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Design and evaluation of a park prescription program for stress reduction and health promotion in low-income families: The Stay Healthy in Nature Everyday (SHINE) study protocol

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... One approach currently gaining popularity is "park prescriptions", defined here as programs where clinicians prescribe or recommend park visits to encourage healthy, active living. In practice, these programs range from providers printing out maps of local parks [5], to partnerships with existing park programs [6], to health care providers leading park outings with patients [7]. ...
... As such, we had the opportunity to extend health behavior theory to the concept of time spent in parks/nature to set the stage for effective clinical programs to encourage healthy living through time in the outdoors. We designed our park prescription program using the Precaution Adoption Process Model (PAPM) health behavior theory (detailed elsewhere and presented in simplified form in Figure 1) [7], which proposes that healthy behavior change occurs in stages. By recommending that children spend more time outdoors through a park prescription from their doctor, the program brings the role of parks in improving heath into the awareness of children and their parents and reinforces knowledge and attitudes with the aim of encouraging behavior change. ...
... This is a secondary data analysis of pooled data from a clinical trial that prescribed park visits to children and their caregivers in a low-income, urban setting and has been described in detail elsewhere, including power and sample size calculations [7,11,12]. Patients (children ages [4][5][6][7][8][9][10][11][12][13][14][15][16][17] and one caregiver at a Federally Qualified Health Center in Oakland, California, were eligible for enrollment if they were not enrolled in a weight loss or exercise program, were able to walk and be physically active, and were available for the park outings and two follow-up visits over three months. Most of the patients were seeing their pediatrician for well-child visits, which are defined as routine doctor visits for comprehensive preventive health services; some patients were being seen for urgent care or sick visits. ...
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We conducted secondary data analyses of pooled data from a clinical trial that prescribed park visits to children and their caregivers in a low-income, urban setting. Data were collected at the prescribing visit (baseline) and at one and three months of follow up from 78 families. Family characteristics were identified at baseline; regression models were used to explore changes during follow up in associations of park use with knowledge, attitudes and perceived access to parks. At baseline, park users differed from non-users in demographics, knowledge of park locations, attitudes about the value of park visits, but not affinity for nature. Park users were also more likely than non-users to feel that their neighborhood was safe for children to play in. Changes in knowledge of park locations, nature affinity, and perceived access to parks were each significantly associated with increased park use by families at one and three months after the park prescription. Adjusting for age, gender, race, poverty, and US birth, increases in knowing the location of parks were associated with an increase of 0.27 weekly park visits (95% CI 0.05, 0.49; p = 0.016); increases in feeling a caregiver had money to visit parks were associated with 0.48 more weekly park visits (95% CI 0.28, 0.69; p < 0.001); increases in perceived money for park outings were associated with 0.24 increased park visits per week (95% CI 0.05, 0.42; p = 0.01); each unit increase in nature affinity was associated with 0.34 more weekly park visits (95% CI 0.09, 0.59; p = 0.007). In other words, knowing where to go, valuing nature, and having time, and money contributed to increased likelihood of visiting a park. We discuss in terms of health behavior theory how demographics, knowledge, attitudes and perceived barriers to park use can inform park prescription interventions.
... We found 11 papers that met our inclusion criteria, including one case study [34], two research protocols or study designs [35,36], and eight empirical studies [37][38][39][40][41][42][43][44]. Two of the papers communicate research design [35] and results [44] of the same study. ...
... We found 11 papers that met our inclusion criteria, including one case study [34], two research protocols or study designs [35,36], and eight empirical studies [37][38][39][40][41][42][43][44]. Two of the papers communicate research design [35] and results [44] of the same study. From these papers, we found documented nature prescription definitions, shown in Table 1. ...
... Razani et al. [35,44] Zarr et al. [43] Patients receive education about local outdoor resources, and a prescription for outdoor physical activity ...
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Nature prescription programs have emerged to address the high burden of chronic disease and increasingly sedentary and screen-based lifestyles. This study examines the base of evidence regarding such programs. We conducted a narrative review of published literature using four electronic databases. We included case studies, research design articles, and empirical studies that discussed any type of outdoor exposure or activities initiated by a health-care provider from an outpatient clinic. We examined articles for information on target populations, health outcomes, and structural and procedural elements. We also summarized evidence of the effectiveness of nature prescription programs, and discussed needs and challenges for both practice and research. Eleven studies, including eight empirical studies, have evaluated nature prescription programs with either structured or unstructured formats, referring patients either to nearby parks or to formal outdoor activity programs. Empirical studies evaluate a wide variety of health behaviors and outcomes among the most at-risk children and families. Research is too sparse to draw patterns in health outcome responses. Studies largely tested program structures to increase adherence, or patient follow-through, however findings were mixed. Three published studies explore providers' perspectives. More research is necessary to understand how to measure and increase patient adherence, short and long-term health outcomes for patients and their families, and determinants of provider participation and participation impacts on providers' own health.
... Parent-child pairs were excluded if either was concurrently enrolled in a weight loss or exercise program, unable to walk or be physically active, or unavailable for the park outings and two follow-up visits over three months. The study was designed to measure stress in adult parents of children accessing a pediatric safety-net hospital, and the sample size was calculated to detect a difference in parental stress measured by the PSS10 instrument [28]. A detailed description of the sample size calculation and rationale for enrollment of both parent and child have been published in a previous publication of the SHINE study methods [28]. ...
... The study was designed to measure stress in adult parents of children accessing a pediatric safety-net hospital, and the sample size was calculated to detect a difference in parental stress measured by the PSS10 instrument [28]. A detailed description of the sample size calculation and rationale for enrollment of both parent and child have been published in a previous publication of the SHINE study methods [28]. Here we present findings from adult participants; a secondary data analysis of pediatric and dyad data will be presented separately. ...
