Abstract
Parks and greenspaces provide well-documented benefits for physical, mental, and social health. Nonprofit hospitals, required to conduct Community Health Needs Assessments (CHNAs) and invest in social determinants of health, could therefore advance health and health equity by supporting park access and quality. We reviewed CHNAs from 51 large nonprofit hospitals in U.S. cities ranking in the lower half of the 2024 Trust for Public Land ParkScore Index. We analyzed how parks and greenspaces were addressed in CHNAs and conducted interviews and focus groups with 29 representatives from hospitals, park agencies, and community organizations. Mental health, access to care, and chronic disease were the most frequently identified community priorities in CHNAs. Although 56.9% of CHNAs included data on greenspaces and 54.9% identified parks as a community need, many CHNAs gave limited attention to parks – largely due to limited familiarity, capacity constraints, and competing priorities rather than opposition. Qualitative findings revealed 4 key themes: (1) CHNAs often included community input but lacked resources and coordination to address built environment needs; (2) parks were widely recognized as vital to mental health and social connection but constrained by inequitable access, safety concerns, and underinvestment; (3) existing collaborations between hospitals, parks, and community groups demonstrated promise yet faced capacity barriers; and (4) historical and ongoing structural racism shaped inequities in park access and investment. Our findings reveal an under tapped opportunity for hospitals to integrate parks and greenspaces into CHNAs, strengthen partnerships with park agencies, and direct community benefit investments toward parks to improve community health outcomes. Doing so could help align hospital community benefit spending with upstream drivers of health. We conclude with recommendations for hospitals, park agencies, and community organizations to collaborate in advancing park equity and health equity.
Introduction
A growing body of research links access to and use of parks and greenspaces to a range of physical and mental health benefits across the lifespan.1 -6 Parks have often been described as urban landscapes with specific purposes of providing passive and active recreation whereas greenspaces are considered public or private land with natural vegetation. 7 However, in many instances, both parks and greenspaces are concurrent infrastructures comprising of natural and non-natural amenities that are beneficial to the environment. 8 Parks and greenspaces mitigate adverse environmental exposures such as air pollution, noise and heat, while supporting health-promoting behaviors including physical activity, social interactions, and quality sleep.9 -11 These benefits align with public health priorities and may contribute to reduced health care costs.12,13
Yet, access to parks and greenspaces is inequitable across the U.S., with racial and ethnic disparities that contribute to broader health inequities. 5 For example, studies in Boston and Miami found that predominantly racially/ethnically marginalized neighborhoods had less access to parks than predominantly white areas.14,15 In some studies, inequities emerge not in access but in park quality and programing. In Baltimore, while predominantly Black neighborhoods had more parks, the parks were smaller and more crowded than those in white neighborhoods. 14 Across various studies, other racially/ethnically marginalized communities, including American Indian, Alaska Native, and Pacific Islanders, reported barriers accessing community parks, personal safety concerns, and poorly maintained or inadequate facilities.16 -18 These inequities reflect longstanding historical forces such as redlining and residential segregation,19 -21 suggesting that expanding equitable park access could support broader health equity goals.
At the same time, nonprofit hospitals represent a largely untapped but potentially powerful partner in addressing these inequities. Under the Affordable Care Act (ACA), all non-profit hospitals in the U.S. are required to conduct Community Health Needs Assessments (CHNAs) every 3 years within the communities they serve. 22 CHNAs are comprehensive reports that assess community health priorities and needs and are meant to inform community investments to address those priorities and needs. 23 The policy builds on a longer history of hospital tax exemption. Until 1969, hospitals were required to provide free or reduced-cost care to low-income patients to qualify for tax-exempt status, a requirement known as the “charity care test.” In 1969, the IRS replaced this with the broader “community benefit” standard, allowing hospitals to demonstrate their charitable purpose through a range of activities that improve community health. This broadened the types of expenditures that would merit tax-exempt status, adding such activities as maintaining an emergency room open to all, professional education and training, and research. 24 The 2010 ACA further institutionalized community benefit by requiring CHNAs every 3 years. At about that time, the IRS introduced a new reporting system, known as Schedule H, which accompanies the Form 990 that tax-exempt hospital organizations file each year (https://www.irs.gov/pub/irs-pdf/f990sh.pdf). Schedule H defines categories of hospital community benefit spending, including: financial assistance; “other benefits” such as community health improvement services, health professional education, and research; and “community building activities” including housing, economic development, and environmental improvements. The instructions for Schedule H (https://www.irs.gov/pub/irs-pdf/i990sh.pdf) provide definitions. “Community health improvement services” are “activities or programs, subsidized by the health care organization, carried out or supported for the express purpose of improving community health,” noting that “such services don’t generate inpatient or outpatient revenue” (p 18). Environmental improvements, according to the IRS instructions, “include, but aren’t limited to, activities to address environmental hazards that affect community health, such as alleviation of water or air pollution, safe removal or treatment of garbage or other waste products, and other activities to protect the community from environmental hazards” (p 3). Investments in parks and greenspaces are therefore fully within scope under these 2 rubrics.
