDH. Here are a few examples that illustrate the convergence of SDH and social determinants of park use:
Capital: Families that are middle class or above are more likely to be healthier and live longer lives. Additionally, most park users (especially for national parks) are middle class and can afford the time and travel costs associated.
It is not a coincidence that SDH and SDPU are aligned in these substantial ways. Most parks were built around the idea of improving community health; Central Park in NYC was intended to be a natural refuge from the mechanical toils of factory work.
As National Public Health Week focuses on positioning the country to be the healthiest nation by 2030, we should pay special attention to nontraditional community health stewards that are already part of the community infrastructure. Mitigating social determinants of park use will be much like mitigating social determinants of health; we will have to be diligent about using resources to uplift the communities especially suffering from these social determinants.
Taking care of a community's health starts at making sure everyone has health coverage, but it doesn't end there. Giving all fourth graders a pass to visit America's national parks is a great first step, but it doesn't end there. To ensure that communities especially feeling the compounded effects of social determinants use their parks and live their healthiest lives, we have a special obligation to dedicate more resources to these specific communities. For a healthier nation in 2030, the onus cannot be on a single mother of two to wait 2 hours in a waiting room to be seen by a physician. As well, the onus cannot be on families living in neighborhoods plagued by gang violence to seek out safer parks.
To create a healthier nation by 2030, systems of care need to be changed and improved so that everyone gets timely care from health care providers, and cities need to work together to reduce gang activity and ensure that every park, no matter their location, is a safe park.
Bonus activity: Can you think of anything that could not be considered a social determinant of health or park use? It's harder than you'd think.
Less than two weeks ago, close to 5,000 leaders from around the world came together in Sydney, Australia, for the IUCN World Parks Congress – the once-in-a-decade global forum on protected areas. Together, we tackled challenges such as climate change and illegal poaching, shared successes of healthcare partnerships to improve wellbeing, and heard from the next generation for stories of inspiration and hope. It was an honor to not only attend, but to share the stage with remarkable leaders from Finland, Australia, Singapore, and beyond to discuss how parks around the world are seeking solutions for a better world.
During the opening ceremony, leaders from across the globe took the stage to share what they bring to the table and express their hopes for a healthier, more sustainable future. We reflected on the last Congress that took place in Durban, South Africa a little over ten years ago, where keynote speaker Nelson Mandela pointed out that our youth may be the key to a better future, but that it will take each and every one of us to teach and empower current and future generations to steward the magnificent places that we are privileged to call home. Mandela’s words rang true at this year’s Congress, but I found examples of leadership and empowerment in unlikely places. The inspiration and examples of action that struck me most came not from the keynote speakers or high up government officials, but from community organizers, Indigenous leaders, and youth. Perhaps this is what Mandela wished for all along.
Given the state of our planet I see no reason why we shouldn't be filling every international stage with stories from the “doers" – those that choose to take the information we already know and turn it into action. I found the most inspiration and hope from the one on one conversations struck up while sharing a bench in the shade between sessions. It was in these deeper more personal moments that I felt the most connected to the global community. Sharing the challenges of partnerships with a community leader from Gabon and swapping ideas on how to engage low-mobility park users with friends in Australia – these are the stories I wish to hear, these are the actions that deserve the attention of our leaders, and these are the people that know enough to act and are bold enough to act now.
To read more about the actions and achievements coming out of all corners of the globe, I encourage you to read the Promise of Sydney. This document includes commitments, goals, and achievements that leaders and organizations from around the world will strive to make before we get back together in the next decade. While the details and testimonials are still coming together, what we do know is that our global community promises to INVIGORATE, INSPIRE, and INVEST in every way that we can to create a healthier and more sustainable future for all.
I personally promise to look for inspiration at all levels and more importantly continue to act so that future generations inherit a better planet than the one we have now. In ten years’ time when park and protected area professionals come together again I have hope that those on stage will be Indigenous leaders, youth, community organizers, and the “doers” of the world. If this comes to fruition I believe we will have made Mandela and our global community proud.