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Introduction Exposure to nature may reduce stress in low-income parents. This prospective randomized trial compares the effect of a physician’s counseling about nature with or without facilitated group outings on stress and other outcomes among low-income parents. Materials and methods Parents of patients aged 4–18 years at a clinic serving low-income families were randomized to a supported park prescription versus independent park prescription in a 2:1 ratio. Parents in both groups received physician counseling about nature, maps of local parks, a journal, and pedometer. The supported group received additional phone and text reminders to attend three weekly family nature outings with free transportation, food, and programming. Outcomes measured in parents at baseline, one month and three months post-enrollment included: stress (using the 40-point Perceived Stress Scale [PSS10]); park visits per week (self-report and journaling); loneliness (modified UCLA-Loneliness Scale); physical activity (self-report, journaling, pedometry); physiologic stress (salivary cortisol); and nature affinity (validated scale). Results We enrolled 78 parents, 50 in the supported and 28 in the independent group. One-month follow-up was available for 60 (77%) participants and three-month follow up for 65 (83%). Overall stress decreased by 1.71 points (95% CI, -3.15, -0.26). The improvement in stress did not differ significantly by group assignment, although the independent group had more park visits per week (mean difference 1.75; 95% CI [0.46, 3.04], p = 0.0085). In multivariable analysis, each unit increase in park visits per week was associated with a significant and incremental decrease in stress (change in PSS10–0.53; 95% CI [-0.89, -0.16]; p = 0.005) at three months. Conclusion While we were unable to demonstrate the additional benefit of group park visits, we observed an overall decrease in parental stress both overall and as a function of numbers of park visits per week. Paradoxically the park prescription without group park visits led to a greater increase in weekly park visits than the group visits. To understand the benefits of this intervention, larger trials are needed. Trial registration ClinicalTrials.gov NCT02623855
... Park prescription also incorporates the concept of exercise prescription, which has been found to increase PA levels among inactive patients [22][23][24][25]. Whilst there have been studies of prescribing PA in parks [26,27], including one randomized-controlled trial (RCT) among parents of children with a high rate of chronic conditions, to our knowledge no RCT has provided evidence for this kind of intervention in the general population [28,29]. ...
... Considering the increasing interest in park prescription programs in many countries, findings from this RCT provide important new evidence. To our knowledge, the only other RCT of a PPI was conducted by Razani and colleagues [28,29] among low income families with parents and children who were clinic patients and had high rates of chronic illness. The study reported significant improvements in stress levels among parents after 3 months. ...
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Background: Programs promoting population health through physical activity (PA) and exposure to nature are popular, but few have been evaluated in randomized-controlled trials (RCTs). Objective: To investigate the effectiveness of a park prescription intervention (PPI) for improving total moderate-to-vigorous PA (MVPA), other PA related behaviors, quality of life (QoL) and cardio-metabolic health among adults. Methods: Healthy individuals aged 40 to 65 years were recruited through community health screenings and randomly assigned to 1) PPI: face-to-face Park Prescription + invitation to weekly exercise sessions in parks, or 2) control: standard PA materials. After the six-month intervention, participants completed accelerometer assessments, questionnaires on health behaviors and QoL, and health screenings. Independent sample t-tests were used to compare outcomes between groups, with secondary analysis adjusted for co-variates via multiple linear regression. A p-value <0.05 was considered statistically significant. Results: Eighty participants were allocated to each group. Participants with mean age of 51.1 (Standard Deviation: 6.3) years were predominantly female (79%) and of Chinese ethnicity (81%). Participation in the group exercise started at 48% and declined to 24% by week 26. At six-months, 145 (91%) participants attended health screenings for outcome measure collection, and 126 (79%) provided valid accelerometer data. Time spent in MVPA favored the PPI group but this difference was not statistically significant (4.4 (- 43.8, 52.7) minutes/week; when removing 2 extreme outliers 26.8 (- 9.7, 63.4) minutes/week). Time spent in parks (147.5 (2.1, 292.9) minutes/month), PA in parks (192.5 (59.5, 325.5) minutes/month), and recreational PA (48.7 (1.4, 96.0) minutes/week) were significantly greater in the PPI group. PPI also significantly improved psychological QoL (4.0 (0.0, 8.0). Discussion: PPI improved park use, PA in parks, recreational PA, and psychological QoL but not total MVPA. Future RCTs' are warranted to investigate PPI in different target populations and to provide further evidence for improvements in health outcomes. Trial registration: ClinicalTrials.gov NCT02615392, 26 November 2015.
... The research described in this review covers the theoretical basis and empirical evidence for establishing a green-outdoors bent to social prescribing, which includes reviews of park prescription programs [46], group hiking prescriptions [47], farmers' market prescriptions [48], "Walk with a Doc" programs (https://walkwithadoc.org/), and exercise referral programs [49][50][51]. ...
... There is an emerging evidence base suggesting that naturebased social prescribing and other related referral schemes providing promising avenues to promote social connection as an antidote to social isolation and loneliness. However, the field could benefit from more quantitative investigations that employ experimental study designs [38,46,77,114] with larger sample sizes [24•], use valid and reliable outcome measures, include control groups, and use inferential statistics [38]. Moreover, there is a need to evaluate the range of interventions across different demographic and social groups to understand the uptake of the intervention by high-risk populations [115]. ...