Despite this alignment, little is known about whether and how nonprofit hospitals currently recognize parks and greenspaces within CHNAs, or how hospitals, park agencies, and community organizations might collaborate to advance shared health equity goals. Most prior research on parks and health has focused on documenting health benefits and inequities in access, while studies of hospital community benefit spending have largely examined financial assistance and clinical services.25,26 Few studies have explicitly investigated the intersection of these 2 domains. If hospitals routinely considered park availability and quality in their CHNAs, they might identify additional opportunities for community investment impact across a range of health outcomes. This study aimed to 1) assess the inclusion of parks and greenspace in CHNAs in a national sample of hospitals, and 2) identify barriers to, and opportunities for hospital investments in parks and greenspace.
Methods
We employed a mixed-methods approach, beginning with quantitative data extraction from CHNAs followed by qualitative semi-structured interviews. Our design was in alignment with the equator (Enhancing the QUAlity and Transparency Of health Research) Network, specifically adapting the “Systematic Development of Standards for Mixed Methods Reporting in Rehabilitation Health Sciences Research” by Tovin & Wormley (2023).27,28
Sample Selection for CHNA Review
We identified the cities ranked 50 through 100 (N = 51) in the 2024 ParkScore index. ParkScore, developed by the Trust for Public Land (TPL), annually ranks park systems in the 100 most populous U.S. cities based on access, equity, investment, amenities, and acreage. 29 We selected the bottom-ranked cities because these would be more likely to have park deficits that might be documented in CHNAs. We identified the largest nonprofit hospital in each city by bed count, using the American Hospital Directory, as these hospitals are most likely to shape substantial community health investments. 30 We excluded Veterans Affairs hospitals, Indian Health Service facilities, children’s hospitals, and other specialty facilities since they serve more specific populations and therefore may produce CHNAs with narrower scope, making them less comparable to general hospitals. We obtained the most recent CHNA from each hospital’s website (see Supplemental Materials).
Data Acquisition and Analysis
From each CHNA we extracted descriptive hospital characteristics (number of staffed beds, facility type); methods used in the CHNA; community health priorities identified; presence or absence of mention of parks, greenspace, trails, and walkable outdoor spaces; park indicators used, if any (access, utilization, equity, investments, health-related benefits); and other community health indicators used. The first author (BPT) independently performed the initial data extraction, and a second author (PT) reviewed a random selection of 50% of the sample; any discrepancies in data extraction were reconciled through discussion. Descriptive statistics were used to explore characteristics of CHNAs. All descriptive analyses were conducted using Stata 18. 31
Sample Selection for Interviews
We identified potential informants from all cities in our sample of CHNAs and invited them to participate in interviews to ascertain opportunities and barriers to including parks in CHNAs and to directing hospital investments in community parks. Because we expected that cross-sectoral collaboration among hospitals, park agencies, and community groups such as land trusts and park advocacy groups would facilitate such investment, we invited representatives of all 3 sectors to be interviewed–ideally together, but individually if joint scheduling was challenging. We identified potential hospital interviewees – generally the community engagement staff – through the CHNAs or the hospital’s website, and we identified park agency and community group interviewees through TPL or online search. All participants were offered $100 as either payment or referred donation. We interviewed all potential participants who accepted our invitation.