Here at the Institute at the Golden Gate, we believe the time is ripe to help bring Park Prescriptions to scale. There are dozens of organizations testing the concept in parks and health clinics around the country, and the early results are encouraging. Imagine what would happen if every healthcare professional began to prescribe nature and every park agency was able to welcome these high health need patients. With so many people suffering from physical and mental illnesses, we have the potential to improve tens of thousands of lives across the United States each year.
To support the national movement, the Institute launched an initiative back in 2012 to connect experts in the fields of parks and health engaging in Park Prescriptions. In partnership with the U.S. Centers for Disease Control and Prevention and the National Recreation and Park Association, we convene a national coalition of over 35 experts and practitioners.
Two weeks ago, the partners co-hosted the 2nd National Convening on Park Prescriptions in Charlotte, North Carolina. The workshop brought together leaders from around the country drawn from both the parks and health fields. During this full day workshop the group created strategies for on-the-ground advancement of the movement in order to support any park or health agency in starting their own program. Together, we set goals for communications, program resources, and data and research, and mapped the year to come.
One personal epiphany at the meeting was hearing from several doctors in the room about how Park Prescriptions can be used not only to treat people with illnesses ranging from ADHD to diabetes, but also as a "preventive" health treatment that can help healthy people stay that way. It is extremely rare for any health intervention to be both a treatment and prevention. I left the meeting inspired to do my utmost to help bring this growing movement to a whole new level across the nation.
In the coming months, we'll have more news as we start to deliver on the goals set by the coalition partners earlier this month.
When we got to East Bay Regional Park District’s (EBRPD) Crab Cove, it was hot, and we were late. Naturalists were teaching participants how to use compasses—real compasses—and real maps, hand-drawn on paper, with lines showing magnetic and true north. They did not come with Siri’s reassuring voice. I felt a little panicked thinking that this was not entertaining enough for the patients who had taken their day off to come into nature with us. My own children sat down and announced they were not participating.
UCSF Benioff Children’s Hospital Oakland (CHO) Primary Care Center has partnered with EBRPD to take our patients into nature by offering a monthly shuttle from our clinic to a local park. Doctors and their families, as well as EBRPD staff, join patients and their families on these monthly outings.
Our goal is to increase opportunities for physical activity while having fun. The Centers for Disease Control and Prevention (CDC) states children should enjoy 60 minutes of physical activity a day, at least 5 days a week, and most of it should be aerobic. That means we should be getting aerobic activity—such as brisk walking—everyday; and three times a week, this should be a vigorous activity, such as running. Adults need 75 minutes of jogging or running every week and muscle-strengthening activities two or more days a week.
This may sound hard to achieve. Yet, research shows that simply being outside leads to increased physical activity. Children are two to three times more physically active outdoors than indoors. For every hour children are outside, they spend about 27 minutes of it in activity. Exercise in natural setting has added emotional and mental health benefits: for example, improved attention span, as well as improved feelings of serenity, energy, happiness.
have access to a variety of landscapes—“hardscapes” such as asphalt as well as natural landscapes. Play in outdoor settings with natural elements, such as a hiking trail or boulder-size rocks, has been shown to have added benefits of improved motor strength, balance, and coordination for children. A variety of landscapes may engage a wider variety of personalities or temperaments of children in physical activity. More imaginative children may be more engaged in natural settings.
As I felt my own mental resistance to figuring out the compass, I worried that this activity was not active enough to achieve our goal—I was wrong.
Once we learned how to use compasses, the families were split into groups and came up with their own team names: Team Confused, Team Larry, Team Gooze, and Team Marbin. Most groups ran off in the wrong direction. Team Marbin, led by CHO’s own Dr. Jyothi Marbin and her husband Seth, realized everyone else’s error and stealthily headed in the other way. By the time others realized, the Marbins were way ahead of the rest.
And then it was on!
As we followed our compasses towards the site where the last flag appeared to be, each team running to catch up with the Marbins, we saw that the Marbins (now joined by members of team Gooze) had veered just slightly to the right of the correct path. Team Confused quietly ran in the direction of the flag while trying not to be seen. They saw it at the same time as the Marbins, and although members of the Marbins and Gooze ran as quickly as they could to the flag, Team Confused touched it first. Team Larry arrived seconds after.