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Purpose of Review Recent reports of a “loneliness epidemic” in the USA are growing along with a robust evidence base that suggests that loneliness and social isolation can compromise physical and psychological health. Screening for social isolation among at-risk populations and referring them to nature-based community services, resources, and activities through a social prescribing (SP) program may provide a way to connect vulnerable populations with the broader community and increase their sense of connectedness and belonging. In this review, we explore opportunities for social prescribing to be used as a tool to address connectedness through nature-based interventions. Recent Findings Social prescribing can include a variety of activities linked with voluntary and community sector organizations (e.g., walking and park prescriptions, community gardening, farmers’ market vouchers). These activities can promote nature contact, strengthen social structures, and improve longer term mental and physical health by activating intrapersonal, interpersonal, and environmental processes. The prescriptions are appropriate for reaching a range of high-risk populations including moms who are minors who are minors, recent immigrants, older adults, economically and linguistically isolated populations, and unlikely users of nature and outdoor spaces. Summary More research is needed to understand the impact of SPs on high-risk populations and the supports needed to allow them to feel at ease in the outdoors. Additionally, opportunities exist to develop technologically and socially innovative strategies to track patient participation in social prescriptions, monitor impact over time, and integrate prescribing into standard health care practice.
... The clinical trial data for parental outcomes such as stress have been published elsewhere (Razani et al., 2018). A detailed description of the sample size calculation and rationale for enrollment of both parent and child have been published in a previous publication of the study methods (Razani et al., 2016). Here we present data from the primary outcomes measured in children, resilience. ...
... After baseline data were gathered, each family met with a pediatrician who provided a map of local parks and prescribed park visits for the purpose of "being in nature" three times a week (Razani et al., 2016). All enrollees received counseling regarding the potential health benefits of time in nature which included: "1. ...
... Only three of the studies were noted as randomised trials. [101][102][103] In relation to effectiveness, only 6 of the 14 intervention studies showed reductions in loneliness. Interventions that reduced or showed promise of reducing loneliness involved home visiting peer support, telehealth involving e-meeting forum with HCP and peers, universally provided child development parenting programme, interpersonal skills training and short-term cognitive therapy. ...
Article
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Aims: Chronic loneliness is experienced by around a third of parents, but there is no comprehensive review into how, why and which parents experience loneliness. This scoping review aimed to provide insight into what is already known about parental loneliness and give directions for further applied and methodological research. Methods: Searches for peer-reviewed articles were undertaken in six databases: PsycINFO, Medline, CINAHL, Embase, Web of Science and Scopus, during May 2019 to February 2020. We searched for English studies which examined loneliness experienced during parenthood, including studies that involved parents with children under 16 years and living at home and excluding studies on pregnancy, childbirth or postbirth hospital care. Results: From 2566 studies retrieved, 133 were included for analysis. Most studies (n = 80) examined the experience of loneliness in specific groups of parents, for example, teenage parents, parents of a disabled child. Other studies examined theoretical issues (n = 6) or health and wellbeing impacts on parents (n = 16) and their offspring (n = 17). There were 14 intervention studies with parents that measured loneliness as an outcome. Insights indicate that parental loneliness may be different to loneliness experienced in other cohorts. There is evidence that parental loneliness has direct and intergenerational impacts on parent and child mental health. Some parents (e.g. with children with chronic illness or disability, immigrant or ethnic minority parents) also appear to be at increased risk of loneliness although evidence is not conclusive. Conclusion: This work has identified key gaps with further international, comparative and conceptual research needed.
... This may require provision of programs or guided activities, and incentives. The impact of offering these kinds of supports has been shown to be effective at ensuring adherence and improving health in longitudinal cohort studies [17,61,62]. These findings align with those of a previous study of resident perceptions of parks to inform a new park prescription program [54]. ...
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Health benefits have been linked to spending time outdoors in nature and green space. However, there is some evidence of inequities to accessing safe outdoor space, particularly in low-resource communities. The primary aim of this study is to assess attitudes towards nature and use of green space in urban areas. A secondary aim is to describe perceptions of physician-initiated nature prescriptions that target local pediatric populations. We conducted six focus group interviews with 42 residents who were guardians or caretakers of children living in low-resource neighborhoods in Philadelphia, PA. We analyzed interview data using a conventional content analysis approach. Three major themes emerged: (1) perceived benefits of being in nature (physical and mental health benefits), (2) barriers to time spent in nature (unsafe and undesirable conditions of local parks), and (3) desired features of outdoor green spaces (amenities that would increase park use). Additionally, we describe participants’ reactions to the idea of a pediatrician-delivered prescription for outdoor green space exposure for a child in their care. Adherence to nature prescriptions programs may hinge on local green space resources, as well as experiential and perceptual barriers and facilitators to nature and park accessibility among caregivers tasked with fulfilling a nature prescription for a child in their care.
... A study investigating pedometer's accuracy according to their position worn at various walking speeds showed that at all positions, pedometers generated significant errors at slow speeds and therefore cannot be used reliably to evaluate the amount of physical activity for people walking slower than 0.6 m/s (2.16 km/h, or 1.24 mph) [15]. Regardless of that, pedometers are used in many areas such as primary care [16] increasing physical activity and stress management [17,18] decreasing cardiovascular risk factors [19] and adolescents [20]. RT6 and pedometer results were not found significantly correlated in our study. ...
... Similar to other studies investigating the link between the environment and stress, salivary cortisol was used to measure stress levels. While some studies have used Alpha-amylase (Razani et al., 2016) or both Alpha-amylase and cortisol (Beil & Hanes, 2013), salivary cortisol is the primary biomarker for measuring physiological stress (El-Farhan, Rees,&Evans,2017)andismoreresilienttoambienttemperaturefluctuations prior to analysis. Additionally, it can be stored at room temperature for three weekswithoutsignificantreductionsinmeasuredcortisol (Djuricetal.,2008). ...
