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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
... 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 ...
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.
... 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. ...
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.
... An approach that has gained some attention is providers using nature prescriptions during their clinical visits to "prescribe" time in nature. Some programs include resources such as information about local parks, park passes, and pedometers [37][38][39] in addition to a written prescription for time outdoors. Other programs include more structured components such as invitations to park outings and referrals to park-based programs. ...
... Other programs include more structured components such as invitations to park outings and referrals to park-based programs. 38,40 Such programs have come up across the country 41 although the evidence for them is sparse and mixed. 17 Most studies included in a recent review of nature prescription programs used convenience samples, evaluated patient adherence (rather than health outcomes), did not include control groups, and rarely included provider perspectives. ...
Aim
Time outdoors and contact with nature are positively associated with a broad range of children’s health outcomes. Pediatricians are uniquely positioned to promote active play in nature (APN) but may face challenges to do so during well child visits. The objective of this study was to understand barriers to children’s APN, before and during the COVID-19 pandemic, and how health care providers could promote APN.
Methods
Focus groups were conducted with 14 pediatric providers and interviews with 14 parents (7 in English, 7 in Spanish) of children ages 3 to 10 on public insurance. Dedoose was used for coding and content analysis. We contextualized this work within the WHO’s Commission on Social Determinants of Health conceptual framework.
Results
Parents mentioned a range of material circumstances (time, finances, family circumstances, access to safe outdoor play spaces and age-appropriate activities) and behavioral/psychosocial factors (previous experiences in nature, safety, and weather concerns), many of which were exacerbated by the pandemic, that serve as barriers to children’s APN. Providers said they were motivated to talk to families about children’s APN but mentioned barriers to this conversation such as time, other pressing priorities for the visit, and lack of resources to give families.
Conclusions
Many pre-pandemic barriers to APN were exacerbated by the COVID-19 pandemic. Well-child visits may be an effective setting to discuss the benefits of APN during and beyond the pandemic, and there is a need for contextually appropriate resources for pediatric providers and families.
... 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. ...
Abstract 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
... 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]. ...
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. ...
... 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. ...
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
... There is growing literature evidence on the impact of greenspace on improving clinical outcomes in CVD and cancer patients through different interventions such as "park prescription" programs and other nature-based interventions (NBI) [83][84][85][86]. Some of this evidence was found through experimental studies, suggesting possible causal relationships, and opportunities for specific interventions to improve CVD and cancer-related health outcomes. ...
Significance
Globally, cardiovascular disease (CVD) and cancer are leading causes of morbidity and mortality. While having different etiologies, CVD and cancer are linked by multiple shared risk factors, the presence of which exacerbate adverse outcomes for individuals with either disease. For both pathologies, factors such as poverty, lack of physical activity (PA), poor dietary intake, and climate change increase risk of adverse outcomes. Prior research has shown that greenspaces and other nature-based interventions (NBIs) contribute to improved health outcomes and climate change resilience.
Objective
To summarize evidence on the impact of greenspaces or NBIs on cardiovascular health and/or cancer-related outcomes and identify knowledge gaps to inform future research.
Methods
Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 and Peer Review of Electronic Search Strategies (PRESS) guidelines, we searched five databases: Web of Science, Scopus, Medline, PsycINFO and GreenFile. Two blinded reviewers used Rayyan AI and a predefined criteria for article inclusion and exclusion. The risk of bias was assessed using a modified version of the Newcastle–Ottawa Scale (NOS). This review is registered with PROSPERO, ID # CRD42021231619.
Results & discussion
Of 2565 articles retrieved, 31 articles met the inclusion criteria, and overall had a low risk of bias. 26 articles studied cardiovascular related outcomes and 5 studied cancer-related outcomes. Interventions were coded into 4 categories: forest bathing, green exercise, gardening, and nature viewing. Outcomes included blood pressure (BP), cancer-related quality of life (QoL) and (more infrequently) biomarkers of CVD risk. Descriptions of findings are presented as well as visual presentations of trends across the findings using RAW graphs. Overall studies included have a low risk of bias; and alluvial chart trends indicated that NBIs may have beneficial effects on CVD and cancer-related outcomes.
Conclusions & implications
(1) Clinical implication: Healthcare providers should consider the promotion of nature-based programs to improve health outcomes. (2) Policy implication: There is a need for investment in equitable greenspaces to improve health outcomes and build climate resilient neighborhoods. (3) Research or academic implication: Research partnerships with community-based organizations for a comprehensive study of benefits associated with NBIs should be encouraged to reduce health disparities and ensure intergenerational health equity. There is a need for investigation of the mechanisms by which NBIs impact CVD and exploration of the role of CVD biological markers of inflammation among cancer survivors.
... Public health research has found that contact with nature is an underutilized health resource (16,17), suggesting an opportunity to further incorporate nature-based physical activity counseling into clinical settings that leverage park and recreation resources in order to address individual and community health through physical activity as a health behavior intervention. Several clinical trials have shown that a park prescription or nature-based physical activity prescription can lead to increases in physical activity, reductions in stress and obesity, and quality of life (18)(19)(20)(21). While PHC providers may not universally be aware of nature-based physical activity prescriptions such as park prescriptions, one study found that nearly 82% of providers expressed interest in park prescription programs (22). ...
Background
eHealth technologies offer an efficient method to integrate park prescriptions into clinical practice by primary health care (PHC) providers to help patients improve their health via tailored, nature-based health behavior interventions. This paper describes the protocol of the GoalRx Prescription Intervention (GPI) which was designed to leverage community resources to provide tailored park prescriptions for PHC patients.
Methods
The GPI study was designed as a 3-arm, multi-site observational study. We enrolled low-income, rural adults either at-risk of or living with hypertension or diabetes ( n = 75) from Federally Qualified Health Centers (FQHC) in two counties in North Carolina, USA into the 3-month intervention. Eligible participants self-selected to receive (1) a tailored park prescription intervention; (2) a tailored home/indoor PA prescription intervention; or (3) a healthy eating prescription (with no PA prescription beyond standard PA counseling advice that is already routinely provided in PHC) as the comparison group. The GPI app paired patient health data from the electronic health record with stated patient preferences and triggered app-integrated SMS motivation and compliance messaging directly to the patient. Patients were assessed at baseline and at a 3-month follow-up upon the completion of the intervention. The primary outcome (mean difference in weekly physical activity from baseline (T0) to post-intervention (T1) as measured by the Fitbit Flex 2) was assessed at 3 months. Secondary outcomes included assessment of the relationship between the intervention and biological markers of health, including body mass index (BMI), systolic and diastolic blood pressure, HbA1c or available glucose test (if applicable), and a depression screen score using the Patient Health Questionnaire 9. Secondary outcomes also included the total number of SMS messages sent, number of SMS messages responded to, number of SMS messages ignored, and opt-out rate.