Interviews
We drew on previous qualitative studies5,32 to develop an interview guide (see Supplemental Material). We constructed the interview guide to query: (1) participants’ reflections on the CHNA; (2) participants’ reflections on parks and greenspace as community needs; (3) existing collaboration between health care institutions, park agencies, and community groups; and (4) impact of discrimination and racism on parks and greenspaces. Interviews were conducted via Zoom by author BPT, lasted up to 60 min, and were audio-recorded and transcribed.
Interview Data Analysis
The authors reviewed interview transcripts as they were completed, iteratively identified themes and defined coding procedures through inductive and deductive reasoning, and extracted interview content. Transcripts from the interviews were analyzed in Dedoose version 9.0.54. 33
Dissemination and Community Engagement
After completing our analysis, we invited all interviewees to a virtual session to gather feedback on our findings and recommendations. Participants were encouraged to share verbal comments during the meeting or submit written input, all of which informed our final conclusions.
Ethics
CHNAs are publicly available sources that contain no identifiable patient information, and we did not collect any identifiable information from individuals who participated in the interviews. The university Institutional Review Board granted this study exemption status. While participants were offered $100 remuneration for participating in interviews, all participants deferred from accepting compensation since they completed the interviews as part of their regular work duties.
Results
CHNA Analysis
Our sample included 51 CHNAs from 16 states: Alaska (n = 1), Arizona (n = 7), California (n = 10), Colorado (n = 1), Florida (n = 3), Kansas (n = 1), Kentucky (n = 2), Louisiana (n = 1), Michigan (n = 1), Nevada (n = 2), New Jersey (n = 1), North Carolina (n = 5), Oklahoma (n = 2), Tennessee (n = 2), Texas (n = 9), and Virginia (n = 3). Almost all CHNAs used a mixed methods approach in collecting data (98%) and involved community members in some aspects of the report (96.1%). The top 3 community health priorities identified were mental health (86.3%), access to health care (60.8%), and chronic diseases (41.2%). Just over half (56.9%) of CHNAs collected general data about greenspaces/parks, whereas about 54.9% clearly mentioned them as community needs. (Table 1).
Descriptives of Community Health Needs Assessments (N = 51).
Figure 1 shows the proportion of CHNAs that mentioned access, utilization, equity, investment, health benefits, and social connection with respect to parks, greenspace, trails, and walkable outdoor spaces. Twenty-three (45%) CHNAs mentioned park access, 19 (37%) mentioned access to walkable outdoor space, 7 (14%) mentioned greenspace access, and 8 (16%) mentioned trail access. Fewer CHNAs addressed utilization: 7 (13%) for parks, 1 (2%) for trails, and 5 (10%) for walkable outdoor space. Smaller numbers of CHNAs assessed equity, investments, health benefits, and social connections in connection with these outdoor settings.
Frequency of park and greenspace measures mentioned as a need among community health needs assessments 2021 to 2023 (n = 51).
Interview Results
We scheduled 9 group interviews and 3 individual interviews between August and November 2024 and interviewed 29 people (8 hospital staff members, 17 park staff members, and 4 community staff members). Using an inductive thematic approach, we organized our findings into 4 main themes described below, each illustrated in greater detail with corresponding sub-themes in Table 2.
Qualitative Themes and Illustrative Quotes.
Theme 1: Reflections on the CHNA
Hospital interviewees described using both secondary data and community input when preparing CHNAs, but noted challenges such as time constraints, limited resources, and difficulties with coordination, particularly when multiple hospitals or health systems participated in a single CHNA. Many reported that CHNAs were shared with community partners to guide programing, such as cooking classes and walking groups. They noted that parks were especially salient for CHNAs during and after the COVID-19 pandemic, when parks were viewed as important resources for supporting mental health and well-being. However, 1 interviewee noted that competing priorities can limit the inclusion of parks and greenspaces in CHNAs. Furthermore, hospital representatives emphasized that there was typically very limited community benefit funding available for direct investment into projects and that the largest investments designated as community benefits consist of uncompensated care and professional education.
Park and community interviewees were generally aware of CHNAs even when parks were not explicitly addressed but few had been directly involved in the CHNA process. Some park agency staff reported using CHNA findings to inform park programing or seek funding that responds to community health needs, often in collaboration with local public health departments.