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One of the primary goals of the Healthy Parks Healthy People (HPHP) program, located in the San Francisco Bay Area, is to offer group-based physical activities in natural settings. These activities are for racially and ethnically diverse groups of individuals as an “upstream” strategy for improving health. This study investigated the health impact of selected two-hour HPHP Bay Area events that targeted low-income racial and ethnic minority groups using physiological and self-reported measures of stress and related variables. Study participants (N = 52) in the selected HPHP Bay Area events donated saliva and filled out psychological measures of perceived stress (PSS-4; Cohen et al.) and mood state (I-PANAS-SF; Thompson, 2007) at the beginning and the end of a two-hour guided walk in green spaces. Moreover, a measure of perceived restoration (SRRS; Han, 2007) was completed at the end of the walk. Study participants wore a physical activity self-monitoring device (Garmin Vivofit 2) to capture their step count and heart rate during the event. Stress, both measured by the analysis of salivary cortisol and self-reported perceived stress, significantly decreased over the course of the event (p
... Study protocols are common in the public health, with examples of some that bridge with urban design (e.g. Chapman et al. 2014) and include how theory underpinned design (Razani et al. 2016). Published protocols should then be referred to in all subsequent published accounts, thus avoiding the need to fully summarise this information further. ...
Article
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Built environment restructuring can improve public health through increased opportunity for healthy behaviors. Behavioral science targets individual health behaviors within place, suggesting the potential to integrate these approaches. This scoping review was one of the first to summarise the impact built environment restructuring has on health outcomes and behaviors and integrate these findings with the Capability-Opportunity-Motivation-Behavior model and Theoretical Domains Framework of behavior change. Potential studies were identified from 12 academic databases in urban design, psychology and public health. Search parameters involved 50 environment types, for example green space or healthy cities, combined with both an intervention (e.g. green infrastructure, active transport) and a measurable health outcome (e.g. exercise, wellbeing). Searches were limited to North America, Europe, or Australia/New Zealand. Of 536 potential studies reviewed against defined inclusion/exclusion criteria, 23 contributed to the findings. Evidence supported the positive influence of restructuring on varied health outcomes, many of which were drivers and domains of health behavior. Most studies indicated a clear contribution to increased physical activity. Recommendations include the need for explicit communication of theories guiding restructuring project design, consideration of health outcomes beyond physical activity, and better investigation of unanticipated barriers to health behaviors arising from built environment restructuring projects.
... The CNI was found to be the most preferred measure, by the children who took part in the study (Bragg et al., 2013). These measures have since been used in several studies evaluating outdoor learning and other environmental education programmes (Crawford, Holder & O'Connor, 2017;Razani et al., 2016;San Jose & Nelson, 2017). Sobko, Jia and Brown (2018), acknowledging the need for measuring nature connectedness in young children devised a parental report measure, based on the CNI (Cheng & Monroe, 2012). ...
Article
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The importance of young children learning about the natural environment has been recognised in policy and curricular frameworks around the world. Moreover, there has been a call for children to spend more time outdoors and to reconnect with nature. However, the distinct construct of nature connectedness has not been examined in detail in relation to early childhood education. This article aims to bring together environmental psychology literature and early years' policy in an attempt to make the case for nature connectedness becoming a distinct goal in early childhood curricular frameworks. Furthermore, it aims to highlight gaps in the research literature and offer clear directions for future research.
... For example, an intervention study conducted in California in 2012 incorporated a "prescription" for caregivers and children from a pediatric primary care FQHC to spend time in a public park; the program used behavioral counseling to decrease caregiver stress, improve family members' physical activity, and increase awareness about the health benefits of nature. 29 ...
... Based on these findings, public health providers have advocated for prescribing nature as an alternative to other preventive and treatment options for promoting mental health (Charles, 2017;Jordan, 2015). A pioneering study evaluated park prescriptions in formal recommendations made by physicians and established screening and assessment protocols (Razani et al., 2016). However, many details regarding the optimal nature exposure are unknown (Frumkin, 2013;Sullivan, Frumkin, Jackson, & Chang, 2014), which hinder the application and evaluation of park prescriptions. ...
Article
Healthy aging is a global health priority. Urban parks and green space have been demonstrated to provide mental health benefits to older adults. Despite growing interest in prescribing nature and park visits by physicians, we do not know what type of park visit is most effective for the psychological benefits. This lack of knowledge prevents planners and designers from making informed decisions to promote mental health. We collected field data from 200 visitors from 15 different parks in Shanghai, China. The participants completed pre-visit and post-visit surveys, wearing a GPS and a pedometer while visiting the park. A multilevel latent class analysis (LCA) yielded a three-class structure of park use patterns: the active park lingerer, the active walker, and the passive scanner. Paired-sample t-test and ANCOVA tests showed that affective states (i.e., anxiety, depression, relaxation, contention) were enhanced after park visits for all subtypes. However, the active park lingerer displayed significantly higher levels of relaxation and contention, compared to the active walker and the passive scanner. The findings offer insights into park design characteristics that could promote the mental health of older adults.
... Intervention process evaluations can help to understand which components worked, which didn't and why by exploring the mechanisms of impact of the intervention on outcomes [22]. Although studies prescribing park PA have been published [11,[23][24][25][26], to our knowledge no process evaluations to understand the mechanisms of impact of such interventions exist in peer-reviewed scientific journals. The Medical Research Council guidance on process evaluation [22,27] outlines three functions to be describedimplementation (process, reach, dose, satisfaction, fidelity); mechanisms of impact (participants' responses to and interaction with the intervention, mediators, unexpected pathways); and, context. ...
