Using Nature Prescriptions to Reconnect People With the Outdoors and Improve Health and Well Being

Henry David Thoreau, who wrote “An early morning walk is a blessing for the whole day,” clearly understood the importance of nature. Yet this nature connection has largely been lost on society in recent years, a time during which we have seen a dramatic rise in chronic conditions affecting both our physical and mental health. Currently, 41% of adults in the U.S. and 20% of individuals ages 19 or younger are obese.^1,2 Furthermore, 23% of adults have been diagnosed with a mental health condition and 15% of adolescents suffered a major depressive episode in the previous year.^3,4 The Network for Excellence in Health Innovation estimated that 59% of an individual’s health determinants can be positively influenced by nature-based health interventions, thus is not surprising that those in more vulnerable populations who have less access to nearby and/or quality greenspace are at even greater risk of developing chronic diseases.^5,6 Research studies demonstrate that increased time spent in greenspace is associated with many health benefits, including a decreased risk of depression, anxiety, obesity, and diabetes symptoms as well as improved sleep, restoration, connection with others and sense of well-being.^7-16

Recognizing the benefits of greenspace on health and the need to improve the health of our communities, a group including practitioners, the National Park Service, National Environmental Education Foundation, and the Institute at the Golden Gate convened in 2013 to discuss how to implement a national movement to promote and encourage nature prescription programs for healthcare providers. ¹⁷ Nature prescriptions are similar to medication prescriptions but provide details on spending time in an outdoor space that includes a specific location, activity, frequency, and duration for the purpose of improving a specific health condition(s). It is estimated that there are currently over 100 nature prescription programs around the country that vary greatly in terms of target audience, activity prescribed, data collection, and follow-up.

A few studies have evaluated the effects of park prescription programs in terms of both patient and provider benefits. One study reported that adults who received park prescriptions were significantly more likely to spend time and be physically active in parks; this group also reported a significantly greater psychological quality of life. ¹⁸ A study on children who received park prescriptions reported an increase in average weekly physical activity from 150 to 172 minutes and an increase in the number of days per month spent in a park for 30 or more minutes from 7 to 8. ¹⁹ An evaluation of families with park prescriptions either with or without additional organized park visits found a decrease in parental stress both overall and as a function of number of park visits per week. ²⁰ Families issued park prescriptions in the clinic setting but without organized visits to a park reported a greater increase in weekly park visits than those who were issued park prescriptions with organized visits.

Studies that evaluated provider participation in nature prescription programs found that participation in such a program improved counseling on physical activity and that simply participating in a study and receiving reminders influenced actual prescription writing.^21,22 More recently, Kondo et al conducted a systematic review on nature prescription programs and identified eleven studies involving children and families. ²³ They concluded that research, to date, is too sparse to identify health outcomes. Further studies are needed to understand both patient benefits and provider participation.

Park Rx America (PRA) is a national non-profit organization that was founded in 2017 to educate health professionals and the public on the benefits of nature for health and to provide a no-cost platform to issue nature prescriptions. ²⁴ We believe that everybody should have accessible nature-rich areas, and our goal is to make outdoor time a daily routine for all to improve the health of both humans and our planet.

To advance our mission, we speak at conferences and other health organizations, conduct continuing medical education, participate in webinars and other media outlets, and write journal articles.^25,26 We also provide articles and other information on our website and publish a newsletter that discusses research, highlights providers and organizations that have used prescriptions in innovative ways, and provides tips regarding nature prescriptions. In addition, we work with other organizations around the country to help them analyze and implement their own nature prescription programs. We also advocate through op-eds and blogs and advise on legislation to increase greenspace and nature education on state and federal levels.

Our website, parkrxamerica.org, guides individuals and organizations on how to register and issue nature prescriptions. We provide easy-to-follow instructions on how to incorporate nature prescriptions into clinical practice and how to enter a prescription into the electronic medical record or simply print it out. When a patient consents to receiving text reminders, they are prompted to fill their prescription. Every time the prescription is filled, the patient logs their visit, and this data is accessible to the provider who issued it.

Currently, almost 1700 professionals have registered at PRA to issue nature prescriptions, with nearly 50% self-identifying as primary care physicians and 15% as behavioral/mental health providers. Many other professionals have registered, including but not limited to researchers, occupational and physical therapists, kinesiologists, physician assistants, nurses, wellness educators and coordinators, and public health employees. To date, over 5000 prescriptions have been issued and 1264 filled. Nearly 12 000 parks and other natural sites from across the country have been entered into our database, any of which can specifically be prescribed.

We regularly monitor the volume of nature prescriptions being issued and collaborate with individuals and groups of providers who utilize our platform for specific purposes, such as drug withdrawal adjunctive therapy, post-traumatic stress disorder, risk reduction in cardiology patients, and employee wellness programs. We have also worked with registrants with other unique needs, including a pediatric cardiologist who sees children with complex congenital heart disease and a pediatrician who cares for adolescents with mental health diagnoses.

One particular partner who deserves special mention is the Employee Wellness Coordinator in Salt Lake County, Utah, who has implemented a nature prescription program for employees 3 times since 2019 and has issued 1213 nature prescriptions. Through our collaborative survey research, we found that almost all employees reported improved mood and reduced stress from filling their nature prescriptions, and greater than 50% reported enhanced sleep, increased energy, improved relationships with others, and decreased sedentary behavior.

The pandemic has certainly highlighted not only our need for greater resources for mental health and sense of well-being, but also the importance of the outdoors. While many providers think getting patients into nature regularly is a great idea and know how important it is for health, translating this enthusiasm into actual issuing of nature prescriptions has its challenges. PRA is determined to close this gap and, to that end, is working with groups to try different tactics and, in a few cases, through some small studies. We recently worked with several pediatricians in Missouri, where we provided welcome packets and a water bottle, posters for offices, and incentives for writing prescriptions, in addition to regular email reminders to write prescriptions. Although we had a couple of providers write prescriptions on a regular basis, most did not. We are currently working with a group in Houston to assess provider burnout, prescription writing, and connection with nature before and after we provide an educational session and nature enhancements in the clinic. In addition, we are collaborating with Dr Jay Maddock on a survey study of our 1600 providers, to investigate motivating factors and barriers to issuing nature prescription, clinicians’ environmental connectedness, and physician burnout.

Since 2019, PRA has been partnering with Kaiser Permanente Southern California on a 5-year NIH-funded randomized clinical trial with children (ages 6-16) at Unity Health Care to evaluate the effect of nature prescriptions on physical activity, in addition to changes in mental health, BMI, blood pressure, lipids and hemoglobin A1C. Recently, we partnered with Child Trends and the International Rescue Committee to submit a research proposal evaluating the effects of nature prescriptions written by community-based mentors on the mental health of refugee adolescents from high-risk countries. We are excited to have so many partners to help us promote human health through time in nature, and to play our part in research, advocacy and education!