Surmounting Barriers to Public Health/Park Agency Partnerships: Insights From a County Public Health Department

Abstract

Executive Summary: Leisure in parks and other forms of protected areas are connected to an individual’s health and well-being. In this paper, we report on the results of a multi-year study that surveyed 1,515 visitors to three Provincial Parks and three Kananaskis Country Provincial Recreation Areas in Alberta, Canada. Results revealed several important findings with significant policy and planning implications for Alberta Parks, as well as the international parks and protected area community more broadly. Findings show that anticipated human health and well-being benefits were a major factor motivating individuals’ decision to visit a park or protected area. Perceived psychological/emotional benefits (89.1% of visitors), social benefits (88.3%), physical benefits (80.3%) and environmental well-being benefits (79.4%) were deemed the most important motivations. However, there was a negative correlation between age and each of these perceived benefits, indicating that older visitors were less motivated to visit protected areas for these reasons. Perceived benefits (outcomes) followed a similar pattern to motivations. The most improved factors were psychological/emotional (90.5%), social (85%), and physical well-being (77.6%). A demographic analysis revealed that females rated financial, social, psychological/emotional and spiritual well-being motivations higher than males. Income and education were also positively related to individuals’ ratings of physical, psychological and environmental well-being. Interestingly, health motivations and benefits (or outcomes) were correlated highly with nature relatedness, meaning the more connected one is to nature, the greater the motivation to visit parks and the greater the health and well-being benefits received from park experiences. Overall, this study represents the largest examination of the human health and well-being benefits associated with visitor experiences in a Canadian protected areas context. The results substantiate the need for park organizations to better understand the “service provider” – “client” relationship from a human health and well-being perspective so that integrated policies and visitor experience programs can be developed or enhanced where appropriate. The Alberta Parks Division, and the international protected areas community more broadly, should actively develop the social science foundation internally, and externally (through partnerships with the social science research community), to ensure that decisions are science-based, society-oriented, and effective at meeting both conservation and visitor experience objectives. Finally, our research indicates the need for a better empirical understanding of the human health and well-being motivations and benefits of visitors representing different social and population subgroups (e.g., youth, elderly, couples, family units, new immigrants) and of the role of distinct natural environments in health promotion.

Full text

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636781103
Surmounting Barriers to Public
Health/Park Agency Partnerships:
Insights From a County Public
Health Department
Volume 34, Number 1
pp. 53–67
http://dx.doi.org/10.18666/JPRA-2016-V34-I1-7065
Journal of Park and Recreation Administration
Spring 2016
Nooshin Razani
Jodi Stookey
Laura Brainin-Rodriguez
Nina S. Roberts
George W. Rutherford
Curtis Chan
EXECUTIVE SUMMARY: The American Public Health Association (APHA)
recently recommended that health professionals partner with park agencies in
order to use nature for health promotion. We aimed to 1) determine the capacity
of a local public health system to implement the APHA recommendations, 2) test
the hypothesis that the likelihood of implementation is associated with health
professional knowledge and beliefs, and 3) identify a framework for facilitating
implementation. We surveyed all staff members at the San Francisco Department
of Public Health (SFDPH) Maternal, Child and Adolescent Health Branch.
SFDPH, like many health departments, provides services for underserved
and marginalized populations. The results of 108 quantitative surveys and
the qualitative analysis from small group discussions with 120 public health
professionals are presented in this paper. The majority of those surveyed (81%)
agreed that patient health would improve if they spent time in nature. However,
few health professionals believed that patients regularly visit parks (11%) or
would follow a practitioner’s recommendation to visit a park (16%) in order to
experience nature. We found that if public health professionals knew of a specic
location and activity to do in nature, and if they were condent that their low
income patients would be welcome at parks, they were more likely to recommend
a park visit. In group discussions, health professionals showed enthusiasm
for collaboration with park agencies, pragmatism that their patients will need
multiple supports in order to sustain outdoor behaviors, and a perspective that
time in nature for underserved communities is the product of a socioecological
system. This socioecological system includes factors to be considered at the
individual, interpersonal, community, and societal levels. Participants engaged
in a rich discussion on how health departments can partner with park agencies
and community-based organizations to encourage nature for health at each of
these levels.We turned to public health professionals for suggestions about how
nature can be integrated into public health systems. The resulting discussions

