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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.

Keywords

parks greenspace community health needs assessments 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 studies^5,32 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).

Table 1.

Descriptives of Community Health Needs Assessments (N = 51).

Hospital / CHNA characteristics	N (%), Mean (std err)
Year published
2021	7 (13.7)
2022	42 (82.4)
2023	2 (3.9)
Number of staffed hospital beds	660.8 (66.6)
Data collection methods (yes)
Primary data	50 (98.0)
Secondary data	51 (100.0)
Both	50 (98.0)
Data analysis methods (yes)
Quantitative	51 (100.0)
Qualitative	47 (92.2)
Mixed methods	47 (92.2)
Involvement of community members (yes)	49 (96.1)
Top health priorities
1. Mental health	44 (86.3)
2. Access to healthcare	31 (60.8)
3. Chronic diseases	21 (41.2)
4. Socioeconomic barriers	16 (31.4)
Incorporates parks & greenspaces measures in data collection	29 (56.9)
Mentions parks & greenspaces as a community need in CHNA	28 (54.9)

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.

Figure 1.

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.

Table 2.

Qualitative Themes and Illustrative Quotes.

Theme 1: Reflections on the CHNA
Subthemes	Illustrative quote
CHNA process and challenges	“With our interviews and our assessments, there’s a small team of us that do the actual interviews.” – Health Rep “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. [It’s] always a process how to engage people in different capacities to make sure that we have a comprehensive report that meets our accreditation needs, but also truly tells the story of what’s happening in the community.” – Health Rep
Knowledge and use of CHNAs by parks agencies	“I am looking at the community health assessment. I have not been involved with it but I do see that our senior centers are partners.” – Park Rep “Public Health has an Office of Chronic Disease Policy & Prevention that does work closely with our Parks and Rec team [. . .] There’s a strategy that is directly connected to the community health assessment and community health improvement planning that addresses the built environment that you may not see in the official report because it’s focused on broad chronic disease prevention umbrella.” – Park Rep
COVID-19 insights	“The lockdown, for example, kept people separated and in their homes. [. . .] Working on partnering on parks was [. . .] an outgrowth of that. We all wanted to do chronic disease prevention. We all want to do mental health work and it was a nice way to do both. [. . .] Greenspaces are incredibly important for mental health, but they also give a sense of community. So working on parks, we can go on and on about the value of working in parks at both a public health issue and a community interest and trust of public lands absolutely added to that ability to focus there because of their parks scores. So nothing speaks more vehemently to a need than when you talk about disinvestment in low income communities.” – Health Rep
CHNA data and masterplans	“The assessments are really good and valuable, but they provide the most value during the comprehensive planning process because that’s the time when we’re looking more at citywide needs versus individual park needs. So through that master planning process, we’re going to get some high priority information. [For example,. . .] we need to offer more cooking classes or we need to provide more classes for people outside of working hours. So it really is just working with the community [. . .].” – Park Rep
Gaps in park-related data in CHNA	“Fitness and green spaces do not come up [. . .]. They don’t emerge without prompting when we’re conducting this, because I think people tend to think of healthcare [. . .as] sufficient primary care. [. . .] Do they have the specialist care available in the community? Is there access to care through transportation and other sources? Is there healthy foods [. . .]? However, I do think we recognize as a health care organization that green space contributes to people’s healing.” – Health Rep
Theme 2: perceived value, benefits, and barriers to parks and greenspaces
Mental health promotion	“In looking at parks, greenspaces are incredibly important for mental health, but it also is a sense of community. It brings people out of their homes. It brings people together in gathering places. It’s a safe place for people to have kids come. [. . .] It’s also injury prevention and it raises property value.” – Health Rep
Holistic well-being	“During the pandemic, parks really proved their true value for the community because outdoors was considered a safe space for people to get out and people being, home more, they needed space for mental health, physical activity. Gyms were closed, fitness centers, our community centers were closed. So our outdoor green spaces really proved to be a critical element for the overall health and well-being of our community.” – Park Rep
Safe public spaces	“Although we have a very robust procedure for how our folks, manage, assist, connect our homeless population in our parks with services, there’s still a lot to be done[. . .] in thinking about the mental health piece of parks and how important, parks are for assuring homeless folks, that they have a safe place or that they can be connected to a safe place.” – Park Rep “That’s constant feedback from our community. Safety perception is a barrier of entry for them. [. . .] Our low income areas are actually really park dense. But if we don’t have the safety perception, you know that access is not just about physically where they’re living, where they’re going. Because they may feel safer at Shelby Farms, which is very far away from them. And it’s not an easy choice to incorporate into their everyday life, but that might be the park that they’re utilizing if they don’t feel safe at the ten neighborhood parks that are closer to them than Shelby Farms?” – Community Rep
Challenges related to access	“A lot of it, in my opinion, comes down to access, right? And access and convenience is really what trumps everything else. Fast food is popular and good people eat it because it’s convenient, right? It’s quick. Easy. It’s on every corner. And there’s a lot of discussion around other types of access to fresh foods. So you got food deserts? Well, the same can be said for parks and recreation in terms of having park gaps or park deserts as well.” – Park Rep