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Background This process evaluation explored the implementation and mechanisms of impact of a Park Prescription Intervention trial (PPI), including the effects of hypothesised mediators (motivation, social support, recreational physical activity [PA], park use and park PA) on trial outcomes. Methods Participants from the community were randomly allocated to intervention (n = 80) or control (n = 80) group. The intervention included baseline counselling, a prescription of exercise in parks, materials, three-month follow-up counselling and 26 weekly group exercise sessions in parks. Process evaluation indicators were assessed at three- and six-months. Implementation indicators included participation rates in intervention components and survey questions plus focus group discussions (FGDs) to understand which components participants valued. FGDs further assessed barriers and facilitators to intervention participation. To explore mechanisms of impact, linear regression was used to compare objectively measured PA between quantiles of group exercise participation. Structural equation modelling (SEM) explored hypothesised mediation of the significant intervention effects. Framework analysis was conducted for FGDs. Results Participants were middle-aged (mean 51, SD ± 6.3 years), predominantly female (79%) and of Chinese ethnicity (81%). All intervention participants received baseline counselling, the park prescription and materials, whilst 94% received the follow-up counselling. Mean minutes of moderate-to-vigorous PA/week (95% CI) differed by group exercise participation (p = 0.018): 0% participation (n = 18) 128.3 (69.3, 187.2) minutes, > 0–35.9% participation (n = 18) 100.3 (36.9, 163.6) minutes, > 35.9–67.9% participation (n = 17) 50.5 (− 4.9, 105.9) minutes and > 67.9% participation (n = 18) 177.4 (122.0, 232.8) minutes. Park PA at three-months had significant mediating effects (95% CI) on recreational PA 26.50 (6.65, 49.37) minutes/week, park use 185.38 (45.40, 353.74) minutes/month, park PA/month 165.48 (33.14, 334.16) minutes and psychological quality of life score 1.25 (0.19, 2.69) at six-months. Prioritising time with family and preferences for unstructured activities were barriers to intervention participation. Human interaction via follow-up or group exercise were facilitators. Conclusion This process evaluation showed park PA consistently mediated effects of the PPI, suggesting activity in parks was a mechanism of its effects. To optimise effectiveness, participants’ preference for prioritising time with family through family involvement and tailoring the intervention to participants’ preferences for structured or unstructured PA could be considered in future studies. Trial registration ClinicalTrials.gov NCT02615392, 26 November 2015.
... Walking or spending time in greenspace can be cost effective way to improve mental wellness, thus in addition to reducing stress, anxiety, and improving mood for those experiencing the wear and tear of everyday life, physical activity in greenspace may also provide an important adjunct therapy to clinical therapies [12,[101][102][103][104][105]. These results support the development of evidence-based recommendations for Nature Rx to encourage people to be physically active in nature [106][107][108][109]. ...
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Although the health benefits of exercise and exposure to nature are well established, most evidence of their interaction comes from acute observations of single sessions of activity. However, documenting improved health outcomes requires ongoing interventions, measurement of multiple outcomes, and longitudinal analyses. We conducted a pilot study to guide the development of a protocol for future longitudinal studies that would assess multiple physiological and psychological outcomes. Herein, we report psychological outcomes measured from thirty-eight participants before and after three conditions: a 50 min walk on a forest path, a 50 min walk along a busy road, and a period of activities of daily living. Changes in positive and negative affect, anxiety, perceived stress, and working memory are reported. We benchmark these results to existing studies that used similar protocols and also identify elements of the protocol that might impair recruitment or retention of subjects in longer-term studies. Linear mixed-models regression revealed that walking improved psychological state when compared to activities of daily living, regardless of walk environment (p < 0.05). Comparison of mean differences showed that forest walks yielded the largest and most consistent improvements in psychological state. Thus, despite a protocol that required a 3.5 h time commitment per laboratory visit, the beneficial effects of walking and exposure to a forested environment were observed.
... It is widely accepted that greenspaces have an important role to play-ecologically and socially-in supporting personal, community and planetary health [68][69][70][71]. Furthermore, greenspaces are a fundamental resource (e.g., the archetypal setting) for GRx activities [72][73][74][75]. The significant association between greenspace presence and abundance within a 100 and 250 m radius of GP surgeries and the likelihood of providing green prescriptions was an interesting finding. ...
Article
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Prescribing nature-based health interventions (green prescribing)-such as therapeutic horticulture or conservation activities-is an emerging transdisciplinary strategy focussed on reducing noncommunicable diseases. However, little is known about the practice of, and socioecological constraints/opportunities associated with, green prescribing in the UK. Furthermore, the distribution of green prescribing has yet to be comprehensively mapped. In this study, we conducted a socioecological exploration of green prescribing. We deployed online questionnaires to collect data from general practitioners (GPs) and nature-based organisations (NBOs) around the UK and conducted spatial analyses. Our results indicate that GPs and NBOs perceive and express some common and distinct constraints to green prescribing. This highlights the need to promote cross-disciplinary communication pathways. Greenspace presence and abundance within close proximity (100 and 250 m) to GP surgeries (but not greenness-as a proxy for vegetation cover) and NBO presence within 5 km were associated with higher levels of green prescribing provision. Lower levels of deprivation were associated with higher frequency of NBOs. This suggests that the availability of greenspaces and NBOs could be important for green prescribing provision, but there could be greater opportunities in less deprived areas. Important foci for future research should be to establish transdisciplinary collaborative pathways, efficient infrastructure management and a common vocabulary in green prescribing-with the overall aim of reducing inequalities and enhancing planetary health.
... Currently underway are a few such interventions that integrate primary care providers. In these programs, a physician's recommendation to visit parks to be active and experience nature are combined with intervention components like behavioral counseling and environmental education [70][71][72]. In addition, low-cost park-based physical activity interventions hold promise for augmenting or expanding the reach of mental health promotion beyond traditional community mental health services, particularly in low-income communities where access to mental healthcare for psychiatric medications and psychotherapy may be limited. ...