Discussion
The goal was to create a protocol utilizing eHealth technologies that addressed the specific needs of rural low-income communities and fit into the natural rhythms and processes of the selected FQHC clinics in North Carolina. This protocol offered a higher standard of health care by connecting patients to their PHC teams and increasing patient motivation to make longer-lasting health behavior changes.
... 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. ...
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.
... 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. ...
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.
... 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. ...
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.
... 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. ...
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.
... 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. ...
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.
... 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]. ...
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.
... 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. ...
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.
... 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]. ...
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.
... 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). ...
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.
... These issues are more common among urban youth, particularly those from low-income communities. Stress is also more common among youth who live in urban settings (Razani et al., 2016). Recent research has revealed that nature is a significant mediator of stress in children, making nature exploration in urban areas particularly important for children's long-term mental and physical health (Corraliza, Collado, & Bethlemy, 2012;Flouri et al., 2014;Zarr & Conway, 2017). ...
To become robust scientific thinkers, children need meaningful opportunities to engage in science learning across a variety of contexts. Unfortunately, many children, especially those in urban settings and from low-income families, do not get the experiences needed to deepen their understanding of a broad range of scientific ideas, nor do they have consistent opportunities to engage in the practice of science. Informal and outdoor education programs offer a pathway to provide meaningful science learning experiences that prepare children for school and beyond, as well as offer health benefits of being physically active and outdoors. This paper discusses a federally funded initiative to develop a Toolkit and to research its promise for supporting children’s active, outdoor environmental science learning through the use of digital resources and hands-on activities. Findings showed that the Toolkit positively influenced participants’ behaviors and supported educators and parents in engaging children with focal science concepts and practices across a range of informal, outdoor contexts (e.g., local park departments, nature centers, school-based after-school programs with open green space).Subscribe to JOREL
... 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. ...
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.
... 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). ...
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
... 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. ...
... 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 ...
Background:
Prevention of obesity in adolescents is an international public health priority. The prevalence of overweight and obesity is over 25% in North and South America, Australia, most of Europe, and the Gulf region. Interventions that aim to prevent obesity involve strategies that promote healthy diets or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective, and numerous new studies have been published over the last five years since the previous version of this Cochrane Review.
Objectives:
To assess the effects of interventions that aim to prevent obesity in adolescents by modifying dietary intake or 'activity' levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events.
Search methods:
We used standard, extensive Cochrane search methods. The latest search date was February 2023.
Selection criteria:
Randomised controlled trials in adolescents (mean age 12 years and above but less than 19 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance.
Data collection and analysis:
We used standard Cochrane methods. Our outcomes were BMI, zBMI score and serious adverse events, assessed at short- (12 weeks to < 9 months from baseline), medium- (9 months to < 15 months) and long-term (≥ 15 months) follow-up. We used GRADE to assess the certainty of the evidence for each outcome.
Main results:
This review includes 74 studies (83,407 participants); 54 studies (46,358 participants) were included in meta-analyses. Sixty studies were based in high-income countries. The main setting for intervention delivery was schools (57 studies), followed by home (nine studies), the community (five studies) and a primary care setting (three studies). Fifty-one interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over 28 months. Sixty-two studies declared non-industry funding; five were funded in part by industry. Dietary interventions versus control The evidence is very uncertain about the effects of dietary interventions on body mass index (BMI) at short-term follow-up (mean difference (MD) -0.18, 95% confidence interval (CI) -0.41 to 0.06; 3 studies, 605 participants), medium-term follow-up (MD -0.65, 95% CI -1.18 to -0.11; 3 studies, 900 participants), and standardised BMI (zBMI) at long-term follow-up (MD -0.14, 95% CI -0.38 to 0.10; 2 studies, 1089 participants); all very low-certainty evidence. Compared with control, dietary interventions may have little to no effect on BMI at long-term follow-up (MD -0.30, 95% CI -1.67 to 1.07; 1 study, 44 participants); zBMI at short-term (MD -0.06, 95% CI -0.12 to 0.01; 5 studies, 3154 participants); and zBMI at medium-term (MD 0.02, 95% CI -0.17 to 0.21; 1 study, 112 participants) follow-up; all low-certainty evidence. Dietary interventions may have little to no effect on serious adverse events (two studies, 377 participants; low-certainty evidence). Activity interventions versus control Compared with control, activity interventions do not reduce BMI at short-term follow-up (MD -0.64, 95% CI -1.86 to 0.58; 6 studies, 1780 participants; low-certainty evidence) and probably do not reduce zBMI at medium- (MD 0, 95% CI -0.04 to 0.05; 6 studies, 5335 participants) or long-term (MD -0.05, 95% CI -0.12 to 0.02; 1 study, 985 participants) follow-up; both moderate-certainty evidence. Activity interventions do not reduce zBMI at short-term follow-up (MD 0.02, 95% CI -0.01 to 0.05; 7 studies, 4718 participants; high-certainty evidence), but may reduce BMI slightly at medium-term (MD -0.32, 95% CI -0.53 to -0.11; 3 studies, 2143 participants) and long-term (MD -0.28, 95% CI -0.51 to -0.05; 1 study, 985 participants) follow-up; both low-certainty evidence. Seven studies (5428 participants; low-certainty evidence) reported data on serious adverse events: two reported injuries relating to the exercise component of the intervention and five reported no effect of intervention on reported serious adverse events. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, do not reduce BMI at short-term follow-up (MD 0.03, 95% CI -0.07 to 0.13; 11 studies, 3429 participants; high-certainty evidence), and probably do not reduce BMI at medium-term (MD 0.01, 95% CI -0.09 to 0.11; 8 studies, 5612 participants; moderate-certainty evidence) or long-term (MD 0.06, 95% CI -0.04 to 0.16; 6 studies, 8736 participants; moderate-certainty evidence) follow-up. They may have little to no effect on zBMI in the short term, but the evidence is very uncertain (MD -0.09, 95% CI -0.2 to 0.02; 3 studies, 515 participants; very low-certainty evidence), and they may not reduce zBMI at medium-term (MD -0.05, 95% CI -0.1 to 0.01; 6 studies, 3511 participants; low-certainty evidence) or long-term (MD -0.02, 95% CI -0.05 to 0.01; 7 studies, 8430 participants; low-certainty evidence) follow-up. Four studies (2394 participants) reported data on serious adverse events (very low-certainty evidence): one reported an increase in weight concern in a few adolescents and three reported no effect.