Theme 2: Perceived Value, Benefits, and Barriers to Parks and Greenspaces
Participants from all sectors recognized parks and greenspaces as vital assets for community well-being, especially during the pandemic when outdoor spaces became essential for physical activity, mental health, and safe social interaction amid widespread closures of indoor facilities. Parks and greenspaces were also viewed as important for fostering social connection, supporting mental health, and creating inclusive public spaces, including for unhoused community members. Participants highlighted the role of parks in community-building and as gathering places that promote a sense of belonging.
Despite the recognized value of parks, participants identified several obstacles to advancing health and health equity through parks. These included limited staff capacity, inadequate funding, and a lack of support from elected officials. Infrastructure challenges were also reported, particularly those that affect the maintenance of existing parks and the expansion of programing.
Several participants emphasized the unequal access to parks and greenspaces. They noted that factors such as location, safety perceptions, and neighborhood infrastructure strongly influence who can benefit from outdoor public spaces. Even in park-dense, low-income areas, concerns about safety were seen as significant barriers to meaningful access. Many participants noted that parks and greenspaces are often treated as low-priority investments in the face of competing demands. Still, some participants described recent policy changes aimed at expanding access, including investments in sidewalks, pedestrian crossings, bike lanes, and improved public transit connections to parks. These efforts were seen as promising steps toward addressing long-standing inequities.
Theme 3: Collaborations Between Health Care Institutions, Park Agencies, and Community Groups
Interviewees from all 3 sectors provided examples of previous or current cross-sector collaborative efforts to advance parks and greenspaces in their area. One park staffer described a collaboration with a local university to address neighborhood food deserts by developing a community garden in a park. Another discussed a collaboration with local service organizations that resulted in dismantling a downtown jail and replacing it with a greenspace for youth sports. Others highlighted how collaborative efforts can center community priorities and expertise. Interviewees cited various perceived benefits of collaborative efforts. One hospital staff member discussed the value of leveraging community voices and input in parks and recreation programing, specifically in the trust and relationship built with the local community.
Despite these successes, participants noted several challenges to collaboration. These included organizational and procedural barriers, as well as limited coordination with potentially helpful partners such as insurance companies. Some described a lack of alignment between non-hospital organizations and hospital-based funding streams, which hindered efforts to expand or sustain collaborative initiatives.
Theme 4: Impact of Discrimination and Racism on Parks and Greenspaces
Interviewees frequently referenced the historical legacy of discriminatory and racist practices on the development and maintenance of parks and greenspaces. In particular, redlining was cited as a key factor shaping current patterns of city land use, including the distribution and maintenance of parks. Participants also pointed to the effects of gentrification, which has driven up housing costs, displaced low-income residents, and changed who has access to quality parks. They also shared that parks have contributed to increasing property values, reinforcing exclusion in already gentrified areas. The legacy of Jim Crow laws was cited in connection with segregated investment in parks and their operations. In addition, participants described how environmentally racist practices continue to shape decisions about where parks are developed and how resources are allocated for their upkeep.
Discussion
This study is among the first to examine how large nonprofit hospitals incorporate parks and greenspaces into CHNAs. In this study of the largest hospitals in 51 cities with lower ParkScore rankings, we found that just over half of CHNAs considered these resources as part of community health needs. Of those CHNAs that collected such data, we found that most focused on access to parks and walkable outdoor spaces; few collected data on access to other greenspaces and trails, and fewer still looked beyond access to measure utilization, equity, or park funding. Access is necessary but not sufficient for advancing health and health equity through parks.5,35 -37 Park amenities (ie, lighting, bathrooms, walking paths, benches, etc.), park quality, safety, and programing to meet local community needs are key to activating those spaces and boosting utilization.38,39 Because parks and greenspace are well established as a public health strategy, especially in the wake of the COVID pandemic, and because the cities studied likely had park deficits in at least some neighborhoods (as evidenced by their ParkScore rankings), these findings suggest that many CHNAs likely overlook a substantial public health opportunity.