54
came together in the form of a framework that provides insight on public health
priorities, a roadmap for those who seek to initiate interdisciplinary alliances,
and suggestions for future research.
KEYWORDS: Nature and health; park, preventive health; public health
practice; national parks; American Public Health Association; San Francisco
Department of Public Health; SFDPH
AUTHORS: Nooshin Razani is attending pediatrician at UCSF Benioff Children’s
Hospital Oakland, nrazani@mail.cho.org. Jodi Stookey is senior epidemiologist,
Maternal, Child and Adolescent Health Section, San Francisco Department of
Public Health. Laura Brainin-Rodriguez is coordinator of the Feeling Good
Project, San Francisco Department of Public Health. Nina S. Roberts is a
professor in the Department of Recreation, Parks, & Tourism, College of Health
and Social Sciences, San Francisco State University. George W. Rutherford is
a professor in the Department of Epidemiology and Biostatistics, University of
California, San Francisco. Curtis Chan is medical director, Maternal, Child and
Adolescent Health Section, San Francisco Department of Public Health.
ACKNOWLEDGMENTS: We thank the leadership and staff of the San
Francisco Department of Public Health, San Francisco Department of Parks
and Recreation and Golden Gate National Recreational Area for their efforts in
advocating for all San Franciscans.
DISCLOSURES: This work was supported by the San Francisco Department
of Public Health, Health Network Division, Maternal, Child and Adolescent
Health Branch, US Department of Agriculture Funds, Nutrition Education and
Obesity Prevention funds. Dr. Razani, lead author, was a Senior Health Fellow at
the Institute at the Golden Gate, a program of the National Park Service, for the
duration of study design. The Institute at the Golden Gate played a substantial
role in organizing, funding, and providing administrative support for a one-day
all-staff training for SFDPH MCAH.
Introduction
In 2013, the American Public Health Association (APHA) adopted a policy to improve
health and wellness through access to nature (American Public Health Association, 2013),
which recommends that “public health ofcials, physicians, nurse practitioners, and other
health professionals should advise patients and the public at large about the benets of
green exercise, personal and community gardening, and nature-based play and recreation.”
Amongst other strategies, APHA recommends health professionals partner with park
administrators “in order to increase access to green spaces where people live, work, and
play and to raise awareness about their value.”
A growing body of literature provides evidence for the role of nature in public
health (McCurdy, Winterbottom, Mehta, & Roberts, 2010). The presence of nature in
communities has been associated with lower rates of all-cause mortality (Maas, Verheij,
de Vries, Spreeuwenberg, Schellevis, & Groenewegen, 2009), higher longevity (Takano,
Nakamura, & Watanabe, 2002), lower prevalence of asthma diagnoses (Lovasi, Quinn,
Neckerman, Perzanowski, & Rundle, 2008; Pilat, McFarland, Snelgrove, Collins,
Waliczek, & Zajice, 2012), lower rates of pre-term labor (Dadvand et al., 2012), (Kihal-
Talantikite, Padilla, Lalloue, Gelormini, Zmirou-Navier, & Deguen, S. 2013), less myopia