Challenges related to political buy-in	“I think there are communities that have gone through this and continue to struggle with that equity lens and the fact that [. . .] we still have not only community members but elected leaders that don’t necessarily get it.” – Health Rep
Challenges related to resources and capacity	“ [. . .One] of the biggest barriers has a lot to do with staff capacity and funding [. . .] That’s an example where that is a barrier to investing in or having manual labor in a park.” – Park Rep “We have to rely on our Department of Transportation for most of our Greenway funding, sidewalk projects. We have to ensure that any changes that we are proposing meet their guidelines as far as curb cuts and parking [. . .]. It would be great if we could just put a curb, cut into a park and consider it accessible. But we can’t do that unless we have parking, appropriate crosswalks, all of that infrastructure and we don’t have a funding mechanism to support that. It all comes through transportation. [. . .] When we’re successful, it’s the result of a project being a high priority for both departments.” – Park Rep
Subthemes	Illustrative quote
Theme 3: Collaboration between health care institutions, park agencies, and community groups
Complimentary goals	“We partnered with [university program]. Their previous chancellor was very interested in community gardens and food deserts and targeted a [. . .] passive park or an undeveloped park [. . .] to do a community garden.” – Park Rep
Local partnerships	“They’re going to take down that [jail] and then [the city] is going to invest in creating greenspaces right there. One of the purposes of Lumen is trying to get people to come together to create a safe and safer environment. {. . .] That’s one of those community groups where there’s multiple organizations working together to try to create green space for downtown Louisville. And then we did partner with Louisville Urban league when we created the Weston Youth Sports and Learning Complex.” – Park Rep
Centering community voices and priorities	“For the last three years, we’ve been bringing in services like that, to talk to people about what they’re going through, how they can get supportive services to be healthy [. . .]. So we feel like some of these programs, with our partnership program, are [. . .] really a call to the community to say, Parks and Rec is not the expert in all the things that you have. [If there’s] something that can benefit the community, do it on our space, do it in our a parking lot. [For example,] we have a mobile market for food, that takes place in one of our community centers and our parking lot every other Saturday where people can come. . .and a mobile, preschool, classroom taking place at our parks and in community centers.” – Park Rep “We did a beautiful mural, took forever to get it through the city in terms of all [. . .]the policies that we had to abide by to get the permission. But we finally did and painted it. But we didn’t do it alone. We did it with the community having input [. . .] The handball court players, this is their handball courts, and they didn’t want a bunch of outsiders coming in and painting [. . .]. So, they helped us design it. And the students in high school, which are really close by, painted it under the auspices of their art director that’s at the high school. But that experience helped us relate, develop relationships with the handball players.” - Health Rep
Bureaucratic challenges	“There’s 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. [. . .] It feels like [. . .] you’re climbing up a slippery slope where it’s hard to get to where you need to be. And even if you have a good idea or something nice to do, or even if you could justify the funding for it, then they’ll be like, okay, well you needed to jump through this barrier, this barrier and this barrier because of the different systems in place.” – Health Rep
Challenges to collaborating	“I don’t know how to get hospitals, and insurance companies more involved. [. . .] The research is clear that if people have access to public recreation. Athletic fields, trails, skate parks to go skateboarding, dog parks to run their dogs in, all these outdoor amenities; if people have access, they will be healthier. And typically the goal of the hospital is in fact [. . .they] don’t want the patient coming back for the same issue, right? They get dinged on that. [. . .] I’d love to have insurance companies in the hospital and the medical profession screaming for and advocating for more parks, more open space, more trails [. . .].” – Park Rep
Theme 4: Impact of discrimination and racism on parks and greenspaces
Implications of historical redlining	“I think we’ve learned to live with it. I think we’ve come into a situation where we almost don’t even notice it, and kind of forgot about what the redlining aspect happened in regards to, back in the 50s and 60s here in Wichita. However, I don’t think we really updated our policies.” – Park rep
Gentrification	“Housing prices have significantly increased, which creates an affordable housing issue in Nashville. That’s definitely led to, you know, gentrification of several areas. . . And, you know, there’s only so much land. And so they knock down one house and they build two houses. Right. And people that live in proximity to a great park, that adds a lot of value to them living there.” – Community Rep “And then as far as the rest of the city, it’s really just historical investment gaps. And that’s what the equity push is doing. And what we’ve had to do is just say we recognize historic inequities. I mean, there are our park deeds that I have in my office that literally say Independence Park is for use by white people only.” – Park Rep
Environmental injustices	“I think that with the park access piece, the ADA piece was really challenging for us because a lot of our parks were developed around our stream corridors and so we have a lot of topography. And so to meet those access needs, historically a lot of our playgrounds were in floodplains or floodways, so they are at a significant grade to access them. So building out our infrastructure in those parks is a big challenge for us.” – Park Rep