Authors' conclusions:
The evidence demonstrates that dietary interventions may have little to no effect on obesity in adolescents. There is low-certainty evidence that activity interventions may have a small beneficial effect on BMI at medium- and long-term follow-up. Diet plus activity interventions may result in little to no difference. Importantly, this updated review also suggests that interventions to prevent obesity in this age group may result in little to no difference in serious adverse effects. Limitations of the evidence include inconsistent results across studies, lack of methodological rigour in some studies and small sample sizes. Further research is justified to investigate the effects of diet and activity interventions to prevent childhood obesity in community settings, and in young people with disabilities, since very few ongoing studies are likely to address these. Further randomised trials to address the remaining uncertainty about the effects of diet, activity interventions, or both, to prevent childhood obesity in schools (ideally with zBMI as the measured outcome) would need to have larger samples.
Background:
Prevention of obesity in children is an international public health priority given the prevalence of the condition (and its significant impact on health, development and well-being). Interventions that aim to prevent obesity involve behavioural change strategies that promote healthy eating or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective and numerous new studies have been published over the last five years, since the previous version of this Cochrane review.
Objectives:
To assess the effects of interventions that aim to prevent obesity in children by modifying dietary intake or 'activity' levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events.
Search methods:
We used standard, extensive Cochrane search methods. The latest search date was February 2023.
Selection criteria:
Randomised controlled trials in children (mean age 5 years and above but less than 12 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance.
Data collection and analysis:
We used standard Cochrane methods. Our outcomes were body mass index (BMI), zBMI score and serious adverse events, assessed at short- (12 weeks to < 9 months from baseline), medium- (9 months to < 15 months) and long-term (≥ 15 months) follow-up. We used GRADE to assess the certainty of the evidence for each outcome.
Main results:
This review includes 172 studies (189,707 participants); 149 studies (160,267 participants) were included in meta-analyses. One hundred forty-six studies were based in high-income countries. The main setting for intervention delivery was schools (111 studies), followed by the community (15 studies), the home (eight studies) and a clinical setting (seven studies); one intervention was conducted by telehealth and 31 studies were conducted in more than one setting. Eighty-six interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over four years. Non-industry funding was declared by 132 studies; 24 studies were funded in part or wholly by industry. Dietary interventions versus control Dietary interventions, compared with control, may have little to no effect on BMI at short-term follow-up (mean difference (MD) 0, 95% confidence interval (CI) -0.10 to 0.10; 5 studies, 2107 participants; low-certainty evidence) and at medium-term follow-up (MD -0.01, 95% CI -0.15 to 0.12; 9 studies, 6815 participants; low-certainty evidence) or zBMI at long-term follow-up (MD -0.05, 95% CI -0.10 to 0.01; 7 studies, 5285 participants; low-certainty evidence). Dietary interventions, compared with control, probably have little to no effect on BMI at long-term follow-up (MD -0.17, 95% CI -0.48 to 0.13; 2 studies, 945 participants; moderate-certainty evidence) and zBMI at short- or medium-term follow-up (MD -0.06, 95% CI -0.13 to 0.01; 8 studies, 3695 participants; MD -0.04, 95% CI -0.10 to 0.02; 9 studies, 7048 participants; moderate-certainty evidence). Five studies (1913 participants; very low-certainty evidence) reported data on serious adverse events: one reported serious adverse events (e.g. allergy, behavioural problems and abdominal discomfort) that may have occurred as a result of the intervention; four reported no effect. Activity interventions versus control Activity interventions, compared with control, may have little to no effect on BMI and zBMI at short-term or long-term follow-up (BMI short-term: MD -0.02, 95% CI -0.17 to 0.13; 14 studies, 4069 participants; zBMI short-term: MD -0.02, 95% CI -0.07 to 0.02; 6 studies, 3580 participants; low-certainty evidence; BMI long-term: MD -0.07, 95% CI -0.24 to 0.10; 8 studies, 8302 participants; zBMI long-term: MD -0.02, 95% CI -0.09 to 0.04; 6 studies, 6940 participants; low-certainty evidence). Activity interventions likely result in a slight reduction of BMI and zBMI at medium-term follow-up (BMI: MD -0.11, 95% CI -0.18 to -0.05; 16 studies, 21,286 participants; zBMI: MD -0.05, 95% CI -0.09 to -0.02; 13 studies, 20,600 participants; moderate-certainty evidence). Eleven studies (21,278 participants; low-certainty evidence) reported data on serious adverse events; one study reported two minor ankle sprains and one study reported the incident rate of adverse events (e.g. musculoskeletal injuries) that may have occurred as a result of the intervention; nine studies reported no effect. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, may result in a slight reduction in BMI and zBMI at short-term follow-up (BMI: MD -0.11, 95% CI -0.21 to -0.01; 27 studies, 16,066 participants; zBMI: MD -0.03, 95% CI -0.06 to 0.00; 26 studies, 12,784 participants; low-certainty evidence) and likely result in a reduction of BMI and zBMI at medium-term follow-up (BMI: MD -0.11, 95% CI -0.21 to 0.00; 21 studies, 17,547 participants; zBMI: MD -0.05, 95% CI -0.07 to -0.02; 24 studies, 20,998 participants; moderate-certainty evidence). Dietary and activity interventions compared with control may result in little to no difference in BMI and zBMI at long-term follow-up (BMI: MD 0.03, 95% CI -0.11 to 0.16; 16 studies, 22,098 participants; zBMI: MD -0.02, 95% CI -0.06 to 0.01; 22 studies, 23,594 participants; low-certainty evidence). Nineteen studies (27,882 participants; low-certainty evidence) reported data on serious adverse events: four studies reported occurrence of serious adverse events (e.g. injuries, low levels of extreme dieting behaviour); 15 studies reported no effect. Heterogeneity was apparent in the results for all outcomes at the three follow-up times, which could not be explained by the main setting of the interventions (school, home, school and home, other), country income status (high-income versus non-high-income), participants' socioeconomic status (low versus mixed) and duration of the intervention. Most studies excluded children with a mental or physical disability.
Authors' conclusions:
The body of evidence in this review demonstrates that a range of school-based 'activity' interventions, alone or in combination with dietary interventions, may have a modest beneficial effect on obesity in childhood at short- and medium-term, but not at long-term follow-up. Dietary interventions alone may result in little to no difference. Limited evidence of low quality was identified on the effect of dietary and/or activity interventions on severe adverse events and health inequalities; exploratory analyses of these data suggest no meaningful impact. We identified a dearth of evidence for home and community-based settings (e.g. delivered through local youth groups), for children living with disabilities and indicators of health inequities.
