The nature cure | May 8, 2019 | Almanac | Almanac Online |


Cover Story - May 8, 2019

The nature cure

For stressed-out families, local doctors are prescribing a new fix — public parks

by Kate Bradshaw

It's no secret that getting outdoors is good for people.

In Japan, a practice called "shinrin yoku" meaning "forest bathing," which "essentially involves hanging out in the woods," according to Outside Magazine, has grown in popularity since the 1980s and is now considered a standard practice in preventive health care.

In Norway, people practice the concept of "friluftsliv," or "open-air living," through lifestyles that prioritize time spent outdoors.

And over the past decade, the Bay Area has been at the heart of a growing national movement to get people in under-resourced communities outdoors to reap the inherent health benefits provided by sunshine, greenery and an open trail. The movement has united doctors, public health officials, community health workers and park rangers alike with a goal of getting more people — especially families with kids, and in particular families that have traditionally underutilized public parks — enjoying time in nature.


While the notion that spending time in nature has health benefits isn't a new one, it is getting increasing scientific scrutiny with daily screen time on the rise and daily outdoors time in decline. Research indicates that besides the straightforward benefit that physical activity burns calories and can help with weight management, nature carries with it a plethora of additional benefits.

In 1984, scientist Edward O. Wilson presented the theory of "biophilia," which posits that humans have an innate tendency to seek connections with nature and other forms of life, developed as part of the evolutionary process.

More recent research suggests that "time spent in nature may improve social bonding and reduce violence, stimulate learning and creativity, help raise standardized test scores, and serve as a buffer to toxic stress, depression and anxiety," according to a recent Sierra Magazine story on efforts to recognize access to nature as a human right.

The good news is that both San Mateo and Santa Clara counties have a significant portion of their land dedicated as open space, much of which is publicly accessible. According to the Bay Area Greenprint Project, a collaboration between The Nature Conservancy, Bay Area Open Space Council, American Farmland Trust, Greenbelt Alliance, and GreenInfo Network, 43% of the land in San Mateo County and 31% of the land in Santa Clara County is protected by ownership or conservation easements.

The nature cure

The movement to "prescribe" parks as a health practice was launched in its current iteration in 2008 when the Institute at the Golden Gate, part of the Golden Gate National Parks Conservancy, was founded. In 2012, the institute first piloted a "park prescription" program in San Francisco's Bayview-Hunters Point neighborhood. Later that year, it launched the "Healthy Parks Healthy People: Bay Area" collaborative with the East Bay Regional Park District and the National Park Service.

According to Betty Sun, program manager at the institute, nature helps people make deeper connections on three levels: with themselves, with others and with the planet.

Being alone outside — and sometimes in places without cellphone service — can help people unplug from devices, she explained. For the already-converted like herself, she said, it's easy to notice how good it feels to take a 20-minute walk outside on a stressful day, or visit a local park on the weekend.

Spending time with people outside can also help deepen the quality of their interactions, Sun says. Going on a road trip or hanging out in nature with friends helps people feel more connected. Among veterans her programs work with, she says, some people prefer to hike in silent contemplation, while others open up on the trail, telling stories and enjoying the companionship of other veterans.

"You can enjoy the quiet side of nature and also enjoy the power of bringing people together," she says.

At the risk of sounding touchy-feely, she added, there's the less tangible feeling that comes from touching redwood trees, walking in the dirt, and contemplating life while gazing out at spectacular vistas.

New research about the science of "awe" indicates that, as Sun describes, "Feeling small is really good for us."

A recent study by Bay Area researcher Craig Anderson found that when military veterans and youth from underserved backgrounds experienced feelings of "awe" while whitewater rafting, they reported lessened symptoms of post-traumatic stress disorder and overall stress a week after the trip, along with improved social relationships, life satisfaction and happiness.

"We believe parks are public lands and should be for everyone," Sun said, but noted that, "Those that need nature most are also not coming to our parks."

Unequal access

Despite the growing body of evidence on the health benefits of outdoors time and the significant amount of land dedicated to public outdoor recreational use, both San Mateo and Santa Clara counties have found in recent analyses that members of the public are not accessing these resources equally.

A 2015-16 study found that in San Mateo County, park visitors tended to be older, whiter, and more educated than county residents as a whole. According to the study, park visitors were on average 50 years old. More than 75% were white and 75% had a bachelor's degree or additional higher education. Among county residents, the median age is 40, 40% of residents are white and 48% of residents have bachelor's degrees or additional higher education.

In Santa Clara County, a 2018 survey of park users found that 53% of visitors were white, 16% were Hispanic, and 22% were Asian — the county's top three most populous ethnicities — compared with population estimates that the county's resident population is 51% white, 26% Hispanic and 37% Asian.

So where do doctors fit into the campaign to make "outdoorsy" a more inclusive adjective, one that doesn't just connote mostly upper middle-class, mostly white folks who don't mind paying a small fortune for waterproof jackets and boots?

Two approaches

Over the last couple of years, both San Mateo and Santa Clara counties have started doing "awesome work" to get "low-income, stressed-out families out at parks to enjoy the health benefits of nature," Sun says.

While there are many similarities in the two counties' efforts, each has taken different first steps to try to get more people out in nature, according to Sun.

