Nature Contact as a Health Behavior: Steps to Maturing the Field

Abstract

There is growing evidence of the positive health benefits of spending time in nature, yet most people in developed economies spend little time in natural environments. Significant disparities in nature contact also exist in several population groups. In this paper, we explore nature contact as a health behavior. We examine the steps that the field of physical activity took starting the in 1990s to become a mature field of study in health behavior. These steps include: 1. creating a professional society and conference; 2. surveillance / common measures; 3. development of national guidelines; 4. a Community Guide review; 5. a Surgeon General’s Report; 6. a National Nature and Health Plan; 7. development of educational Programs; 8. creation of a journal; 9. Funding agency priorities and consensus document; 10. creation of a Centers for Disease Control and Prevention (CDC) Nature and Health Branch; 11. clinical guidelines and reimbursement for nature prescriptions. The proposed steps can reinforce each other, creating a strong, interconnected framework that accelerates the field’s growth and impact.

There is growing evidence of the positive health benefits of spending time in nature (Franco, Shanahan & Fuller, 2017). Time in nature and living in neighborhoods with high levels of green spaces, together referred to as nature contact, have been shown both in ecological and experimental studies to improve mood, reduce stress, improve mental and cardiovascular health, reduce obesity, increase immune function, and improve eyesight (Frumkin et al., 2017). Despite the overwhelming benefits of time in nature, most adults and children spend little time outdoors—as little as 4–7 min a day in free play outdoors according to one source (Clements, 2004). A nationwide survey in the United States indicated that more than 50% of adults spend less than 5 hours a week in nature (Kellert et al., 2017). There are also significant disparities in nature access among different racial and ethnic groups due in part to historical racism, redlining, and environmental injustices (Roberts, 2022).

As we lay out the steps to establish nature contact as a health intervention, we proceed with caution. Although the benefits of nature are widely acknowledged, formalizing nature-based interventions introduces risks, such as creating barriers to access that mirror barriers to accessing medical care, commodifying nature, and disproportionately affecting vulnerable communities (Lantz et al., 2023). Our suggestion of formal structures is not intended to create barriers to entry or diminish the expansive body of findings but to propel advocacy into policy and to organize the science into actionable and inclusive frameworks. We do this entirely acknowledging that fundamental aspects of the field, such as the definition of “nature,” continue to evolve. While our field continues to demonstrate an ever-expanding list of the significant benefits of nature exposure—including an impressive range of outcomes (Nieuwenhuijsen et al., 2017)—the research remains fragmented. The relationship between natural environments and human health is clearly complex and shaped by ecological interdependencies (Coutts et al., 2014). Nature’s benefits are not uniform across populations; they can vary based on age, health status, cultural background, socioeconomic status, and may evolve throughout a person’s lifespan. Nature itself may be a cultural concept, experienced differently by individuals and communities. Indigenous communities, for example, have long recognized the reciprocal relationship between nature and human health, viewing humans as intrinsically connected to nature rather than separate from it (Redvers et al., 2024).

These nuances don’t diminish the urgency of advancing formal approaches to advocate for our right and need to heal in nature. Cohesive frameworks that account for these subtleties, particularly those integrating upstream theories connecting nature to resilience (White et al., 2023) and the mind–body connection (Scott et al., 2021), are essential for advancing the field in actionable ways. The strength of such frameworks lies in their inclusion of diverse findings, voices and perspectives, ensuring that research remains open to multiple interpretations of what nature means and how it impacts health. These frameworks must also consider the socio-cultural factors that influence people’s engagement with nature, as well as the need to account for inequity in accessing any health intervention (Roberts et al., 2008; Mitchell & Popham, 2008; Razani N et al., 2022).

As the concept of healing in nature is universal, we are excited and grateful for the many scientists contributing to this growing field. It is essential that this field continues to support emerging researchers from diverse backgrounds and experiences. Just a few years ago, the connection between nature and health was largely studied by independent scientists scattered at universities across the nation and with unsustainable funding. In 2022, the REI Cooperative Action Fund (https://www.reifund.org/) awarded a grant to a small group of researchers to create the Nature and Health Alliance (https://www.natureandhealthalliance.org/). This meeting was highly successful leading to the development of a mission and vision, leadership structure, and launching of open membership. However, the major question before the group was how do you take a set of individual researchers and practitioners to create a new field?