Significant declines in outdoor activity and engagement with the natural environment are growing concerns with negative impacts on well-being. We pilot-tested an intervention encouraging outdoor activity among adult mentor and child mentee pairs and families, in partnership with Milwaukee’s Urban Ecology Center. The study used a mixed methods approach, including pre and post-program surveys and in-depth interviews. Findings indicate the significance of environmental barriers to behavior change, especially in urban areas, as well as the potential utility of programs like Nature Mentors in producing shifts towards more time spent outdoors and in contact with nature.
Ecotherapy-based experiences have been shown to provide multiple benefits such as improved cognitive functioning, increased overall well-being and improved mental and physical health. Few, if any studies have considered the benefits of providing these types of experiences for urban community college students. This pilot study introduces an eco-art based workshop and an animal-assisted therapy interactive presentation as case examples to demonstrate the potential benefits that these types of experiences can have on this population. Based on these preliminary findings, the benefits of these activities can be grouped into three themes: (1) General satisfaction with experience, (2) Opportunity for self-expression, and (3) Awareness of stress-reduction.
Background:
Prevention of childhood obesity is an international public health priority given the significant impact of obesity on acute and chronic diseases, general health, development and well-being. The international evidence base for strategies to prevent obesity is very large and is accumulating rapidly. This is an update of a previous review.
Objectives:
To determine the effectiveness of a range of interventions that include diet or physical activity components, or both, designed to prevent obesity in children.
Search methods:
We searched CENTRAL, MEDLINE, Embase, PsychINFO and CINAHL in June 2015. We re-ran the search from June 2015 to January 2018 and included a search of trial registers.
Selection criteria:
Randomised controlled trials (RCTs) of diet or physical activity interventions, or combined diet and physical activity interventions, for preventing overweight or obesity in children (0-17 years) that reported outcomes at a minimum of 12 weeks from baseline.
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.
Throughout the years, scholars and practitioners in the environmental and public health fields have experienced communication issues due to differences in disciplinary background, explanatory frameworks, and streams of funding. As a result, public health professionals have rarely discussed the ecosystem services derived from green spaces until recently. Ecologists and natural scientists interested in improving the ecosystem health of natural spaces have not traditionally emphasized the potential impacts on human health in their published work. Despite these disciplinary gaps, public health and ecosystem services derived from green spaces are inextricably linked. Green spaces provide regulating, supporting, provisioning, and cultural services that benefit people. Green spaces also fit within the broader framework of social determinants of health, which describe how a person’s social and natural environment impacts their health and well-being. We discuss how these socio-ecological frameworks connect green space with public health, and we explain how green space initiatives have been used to promote public health in the United States.
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.
The U.S. Preventive Services Task Force (USPTF) recognizes that behaviors have a major impact on health and well-being. Currently, the USPSTF has 11 behavioral counseling intervention (BCI) recommendations. These BCIs can be delivered in a primary care setting or patients can be referred to other clinical or community programs. Unfortunately, many recommended BCIs are infrequently and ineffectually delivered, suggesting that more evidence is needed to understand which BCIs are feasible and referable. In response, the USPSTF convened an expert forum in 2013 to inform the evaluation of BCI feasibility. This manuscript reports on findings from the forum and proposes that researchers use several frameworks to help clinicians and the USPSTF evaluate which BCIs work under usual conditions. A key recommendation for BCI researchers is to use frameworks whose components can support dissemination and implementation efforts. These frameworks include the Template for Intervention Description and Replication (TIDieR), which helps describe the essential components of an intervention, and pragmatic frameworks like Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) or Pragmatic-Explanatory Continuum Indicator Summary (PRECIS), which help to report study design elements and outcomes. These frameworks can both guide the design of more-feasible BCIs and produce clearer feasibility evidence. Critical evidence gaps include a better understanding of which patients will benefit from a BCI, how flexible interventions can be without compromising effectiveness, required clinician expertise, necessary intervention intensity and follow-up, impact of patient and clinician intervention adherence, optimal conditions for BCI delivery, and how new care models will influence BCI feasibility.
Copyright © 2015 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.
Low-income families often simultaneously encounter housing and neighborhood problems pertaining to safety, affordability, and quality issues that necessitate strategies to maximize limited budgets and ensure safety. Such constrained decisions regarding inadequate housing and poor neighborhood conditions, however, may themselves create or exacerbate health risks. Building on the survival strategies literature, this article offers rich and detailed accounts of coping and management strategies on the part of vulnerable families facing housing and neighborhood hardships. The findings are based on in-depth interviews with 72 respondents and ethnographic observations in an urban community. The results illustrate how low-income women avoid neighborhood danger by relegating family life to the home environment, thereby increasing exposure to health risks such as stress, depression, and asthma. The discussion focuses on public health literature linking housing and health and proposes the use of legal strategies and community engagement as resources to complement current approaches to housing and neighborhood problems.
Purpose
The purpose of this study was to review articles related to the psychometric properties of the Perceived Stress Scale (PSS).
Methods
Systematic literature searches of computerized databases were performed to identify articles on psychometric evaluation of the PSS.
Results
The search finally identified 19 articles. Internal consistency reliability, factorial validity, and hypothesis validity of the PSS were well reported. However, the test-retest reliability and criterion validity were relatively rarely evaluated. In general, the psychometric properties of the 10-item PSS were found to be superior to those of the 14-item PSS, while those of the 4-item scale fared the worst. The psychometric properties of the PSS have been evaluated empirically mostly using populations of college students or workers.
Conclusion
Overall, the PSS is an easy-to-use questionnaire with established acceptable psychometric properties. However, future studies should evaluate these psychometric properties in greater depth, and validate the scale using diverse populations.
Child maltreatment is recognized as a widespread problem with huge implications for mental health and quality of life. Studies have repeatedly shown that victims of child maltreatment report significantly more adverse life outcomes than non-victims. The main objective of the study is (1) to examine the mental health and quality of life of maltreated children over a 1.5 year period beginning shortly after a report has been filed with an Advies- en Meldpunt Kindermishandeling (AMK) (advice and reporting center on child abuse and neglect). Secondary objectives are: (2) to examine how relevant determinants influence the mental health and quality of life of maltreated children, and (3) to examine differences in mental health and quality of life outcomes when comparing families of Dutch origin with families originating from Morocco and Suriname.Methods/designA prospective study will be performed, in which parent--child dyads will be followed over a 1.5 year period. Participants will be recruited shortly after the report to the AMK and they will be asked to complete a questionnaire four times, at baseline and every six months thereafter. Data will be analyzed using a longitudinal multi-level analysis.