In the end, Marbins, Confused, and Gooze happily shared the glory.
A quiet calm came over the well-exercised children and adults as we walked back to the Crab Cove visitor’s center to watch some fish-feeding. That is, until doctors and patients, children and adults, burst into a fierce game of banana tag.
I can’t tell you exactly how many minutes of physical activity we got that day. But I can tell you that no family was going to be left behind. And, my total pedometer steps in that 2 hour excursion: 6,000.
With that, I hope to see you in the parks!
Nooshin Razani, MD MPH. Nooshin is a pediatrician and Nature Champion trained by the National Environmental Education Foundation to prescribe nature for health. She is currently Senior Health Fellow at the Institute at the Golden Gate.
with Kelley Meade, MD. Dr. Meade is a pediatrician and Associate Director of the Primary Care Clinic at UCSF Benioff Children’s Hospital Oakland. The shuttle project is part of her healthcare leadership fellowship at the Center For Health Professions sponsored by the California Healthcare Foundation.
Photos by Nooshin Razani and Mona Koh of EBRPD.
Many thanks to East Bay Regional Parks Foundation for sponsoring the outings, and to the Institute at the Golden Gate for donating water bottles and pedometers.
The SEEDS program, or Senior Environmental Education Docent Support program, continues to build relationships and strengthen existing Healthy Parks, Healthy People networks. The docents are community members of southeastern San Francisco who help to recruit people to attend HPHP events both at McLaren Park and Heron’s Head on the third and fourth Saturday’s of the month. My first experience meeting the SEEDS was at their training held in late June. The training focused on strengthening the docents’ environmental knowledge as well as helping them understand recruitment tactics for HPHP events. The learning goals for SEEDS participants after the summer events include, describing three health benefits of nature, sharing with others three aspects of local ecology, suggesting three parks in the Bayview Hunters Point where people can go to improve their health, leading a warm welcome and stretch in the outdoors, and sharing their excitement for the outdoors with a group.
The SEEDS are wonderfully kind and willing to share incredible personal stories of their early experiences in nature as well as other experiences as local San Franciscans. The training was a mix of heart felt conversations about what it means to connect with nature, how to successfully recruit members of the community as well as group stretching followed by a healthy amount of laughter.
I was also fortunate enough to attend a HPHP Bay Area event at McLaren Park lead by SFRPD’s Lisa McHenry with the help of SEEDS docents. McLaren Park is a great place to take a walk namely because of its size, and feeling of wilderness. Tucked away in the morning fog, you almost feel like you are hundreds of miles away from any city until you bask in the gorgeous views of the Bay Bridge below the blue water tower in the center of the park. In addition to the thrill of walking through one of my favorite parks in the Bay Area, I was able to talk and share knowledge with attendees who made me crack up with their inside jokes, and intimate knowledge of SF nightlife. Taking a walk with the SEEDs was moving, powerful and inspiring and spoke to the important forces of social cohesion in nature. I encourage everyone to get outside with new friends!
Last Thursday, Institute staff and Healthy Parks Healthy People: Bay Area (HPHP: Bay Area) champions made the trek to Microsoft’s offices in Mountain View to attend a “Collaboration for Great Impact” workshop. We joined our friends who have been working on environmental and climate change initiatives to reflect on the Collective Impact model’s role in our own work with HPHP: Bay Area. Pioneered by the social impact consultants, FSG, Collective Impact is a framework to align the work of different organizations into a single goal. Briefly, the five pillars of Collective Impact are: (1) a common agenda, (2) shared measurement, (3) mutually reinforcing activities, (4) continuous communication, and (5) backbone support.
When the HPHP: Bay Area program started in 2012, the Institute was under no illusions that this would be anything but a seriously complicated endeavor. Not only were we asking for help to create more public programming in the park, but we were asking the collective Bay Area to see nature and parks through the lens of wellness. In working with physicians to prescribe nature and encouraging parks to pave more trails in underserved communities, we have been making small steps towards a change in the broader culture of health, wellness, and parks.