In many ways, the field of nature contact and health is where the field of physical activity and public health was in the mid-1990s. A few years prior, there had been a major shift in public health thinking and research from the need for vigorous physical activity for health to the health benefits of moderate physical activity. In 1995, the first national physical activity guidelines were released (Pate et al., 1995). This was closely followed by the 1996 Surgeon General’s report on physical activity and health (Howell, 1996). Physical activity was first included on the Behavioral Risk Factor and Surveillance Survey (BRFSS) in 1996 (Centers for Disease Control and Prevention, 2024). The first national physical activity plan was released in 2010 (Physical Activity Alliance, 2024). Today, almost 30 years after the release of the first national guidelines, physical activity is seen as an integral and essential behavior for healthy living. The emerging research on spending time in nature shows a similar portfolio of benefits to physical activity. Indeed, physical activity is often performed in natural settings and can provide both sets of health benefits (Maddock & Frumkin, 2024). In this commentary, we explore how we can follow the physical activity playbook to mature the field of nature and health and hopefully condense the timeline to a much shorter one.

After the physical activity playbook, there are several areas where nature and health could advance the field. These include: (1) creating a professional society and conference; (2) surveillance/common measures; (3) development of national guidelines; (4) a community guide review; (5) a Surgeon General’s report; (6) a national nature and health plan; (7) development of educational programs; (8) creation of a journal; (9) funding agency priorities and consensus document; (10) creation of a Centers for Disease Control and Prevention (CDC) Nature and Health Branch; and (11) clinical guidelines and reimbursement for nature prescriptions. We will review each of these areas in turn. They are not listed in a particular order and they are a list of our experience and expertise and not meant to be exhaustive. Many of these could happen concurrently, but some do need to happen in sequence.

Creation of a Professional Society and Conference

Creating a mature field takes a coordinated national effort. As new fields develop, there tends to be isolated researchers and practitioners in different parts of the country. Given the complexity of most health behavior issues, multidisciplinary efforts are needed to fully comprehend and address them. Creating vehicles for researchers and practitioners to connect on a shared topic are important. Two ways to do this include: the development of a professional society and the hosting of conferences. In physical activity, there are two international societies: the International Society of Physical Activity and Health (https://ispah.org/) and the International Society of Behavioral Nutrition and Physical Activity (https://isbnpa.org/). Each of these organizations also hosts a conference. Both of these organizations have been instrumental in fostering global connections and advancing the field of physical activity and public health.

Professional societies and conferences not only facilitate collaboration but also provide a platform for disseminating research and influencing policy and practice on a national scale. These conferences not only foster national collaboration but also provide a platform to share US insights with international partners, facilitating the exchange of global perspectives and best practices that can accelerate the growth of the field worldwide. This is one area in which nature and health has made good progress. In May 2023, the Nature and Health Alliance was founded in Salt Lake City, Utah with funding from the REI Cooperative Action Fund. Open for membership since December 2023 and exceeding 100 members by October 2024, the Alliance connects researchers and practitioners to address the other items in this playbook. Additionally, the first Nature and Health Alliance Conference will be held in Houston, Texas in April 2025.

Creation of a Journal

One of the difficulties of an interdisciplinary field is that authors tend to publish in their respective disciplines making it difficult to capture all the related research. In the field of health and nature, disciplines including the health sciences, architecture and landscape architecture, parks and recreation, psychology, sociology, economics and other social sciences, tourism, agriculture including horticulture, environmental sciences, and many more. Not only do these fields not share the same journals but they are also not even included in the same citation databases (i.e., PubMed, PsychInfo). This was also recognized as a limitation in the field of physical activity which has researchers from many of the same fields and led to the launching of the International Journal of Behavioral Nutrition and Physical Activity in 2003, Journal of Physical Activity and Health in 2004, and the Journal of Healthy Eating and Active Living in 2020. The editor-in-chief of EcoPsychology has committed to a special issue each year devoted to nature and health of which this is the inaugural issue. A dedicated journal will not only unify diverse disciplines but also increase the field’s credibility, making research more accessible to policymakers and funders.