Article
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Increasing global urbanization limits interaction between people and natural environments, which may negatively impact population health and wellbeing. Urban residents who live near parks report better mental health. Physical activity (PA) reduces depression and improves quality of life. Despite PA's protective effects on mental health, the added benefit of urban park use for PA is unclear. Thus, we examined whether park-based PA mediated associations between park proximity and mental distress among 3652 New York City residents (61.4% 45 + years, 58.9% female, 56.3% non-white) who completed the 2010-2011 Physical Activity and Transit (PAT) random-digit-dial survey. Measures included number of poor mental health days in the previous month (outcome), self-reported time to walk to the nearest park from home (exposure), and frequency of park use for sports, exercise or PA (mediator). We used multiple regression with bootstrap-generated 95% bias-corrected confidence intervals (BC CIs) to test for mediation by park-based PA and moderation by gender, dog ownership, PA with others, and perceived park crime. Park proximity was indirectly associated with fewer days of poor mental health via park-based PA, but only among those not concerned about park crime (index of moderated mediation = 0.04; SE = 0.02; 95% BC CI = 0.01, 0.10). Investment in park safety and park-based PA promotion in urban neighborhoods may help to maximize the mental health benefits of nearby parks.
... 19,[42][43][44] Not surprisingly, ParkRx interventions are gaining national attention 45,46 and multiple randomized control trials are currently in progress. [47][48][49] Despite the clinical and cost effectiveness of prescribing PA for chronic disease prevention, patient counseling on PA remains underutilized. 50,51 For example, one study found that PA counseling occurred in <30% of patient visits. ...
Article
Background: Health care providers (HCPs) promoting physical activity (PA) through programs such as Park Prescriptions (ParkRx) are gaining momentum. However, it is difficult to realize provider PA practices and program interest, and differences in program success exist by provider type (eg, primary vs secondary). This study explored HCPs' (1) PA counseling practices, (2) knowledge/interest in ParkRx, (3) barriers and resources needed to implement PA counseling and ParkRx programs, and (4) differences in primary versus secondary HCPs. Methods: An e-survey administered in Spring/Summer 2018 to HCPs in 3 states examined study objectives. Results: Respondents (n = 278) were mostly primary (58.3%) HCPs. The majority asked about patient PA habits and offered PA counseling (mean = 5.0, SD = 1.5; mean = 4.8, SD = 1.5), but few provided written prescriptions (mean = 2.5, SD = 1.6). Providers were satisfied with their PA counseling knowledge (mean = 3.8, SD = 1.0) but not with prescribing practices (mean = 3.2, SD = 1.1). Secondary HCPs placed higher importance (P = .012) and provided significantly more written PA prescriptions (P = .005). Time was a common barrier to prescribing PA (mean = 3.4, SD = 1.2), though more so for primary HCPs (P = .000). Although few HCPs knew about ParkRx programs, 81.6% expressed interest. Access to park information and community partnerships was an important resource for program implementation. Conclusions: HCPs underutilize PA prescriptions. Despite little awareness, HCPs were interested in ParkRx programs.
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Data collection and analysis: Two authors independently extracted data, assessed risk-of-bias and evaluated overall certainty of the evidence using GRADE. We extracted data on adiposity outcomes, sociodemographic characteristics, adverse events, intervention process and costs. We meta-analysed data as guided by the Cochrane Handbook for Systematic Reviews of Interventions and presented separate meta-analyses by age group for child 0 to 5 years, 6 to 12 years, and 13 to 18 years for zBMI and BMI. Main results: We included 153 RCTs, mostly from the USA or Europe. Thirteen studies were based in upper-middle-income countries (UMIC: Brazil, Ecuador, Lebanon, Mexico, Thailand, Turkey, US-Mexico border), and one was based in a lower middle-income country (LMIC: Egypt). The majority (85) targeted children aged 6 to 12 years.Children aged 0-5 years: There is moderate-certainty evidence from 16 RCTs (n = 6261) that diet combined with physical activity interventions, compared with control, reduced BMI (mean difference (MD) -0.07 kg/m2, 95% confidence interval (CI) -0.14 to -0.01), and had a similar effect (11 RCTs, n = 5536) on zBMI (MD -0.11, 95% CI -0.21 to 0.01). Neither diet (moderate-certainty evidence) nor physical activity interventions alone (high-certainty evidence) compared with control reduced BMI (physical activity alone: MD -0.22 kg/m2, 95% CI -0.44 to 0.01) or zBMI (diet alone: MD -0.14, 95% CI -0.32 to 0.04; physical activity alone: MD 0.01, 95% CI -0.10 to 0.13) in children aged 0-5 years.Children aged 6 to 12 years: There is moderate-certainty evidence from 14 RCTs (n = 16,410) that physical activity interventions, compared with control, reduced BMI (MD -0.10 kg/m2, 95% CI -0.14 to -0.05). However, there is moderate-certainty evidence that they had little or no effect on zBMI (MD -0.02, 95% CI -0.06 to 0.02). There is low-certainty evidence from 20 RCTs (n = 24,043) that diet combined with physical activity interventions, compared with control, reduced zBMI (MD -0.05 kg/m2, 95% CI -0.10 to -0.01). There is high-certainty evidence that diet interventions, compared with control, had little impact on zBMI (MD -0.03, 95% CI -0.06 to 0.01) or BMI (-0.02 kg/m2, 95% CI -0.11 to 0.06).Children aged 13 to 18 years: There is very low-certainty evidence that physical activity interventions, compared with control reduced BMI (MD -1.53 kg/m2, 95% CI -2.67 to -0.39; 4 RCTs; n = 720); and low-certainty evidence for a reduction in zBMI (MD -0.2, 95% CI -0.3 to -0.1; 1 RCT; n = 100). There is low-certainty evidence from eight RCTs (n = 16,583) that diet combined with physical activity interventions, compared with control, had no effect on BMI (MD -0.02 kg/m2, 95% CI -0.10 to 0.05); or zBMI (MD 0.01, 95% CI -0.05 to 0.07; 6 RCTs; n = 16,543). Evidence from two RCTs (low-certainty evidence; n = 294) found no effect of diet interventions on BMI.Direct comparisons of interventions: Two RCTs reported data directly comparing diet with either physical activity or diet combined with physical activity interventions for children aged 6 to 12 years and reported no differences.Heterogeneity was apparent in the results from all three age groups, which could not be entirely explained by setting or duration of the interventions. Where reported, interventions did not appear to result in adverse