Thankfully, we at the Institute are not doing this alone. Through the years, the HPHP: Bay Area program has cultivated a group of organizations and advocates that is engaged in bridging public health and public parks. As we continue to roll out the HPHP: Bay Area programming and bring more healthcare advocates to the fold, this workshop was a time for us to think critically about the future of HPHP: Bay Area through the lens of Collective Impact and its five pillars of success. Often, we are so wrapped up in the day-to-day operations that it is hard to find the time to reflect and learn from our past efforts.
During the workshop we participated in an exercise that had us imagine what HPHP: Bay Area would look like in 2025 and what would be telltale signs of its success. One partner answered that all awareness campaigns about the significant linkages between nature and wellness are obsolete because communities in 2025 will see that as blatantly obvious. Another partner highlighted the potential lessening of chronic diseases in 2025 as a measurement of success. Working backwards from these visions for the future, our group looked at potential steps we could take in the next month or year to make these goals a possibility. We listed different sectors we wanted to bring into the world of HPHP: Bay Area, as well as plans to create ongoing communication and dialogue within the group. We are still digesting all of the different ideas related to the five pillars that we came up with and will be eager to share them with you soon!
The year 2025 might be over a decade away, but we at HPHP: Bay Area know that change does not happen all at once. We are amplifying our efforts today in order to make sure that communities in 2025 have the motive, means, and opportunities to visit parks and increase wellness.
Special thanks to our friends at ChangeScale for hosting such a great event!
Urban parks create opportunities for community intervention and social interaction, which allows for the transfer of social capital. As social beings, humans require interactions with others and what better place to be amongst friends and soon–to-be friends than an urban park! A question that I have grappled with throughout my research as a health consultant at the Institute at the Golden gate is--how do we create positive interactions within these immensely important spaces? Parks can be both loved and feared places depending on how the space is being used.
Through my previous work as a park ranger and environmental educator I have seen first-hand what green space can do for people from all walks of life. Now, at the Institute I am able to dig a little deeper on the important connection between parks and social cohesion. The great landscape architect, Fredrick Law Olmstead, designed both Central Park and Prospect Park with the grand notion of vast open plazas built for social interaction. The ultimate melting ground—parks—offer an opportunity for tremendous information sharing and knowledge. The great opportunity of parks as a place for social cohesion also proposes a potential problem; parks are not always a safe place. As a UC Berkeley masters student studying city planning, I have often looked to Jane Jacobs, a journalist, author and activist known for her fight against urban renewal. Jacobs proposes more eyes on the street—meaning taking ownership of your community.
One of the most successful community based projects is the Dudley Street Neighborhood Initiative. Tired of disinvestment, neglect and redlining practices, members of the Roxbury/North Dorchester neighborhood of Boston established the coalition in 1984. The initiative accomplished so many wonderful things including convincing the government of Boston to grant the power of eminent domain over 60 acres of abandoned land called the Dudley Triangle. Another important success story was turning three urban parks in this neighborhood, once used as a primary instrument for drug trade, into positive coalition driven public space.
The opportunity is the nexus between city planning and health- which the Institute at the Golden Gate strives to answer with both Park Prescriptions and Healthy Parks, Healthy People. The built environment can influence all aspects of a person’s life from education, job opportunities, physical fitness, food offerings, and overall life span. Parks provide a tremendous opportunity for connection amongst a growing diversity of people in urban areas. Much of the existing research has focused on connections between social cohesion and health but many studies have not included how parks can influence social cohesion. The Institute will be digging further into these important links and I look forward to sharing this research and work.
UCSF Benioff Children’s Hospital Oakland (CHO) Primary Care Clinic has partnered with the East Bay Regional Park District (EBRPD) to bring families to nature for health. The result has been, in a word, magical. Through the generosity of the Regional Parks Foundation, a Nature Shuttle takes patients, their families, and accompanying clinic staff to a variety of East Bay Regional Parks on the first Saturday of each month. The first two trips have been to Healthy Parks Healthy People programming at Crab Cove Visitor Center at Crown Memorial State Beach on the Alameda Shoreline where we were greeted by a naturalist, participated in guided activities exploring the outdoors, and have enjoyed a meal together.