Surveillance/Common measures

A common saying in program evaluation is, “What gets measured gets done.” Systematic on-going surveillance is essential to knowing how much time people are currently spending in nature, which groups of people are facing disparities in nature access and if we are making progress in getting more people into nature. The landmark study, The Nature of Americans provided a first snapshot of time spent in nature and related adults among American adults (Kellert et al., 2017). Unfortunately, this survey was collected in 2015–2016 and has not been repeated. In the summer of 2024, the CDC added nature questions to their SummerStyles survey. This is the first known US government led collection of nature and health data and could provide a surveillance baseline. By comparison, Natural England has been collecting both an adult and youth survey annually since 2009. A measure of maturity would be adding nature questions to several of the Federal surveillance surveys including the General Social Survey, BRFSS, YRBS, and NHANES. Implementing these surveillance measures will require securing sustained funding and ensuring consistent data collection across regions. Partnerships with universities, NGOs, and private organizations can be explored to pool resources toward these ends.

National Guidelines

One fundamental question that needs to be addressed is how much nature do people need to receive substantial health benefits. One recent study from the United Kingdom found a significant benefit from 2 h a week of self-reported time spent in nature (White et al., 2019). Preliminary data indicate that different doses made be necessary for different health outcomes and that some combination of daily micro doses with monthly macro doses may be most beneficial. For physical activity, a planning committee of five scientists was created by the CDC to organize a workshop. With other invited participants, the group reviewed the existing evidence and created a public health message that was endorsed by both the CDC and the American College of Sports Medicine (Pate et al., 1995). The recommendation was that American adults should accumulate 30 min of moderate intensity physical activity most if not all days of the week. This is remarkably similar to the second edition of the guidelines published in 2018 recommending that adults accumulate 150 min of week of moderate to vigorous physical activity (Piercy et al., 2018). The development of guidelines is essential for tracking progress of public health initiatives and for providing guidance. Much like the physical activity guidelines, these nature guidelines could be tailored for different populations, ensuring that children, adults, and vulnerable groups all benefit from time spent in nature.

Surgeon General’s Report

The Surgeon General has the bully pulpit to bring attention to major public health issues facing the county. Landmark reports on smoking in 1964, nutrition in 1988, and physical activity in 1996 led to focused efforts to address these health behaviors. The release of the 1996 Surgeon General’s Report on Physical Activity and Health was linked to the launching of the National Coalition for Promoting Physical Activity with more than 100 organizational members (Johnson & Ballin, 1996). The release of a Surgeon General’s report indicates the importance of the issue, allows federal agencies to focused resources on the topic, and provides guidance to nonprofit agencies. Securing a Surgeon General’s report involves extensive review, collaboration across agencies, and strong advocacy to ensure the topic receives the national attention it deserves. A Surgeon General’s report would not only bring national attention to nature as a health intervention but could also influence public policy and increase public awareness.

National Nature and Health Plan

Having a nation physical activity plan and eventually state plans helps to focus resources and efforts in the same direction. A coordinating committee took three years to develop the first national physical activity plan (Bornstein et al., 2014). In 2010, the first National Physical Activity Pan was published followed by a second edition in 2016. This plan was essential in providing guidance at both the national, state, and local level (Esparza et al., 2014). Using a sector-based approach, the plan was able to identify priorities and track progress toward overall objectives. The development of a plan could be led by the Nature and Health Alliance and can hopefully influence other strategic plans including Healthy People, state health departments and large non-profit health agencies. As seen with the physical activity plans, state and local governments could adapt these guidelines to meet regional needs

Community Guide Review

The Community Guide (https://www.thecommunityguide.org/) publishes evidence-based recommendations and findings for what works to improve community health. Administrated by the US Department of Health and Human Services and overseen by the Community Preventive Services Task Force, the reviews are seen as the gold standard in the field for evidence-based interventions. Numerous reviews have been published on physical activity with the oldest dating back to 2000. Some of these are nature adjacent such as Park, Trail and Greenway Infrastructure Interventions when combined with additional interventions. There are currently 22 topics assessed by the Community Guide. Adding nature contact to this list would be a powerful step toward improving evidence-based practice. Potential areas for review could include forest bathing and nature prescriptions (Hansen et al., 2017; Kondo et al., 2020). Inclusion in the Community Guide would validate nature-based interventions and influence public health policy and funding decisions.