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 partnerships^26,45
-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.

Table 3.

Recommendations for Advancing Parks and Health Equity.

1. Collaborations between the health sector and parks organizations are necessary to promote health and health equity, particularly for communities facing multiple intersecting inequities. This may need to begin by increasing awareness of why parks and greenspaces are important for health. These collaborations are more likely to happen if organized intentionally rather than leaving it to individuals to collaborate across sectors.
2. CHNAs could be utilized more effectively to advance community health by including data regarding the neighborhood built environment to inform hospital investments. Given known health benefits of parks and greenspaces, hospital CHNAs should collect information about the built environment, including parks and greenspace.
3. Hospital staff working on CHNAs could collaborate with local representatives from their parks departments and community organizations to seek relevant input and identify sources of data and information.
4. CHNAs would ideally include both primary and secondary data sources related to parks and greenspaces, and community input for a comprehensive picture. Most CHNAs already utilize these methods albeit not for park related information. Some specific methods and resources include:
a. Surveys, interviews, and/or focus groups of community members and key informants regarding their access, utilization, and perceived needs pertaining to local parks and other greenspaces (such as trails, green schoolyards, and other public outdoor spaces).
b. GIS-based data on local parks and nature access including metrics such as (1) proportion of residents with access to a park within a 10 min walk (0.5 mi) of home, (2) park acreage, (3) park quality and programing, (4) access to trails, (5) tree canopy coverage.
c. Community advisory boards that include representatives from Parks & Recreation departments, schools, and community organizations that work in this space.
d. Include considerations of equity with respect to race, ethnicity, age, national origin, sexual preference, and other demographic characteristics associated with reduced park use, and inclusive spaces for those with disabilities.
5. Community benefits investments, in alignment with identified health priorities, should include investments in improving access to or activation (amenities, programing) of parks, green community schoolyards, and other public greenspaces to improve health and well-being. Especially when faced with competing priorities, support from the health sector could go a long way in promoting park equity and improving health outcomes. Numerous examples of such investments exist across the U.S.
6. Hospitals and hospital-affiliated research institutions can offer their analytical capabilities to assist park departments in evaluating park investments, particularly in assessing health outcomes.
7. Hospitals, parks, and community organizations should share case studies and lessons learned from cross-sector collaboration for park equity in a diverse range of forums (conferences, meetings, journals, etc) to reach a broad audience from all sectors. When possible, highlight return on investments in terms of health outcomes, health savings, and other metrics relevant to the audience.
8. Parks and community organizations could leverage the findings of CHNAs from their local hospitals to identify areas where they could support community health. They could also use that information for fund-raising and advocacy related to increasing and improving parks and greenspace resources in their community.
9. Additional research and evaluation, including focus on economic benefits, climate impact, and health equity outcomes related to health sector support of park equity, is needed inform future efforts. This work should be undertaken with racial equity and environmental justice considerations so as to avoid unintended negative consequences.

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.

ORCID iDs

Bryce Puesta Takenaka

Pooja Sarin Tandon

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.

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