One family was recruited to the Nature Shuttle during a busy clinic morning when a single mother and two toddlers had come in for vaccines and asthma. During the course of the visit, the doctor learned that the family was struggling with housing. Among other more urgent topics, the provider was able to suggest this specific nature activity as a way to relax and recuperate. Once at the tide pools, with her boots covered in mud, this mother said: “This is my last pair of shoes.” She laughed and said that she had to wait until next month to have enough funds to buy a replacement pair, but that it was worth it.
We are a Federally Qualified Health Center, so a large portion of our patients live below the poverty line. Many lack basic resources such as food, house stability, transportation and child care. Poverty has profound effects on health. Over the course of life, the increased health risks associated with poverty have a cumulative impact of 14 years of difference in life expectancy. It also happens that people with the lowest resources, highest health needs, are often those with the least access to nature.
We look to nature to help our patients become resilient. We believe nature has the potential to heal because it buffers stress. When people have trees and vegetation around them, they have lower blood pressure, better emotional control, and improved attention and cognition. In larger population studies, green environments reduce stress, anxiety, depression, and increase the sense of well-being and longevity. Children living in more green environments have been shown to have more resilience against stressful life events such as family strife, divorce, and bullying. Associations with improved mental health and access to nature are even more profound for people living in poverty.
We also look to nature to help families spend quality time with each other. The best conditions to reduce childhood stress are those where young people can feel safe and connected to others and to the world around them; spending time with a loving adults builds resilience in children. Opportunities for quality time increase when families are outdoors. We have observed many distraction-free moments of quiet, tenderness, and laughter between parents, grandparents, and siblings in nature.
We refer patients to the nature shuttle to increase physical activity, but also to help with stress relief and social isolation.
I want to stay here forever
“I want to stay here forever,” said an 11-year-old girl at the end of one of our trips. Her exclamation surprised us as she had been completely silent through out the excursion. For the most part, she helped her parents care for three younger siblings, quietly accompanying them around the tide pools, pond and the Crab Cove Visitor Center. She maintained a vigorous grasp on an adult’s hand as we followed a naturalist out into the muddy tide pools to search for crabs, worms and bat rays. Her sequined pink sneakers were covered in mud, and after a few minutes she turned around and quietly went back to the shore.
Partnering with children such as this young girl and families to get outdoors has taught us not to make assumptions about how children feel about or experience nature. One young boy jumped into the dirt almost head first, elated, running back and forth to the group to announce his latest discovery such as Mermaid’s Hair Seaweed. One family group spanned three generations, including a teenager wearing headphones. Despite this teen’s cool demeanor, she was just as engaged as her elders when we saw baby ducks. Another boy separated from the group; staying on shore. When we returned from the tide pools we discovered that he had been completely engrossed in finding crabs of different sizes. Filled with pride, he held up his hand which was filled with several little crabs. The toddlers in the group often struggle to sit still, but come to life when allowed simply to run.
Fun looks different depending on a child’s developmental stage. Young children ages zero to five learn, explore, engage and get active through play. Play is best when spontaneous and self directed. Natural environments that are enriched – that is, with natural elements such as sticks, rocks, and streams – foster healthy development and invite young children to explore while gaining physical skills and coordination. With the little ones, we are often reassuring and encourage parents to find a safe outdoor space and to give their preschooler unstructured time to discover and play. Elementary aged children, on the other hand, enjoy being outside with their parents or friends. To engage an adolescent, it is important to listen to her ideas on where to go and what to do in the outdoors.
Getting kids to nature is not always easy on the adults
The parents on our trips work hard to give their children this opportunity. A half-day excursion into the outdoors takes time, access to nature, and money for supplies, meals, transportation, and childcare. For many people these are formidable challenges. The shuttle leaves from our clinic on the first Saturday of each month. Getting to our clinic poses it’s own challenges: one couple with four children had taken three buses to get there and were running to get to our clinic, as one of their buses was delayed. One grandmother had hailed a taxi when her connecting bus failed to show up. Another mother arrived early so her children could take a nap and catch up on sleep before the trip. Another family of four children had spent two hours on a bus to get to our shuttle. We are humbled by our families’ determination to explore with us.