The study is expected to yield evidence about the mental health and quality of life of maltreated children and about determinants that influence their mental health and quality of life outcomes. Strengths of this study are (1) the design which makes it possible to start examining outcomes shortly after or even during the actual maltreatment and to follow parent--child dyads for 1.5 years, and (2) asking children as informants about their own situation by making use of self-report questionnaires as much as possible. Limitations include the risks of selection bias and loss to follow-up during 1.5 years of data collection.Trial registrationNTR3674, funded by ZonMw, project 15700.2012.
Identifying mechanisms that buffer children from life's stress and adversity is an important empirical and practical concern. This study focuses on nature as a buffer of life stress among rural children. To examine whether vegetation near the residential environment might buffer or moderate the impact of stressful life events on children's psychological well-being, data were collected from 337 rural children in Grades 3 through 5 (mean age=9.2 years). Dependent variables include a standard parent-reported measure of children's psychological distress and children's own ratings of global self-worth. In a rural setting, levels of nearby nature moderate the impact of stressful life events on the psychological well-being of children. Specifically, the impact of life stress was lower among children with high levels of nearby nature than among those with little nearby nature. Implications of these finding are discussed with respect to our understanding of resilience and protective mechanisms.
Young children who experience toxic stress are at high risk for a number of health outcomes in adulthood, including cardiovascular disease, cancers, asthma, and depression. The American Academy of Pediatrics has recently called on pediatricians, informed by research from molecular biology, genomics, immunology, and neuroscience, to become leaders in science-based strategies to build strong foundations for children's life-long health. In this report, we provide an overview of the science of toxic stress. We summarize the development of the neuroendocrine-immune network, how its function is altered by early life adversity, and how these alterations then increase vulnerability to disease. The fact that early environments shape and calibrate the functioning of biological systems very early in life is both a cautionary tale about overlooking critical periods in development and reason for optimism about the promise of intervention. Even in the most extreme cases of adversity, well-timed changes to children's environments can improve outcomes. Pediatricians are in a unique position to contribute to the public discourse on health and social welfare by explaining how factors that seem distal to child health may be the key to some of the most intractable public health problems of our generation. We consider the challenges and opportunities for preventing toxic stress in the context of contemporary pediatric practice.
We present the precaution adoption process model—a stage theory consisting of seven distinct states between ignorance and completed preventive action. The stages are “unaware of the issue,” “aware of the issue but not personally engaged,” “engaged and deciding what to do,” “planning to act but not yet having acted,” “having decided not to act,” “acting,” and “maintenance.” The theory asserts that these stages represent qualitatively different patterns of behavior, beliefs, and experience and that the factors that produce transitions between stages vary depending on the specific transition being considered. Data from seven studies of home radon testing are examined to test some of the claims made by this model. Stage theories of protective behavior are contrasted with theories that see precaution adoption in terms of movement along a single continuum of action likelihood.
Key words: stage theory, radon, prevention, health behavior, risk perception, lung cancer
The Golden Gate National Recreation Area (GGNRA), one of the most highly visited national parks in the United States, is an important cultural symbol in the San Francisco Bay Area. Traditionally absent groups are expressing a desire to enjoy the benefits associated with outdoor recreation including public lands that may be lesser known to them. Understanding how national parks are used by ethnic minorities is of increasing importance to both the public and the National Park Service. In 2006, the GGNRA commissioned a focus-group study with nearly 100 people of color living in the Bay Area to provide indicators of constraints to park use. While identifying physical, mental, and spiritual benefits of access to nature in parks, many participants expressed frustration with limited physical access, subtle racism, and general exclusion from the culture of parks as reasons why they avoid these public spaces. The results of this study corroborate over four decades of research on park constraints. This article presents results of narratives provided by those who experience constraints and their desire to participate. For national parks to become representative of the people they serve, we suggest the need to mitigate silent exclusion and move toward proactive inclusion both inside and outside the parks. Key considerations include outreach through more intentional communication strategies, multilingual signage, responding to complaints of discrimination, and more representative hiring practices.Environmental Practice 13:354–369 (2011)
Different conceptual perspectives converge to predict that if individuals are stressed, an encounter with most unthreatening natural environments will have a stress reducing or restorative influence, whereas many urban environments will hamper recuperation. Hypotheses regarding emotional, attentional and physiological aspects of stress reducing influences of nature are derived from a psycho-evolutionary theory. To investigate these hypotheses, 120 subjects first viewed a stressful movie, and then were exposed to color/sound videotapes of one of six different natural and urban settings. Data concerning stress recovery during the environmental presentations were obtained from self-ratings of affective states and a battery of physiological measures: heart period, muscle tension, skin conductance and pulse transit time, a non-invasive measure that correlates with systolic blood pressure. Findings from the physiological and verbal measures converged to indicate that recovery was faster and more complete when subjects were exposed to natural rather than urban environments. The pattern of physiological findings raised the possibility that responses to nature had a salient parasympathetic nervous system component; however, there was no evidence of pronounced parasympathetic involvement in responses to the urban settings. There were directional differences in cardiac responses to the natural vs urban settings, suggesting that attention/intake was higher during the natural exposures. However, both the stressor film and the nature settings elicited high levels of involuntary or automatic attention, which contradicts the notion that restorative influences of nature stem from involuntary attention or fascination. Findings were consistent with the predictions of the psycho-evolutionary theory that restorative influences of nature involve a shift towards a more positively-toned emotional state, positive changes in physiological activity levels, and that these changes are accompanied by sustained attention/intake. Content differences in terms of natural vs human-made properties appeared decisive in accounting for the differences in recuperation and perceptual intake.
A key public health objective is increasing health-enhancing physical activity (PA) for older adults (OAs). Daily trip frequency is independently associated with objectively assessed PA volumes (OAs). Little is known about correlates and these trips' transport mode, and how these elements relate to PA. Purpose: to describe the frequency, purpose, and travel mode of daily trips in OAs, and their association with participant characteristics and objectively-assessed PA.
Participants (n = 214, aged 78.1 SD 5.7 years), completed a seven-day trips log recording daily-trip frequency, purpose and transport mode. Concurrently participants wore an accelerometer which provided mean daily steps (steps·d-1), and minutes of moderate to vigorous PA (MVPA·d-1). Participants' physical function (PF) was estimated and demographic, height and weight data obtained.