55
(Ip, Rose, Morgan, Burlutsky, & Mitchell, 2008; Morgan, Ohno-Matsui, & Saw, 2012;
Rose, Morgan, Ip, Kiey, Huynh, Smith, & Mitchell, 2008), higher vitamin D levels,
improved attention decit hyperactivity disorder symptomatology (Taylor & Kuo, 2009),
improved self-reported well-being (Cervinka, Roderer, & Heer, 2012), and less physician-
diagnosed anxiety and depression. Mental health benets are even more pronounced for
those living in poverty (Sugiyama, Leslie, Giles-Corti, & Owen, 2008). Health benets
associated with exposure to nature are thought to be mediated by air quality, opportunities
for social interaction (Maas, van Dillen, Verheij, & Groenewegen, 2009; Sugiyama, Leslie,
Giles-Corti, & Owen, 2008), reduced stress (Wells & Evans, 2003), and increased physical
activity (Davis et al., 2011). Physical activity has been reported not only to increase in
outdoor spaces, but also to change in quality when those outdoor areas are green spaces
(Cooper, Page, Wheeler, Hillsdon, Griew, & Jago, 2010). The same exercise done in nature
(“green exercise”) results in reduced aggression, anger, fatigue, and sadness, and improved
attention and cognition (Bowler, Buyung-Ali, Knight, & Pullin, 2010) compared to when
it occurs in a built or indoor environment. Green areas on elementary school property
support improved motor coordination, and social and emotional development as compared
to exclusively asphalt playgrounds (Cooper, Page, Wheeler, Hillsdon, Griew, Jago, & 2010;
Fjortoft, Lofman, & Halvorsen Thoren, 2010; Hart, 1998).
Public health-park alliances, while not fully documented, are prevalent and increasing
(Mowen, Payne, Orsega-Smith, & Godney, 2009). Park agencies have been attractive
partners for public health departments because local parks are the most readily available,
or sometimes the only, source of physical activity for local communities (Bedimo-Rung,
Mowen, & Cohen, 2005; Floyd, Crespo, & Sallis, 2008; Kaczynski & Henderson, 2008).
Park agencies are motivated to partner with health departments because they would like to
grow the number of users, increase their relevance, and foster future environmental stewards
(Cohen, McKenzie, Sehgal, Williamson, Golinelli, & Lurie, 2007; Kruger, 2008). Park
agencies have researched how to increase park use by changing park structure, programs
offered, and stafng (Bedimo-Rung, Mowen, & Cohen, 2005; Kaczynski, Potwarka, &
Saelens, 2008). Best practices for integrating nature into health care departments remain
to be determined. It is unknown whether public health professionals at the local level are
aware of the health benets of nature, the role of parks in providing access to nature, or
if they are prepared and willing to advise the public about the health benets of nature.
The capacity for public health departments to implement partnerships for nature contact
is unknown. Likewise, we are not aware of any existing theoretical framework that might
guide these partnerships.
As many public health departments care for safety-net populations, this article
focuses on how to implement the APHA recommendations for low-income and diverse
communities that, at baseline, lack access to green space (Taylor, Floyd, Whitt-Glover,
& Brooks, 2007). Park, recreation, and leisure scientists have identied common barriers
to getting outdoors (Department of the Interior 1999; Jackson, 1988; Meeker, Woods, &
Lucas, 1973; Rodriguez, Roberts, & National Park Service, 2002; Washbure, 1978). Lack
of time, lack of access, and not feeling comfortable or welcome are documented barriers
for low-income groups. The number of constraints discouraging people from leaving home
for leisure experiences increases for individuals with lower socioeconomic status (Shores,
Scott, & Floyd, 2007). Marginalized populations of color often have added constraints such
as lack of familiarity and perceived racism (Roberts & Chitewere, 2011). Alleviating only
one barrier (for example, waiving or reducing an entry fee to a park) does not necessarily
lead to increased park visitation (More & Stevens, 2000).
In 2013, the San Francisco Department of Public Health (SFDPH) partnered with
local park agencies to increase access to nature for low-income populations of color.
They undertook several initiatives, one of which was a pilot project that included “park
prescriptions” at a public health clinic. One resulting hypothesis from the pilot project
was that health professionals are more likely to recommend nature to their patients if they
themselves have knowledge about the health benets of nature. Another hypothesis was that
health professionals were also more likely to recommend nature if they have knowledge