In interviews, many respondents acknowledged the potential of parks to deliver community health benefits, but cited a litany of barriers to pursuing these opportunities. For instance, several mentioned the limited knowledge of the public health benefits of parks and limited capacity to acquire the needed information. One health representative shared that “fitness and greenspaces do not come up[. . .]. They don’t emerge without prompting when you’re conducting this [CHNAs], because I think people tend to think of healthcare [. . .as] sufficient primary care.” Another health representative shared “I think the biggest challenge for us has been since the county and our partner network is so large, how to have a manageable group where we can advance and create a document that works for a large segment of the population without having too many people where it stalls the work,” which speaks to barriers with capacity-related challenges to conducting CHNAs. Respondents also noted that hospital funds for investment in assets such as parks are limited. Health and park representatives shared investment-related challenges due to the “struggle with that equity lens and the fact [. . .] that not only community members but elected leaders don’t necessarily get it.” and “ a lot of systematic barriers sometimes, especially with government or rules or [. . .] getting approval for certain things. And so it’s like sometimes it feels like it’s working against you when [. . .] you see a need and you want to invest in it.”
Is it feasible for hospitals to invest in parks and greenspaces as a strategy for community benefit? Feasibility rests on at least 2 conditions. First, hospitals would need to seek information about the availability, access, and quality of parks as part of their CHNAs. Second, if CHNAs revealed park deficits, hospitals would need to prioritize investments accordingly. Our study suggests there is substantial room for improvement in how parks and greenspaces are considered in CHNAs. Strengthening partnerships among hospitals, park departments, and community advocacy groups could help elevate parks as a recognized social determinant of health, alongside other priorities such as housing and access to healthy food.40,41 Local priorities could then determine whether, and how, to prioritize park investments. These gaps matter because access to parks and greenspaces is not equitably distributed, and disparities in park availability, quality, and safety reinforce broader health inequities.15,17 By overlooking parks in CHNAs, hospitals risk missing opportunities to address upstream drivers of health and to partner with local agencies already working toward more equitable access. Given the ACA’s emphasis on social determinants of health and the IRS’s recognition of environmental improvements as eligible community benefit activities, the underrepresentation of parks in CHNAs reflects both a gap in practice and an untapped avenue for advancing health equity.
With regard to funding parks through hospital community investments, some larger context is relevant. Critics have claimed that hospitals underinvest in community benefit; that community benefit spending disproportionately goes to the wealthiest and whitest communities 42,43; that hospital community investments do not reflect community needs, 36 including health inequities 44 ; and that funding for clinical care displaces funding for community-level needs. A particular concern has been the allocation of funds to uncompensated care rather than investments into community spaces or programing. In 2022, only 3.6% of total community benefit spending went to the category of “community health improvement and community benefit operations” – far less than to covering Medicaid reimbursement shortfalls (44.1%) and to financial assistance (16.1%). 25 What may be needed is a larger re-orientation toward identifying community needs and investing in solutions, grounded in innovative CHNAs, robust community advocacy, and effective community partnerships26,45 -48 with parks and greenspace just 1 of the types of investment that could emerge. Of note, while major capital investments to create or renovate parks may be prohibitively expensive for hospitals, limited improvements such as lighting and benches, or programing such as sports teams or community gardening, can deliver substantial health benefits at far lower cost, and are likely more feasible. Investing in initiatives that directly engage clinicians and hospital staff in promoting outdoor recreation, such as social prescriptions for park use and clinician-led park programing,49 -51 can benefit both community members and the healthcare workforce. 52
Success stories suggest that hospital investment in parks and greenspace is indeed feasible. Examples include Boston Medical Center’s rooftop farm, 53 Children’s Hospital of Philadelphia’s initiatives to support green community schoolyards, 54 Tampa General Hospital’s Walk with a Doc program, 51 and Memorial Hermann Health System’s investments in Houston parks. 55 On the other hand, Federal cutbacks in Medicaid legislated in 2025 will likely impose considerable financial pressure on hospitals, especially those that serve the poor, creating pressure to allocate available community funds to uncompensated care.