Trip frequency was associated with gender, age, physical function, walking-aid use, educational attainment, number of amenities within walking distance and cars in the household. Participants reported 9.6 (SD 4.2) trips per week (trips·wk-1). Most trips (61%) were by car (driver 44%, passenger 17%), 30% walking or cycling (active) and 9% public transport/other. Driving trips·wk-1 were more common in participants who were males (5.3 SD 3.6), well-educated (5.0 SD 4.3), high functioning (5.1 SD 4.6), younger (5.6 SD 4.9), affluent area residents (5.1 SD 4.2) and accessing > one car (7.2 SD 4.7). Active trips·wk-1 were more frequent in participants who were males (3.4 SD 3.6), normal weight (3.2 SD 3.4), not requiring walking aids (3.5 SD 3.3), well-educated (3.7 SD 0.7), from less deprived neighbourhoods (3.9 SD 3.9) and with ≥ 8 amenities nearby (4.4 SD 3.8).Public transport, and active trip frequency, were significantly associated with steps·d-1 (p < 0.001), even after adjustment for other trip modes and potential confounders. Public transport, active, or car driving trips were independently associated with minutes MVPA·d-1 (p < 0.01).
Daily trips are associated with objectively-measured PA as indicated by daily MVPA and steps. Public transport and active trips are associated with greater PA than those by car, especially as a car passenger. Strategies encouraging increased trips, particularly active or public transport trips, in OAs can potentially increase their PA and benefit public health.
There is increasing interest in the potential role of the natural environment in human health and well-being. However, the evidence-base for specific and direct health or well-being benefits of activity within natural compared to more synthetic environments has not been systematically assessed.
We conducted a systematic review to collate and synthesise the findings of studies that compare measurements of health or well-being in natural and synthetic environments. Effect sizes of the differences between environments were calculated and meta-analysis used to synthesise data from studies measuring similar outcomes.
Twenty-five studies met the review inclusion criteria. Most of these studies were crossover or controlled trials that investigated the effects of short-term exposure to each environment during a walk or run. This included 'natural' environments, such as public parks and green university campuses, and synthetic environments, such as indoor and outdoor built environments. The most common outcome measures were scores of different self-reported emotions. Based on these data, a meta-analysis provided some evidence of a positive benefit of a walk or run in a natural environment in comparison to a synthetic environment. There was also some support for greater attention after exposure to a natural environment but not after adjusting effect sizes for pretest differences. Meta-analysis of data on blood pressure and cortisol concentrations found less evidence of a consistent difference between environments across studies.
Overall, the studies are suggestive that natural environments may have direct and positive impacts on well-being, but support the need for investment in further research on this question to understand the general significance for public health.
Observational studies have shown a positive association between time outdoors and physical activity in children. Time outdoors may be a feasible intervention target to increase the physical activity of youth, but methods are required to accurately measure time spent outdoors in a range of locations and over a sustained period. The Global Positioning System (GPS) provides precise location data and can be used to identify when an individual is outdoors. The aim of this study was to investigate whether GPS data recorded outdoors were associated with objectively measured physical activity.
Participants were 1010 children (11.0 +/- 0.4 years) recruited from 23 urban primary schools in South West England, measured between September 2006 and July 2008. Physical activity was measured by accelerometry (Actigraph GT1M) and children wore a GPS receiver (Garmin Foretrex 201) after school on four weekdays to record time outdoors. Accelerometer and GPS data were recorded at 10 second epochs and were combined to describe patterns of physical activity when both a GPS and accelerometer record were present (outdoors) and when there was accelerometer data only (indoors). ANOVA was used to investigate gender and seasonal differences in the patterns of outdoor and indoor physical activity, and linear regression was used to examine the cross-sectional associations between GPS-measured time outdoors and physical activity.
GPS-measured time outdoors was a significant independent predictor of children's physical activity after adjustment for potential confounding factors. Physical activity was more than 2.5 fold higher outdoors than indoors (1345.8 +/- 907.3 vs 508.9 +/- 282.9 counts per minute; F = 783.2, p < .001). Overall, children recorded 41.7 +/- 46.1 minutes outdoors between 3.30 pm and 8.30 pm, with more time spent outdoors in the summer months (p < .001). There was no gender difference in time spent outdoors. Physical activity outdoors was higher in the summer than the winter (p < .001), whilst there was no seasonal variation in physical activity indoors.
Duration of GPS recording is positively associated with objectively measured physical activity and is sensitive to seasonal differences. Minute by minute patterning of GPS and physical activity data is feasible and may be a useful tool to investigate environmental influences on children's physical activity and to identify opportunities for intervention.
We compare the restorative effects on cognitive functioning of interactions with natural versus urban environments. Attention restoration theory (ART) provides an analysis of the kinds of environments that lead to improvements in directed-attention abilities. Nature, which is filled with intriguing stimuli, modestly grabs attention in a bottom-up fashion, allowing top-down directed-attention abilities a chance to replenish. Unlike natural environments, urban environments are filled with stimulation that captures attention dramatically and additionally requires directed attention (e.g., to avoid being hit by a car), making them less restorative. We present two experiments that show that walking in nature or viewing pictures of nature can improve directed-attention abilities as measured with a backwards digit-span task and the Attention Network Task, thus validating attention restoration theory.
In the general population, attention is reliably enhanced after exposure to certain physical environments, particularly natural environments. This study examined the impacts of environments on attention in children with ADHD.
In this within subjects design, each participant experienced each of three treatments (environments) in single blind controlled trials. Seventeen children 7 to 12 years old professionally diagnosed with ADHD experienced each of three environments-a city park and two other well-kept urban settings-via individually guided 20-minute walks. Environments were experienced 1 week apart, with randomized assignment to treatment order. After each walk, concentration was measured using Digit Span Backwards.
Children with ADHD concentrated better after the walk in the park than after the downtown walk (p = .0229) or the neighborhood walk (p = .0072). Effect sizes were substantial (Cohen's d =.52 and .77, respectively) and comparable to those reported for recent formulations of methylphenidate.
Twenty minutes in a park setting was sufficient to elevate attention performance relative to the same amount of time in other settings. These findings indicate that environments can enhance attention not only in the general population but also in ADHD populations. "Doses of nature" might serve as a safe, inexpensive, widely accessible new tool in the tool kit for managing ADHD symptoms.
While resilience has been defined as resistance to illness, adaptation, and thriving, the ability to bounce back or recover from stress is closest to its original meaning. Previous resilience measures assess resources that may promote resilience rather than recovery, resistance, adaptation, or thriving.
To test a new brief resilience scale.
The brief resilience scale (BRS) was created to assess the ability to bounce back or recover from stress. Its psychometric characteristics were examined in four samples, including two student samples and samples with cardiac and chronic pain patients.