56
about where exactly to refer patients, or if they felt that parks would welcome low-income
patients. In order to inform the further design of collaborative strategies, SFDPH sought to
test these hypothesis as well as to gather more detailed information was needed about the
current public health system capacity for partnership and impact. The aims of this study
were therefore to
1. test the hypothesis that the likelihood of health professionals referring patients
to parks for nature is associated with their knowledge and beliefs about parks,
2. determine the capacity of a local public health department to implement the
APHA recommendations, and
3. create a framework for increasing access to nature through park use via health
departments.
Methods
We conducted a descriptive cross-sectional survey with quantitative and qualitative
components. The quantitative survey was conducted in October 2014, two weeks before
an all-staff training about nature and health. Qualitative data were gathered during group
discussions on the day of the training.
Study Population
All full-time staff members (n = 164) assigned to the Division of Maternal, Child and
Adolescent Health (MCAH) branch of SFDPH were eligible to participate in the study.
MCAH employees represent a range of public health professionals with a core function
of addressing health inequities for women and children, including those with special
needs. The division operates as a bridge between communities and clinics, with programs
that provide direct patient care, outreach for high-risk populations, linkage of patients to
community services, and clinical supports such as health professional training. Although
MCAH does not represent the entire San Francisco public health system, they are at the
forefront of the clinic-community public health interface, providing the important link
between individuals and services at a critical time for public health intervention early in
the course of life.
Park Agencies
San Francisco has more than 5,000 park acres administered by three separate park
agencies (San Francisco Recreation and Parks, The National Park Service, and California
State Parks). Throughout San Francisco, 145 people are served per acre of parks. Maps of
social inequities mirror maps of park needs in San Francisco (Trust for Public Land, 2014).
Survey Procedures and Variables
Closed-ended questions used a Likert-type scale and covered knowledge about the
physical, mental and social health benets of nature, knowledge of specic walks or
activities in nature to recommend, attitudes about whether patients currently spend time in
natural parks, whether low-income patients feel welcome in natural parks, whether patients
will follow their recommendation to visit parks, and current practices recommending a
visit a park to enjoy nature. The phrases “nature,” “visit to a park to enjoy nature” and
“natural park” were chosen after eld testing. While not all parks have nature and not all
nature is found in parks, we informed participants that we were discussing outdoor open
spaces in parks with natural components. Two open-ended questions were included at the
end of the survey:
1. What do you advise park leaders do in order to improve community health?
2. What do you advise health leaders do to improve community health through
parks and nature?

57
Breakout Group Discussions
During the all-staff meeting, MCAH employees were assigned to one of 15 groups,
each including six to ten health practitioner participants and one or two staff members
from San Francisco Recreation and Parks and/or the National Park Service. Each group
focused its discussion on a case study based on a particular health outcome or vulnerable
population group. Small group participants reported back to the larger group with answers
to the following questions:
1. List three ways in which health and parks can cooperate to better serve the family
in this case study.
2. List three ways parks can better serve the populations you work with.
3. List the community partners you plan to share [information about health/parks
partnerships with] in the next three months.
Data Analysis
We analyzed the quantitative data using STATA 10 (College Station, TX) and
present them as descriptive statistics. We used logistic regression to test the relative odds
that the current practice of recommending time in parks for nature was associated with
knowledge and attitudes. For hypothesis testing, and for presentation in the text, the ve-
level categorical variables were collapsed into dichotomous variables (very or extremely
vs. somewhat, slightly, or not at all).
Qualitative data from the survey and transcripts of small group discussions were
imported into Dedoose software (SocioCultural Research Consultants, Los Angeles, CA).
One member of the research team read over each of the transcripts three times. At the
rst reading, she noted the main points and created a list of codes. During the second
reading, she grouped the codes according to themes. These themes were then presented
to a team of representatives from SFDPH and a park agency partner and modied based
on their feedback. On third reading, the team member applied the revised codes. These
themes were then organized into a logic model and a socio-ecological model using the
Center for Disease Control and Prevention’s (CDC) framework (Center for Disease Control
2015). The socio-ecological model described by the CDC considers the interaction between
individual, relationship, community, and societal factors. The framework shows how
factors at one level inuence factors at other levels and the potential impact of preventive
measures at multiple levels. Once conclusions were made and gures drafted, they were
presented to the research team and went through several iterations of feedback and revision
from researchers and SFDPH.
Ethical Considerations
SFDPH collected these data for program planning purposes. All data were anonymous
with no identifying information gathered; the study was therefore deemed exempt from
human subjects’ approval by the UCSF Benioff Children’s Hospital Oakland Investigational
Review Board.
Results
Survey
Of 164 eligible MCAH staff members, 108 (66%) responded to the survey. One third
of the survey respondents were public health nurses, representing a variety of roles, and
3% of the respondents were physicians. Eleven (10%) did not provide direct patient care
(Table 1).