Our findings suggest several strategies to advance parks and health equity (Table 3). Intentional collaborations between hospitals, park agencies, and community organizations are essential, particularly in communities facing multiple inequities. CHNAs can support these efforts by systematically collecting data on park access, quality, programing, and greenspace availability, using both primary (eg, surveys, interviews, focus groups) and secondary sources (eg, GIS data). Hospitals can align community benefit investments with identified priorities to improve park access and amenities, and their affiliated researchers could collaborate on interdisciplinary grant proposals to evaluate impact of these investments on community health outcomes. Sharing case studies and lessons learned can disseminate best practices and demonstrate returns on investment, and local parks and community organizations can leverage CHNA findings to guide advocacy and programing. Finally, additional research on the economic, climate, and health equity outcomes of hospital-supported park investments is needed to inform future strategies.
Recommendations for Advancing Parks and Health Equity.
Strengths and Limitations
This study is not without limitations. First, while the sample of this study comprised of CHNAs and interviewees from various cities, the sample of CHNAs and interviewees were relatively small and geographically limited (2 cities in Midwest and 1 in Northeast), thus, our findings cannot be generalized across other cities. Additionally, our proportion of community group interviewees were small compared to hospital and park representatives, which potentially limited our findings to understand direct implications of parks and greenspaces for community agencies. While we excluded veterans, children’s and Indian Health Service hospitals in this project, and many of the recommendations are likely applicable to them, future initiatives should include considerations unique to those institutions. Despite these limitations, to our knowledge, this is one of the first papers to comprehensively review CHNAs from across the country through the lens of parks and greenspace provision. Our mixed-methods approach aimed to generate insights and themes rather than produce generalizable estimates. 56 Strengths include the selection of cities with identified needs in their park systems, the systematic analysis of major hospital CHNAs, the in-depth interviews with multisectoral stakeholders, and the engagement of interviewees at the end of the study to formulate and ground-truth the recommendations in Table 3.
Conclusion
Although extensive evidence establishes the value of parks and greenspace in promoting community health, these assets are not systematically or thoroughly assessed in CHNAs. This represents a missed opportunity to identify effective community health investment opportunities. Parks and greenspaces are entirely appropriate forms of hospital community investments under IRA rules, yet they remain underutilized in practice. More routine inclusion could be achieved through advocacy by community groups, stronger partnerships between hospitals, park agencies, and community groups, and dissemination of successful models. Such efforts would not only expand hospital investments in parks and greenspaces but also align them with commonly identified community health priorities, ultimately contributing to improved community health and equity outcomes.
Supplemental Material
sj-docx-1-inq-10.1177_00469580251404376 – Supplemental material for Health Funding for Parks and Greenspace: An Innovative Community Investment Strategy
Supplemental material, sj-docx-1-inq-10.1177_00469580251404376 for Health Funding for Parks and Greenspace: An Innovative Community Investment Strategy by Bryce Puesta Takenaka, Hareen Seerha, Howard Frumkin and Pooja Sarin Tandon in INQUIRY: The Journal of Health Care Organization, Provision, and Financing
Supplemental Material
sj-docx-2-inq-10.1177_00469580251404376 – Supplemental material for Health Funding for Parks and Greenspace: An Innovative Community Investment Strategy
Supplemental material, sj-docx-2-inq-10.1177_00469580251404376 for Health Funding for Parks and Greenspace: An Innovative Community Investment Strategy by Bryce Puesta Takenaka, Hareen Seerha, Howard Frumkin and Pooja Sarin Tandon in INQUIRY: The Journal of Health Care Organization, Provision, and Financing
Footnotes
Acknowledgements
We are grateful to the representatives from hospitals, park agencies, and community organizations who shared their time, insights, and experiences to inform this study.
Ethical Considerations
The Human Subjects Division at the University of Washington determined that this study qualified for exempt status (Approval No. STUDY00020660).
Consent to Participate
All participants provided written consent before participating in the interviews.
Author Contributions
BPT: Conceptualization; Methodology; Data collection; Formal analysis; Writing – original draft; Writing – review & editing. HS; Formal analysis; Writing – original draft; Writing – review & editing. HF: Funding acquisition; Investigation; Supervision; Validation; Conceptualization; Methodology; Writing – original draft; Writing – review & editing. PST: Funding acquisition; Investigation; Project administration; Supervision; Validation; Conceptualization; Methodology; Writing – original draft; Writing – review & editing.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported by the Rx Foundation.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
The CHNA data used in this study is publicly available and is available upon request.
Supplemental Material
Supplemental material for this article is available online.
References
Supplementary Material
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