The BRS was reliable and measured as a unitary construct. It was predictably related to personal characteristics, social relations, coping, and health in all samples. It was negatively related to anxiety, depression, negative affect, and physical symptoms when other resilience measures and optimism, social support, and Type D personality (high negative affect and high social inhibition) were controlled. There were large differences in BRS scores between cardiac patients with and without Type D and women with and without fibromyalgia.
The BRS is a reliable means of assessing resilience as the ability to bounce back or recover from stress and may provide unique and important information about people coping with health-related stressors.
The development of competence holds great interest for parents and society alike. This article considers implications from research on competence and resilience in children and adolescents for policy and interventions designed to foster better outcomes among children at risk. Foundations of competence in early development are discussed, focusing on the role of attachment relationships and self-regulation. Results from studies of competence in the domains of peer relations, conduct, school, work, and activities are highlighted. Lessons are drawn from studies of naturally occurring resilience among children at risk because of disadvantage or trauma and also from efforts to deliberately alter the course of competence through early childhood education and preventive interventions. Converging evidence suggests that the same powerful adaptive systems protect development in both favorable and unfavorable environments.
The Conners Teacher Rating Scale (CTRS) is a commonly used research and clinical tool for assessing children's behavior in the classroom. The present study introduces the revised CTRS (CTRS-R) which improves on the original CTRS by (1) establishing normative data from a large, representative North American sample, (2) deriving a factor structure using advanced statistical techniques, and (3) updating the item content to reflect current conceptualizations of childhood disorders. Using confirmatory factor analysis, a six-factor structure was found which includes Hyperactivity-Impulsivity, Perfectionism, Inattention/Cognitive Problems, Social Problems, Oppositionality, and Anxious/Shy factors. The reliability of the scale, as measured by test-retest correlations and internal consistency, is generally satisfactory. Using all of the scale factors to discriminate between attention deficit hyperactivity disordered and normal children, 85 percent of children were correctly classified, supporting the validity of the scale and indicating excellent clinical utility. Similarities and differences between the original CTRS factor structure and the CTRS-R factor structure are discussed.
The Conners' Parent Rating Scale (CPRS) is a popular research and clinical tool for obtaining parental reports of childhood behavior problems. The present study introduces a revised CPRS (CPRS-R) which has norms derived from a large, representative sample of North American children, uses confirmatory factor analysis to develop a definitive factor structure, and has an updated item content to reflect recent knowledge and developments concerning childhood behavior problems. Exploratory and confirmatory factor-analytic results revealed a seven-factor model including the following factors: Cognitive Problems, Oppositional, Hyperactivity-Impulsivity, Anxious-Shy, Perfectionism, Social Problems, and Psychosomatic. The psychometric properties of the revised scale appear adequate as demonstrated by good internal reliability coefficients, high test-retest reliability, and effective discriminatory power. Advantages of the CPRS-R include a corresponding factor structure with the Conners' Teacher Rating Scale-Revised and comprehensive symptom coverage for attention deficit hyperactivity disorder (ADHD) and related disorders. Factor congruence with the original CPRS as well as similarities with other parent rating scales are discussed.
Park-based physical activity is a promising means to satisfy current physical activity requirements. However, there is little research concerning what park environmental and policy characteristics might enhance physical activity levels. This study proposes a conceptual model to guide thinking and suggest hypotheses. This framework describes the relationships between park benefits, park use, and physical activity, and the antecedents/correlates of park use. In this classification scheme, the discussion focuses on park environmental characteristics that could be related to physical activity, including park features, condition, access, aesthetics, safety, and policies. Data for these categories should be collected within specific geographic areas in or around the park, including activity areas, supporting areas, the overall park, and the surrounding neighborhood. Future research should focus on how to operationalize specific measures and methodologies for collecting data, as well as measuring associations between individual physical activity levels and specific park characteristics. Collaboration among many disciplines is needed.
Whilst urban-dwelling individuals who seek out parks and gardens appear to intuitively understand the personal health and well-being benefits arising from 'contact with nature', public health strategies are yet to maximize the untapped resource nature provides, including the benefits of nature contact as an upstream health promotion intervention for populations. This paper presents a summary of empirical, theoretical and anecdotal evidence drawn from a literature review of the human health benefits of contact with nature. Initial findings indicate that nature plays a vital role in human health and well-being, and that parks and nature reserves play a significant role by providing access to nature for individuals. Implications suggest contact with nature may provide an effective population-wide strategy in prevention of mental ill health, with potential application for sub-populations, communities and individuals at higher risk of ill health. Recommendations include further investigation of 'contact with nature' in population health, and examination of the benefits of nature-based interventions. To maximize use of 'contact with nature' in the health promotion of populations, collaborative strategies between researchers and primary health, social services, urban planning and environmental management sectors are required. This approach offers not only an augmentation of existing health promotion and prevention activities, but provides the basis for a socio-ecological approach to public health that incorporates environmental sustainability.
We experienced a case of fetal overgrowth probably due to maternal hyperglycemia following the interruption of insulin therapy in a woman with gestational diabetes mellitus (GDM), probably undiagnosed type 2 diabetes mellitus. A 27-year-old Japanese woman was referred to our center because of GDM at 15 weeks of gestation. During the course of her educational admission, diet control and insulin therapy resulted in favorable blood sugar levels and she was discharged at 17 weeks of gestation. During these periods, fetal growth remained below average at between -1 and -1.5 S.D. After a check-up in the 29th week, she failed to appear for any further appointments. After the onset of labor, at 38 weeks of gestation, she suddenly consulted her former physician who delivered a baby weighing 4852g by cesarean section on the 38th week. A noteworthy point in this case is the growth curve of the fetus. Even if rapid overgrowth is assumed, starting after the time of interruption of insulin at 30 weeks of gestation, fetal weight gain appears to be about 400g per week, suggesting a weight increase at twice the normal rate. This case prompted us to keep in mind that rigid glycemic control will prevent the development of fetal macrosomia in diabetic pregnant women.
Studies have shown associations between health indices and access to "green" environments but the underlying mechanisms of this association are not clear.
To examine associations of perceived neighbourhood "greenness" with perceived physical and mental health and to investigate whether walking and social factors account for the relationships.
A mailed survey collected the following data from adults (n = 1895) in Adelaide, Australia: physical and mental health scores (12-item short-form health survey); perceived neighbourhood greenness; walking for recreation and for transport; social coherence; local social interaction and sociodemographic variables.