58
Table 1
Roles of Public Health Professionals Surveyed Regarding Knowledge, Attitudes, and
Practices about Nature, San Francisco, California, 2014
Role Number (%) Number not
providing direct
client care
Administrative (Program Coordinators,
Eligibility Specialists, Epidemiologists)
17 (16) 6
Public Health or other Nurse 40 (37) 1
Physical or Occupational Therapist 15 (14) 0
Health Educator/Worker 19 (18) 3
Social Worker 2 (2) 0
Student 1 (1) 0
Dietitian 6 (6) 0
Other provider (Dental Hygiene, Audiometry,
other)
4 (4) 1
Physician 3 (3) 0
Missing 1 (1) 0
Total 108 11
MCAH public health professional knowledge and attitudes, and behaviors are
presented in Table 2. Sixty percent were knowledgeable about the physical health benets
of nature, 61% about the mental health benets, and 44% about the social health benets;
only 25% knew about a specic walk or activity in nature that they could recommend to
patients.
Although 81% of 97 direct service providers believed patients would improve their
health by increasing time in nature, only 11% believed their patients regularly visited
parks, only 16% believed patients would follow their recommendation to spend time in
nature.
When asked how often they recommend a visit to a park in order to enjoy nature, 26%
answered always or often. Health professionals who were knowledgeable about physical
health benets were four times more likely to recommend parks to enjoy nature than health
professionals who were less knowledgeable (4.4, 95% CI: 1.4-14.2). Health professionals
who were knowledgeable about mental health benets were four times more likely to
recommend parks to enjoy nature than health professionals who were less knowledgeable
(OR 4.70, 95% CI 1.47, 15). Health professionals who were knowledgeable about social
health benets were three times as likely to recommend parks to enjoy nature compared to
health professionals who were less knowledgeable (OR 3.54, 95% CI 1.35, 9.3).
Fifty percent (50%) of the health professionals who knew about a specic walk or
activity in nature regularly recommended parks to enjoy nature, compared to 18% of those
who did not know of a specic walk or activity (OR 4.44, 95% CI 1.39, 14). Health
professionals who thought that low-income and ethnic groups feel welcome in parks were
more likely to recommend them to patients (OR 3.5, 95% CI 1.21, 10).
Small Group Discussions
One hundred twenty staff members (73%) attended the all-day meeting and
participated in the group discussions. Qualitative data identied three salient themes.

59
Enthusiasm for collaboration. The majority of participating SFDPH MCAH health
professionals expressed an enthusiasm for partnerships with park agencies. Information
about where and how patients can access nature in local parks was of particular value.
Participants were interested in the mental health and stress-related applications of nature in
health, for themselves and patients. Several participants felt mental health benets of nature
would resonate well with patients. One participant stated: “Less focus on physical exercise,
more focus on nature.” As others stated:
Appreciate this collaboration! ‘Green time’ is essential! Inspired to incorporate
this in our program culture for staff and patients.
I think that this is a great start and looking forward to greater collaboration.
Please note: . . . I think that it is not welcoming to assume weight loss is a goal
. . . To make the walks genuinely welcoming to people of all sizes, I think it
is important to de-emphasize weight and weight loss and focus on other health
benets. I know of several community-based groups that advocate for, and
inform community members about opportunities for exercise that won’t if there
is weight bias.
Emphasis on reinforcing behavior change. SFDPH MCAH health professionals
demonstrated pragmatism about their role in helping patients integrate nature into daily
Table 2
Public Health Professional Knowledge and Attitudes Regarding Nature, San Francisco,
California, 2014
Not at all Slightly Somewhat Very Extremely
How knowledgeable are you of the following? N = 108
Specic physical health
improvements in nature
3% 6% 31% 40% 20%
Specic mental health
improvements in nature
2% 7% 3% 38% 23%
Specic social health benets
of group activity in nature
4% 12% 40% 26% 18%
Specic walks or other
activities in nature that you can
recommend in SF
11% 10% 33% 14% 11%
How much do you agree with the following? N = 97
Many of my patients would
improve their health by
increasing time in nature.
0% 2% 12% 36% 45%
Many of my patients regularly
visit parks.
13% 36% 26% 8% 3%
Many of my patients feel that
the parks are welcoming to
low-income and ethnic groups.
6% 25% 30% 13% 6%
Many of my patients would
follow my recommendation to
visit a natural park within the
next month.
2% 20% 44% 12% 4%