CDC—Nature and Health Branch

The creation of the Physical Activity and Health Branch within the Division of Nutrition, Physical Activity, and Obesity at the CDC was a major step forward in having a federal government home for physical activity. In the past 25 years, it has provided a mechanism for congress to fund state plans and intervention efforts, has added questions to government surveillance surveys and conducted essential public health research. Today it is contributing to the Active People, Healthy Nation initiative to increase physical activity across settings and sectors. The development of a Nature and Health Branch at the CDC would be a major milestone in maturing the field and provide a mechanism to work across all US states and territories. This office could help ensure a voice for nature and health throughout the CDC, provide state and local funding, and publish research and surveillance data on nature and health. Creating a new branch within the CDC may face obstacles such as budget constraints and competing health priorities, but the long-term benefits to public health make it a worthwhile goal.

Funding agency priorities

Any developing field needs steady funding to drive the epidemiological and intervention research. At the National Institutes of Health, physical activity research grants are now funded across a variety of institutes including the National Cancer Institute, National Heart, Lung, and Blood Institute, National Institute on Aging, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institute of Diabetes and Digestive and Kidney Disease, National Institute of Mental Health, National Institute on Minority Health and Health Disparities, National Institute of Neurological Disorders and Stroke, and the National Institute of Nursing Research. The epidemiological evidence on time spent in nature indicates a systemic effect that improves health in a variety of bodily systems and is important throughout the lifespan. With more longitudinal studies, the effect of nature on several disease states should become apparent and could lead to finding priorities from multiple agencies.

Philanthropic funders should also be explored. One of the major milestones of the physical activity movement was the creation of the Active Living Research program funded by the Robert Wood Johnson Foundation. This effort led by Dr. Jim Sallis provide grants funds to numerous investigators, hosted a conference, brought numerous researchers together from disparate disciplines and created connections between the research and practice communities. Several issues made this effort stand out. Funding was provided for 12 years, and funding was significant enough to build capacity. Visionary funding by groups such as the REI Cooperative Action fund is needed to help develop a field at an expedited timeline. The fact that this field brings together many disciplines and stakeholders is a benefit to attracting funding, as seen in similar efforts in the physical activity field.

Education

One of the hallmarks of a maturing field is the education and training of the next generation of scientists and practitioners. In 1995, the University of South Carolina with funding and support from the CDC launched the postgraduate course on physical activity and public health. In 1998, a concurrent course focused on practitioners was launched. These courses which are still being offered in 2024 bring together that nation’s leading faculty in the discipline with top postdoctoral fellow, junior faculty members, and practitioners. These courses have trained hundreds of fellows over the years and has been strongly linked to advancing the science and practice of the field (Evenson et al., 2015; Evenson et al., 2016). The development of similar training opportunities could help ensure that future researchers and practitioners are trained in the latest nature and nature methodologies.

The creation of shared coursework is also a way to train the next generation. In physical activity, several textbooks have been written. These include Foundations of Physical Activity and Public Health and Physical Activity and Public Health Practice. Shared syllabi and lectures can facilitate teaching across a network. Additionally, training of health care professionals (i.e., physicians, nurses, physical therapists, mental health providers) should include module on health and nature. The development of teaching materials including courses, textbooks and shared syllabi can ensure that the emerging field has a well-trained cadre of new scientists and practitioners to carry on with the work. As healing in nature belongs to all of us on this planet, we are excited and grateful for the many scientists contributing to this field and emphasize the need for this field to remain supportive as possible to upcoming researchers from diverse backgrounds and experiences. Education programs not only develop the next generation of researchers but also ensure the sustainability of the field by connecting research to practice in real-world settings.