San Mateo County

In San Mateo County, initial efforts have come from the county's top public health official, Dr. Scott Morrow, to make it easier for doctors to talk to patients about outdoors time by embedding the option of prescribing park time into the county health system's electronic medical records software. With a few clicks, doctors — mainly pediatricians at this point — can now direct their patients to their prescribed outdoor remedy, which even includes a preset dosage: "Spend time in nature, one hour, twice a week."

Embedding this option into the workflow of harried physicians is a critical step toward making such prescriptions sustainable in the medical community, Morrow explains.

"There's lots of evidence this is an effective recommendation," he says. What's less evident is which type of park or what kind of activity or program is best. When it comes to which parks to seek out, as a Half Moon Bay resident, Morrow says he's biased toward the majesty of the Coastside redwoods, but proximity and convenience of outdoor spaces are important factors too.

So far, it's been easier for pediatricians to incorporate prescribing parks into their interactions with patients — a symptom of an adult health care system more focused on addressing acute problems than preventive care, especially for the low-income adults he sees at the county clinic, Morrow says. But he adds that he's very interested in getting these recommendations systematically provided to adults as well.

"It's a culture change we're going for," he says.

Morrow adds that for him, nature time is more about mental than physical health. Sure, walking in a park for an hour is healthy for one's body. But even just sitting on a bench in a park can be great for one's mental health. Dedicated nature time can also help people with another practice he recommends, what he calls a "digital sabbath" — the notion of setting boundaries with personal technology use and taking one day a week to unplug from technology.

The county health department also helps to organize outdoor activities with specific clinics, including the Ravenswood Family Health Center in East Palo Alto. The health department works with the state's Nutrition Education and Obesity Prevention Branch program and its coordinator, Gloria Cahuich Gonzalez, to assemble participants and provide transportation when needed to outdoor programs, which are led by park rangers and park support nonprofits such as Friends of Huddart and Wunderlich Parks and Peninsula Open Space Trust. In a trial study, participating doctors are also providing patients free passes — funded by the San Mateo County Parks Foundation — to parks that charge access fees.

But there are still some barriers families face when venturing outside for the first time. As Sun explained, it can be intimidating to go places where there may not be information available in one's native language. Knowing what to wear, where to go, and how to get there, especially with limited transportation options, are other common barriers people can experience.

While the project is still in a pilot phase with limited public results, Dr. Rachel Borovina, a pediatrician at the San Mateo Medical Center, will be speaking at the Children & Nature Network Conference May 16 through 18 to present the findings of the county's case study.

Santa Clara County

In contrast, Santa Clara County's efforts to prescribe parks, Sun says, focus on working with families to remove the barriers they experience in accessing the outdoors, though this can be more expensive and require more intensive efforts by physicians.

According to Michelle Wexler, prevention program analyst with the Santa Clara County Public Health Department, the county first got involved through the "Healthy Parks Healthy People" initiative. Members in the initiative started hosting "First Saturday" events that encouraged first-time or infrequent park visitors to access free, introductory park activities.

About two years ago, she says, she partnered with the county parks department for a grant from Santa Clara Valley Open Space Authority, funded by Measure Q, to work with physicians to write park prescriptions, hire a bilingual community worker to follow up with families and help get them to parks, and organize monthly "First Saturdays" at parks where free activities and programs are organized the first Saturday of each month.

Since then, the program has only grown, with many families returning to the events again and again, she says. Today, it is so popular they've expanded it to the first and third Saturdays of each month.

They also provide families with free passes since many of the local county parks have paid parking. And for families with limited or no car access — say they have only one car and a parent needs to take it to work on Saturday — the community worker helps families figure out transportation options. In some cases, this involves lining up a taxi to take a family to the park.

Laurie Cammon, a pediatrician with the Santa Clara Valley Medical Center in Santa Clara County, explains that in addition to seeing patients become more active outside, the program has had significant, less obvious benefits for her patients and her practice.

Many of the families who participate in the program, she says, have developed friendships and are building a community around the park walks. And for the health providers in her clinic, she adds, going out and connecting with patients in the outdoors can help them avoid burnout.

Since the program began, she says, she's also seen her rate of patient no-shows and cancellations decline. "When families attend, then come back to the clinics, they feel more comfortable with (health care) providers," she says.

She tells the story of how one teen she works with often missed appointments, avoided eye contact, and gave one-syllable responses to questions before participating in the program. After attending the program, the teen seemed more comfortable talking to her, provided more thorough responses and smiled more.

Another family she works with, she recalls, was feeling really overwhelmed and stressed out, and didn't feel like they'd be able to make some of the lifestyle changes she was recommending.

She told them: "If you can't do anything else, just come to a park walk."

The whole family came.

At their next visit, Cammon says they told her: "It's a wonderful thing you do. We felt like we could breathe there." They reported feeling less overwhelmed, more relaxed, and more empowered to make lifestyle changes.

"The experience of being outside at this program gave them some hope and confidence to make changes they hadn't felt before," Cammon says.

"I was a true believer before," she says. "Now I'm an over-the-top believer."

As for what's next for the program, Wexler says, "We're dreamers. We would love to make it so that every pediatrician in Santa Clara County could write a park prescription for their patients."


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