60
life. Participants explained that their patients face considerable barriers and may require
efforts above and beyond a health professional recommendation in order to get to parks.
They expressed that a health professional’s recommendation for nature should be met
with other staff in the clinic who support patients in following the recommendation. Other
respondents expressed reservations about “park prescription” type programs. It was noted
that “these will require buy-in and engagement by clinic staff and depend on the health
professional and their commitment to this idea.”
The populations mentioned that would require support in getting to parks included
families, mothers (especially mothers in the perinatal period), physically or mentally
disabled, children with developmental or behavioral issues, anyone who is prior to
physically or mentally disabled, and the elderly. Specic barriers listed by participants
included lack of awareness, how culturally welcoming the parks appeared, language
barriers, access to nature, crime in outdoor spaces, safety from trafc for pedestrians in
San Francisco, transportation, and the cost. This quote demonstrates concern with cost:
I believe the eld nurses need a tool that will bridge the parks programs and
resources to our particular marginalized population, such as scholarships . . . and
programs our clients will qualify for.
In addition to these barriers, MCAH patients were felt to benet from special
programming and accomodations in order to feel comfortable at parks. Respondents
expressed concerns about the presence of drinking fountains, wheelchair routes, parking,
breastfeeding accommodations, and suggested family friendly programming, prenatal
programs, programs for new mothers, toddlers, and elderly, and buddy supports for
children with disabilities.
A diversity of ideas were generated on how to support and reinforce nature-related
behaviors in a low income or otherwise vulnerable patient. Suggestions are summarized
in the form of a logic model in Figure 1. The model starts by considering the assets found
in not only in the individual, but also in health and park partners, and with partnering
community-based organizations (CBOs). SFDPH MCAH has numerous pre-existing
partnerships with CBOs, and respondents felt these partnerships would bolster a health
professional’s recommendation to spend time in nature. Specic potential partners listed
include Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
Supplemental Nutrition Program program, Family Resource Network Centers, low-income
childcare centers, family associations, school districts, Boys and Girls Clubs, senior
centers, community resource centers, and faith communities. These quotes demonstrate
the potential role for CBOs:
We need to go to the community and to community events to engage our clients
with park programs.
Figure 1. Logic model to reinforce health care professional referrals to nature. Based on
suggestions from public health professionals in San Francisco, California, 2014.

61
We need to engage community leadership to plan programs like family reunions,
neighborhood reunions, parent-child activities in parks.
The logic model’s suggested activities fall into into three general categories and
are described in further detail in Table 3. Resulting short term goals included increased
communication about patients between partnering agencies through warm handoffs and
feedback, inclusion for vulnerable populations in parks, and increased park visits for
the patient. Warm hand-offs were described as an active effort from health care health
professionals and community-based organizations to mobilize patients, as well as a clear
Table 3
Activities for Health Departments, Park Agencies, and Community-Based Organizations
to Promote Health through Nature. Summarized from suggestions given by public health
professionals, San Francisco, California, 2014.
Activity Public Health
Department
Park Agency Community-Based
Organization
(CBO)
Form alliances
between health
departments, park
agencies, and
CBOs
Health professionals
and park staff
work together to
overcome patients’
specic barriers
Health professionals
communicate with
park staff when
patients are referred
Identify a specic
park staff as health
liaison by name and
phone number
Give feedback to
health professionals
or CBOs when
patients participate
CBOs assist with
recruitment and
overcoming patient
barriers through
pre-existing social
networks
Health professionals
visit CBOs to
recommend nature
Create consistent
public health
messaging in
clinics, parks,
communities
Provide easy-to-
use and easily
reproducible
materials:
• Maps specic
to health
professionals’
patients
• Databases for
nding parks
• Prescription pads
Provide consistent
and reliable
programming for
health professionals
to recommend (e.g.,
same day each
month)
Sponsor website
with resources
targeted toward
health health
professionals
Spread the word
via:
• Traditional and
ethnic media,
public service
announcements
• Social media
• Billboards
• Politician
endorsements
• Businesses
partnerships
Build capacity to
serve vulnerable
populations
Park staff lead
trainings for health
professionals on:
• indications for
nature referrals
• where, when,
how low income
patients can nd
nature in local
parks
Health professionals
lead trainings for
park staff on health
equity and issues
facing vulnerable
populations
Develop inclusive
programming
for low-income
populations of color
and those with
special needs.
Empower
community
members as leaders
Allow
neighborhoods
to participate in
environmental
stewardship outings
for health