effects (16 RCTs) or increase health inequalities (gender: 30 RCTs; socioeconomic status: 18 RCTs), although relatively few studies examined these factors.Re-running the searches in January 2018 identified 315 records with potential relevance to this review, which will be synthesised in the next update. Authors' conclusions: Interventions that include diet combined with physical activity interventions can reduce the risk of obesity (zBMI and BMI) in young children aged 0 to 5 years. There is weaker evidence from a single study that dietary interventions may be beneficial.However, interventions that focus only on physical activity do not appear to be effective in children of this age. In contrast, interventions that only focus on physical activity can reduce the risk of obesity (BMI) in children aged 6 to 12 years, and adolescents aged 13 to 18 years. In these age groups, there is no evidence that interventions that only focus on diet are effective, and some evidence that diet combined with physical activity interventions may be effective. Importantly, this updated review also suggests that interventions to prevent childhood obesity do not appear to result in adverse effects or health inequalities.The review will not be updated in its current form. To manage the growth in RCTs of child obesity prevention interventions, in future, this review will be split into three separate reviews based on child age.
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This report presents the development, plan, and operation of the 2007 National Survey of Children's Health, a module of the State and Local Area Integrated Telephone Survey, conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics. This survey was designed to produce national and state-specific prevalence estimates for a variety of physical, emotional, and behavioral health indicators and measures of children's experiences with the health care system. The survey also includes questions about the family (for example, parents' health status, stress and coping behaviors, family activities) and about respondents' perceptions of the neighborhoods where their children live. Funding and direction for this survey was provided by the Maternal and Child Health Bureau of the Health Resources and Services Administration. A random-digit-dialed sample of households with children under age 18 years was selected from each of the 50 states and the District of Columbia. One child was randomly selected from all children in each identified household to be the subject of the survey. The respondent was a parent or guardian who knew about the child's health and health care. A total of 91,642 interviews were completed from April 2007 to July 2008. Nearly 80% of the interviews were completed in 2007. Interviews were completed in 66.0% of identified households with children. The weighted overall response rate was 46.7%. A data file has been released that contains demographic information on the selected child, substantive health and well-being data for the child and his or her family, and sampling weights. Estimates based on the sampling weights generalize to the noninstitutionalized population of children in each state and nationwide.
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This study explored whether social contacts are an underlying mechanism behind the relationship between green space and health. We measured social contacts and health in 10,089 residents of the Netherlands and calculated the percentage of green within 1 and a 3km radius around the postal code coordinates for each individual's address. After adjustment for socio-economic and demographic characteristics, less green space in people's living environment coincided with feelings of loneliness and with perceived shortage of social support. Loneliness and perceived shortage of social support partly mediated the relation between green space and health.
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Studies have shown that exposure to the natural environment, or so-called green space, has an independent effect on health and health-related behaviours. We postulated that income-related inequality in health would be less pronounced in populations with greater exposure to green space, since access to such areas can modify pathways through which low socioeconomic position can lead to disease. We classified the population of England at younger than retirement age (n=40 813 236) into groups on the basis of income deprivation and exposure to green space. We obtained individual mortality records (n=366 348) to establish whether the association between income deprivation, all-cause mortality, and cause-specific mortality (circulatory disease, lung cancer, and intentional self-harm) in 2001-05, varied by exposure to green space measured in 2001, with control for potential confounding factors. We used stratified models to identify the nature of this variation. The association between income deprivation and mortality differed significantly across the groups of exposure to green space for mortality from all causes (p<0.0001) and circulatory disease (p=0.0212), but not from lung cancer or intentional self-harm. Health inequalities related to income deprivation in all-cause mortality and mortality from circulatory diseases were lower in populations living in the greenest areas. The incidence rate ratio (IRR) for all-cause mortality for the most income deprived quartile compared with the least deprived was 1.93 (95% CI 1.86-2.01) in the least green areas, whereas it was 1.43 (1.34-1.53) in the most green. For circulatory diseases, the IRR was 2.19 (2.04-2.34) in the least green areas and 1.54 (1.38-1.73) in the most green. There was no effect for causes of death unlikely to be affected by green space, such as lung cancer and intentional self-harm. Populations that are exposed to the greenest environments also have lowest levels of health inequality related to income deprivation. Physical environments that promote good health might be important to reduce socioeconomic health inequalities.
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Research electronic data capture (REDCap) is a novel workflow methodology and software solution designed for rapid development and deployment of electronic data capture tools to support clinical and translational research. We present: (1) a brief description of the REDCap metadata-driven software toolset; (2) detail concerning the capture and use of study-related metadata from scientific research teams; (3) measures of impact for REDCap; (4) details concerning a consortium network of domestic and international institutions collaborating on the project; and (5) strengths and limitations of the REDCap system. REDCap is currently supporting 286 translational research projects in a growing collaborative network including 27 active partner institutions.