But, as is the magic of nature, the barriers between families fall when we are outdoors. Families and staff help each other out. On the bus ride over, several of the mothers traded information on housing options. A naturalist held one mother’s toddler for much of the day so she could tend to another child. The formalities between doctor and patients also drop; one doctor ran and ran with a two year old across a grassy lawn until they both sat down, smiling, and finally tired. The physicians had the opportunity to talk with families in a way that they would never have the opportunity to do otherwise. As social isolation is a true public health issue, the potential for community building in these trips is profound.
When we say nature, we mean community
What is it exactly about being outdoors that heals us and heals children? Science tells us the health benefits of nature include physical activity, stress relief, and social contact. Our experience tells us nature is about having fun with friends, family, and community. Being in nature is also about expanding our definition of community. For a child, attaching to the place where they live, and to the plants and animals that share this space with them also has the potential to help them feel connected. Reducing stress and being connected to loving adult and community helps kids become resilient.
Parks remain an invaluable resource for free and local opportunities to experience nature. Thank you, East Bay Regional Park District for being an amazing collaborator and for caring for our parks. Thank you to UCSF Benioff Children’s Hospital for believing in nature. Thank you to parents and caregivers for exploring. Thank you to all the naturalists, environmental educators, and guardians of our nation’s natural resources. You are public health in action.
We would like to recognize Carol Johnson, Elizabeth Carmody, Sharon Nelson-Embry, Yogi Francis, Pat Chase, Kelley Meade, Christine Schudel, Kelvin Dunn, Curtis Chan, and Kristin Wheeler for helping to create this vision.
About the Authors
Dr. Dayna Long is a staff pediatrician at UCSF Benioff Children's Hospital Oakland (CHO) where she co-directs the Family Information and Navigation Desk (FIND). She has been a dedicated Nature Champion at CHO and currently collaborates with EBRPD to integrate nature into clinical care in a program called FIND Nature! Dr. Long also serves as Medical Director for the Asthma Clinic where she and her team run an annual camp for children with asthma to spend a week in nature called "Camp Breath Easy."
Dr. Nooshin Razani is a pediatrician practicing at the Silva Clinic in Hayward and UCSF Benioff CHO. She was trained as a "Nature Champion" by the National Environmental Education Foundation in 2010 and serves as the lead medical Senior Fellow to the Institute at the Golden Gate. She is thrilled at this opportunity to share her love for nature with families through a collaboration with the FIND Nature! team at Children's Hospital Oakland and EBRPD.
Photos by Nooshin Razani and Elizabeth Carmody
Parks exist to enhance and add value to our lives. From the economic boost they give to cities to the social interactions they help facilitate, we may sometimes take the uncounted benefits of parks for granted.
The Healthy Parks Healthy People: Bay Area (HPHP: Bay Area) initiative positions parks as health resources for the whole family—especially those in the highest health need communities. This movement is engaging and creating a whole new group of lifelong park users who will help ensure a future for our parks and public lands for generations to come, while improving their own health at the same time.
In the last year alone, over 35 park sites throughout the Bay Area have offered Healthy Parks, Healthy People programming on the first Saturday of every month—engaging hundreds of new park users. Parks and health agencies are working together to guarantee that park facilities and programs encourage physical activity, foster social connections, and extend a warm welcome to new visitors.
Park and healthcare providers hope that this regional initiative can be a catalyst for broad policy change that advances the adoption of measurable recreational models to support the delivery of healthcare to improve the physical and mental health of our population. In the next year we hope to reach an even wider audience and begin to create lifelong park users who will improve the health of our communities and our planet.
The next time you find yourself overwhelmed by work or stressed out from the daily to-do’s, make the time to go for a walk in your park. We guarantee you'll feel better once you do. The HPHP: Bay Area collaborative is continuing to welcome new and returning park users each month and we hope to see you out there soon. For more information on the collaborative and to find a program near you click here.
See you in the parks!