Clinical guidelines/reimbursement

Health care professionals can play a major role in encouraging health behaviors. The Exercise is Medicine program which was started in 2007 by the American College of Sports Medicine and grew into a global movement is a promising framework (Thompson et al., 2020). This connects into the idea of social prescriptions for physical activity and healthy food. There has been a nascent movement for nature prescriptions by groups such as ParkRX America (https://parkrxamerica.org/). While promising, health care providers face numerous barriers including lack of reimbursement and not including access to nature in the electronic medical record. These systemic barriers would need to be addressed before nature prescribing will become mainstream. Advocacy efforts will be critical in ensuring that nature prescriptions are recognized and reimbursed, helping integrate them into mainstream health care. Collaborations with insurance companies and public health organizations could be key in advocating for the inclusion of nature prescriptions in health care plans, securing reimbursement, and integrating nature-based interventions into mainstream health care.

Updating the Research Agenda for Nature Contact and Health

In addition to the 10 steps in the physical activity playbook, they are several other activities that could advance the field. One of the landmark papers published in 2017 laid out a research agenda for the field (Frumkin et al., 2017). With a rapidly developing field, a comprehensive update is probably overdue. Some areas may include:

• 1.

The relationship between the natural environment and human health has evolved over time, transitioning from a simplistic view of nature as a source of disease to a more nuanced understanding of the complex ecological interdependencies that exist (Coutts et al., 2014). Recent research has highlighted the significant health benefits associated with exposure to natural environments, including improved physical and mental well-being, reduced stress, and healthier dietary choices. However, the research is diffuse.

2.

Create key research priorities here. Advancing the field of nature-based health will require a concerted effort to establish a robust theoretical foundation, develop rigorous empirical studies, and translate findings into effective public health interventions.

3.

We need to understand what is happening in the person, not just promote programs. To begin, research is needed to elucidate the mechanisms underlying the health-promoting effects of nature exposure. This may include investigating physiological pathways, such as the role of the immune system and stress response, as well as psychological processes, such as attention restoration, emotional regulation, and proenvironmental behavior (Bosch & Sang, 2017).

4.

Beyond that, longitudinal studies are needed to examine the long-term impacts of nature exposure on health outcomes, as well as the potential for nature-based interventions to prevent and manage chronic diseases.

In addition, there is a need to understand the dose–response relationship between nature exposure and health benefits.

We need to understand the community understanding of nature. Nature is a concept that belongs to all of us. It is important that the work we do doesn’t further stigmatize people by making nature less accessible. As such, research should also explore socio-cultural factors that influence people’s engagement with and perceptions of natural environments, as well as the potential for nature-based interventions to promote health equity (Moyers-Kinsella et al., 2022).

Finally, to bridge the gap between research and practice, studies are needed to evaluate the effectiveness of various nature-based health interventions and strategies for implementation within real-world settings, such as health equity urban planning, health care systems, and educational curricula. Key research questions could include exploring the role of nature in mental health interventions and investigating the dose–response relationship between nature exposure and chronic disease prevention. Interdisciplinary research, combining fields such as environmental science, public health, and behavioral psychology, will be essential to uncovering new insights and advancing the understanding of how nature influences human health.

Steps Forward

COVID-19 pandemic stimulated in many people the recognition of the importance of spending time in nature. Although early research connecting health and nature occurred in the early 1980s and showed strong promise, no movement ever coalesced. Today, we face another inflection point. Over the past decade, we have witnessed a massive increase in time spent in front of an electronic devise while deaths of despair have also sky rocketed. In many ways, we face a potential tipping point, where spending time in nature can be viewed as an essential health behavior or it can fade back into relative obscurity. The REI Cooperative Action Fund and the founding of the Alliance has provided a catalyst to create this movement. Implementing the steps above can make this happen. The proposed steps—developing guidelines, forming a professional society, and establishing a CDC branch—will reinforce each other, creating a strong, interconnected framework that accelerates the field’s growth and impact.