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This paper presents evidence from three samples, two of college students and one of participants in a community smoking-cessation program, for the reliability and validity of a 14-item instrument, the Perceived Stress Scale (PSS), designed to measure the degree to which situations in one's life are appraised as stressful. The PSS showed adequate reliability and, as predicted, was correlated with life-event scores, depressive and physical symptomatology, utilization of health services, social anxiety, and smoking-reduction maintenance. In all comparisons, the PSS was a better predictor of the outcome in question than were life-event scores. When compared to a depressive symptomatology scale, the PSS was found to measure a different and independently predictive construct. Additional data indicate adequate reliability and validity of a four-item version of the PSS for telephone interviews. The PSS is suggested for examining the role of nonspecific appraised stress in the etiology of disease and behavioral disorders and as an outcome measure of experienced levels of stress.
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This is a three-part study that examined the accuracy of five brands of electronic pedometers (Freestyle Pacer, Eddie Bauer, L.L. Bean, Yamax, and Accusplit) under a variety of different conditions. In Part I, 20 subjects walked a 4.88-km sidewalk course while wearing two devices of the same brand (on the left and right side of the body) for each of five different trials. There were significant differences among pedometers (P < 0.05), with the Yamax, Pacer, and Accusplit approximating the actual distance more closely than the other models. The Yamax pedometers showed close agreement, but the left and right Pacer pedometers differed significantly (P = 0.0003) and the Accusplit displayed a similar trend (P = 0.0657). In Part II, the effects of walking surface on pedometer accuracy were examined. Ten of the original subjects completed an additional five trials around a 400-m rubberized outdoor track. The devices showed similar values for sidewalk and track surfaces. In Part III, the effects of walking speed on pedometer accuracy were examined. Ten different subjects walked on a treadmill at various speeds (54, 67, 80, 94, and 107 m.min-1). Pedometers that displayed both distance and number of steps were examined. The Yamax was more accurate than the Pacer and Eddie Bauer at slow-to-moderate speeds (P < 0.05), though no significant differences were seen at the fastest speed. While there are variations among brands in terms of accuracy, electronic pedometers may prove useful in recording walking activities in free-living populations.
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We present the adaptation of an IFCC method for alpha-amylase using 2-chloro-4-nitro-phenyl-alpha-D-maltotrio-side as substrate (1) suited for routine work at 37 degrees C. In the assay, a constant proportion of substrate, i. e. 92%, is directly converted to 2-chloro-4-nitrophenol and maltotriose. The method is based on multi- and univariate optimization leading to following measurement conditions: substrate, 2.25 mmol/l; chloride, 310 mmol/l; calcium 5.0 mmol/l; 4-morpholinoethanesulphonic acid, 50 mmol/l; pH 6.28. The assay may be carried out manually or by mechanized procedures, with substrate or sample start, and it shows these analytical properties in measuring amylase activity of sera: no lag phase, detection limit 2.9 U/l, linear range < or = 820 U/l (for 300 s) or < or = 1450 U/l (for 120 s of measurement), and total manual imprecision 3.2% (CV) at 46 U/l. Bilirubin < or = 630 micromol/l, haemoglobin < or =6 g/l, triacylglycerols < or =30 mmol/l, heparin < or =100 kU/l, and glucose < or =120 mmol/l do not interfere. For adults, we established a preliminary 0.95-reference interval of 30-90 U/l not dependent on sex or age. A close association with the IFCC method demonstrates the reliable transfer of its measurement conditions to a robust routine method with minimal changes.
Measuring Connection to Nature in Children Aged 8–12: A Robust Methodology for the RSPB
  • R Bragg
  • C Wood
  • J Barton
  • J Pretty
R. Bragg, C. Wood, J. Barton, J. Pretty, Measuring Connection to Nature in Children Aged 8–12: A Robust Methodology for the RSPB. A Short Report for RSPB, Essex Sustainability Institute and School of Biological Sciences, University of Essex, Wivenhoe Park, Colchester, United Kingdom, March 2013.
  • T Hartig
  • R Mitchell
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  • H Frumkin
T. Hartig, R. Mitchell, S. de Vries, H. Frumkin, Nature and health, Annu. Rev. Public Health 35 (2014) 207-228.
  • N Razani
N. Razani et al. / Contemporary Clinical Trials 51 (2016) 8–14
Sharing Nature with Children: The Classic Parents' and Teachers' Nature Awareness Guidebook
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J.B. Cornell, Sharing Nature with Children: The Classic Parents' and Teachers' Nature Awareness Guidebook, Dawn Publications, Nevada City, California, 1998.
Nearby nature: a buffer of life stress among rural children
  • N M Wells
  • G W Evans
N.M. Wells, G.W. Evans, Nearby nature: a buffer of life stress among rural children, Environ. Behav. 35 (2003) 311-330.
  • A H Krist
  • L J Baumann
  • J S Holtrop
  • M R Wasserman
  • K C Stange
  • M Woo
A.H. Krist, L.J. Baumann, J.S. Holtrop, M.R. Wasserman, K.C. Stange, M. Woo, Evaluating feasible and referable behavioral counseling interventions, Am. J. Prev. Med. 49 (3 Suppl 2) (2015) S138-S149.
Measuring Connection to Nature in Children Aged 8-12: A Robust Methodology for the RSPB. A Short Report for RSPB, Essex Sustainability Institute and School of Biological Sciences
  • R Bragg
  • C Wood
  • J Barton
  • J Pretty
R. Bragg, C. Wood, J. Barton, J. Pretty, Measuring Connection to Nature in Children Aged 8-12: A Robust Methodology for the RSPB. A Short Report for RSPB, Essex Sustainability Institute and School of Biological Sciences, University of Essex, Wivenhoe Park, Colchester, United Kingdom, March 2013.