San Francisco took a huge stride forward last month by committing to fully adopting Park Prescriptions throughout their public health system. The estimated 30% of San Franciscans who use some form of public health service will be "prescribed" time outside in one of the city’s local, national, or state parks. The program is being implemented by the Department of Public Health in partnership with San Francisco Recreation and Parks and the Golden Gate National Recreation Area and represents the first time in the world that an entire city has taken steps to fully implement Park Prescriptions.
Thanks to the leadership of San Francisco’s park agencies, patients are able to fill their prescription at one of the specially designed Healthy Parks, Healthy People programs. Patients are met by a park staff member and led on an introductory walk to get them familiar with the features of the park while getting physically active and improving their overall wellbeing.
The first Park Prescription program in San Francisco was piloted at the Southeast Health Center in the Bayview Hunters Point neighborhood. The Kaiser Permanente funded pilot was led by the Institute and championed in clinic by Dr. Nooshin Razani and Dr. Jamal Harris. The lessons learned from this pilot and many others in the Bay Area and across the country will help guide the implementation and long-term plan for the program throughout San Francisco.
See you in the parks...Doctor's orders!
There is growing consensus that nature has many health benefits, from increased physical activity to mental, emotional, and community health benefits. At the Institute we have brought this concept to implementation on a local, regional, and national scale. Recently our local Park Prescriptions pilot in the Bayview Hunters Point community in San Francisco was highlighted in the National Parks Magazine, produced quarterly by the National Parks Conservation Association. The article, A Prescription For Nature, was written by Dr. Daphne Miller - a partner and early advocate of the Healthy Parks, Healthy People movement.
The pilot program has made significant strides since its inception in summer 2012. This opportunity, funded by a Community Benefit grant from Kaiser Permanente, allowed us to take lessons learned and existing promising practices from around the country and adapt them to fit the unique needs of the Bayview Hunters Point community. After successfully training the staff of the Southeast Health Center and implementing park prescriptions in the clinic we will be continuing to elevate the important message of spending time outside to improve your health by training community leaders this summer. The community docents will have the knowledge and resources to be ambassadors for the parks and will help bring new audiences to participate in Healthy Parks, Healthy People programs in the Bayview Hunters Point neighborhood.
Stay tuned for stories and images from this summer's community docent program. Until then, see you in the parks!
I want to share one example of a process we have used to strengthen Healthy Parks, Healthy People practice in our region. The model is called “collective impact” and it is gaining traction around the country. We first heard about collective impact in Stanford Social Innovation Review (SSIR) and have been implementing it ever since.
Healthy Parks, Healthy People (HPHP) doesn’t refer to any one program. Originally a messaging campaign adopted by Parks Victoria in Australia, HPHP serves as an umbrella for any and all activities that draw a connection between public lands and human health.
For the past several years, parks all over the globe have been working to put this concept into practice, figuring out what it means by reaching out to unfamiliar partners and testing new programs and practices. Here in the Bay Area, we saw this happening to varying degrees of success. There was a fair amount of friendly competition as different agencies were tried to solve different pieces of the HPHP puzzle. Here at the Institute, we thought creating a more formalized community of practice could create a rising tide to lift all boats. But more than just sharing information with each other, we believed there may be some things we could only achieve if we tackled them together—an elephant in the room we might only move if we each put a hand on it.
Beginning in June 2012, we launched a series of monthly meetings that were very carefully crafted to help all park and public land agencies in the Bay Area to realize a common health agenda. Participants spanned parks and public lands, public health, private healthcare, and community advocacy groups.
Get Others Excited
Our first meeting was an invitation to play in the kiddie pool, giving our participants an opportunity to see if this kind of collaborative work was for them. We asked participants to think about areas in their HPHP practice where they were struggling to make traction on their own as a single organization. We shared those—which ranged from addressing transportation needs to using the right language to communicate with local communities—and then broke into groups to tease out what some collaborative solutions in those areas might look like. At our meeting’s close, we invited folks to continue the conversation by joining our series of monthly strategy meetings and craft an HPHP agenda that would move our entire region forward. Of the 50+ participants in this meeting, about 12 organizations committed to meeting monthly with us to create the initiative from scratch.
