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Methods
Adherence with park prescriptions for stress amongst low-income families
Nooshin Razani, MD MPH; Michael A. Kohn MD MPP, George Rutherford, MD MA
Center for Nature and Health, UCSF Benioff Children’s Hospital Oakland; Department of Epidemiology and Biostatistics,
University of California at San Francisco
Figure 3. Family nature outings
Social inequities and associated toxic stress result in health inequities for families living in poverty. The Stay
Healthy In Nature Everyday (SHINE) program is a park prescription program designed by a pediatric clinic and
their local park district, and draws on growing research that being in nature decreases stress and improves
health. Compliance with a physician's recommendation to be in nature, and factors associated with compliance
are unknown.
Background
Clinicians have been called upon to intervene and to develop community partnerships to minimize the impact of
stress on poor health outcomes. Because parks provide the readiest access to nature for many individuals living
in urban areas [1], we propose to refer patients to local nature using our clinic's partnerships with our local park
district. We present here the compliance data from patients enrolled in our park prescription evaluation.
Setting
In 2012 our pediatric primary care clinic (PCC) partnered with our local park agency to design a park prescription
program. Our PCC is a Federally Qualified Health Center (FQHC) that serves a linguistically, ra- cially and
culturally diverse group of pediatric patients living near the federal poverty level. This population has higher rates
of chronic illness than the national pediatric population [2].
Intervention design
We hypothesized that just as sustained lifestyle changes for obesity prevention such as changes in diet require
intense behavioral counseling [3], lifestyle changes related to nature will require supports for sustained change.
Low-income populations of color and populations with special needs encounter multiple barriers to experiencing
nature: lack of access [4], lack of leisure time, competing priorities, lack of familiarity, and discrimination faced in
parks [5]. Alleviating a single barrier, such as waiving a park entry fee, has not lead to increased park visitation in
underserved populations [6]. In contrast, across a diversity of respondents, memories of and a history of positive
experiences in nature, especially those with friends and family, are associated with park visits [7]. We therefore
hypothesized that a physician recommendation to be in nature will be more effective if accompanied by
supportive and culturally appropriate reinforcements for creating behavior change.
The Stay Healthy in Nature Everyday (SHINE) study examines two levels of intensity in behavioral counseling.
One group of participants will receive a park prescription in the form of a physician recommendation with written
resources. The other group will receive the same park prescription, plus assistance in planning park outings and
invitations to three successive Saturday afternoon nature outings of four hour dura- tion each with free
transportation and meals provided. The research team, in collaboration with clinic providers, deemed it was
unethical to include a study arm that received no intervention.
The SHINE intervention design has been guided by the Precaution Adoption Process Model (PAPM) described
by Weinstein and Sandman [8], summarized as a logic model in Fig. 1. PAPM proposes healthy behavior change
occurs in stages: not being aware, not being engaged, considering action, deciding whether to act or not to act,
acting and maintaining the choice to act. An individual may progress or regress through the stages. The park
prescription provided to both arms of the study is intended to bring awareness to participants of the health bene-
fits and location of local nature (steps 1, 2). SHINE intervention activities are designed to encourage families to
decide to participate (steps 3, 4, 5), act (step 6) and, through positive experiences in nature, maintain the
behavior of park visitation (step 7).
Those who may benefit the most (with poorest health, highest stress and social isolation) were those least
likely to participate in our park prescription program, even with transportation and food provided.
Study limitations include generalizability to other contexts, climates, or populations. The findings of this study
may not generalize to moderate and high-income families or to those living in other settings. The parks
available to this clinic included a bayfront, a lake, and a forest, areas not accessible to all urban primary care
clinics. The small sample size was also insufficient to examine the impact of the intervention on sub-groups
including groups stratified by age, gender or specific medical condition.
Despite these limitations, this study provides much needed implementation information about a parks
prescriptions program. The SHINE protocol is the first to coalesce varied disciplines into a replicable nature-
based clinical intervention and evaluation. The SHINE study is also intended to examine nature's role as a
health intervention within the contexts of an imperfect and sometimes inequitable medical system. Our study
design allowed us to measure adherence with park prescriptions, to understand which patients benefit from
a parks prescription, and which supports are needed to encourage outdoor time in nature for health.
On going research is necessary to understand how to support high health needs families to engage in the
outdoors for health.
Introduction
Conclusions
A secondary analysis of those in the intervention arm of the SHINE study, a randomized trial of the impact of park
prescriptions on stress on low income patients ages 4-18 and their parent, was conducted. A baseline
questionnaire measured parental stress (PSS10), loneliness (modified UCLA Loneliness score), parental health
and neighborhood social support (NSCH2011), and nature affinity (LCN score). Stress (PSQ8-11) and nature
affinity (CNI score) were measured in children. Dyads received physician counseling, case management and a
prescription to attend three weekly park outings. Transportation and food were provided for outings. Non-
adherence is defined by attending zero or one, adherence as attending two or three prescribed park visits. T-test
or Chi-squared analyses are presented.
Results
Of 50 parent-child dyads, 56% attended at least one outing and 44% were compliant. Parents who were
non-compliant were younger (p=0.01), more likely to be female (RR 0.6 (0.3,1.1)), to report poor health
(p=0.00), higher stress (p=0.03), social isolation (p=0.04), and lower neighborhood social support (p=0.00).
Non-compliant children trended towards higher stress (p=0.06) and lower nature affinity (p=0.05).
CHART or
Figure 2. Written prescription given to Stay
Healthy In Nature Everyday study participants.
Acknowledgements
Photo credits Mona Koh, EBRPD and Nooshin Razani, MD MPH, UCSF Benioff Children’s Hospital Oakland
We would like to thank the patients and staff at UCSF Benioff Children's Hospital Oakland Primary Care
Clinic and Center for Community Health and Engagement, and staff and volunteers at East Bay Re-
gional Parks District. This work was supported by East Bay Regional Parks District, East Bay Regional
Parks Foundation, and the National Recreation and Parks Administration. Funders assisted with study
design. The funders had no role in writing this report or the decision to submit this report for presentation.
References
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Keywords
Environmental Justice, Health Promotion and Education
Learning Areas
Chronic disease management and prevention Clinical medicine applied in public health Environmental
health sciences Epidemiology Planning of health education strategies, interventions, and programs Social
and behavioral sciences
Learning Objectives
Describe barriers to compliance with a park prescription in a low income primary care clinic. Identify patients
who may best benefit from a park prescription in a low income primary care clinic. Discuss the feasibility of
park prescriptions in a low income primary care clinic.!
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