62
welcome from park agencies that receive them. Paraprofessionals could be helpful in
encouraging behavior change via targeted discussion and case management if a physician
or nurse practitioner is busy. It is of note that MCAH SFDPH health professionals did
not limit these paraprofessionals to health professionals. Case management, whether done
by a clinician, community member, or park personnel, was valued to help patients work
through barriers to time in nature. Examples of suggested case management included park
ranger visits to health clinics for patient education and to meet patients, transportation to
and from clinics and community-based organizations. A plan for monitoring or providing
follow up information to referring health professionals or community-based organizations
was also deemed valuable. Several quotes demonstrate the recommendation for facilitating
behavior change:
It would be great to directly connect our clients with specic park personnel for
a ‘warm hand off.’
[We can] partner with [the] park and recreation department to coordinate
programs for clients and/or facilitate participation in existing programs.
[Parks need to] have a community liaison that is willing to come out to our
programs and present information about parks. You may already have it, but I
don’t know how that works.
In addition to improved health, other long-term outcomes mentioned included
creating environmental stewards and increased equity in access to nature.
Awareness of a socioecological system affecting nature and health. While many
suggestions were given to reinforce individual behavior change, another dominant
theme was that individual behavior would need to be supported by broad base systems
change in order to be successful and sustainable. Like with other health behaviors, the
surveyed health professionals viewed individual choices about nature in the context of an
individual’s environments, as demonstrated in this quote:
It seems there will still be signicant work to develop the infrastructure to
allow [health/parks partnerships] to reach the target population of lower
socioeconomic status. But if [there is] continued push and commitment from
health professionals, public health agencies, transportation agencies, and parks
services, there will be a time when [parks] will be a critical program in the health
of the local population.
Multiple levels of systems change were suggested to augment public health efforts
to increase nature exposure; these are summarized in Figure 2. At the individual level,
strategies to build client knowledge dovetail with the recommendations shown in the logic
model in Figure 1. Some participants saw health professionals as respected community
members who can model outdoor behavior by holding clinic visits, home visits, and group
classes outdoors in nature. At the interpersonal level, strategies were listed to inuence
social norms. At the community level, interdisciplinary coalitions were valued, especially
with transportation agencies and the media. At the societal level, systems changes were
valued if they would make nature more accessible to vulnerable populations. Participants
perceived inequity in the current distribution of natural resources and a need for advocacy
in order to expect patients to spend more time in parks. Several respondents reected this
sentiment:
[We need] greater accessibility—more resources in poor neighborhoods.
Golden Gate is beautiful, but it is usually lled with tourists.
[We] need to . . .keep our community parks safe and accessible to all people.

63
Respondents suggested advocacy and policy changes which included the following
recommendation:
I think it is important for park staff to reect the underserved communities of
color. Having more park staff that reect those communities to outreach and share
inspirational stories . . . will help get isolated families out of their neighborhoods
and into the parks.
Discussion
This is the rst study, to our knowledge, to explore best practices for public health
departments in increasing nature contact for low-income populations. The public health
professionals surveyed were aware of the health benets of nature and were enthusiastic
about partnering with park departments in order advise the public about the health
benets of nature. Despite this enthusiasm, we found that few of the participants believed
their patients currently make use of parks, few thought their low-income patients feel
welcome in parks, and few regularly recommended parks to patients for time in nature. As
hypothesized, health professionals that regularly referred patients to parks were more likely
to have knowledge about the health benets of nature, more likely to know of a specic
walk or activities in nature to recommend, and were more likely to believe that their low-
income patients felt welcome in parks. Educating health professionals about the health
benets of nature, as well as the location of local nature is one way to begin implementing
health and parks partnerships.
Future research should investigate what percent of health professionals live and
recreate in the neighborhoods they serve, and whether they know about nature that are easily
Figure 2. A socioecological model to promote nature for health. Summarized from
suggestions given by public health professionals in San Francisco, California, 2014.