After adjusting for sociodemographic variables, those who perceived their neighbourhood as highly green had 1.37 and 1.60 times higher odds of better physical and mental health, respectively, compared with those who perceived the lowest greenness. Perceived greenness was also correlated with recreational walking and social factors. When walking for recreation and social factors were added to the regression models, recreational walking was a significant predictor of physical health; however, the association between greenness and physical health became non-significant. Recreational walking and social coherence were associated with mental health and the relationship between greenness and mental health remained significant.
Perceived neighbourhood greenness was more strongly associated with mental health than it was with physical health. Recreational walking seemed to explain the link between greenness and physical health, whereas the relationship between greenness and mental health was only partly accounted for by recreational walking and social coherence. The restorative effects of natural environments may be involved in the residual association of this latter relationship.
Most studies of social relationships in later life focus on the amount of social contact, not on individuals' perceptions of social isolation. However, loneliness is likely to be an important aspect of aging. A major limiting factor in studying loneliness has been the lack of a measure suitable for large-scale social surveys. This article describes a short loneliness scale developed specifically for use on a telephone survey. The scale has three items and a simplified set of response categories but appears to measure overall loneliness quite well. The authors also document the relationship between loneliness and several commonly used measures of objective social isolation. As expected, they find that objective and subjective isolation are related. However, the relationship is relatively modest, indicating that the quantitative and qualitative aspects of social relationships are distinct. This result suggests the importance of studying both dimensions of social relationships in the aging process.
This chapter examines the convergence of two literatures: one addressing human resilience, the other focused on the natural environment and human well-being. Research evidence suggests that views of and access to nearby nature serve as protective factors, bolstering the resilience of youth. However little effort has been made to explicitly integrate resilience or positive psychology with nature and well-being research and theory. First, a brief historical overview of childhood resilience literature is presented with a focus on the evolution from protective factors to protective mechanisms. Second, the chapter presents research connecting nature to positive outcomes, particularly in the context of stress, adversity, and other risk factors. Third, we consider two particularly viable, well-grounded mechanisms linking nature to resilience: social relationships and cognitive functioning. Lastly, directions for future research are presented. Further examination of the intersection of resilience and the natural environment holds promise for theory as well as practice, and has the potential to substantially influence the lives of children facing the challenges of life in a red zone.
A mail survey of New Hampshire and Vermont households shows that although user fees are widely accepted, they may substantially reduce participation in resource-based recreation by those earning less than 5 daily fee for use of public lands would affect about 49% of low-income people as compared to 33% of high-income respondents. We conclude that potential impacts of this magnitude highlight several critical problems in the design of recreation fee programs.
Ecopsychologists theorize that a sense of connection to nonhuman nature inspires empathy that should lead to proenvironmental behavior. Widely used measures of connectedness to nature consist largely of items we suspect may be endorsed by individuals who feel affectively or spiritually connected to nature yet rarely, if ever, subjectively experience their fundamental physical interdependence with the larger ecosystem. In this paper, we borrow the phrase "participation in nature" (PIN; Elpel, 1999) to refer to activities that involve unmediated intimate interaction with, and immersion in, the wild ecosystem for the purpose of meeting one's basic survival needs. We suggest that these activities represent a form of corporeal connection to nature that is not captured by existing conceptualizations and measures. To explore the relationship between PIN, existing measures of connectedness to nature, and environmental behavior, we surveyed 50 participants at a weeklong earth-living skills gathering, some of whom participate in nature as a lifestyle. As predicted, PIN was significantly positively correlated with connection measures and, like other forms of connection, predicted self-reported environmental decision making. Importantly, regression analyses revealed PIN to be the only significant predictor of green decision making for this particular sample; thus, we consider it a valuable addition to the ecological connection construct. Results of this study and other researchers' recent work point to the importance of conceptually and operationally teasing apart affective, cognitive, and behavioral connections to nature.
Psychological stress was assessed in 3 national surveys administered in 1983, 2006, and 2009. In all 3 surveys, stress was higher among women than men; and increased with decreasing age, education, and income. Unemployed persons reported high levels of stress, while the retired reported low levels. All associations were independent of one another and of race/ethnicity. Although minorities generally reported more stress than Whites, these differences lost significance when adjusted for the other demographics. Stress increased little in response to the 2008–2009 economic downturn, except among middle-aged, college-educated White men with full-time employment. These data suggest greater stress-related health risks among women, younger adults, those of lower socioeconomic status, and men potentially subject to substantial losses of income and wealth.
Urbanization, resource exploitation, and lifestyle changes have diminished possibilities for human contact with nature in urbanized societies. Concern about the loss has helped motivate research on the health benefits of contact with nature. Reviewing that research here, we focus on nature as represented by aspects of the physical environment relevant to planning, design, and policy measures that serve broad segments of urbanized societies. We discuss difficulties in defining "nature" and reasons for the current expansion of the research field, and we assess available reviews. We then consider research on pathways between nature and health involving air quality, physical activity, social cohesion, and stress reduction. Finally, we discuss methodological issues and priorities for future research. The extant research does describe an array of benefits of contact with nature, and evidence regarding some benefits is strong; however, some findings indicate caution is needed in applying beliefs about those benefits, and substantial gaps in knowledge remain. Expected final online publication date for the Annual Review of Public Health Volume 35 is March 18, 2014. Please see http://www.annualreviews.org/catalog/pubdates.aspx for revised estimates.
This paper provides a brief review of past research on leisure constraints, paying particular attention to conceptual and analytical issues and to the practical applications of investigating constraints on leisure behavior. Specific findings are not reviewed; the intention is to clarify concepts by focusing upon broadly‐defined methodological aspects of past research. These include the nature and role of constraints on leisure participation, the distinction between barriers and reasons (e.g., for non‐participation), and empirical and conceptual methods of classifying constraints. It is suggested that future investigations of leisure constraints will give rise to findings that can be generalized across time, space, and social groups only if they are based upon clearly‐defined and standardized concepts.
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.
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.
This study aimed to develop a psychometrically sound measure of the construct of love and deep caring for nature as an expression of people’s personal and explicitly emotional relationship with nature. Expert opinion and pre-pilot surveys were employed for refinement of the item pool, and a sample of 307 university students was used in a major pilot study aiming to further purify scale items. A field trial was conducted using a sample of 261 tourists at leisure with nature. The final 15-item Love and Care for Nature (LCN) scale is differentiated from established measures of similar constructs, and demonstrates high internal consistency and sound validity. This research extends the psychological frameworks of environmental altruism, and has also taken the philosophical concept of biophilia, as love for nature, into the operational realm by making it perceptible and measurable.
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.
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.
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.
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.
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.
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
- S Vries
- 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
- J B Cornell
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.