Define a Clear Target
At the next session with this committed leadership team, we mapped out all of our current activities and identified gaps. We started to see that we weren’t sure if our HPHP activities were reaching those communities that could benefit the most from healthy activities in our parks. And to be honest, we didn’t know those communities very well. We also recognized that, so far, our new HPHP regional collaboration had mostly attracted interested park actors but not as many health or community leaders. We guessed that we might not yet be attracting the right health stakeholders because we didn’t have something really concrete to offer yet from the park side and took that into account as we proposed activities we might take on together.
At our third session, we tried to more concretely articulate our purpose statement in coming together. We recognized that we could not take on all HPHP principles at once, so we chose a defined target. There is evidence that park prescriptions most benefit communities of low income and traditionally low access to parks. These are often also communities with the most health disparity and at the highest risk of chronic health problems. We decided that, to really make an impact with HPHP, we were going to prioritize our activities to serve those communities with high health risk first.
Start Something Tangible
With this target now in place, we had a clear outcome to strategize toward: increase the wellbeing of high health need communities through regular use and enjoyment of our parks. This statement, though simple, clarified our audience (high health needs first) and the type of behavior change we were aiming for (prioritize enjoyment rather than rigorous activity; regular use rather than one-off or semi-annual events).
We debated several proposals for “first step, low-hanging fruit” activities we could take on together. We judged them against a set of criteria we created to help us stick close to our target. After much brainstorm and debate, we agreed that the best first step we could take was to commit to offering consistent, culturally relevant programing designed for first-time park users that health care providers could prescribe just as easily as a drug you could pick up at Walgreens. We thought, how incredible would it be for this to take place in every park and open space in the Bay Area at a time that works for residents and is consistent? The Director of Maternal and Child Health at the San Francisco Department of Public Health agreed that this targeted programming would be a huge offering to the healthcare and public health community in our region. This became our agenda for 2013.
The Power of Collective Impact
Our “warm-welcome” HPHP park programming now takes place the first Saturday of every month in over 23 park sites around the Bay Area with over thirty agencies and organizations on board. Some things are standardized, like the way we measure participation and program outcomes, but in many ways the programming itself is varied, as well as the recruitment strategy, so we are able to compare different approaches in different communities, evaluate and improve what we are doing.
Just to tease out the timeline: within two months we were committed to a target—the change or outcome we were trying to seek together. Within about four months we had committed to an agenda for action and a timeline. And after twelve months we are moving full steam ahead, practicing and measuring our progress. This group of over twenty park agencies and a dozen health and community supporters decided that it wanted to create an MOU that would hold us accountable to this agenda through 2015. All of this was driven by the members of the collaborative; as the facilitative leaders, we committed to holding the process and asking the right questions at the right times.
Friends and Allies
If you are looking to create a collective impact collaboration for your social issue or cause, know that you’ve got allies behind you. Click here for a summary of different programs we modeled our own effort on. While it may not be exactly clear which “low-hanging fruit” your community will take on right away, we are confident that you can get started with only the resources you have at hand. Once you share a commitment to improvement with the right stakeholders and have set a few ways you plan to measure your success and hold yourselves accountable, taking meaningful action comes easily.
Since 2009, the Institute at the Golden Gate has been catalyzing partnership opportunities into action and helping to make the idea of Healthy Parks, Healthy People mainstream. To this point, the Institute has built a national movement by telling the stories of successful "park prescriptions" programs around the country and inspiring leaders in the parks and health fields to take up the charge.
Over the last year we have begun a partnership with the Centers for Disease Control & Prevention and the National Recreation and Park Association to compare data from park prescription pilots around the country. Together we have reached out to over two dozen experts and those already implementing park prescriptions, in order help to set national standards for programming. These experts and implementers will gather for an in-person convening in October 2013 to set the agenda and vision for park prescriptions moving forward. We hope this will further solidify Healthy Parks, Healthy People as a policy practice, and provide the evidence and rigor it needs to survive beyond any one administration or individual champion.
The Institute is committed to supporting a growing network of medical practitioners, insurance providers, parks and federal lands, and the communities they serve to establish and share best practices to connect healthcare and park resources. We look forward to reporting back in mid-October to share next steps on how park prescriptions programs will be improved and increased around the country in the coming years.
See you in the parks!