64
accessible for patients. One interesting question for future research is whether using nature
as an intervention for stress or mental health resonates better with health professionals and
patients than its use for obesity prevention and/or management? Although our qualitative
data suggest “yes,” more research is needed on public health promotion and marketing
strategies.
This study helped determine the capacity of a local public health department to
implement the APHA recommendations. Participating health professionals presented an
appreciation for the potential benets of nature in enhancing quality of life for patient’
health, and even in their own personal health. Our ndings suggest that health care
departments view themselves as part of a series of partnerships that would be necessary
to encourage and sustain outdoor behaviors. They demonstrated a depth of understanding
regarding the complexity of barriers facing their patients in experiencing the health
benets of parks and other green space. Rather than thinking of partnerships between
health and park departments as a matter of simple referrals (or a park prescription), they
made suggestions for in-depth partnerships with park agencies and CBOs and encouraged
a feedback loop between agencies. Future research can further explore mechanisms for
health professionals to share relevant health information with park agencies, and for park
administrators to give feedback about patients to health professionals.
This study is the rst to create a framework for increasing access to nature specically
through park use via health departments. Our qualitative ndings suggest that public health
professionals will value partnerships that address and deal with the root causes of nature
deciency. We surmise that public health professionals view access to nature as a social
determinant of health, and come to the table with with an understanding that broader social
and economic issues need to be dealt with before, or parallel to, clinical interventions.
Participants expressed interest in not only improved health but equity in the distribution
of greenspace as long-term outcomes. The fact that equity in access to nature was a priority
in our sample of public health staff is consistent with national ndings that disparities in
health mirror access to nature (Dahmann, Wolch, Joassart-Marcelli, Reynolds, & Jerrett,
2010). Our study suggests that the public health community, at least in San Francisco,
could see itself as allied to those in the environmental justice movement who advocate
for increased equity in resource distribution regarding nature. Future research should
investigate whether increasing equity of such distribution is, in itself, a public health
intervention. The cost effectiveness of partnerships to reinforce patient behavior through
case management could be compared with increasing equity in access to greenspace as a
public health intervention.
The health care professionals surveyed also considered environmental stewardship as
a long-term outcome to their efforts. It is possible that public health departments will be
willing to advocate for the importance of park departments in ways other than providing
patient referrals—for example, in helping draft legislation on the importance of nature for
health. An important area of future research will be to understand whether there is common
language between parks and health agencies around health equity and what their collective
impacts are or could be.
Limitations of this study include the fact that one county was sampled, and that the
largest group of respondents were public health nurses, although they played a variety of
roles in the health department. The small sample size limited our ability to explore how
the various factors correlate and interact in the quantitative section. However, the sample
size was adequate to generate depth and variety in qualitative data. Parks are not the only
kind of nature to which low-income populations have access and, in the future, it will be
benecial to include community gardens and other types of settings in the discussion.
Despite these limitations, the strengths of this work are reected in the representation
of an array of opinions of public health employees in a large metropolitan public health
department. It is also timely in that health and park agency partnerships are becoming more
prevalent and increasing both in this metropolitan area and around the nation.
This study may be the rst of its kind to delineate the role public health departments
have in promoting health by using nature in low income populations. Our ndings

65
provide ample guidance on how to continue moving toward APHA’s call to improve
health and wellness through access to nature and insight into what gaps remain in our
current understanding of how public health can increase this access as well as enhance
greater comfort outdoors overall. Using health professionals’ own words, opportunities
are described to introduce the importance of nature across multiple contexts in any given
community of interest.
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