Physical Activity in Natural Settings: An Opportunity for Lifestyle Medicine

Abstract

Physical activity is a well-known behavior for promoting health and preventing a variety of chronic diseases. Despite widespread knowledge of the benefits of physical activity, most Americans do not engage in sufficient physical activity. Over the past decade, there has been increasing recognition of the health benefits of spending time in nature, mediated in part through physical activity. This has led to new partnerships across health, parks and recreation, public lands, and environmental organizations to increase time spent, and physical activity, in natural settings. This review assesses the current evidence around physical activity in natural settings (PANS), strategies for promoting PANS including health professional engagement, and current gaps in the research literature.

Keywords

nature exposure greenspace physical activity prescriptions lifestyle medicine behavior change

“Health professionals can help increase their patients’ time spent in nature through prescription programs, modeling, and other programmatic activities.”

Introduction

Regular physical activity provides a wide range of health benefits across the lifespan.^1-7 These include primary and secondary prevention of chronic conditions including cardiovascular disease, diabetes, some cancers, and osteoporosis. Immune function is improved, pain control enhanced, the risk of falls reduced, life expectancy extended. Physical activity appears to have a positive effect on several aspects of mental health including mood, mild cognitive impairment, anxiety, dementia, and depression.^8-11 The Physical Activity Guidelines for Americans recommends that adults get 150-300 minutes a week of moderate physical activity or 75-150 minutes a week of vigorous physical activity a week for health benefits, and that children and adolescents get 60 minutes or more ofmoderate to vigorous physical activity daily.¹² There may be a dose-response relationship in health benefits up to 300 minutes a week of moderate to vigorous physical activity (MVPA).² However, an on-line survey 2 years after the 2018 release of guidelines showed that less than one-quarter of American adults were aware of them.¹³ Indeed, despite almost 30 years of physical activity guidelines, recent CDC data showed that more than one-quarter of Americans got no leisure time physical activity in the past month and only 24% meet both the aerobic and muscle strengthening guidelines (https://www.cdc.gov/nccdphp/dnpao/data-trends-maps/index.html). Given the limited progress in increasing physical activity, new approaches may be needed to motivate sedentary people to become active.

There is growing evidence and recognition of the health benefits of spending time in nature. Like physical activity, nature contact offers a wide range of benefits, ranging from improved cognitive function and mood to pain control, improved immune function, improved birth outcomes, and reduced mortality. These benefits have been extensively reviewed.^14-19 A predisposition to benefit from nature contact may have evolutionary roots, as proposed by biologist E.O. Wilson’s biophilia hypothesis.²⁰ Multiple mechanisms likely operate in delivering the benefits, including stress reduction,²¹ attention restoration,²² social connections,²³ and enhanced immune function.²⁴ One likely pathway is physical activity: natural settings are appealing, even inspiring, venues for walking, jogging, cycling, and other forms of utilitarian and recreational active living.²⁵

Benefits Other than Physical Activity

A discussion of the benefits of PANS would be incomplete without mentioning collateral benefits that accompany the benefits of physical activity. Natural settings such as parks are associated with improved mental health,²⁶ social connections,^23,27 sense of community,²⁸ climate resilience,²⁹ and other benefits, apart from those of physical activity. A full reckoning of public health benefits needs to account for this broad portfolio.

Growing recognition of the health benefits of nature contact may present lifestyle medicine with opportunities to promote physical activity.³⁰ In this narrative review, we examine the following questions at the intersection of 2 health-promoting behaviors—physical activity and nature contact:

1. Does Physical Activity in Natural Settings (PANS) deliver health and well-being benefits above and beyond the benefits of physical activity in indoor or other nature-poor settings?

2. What are the correlates of PANS at the individual and community level?

3. What should be taken into account when promoting PANS in priority populations?

4. What can health professionals do to promote PANS?

Does Physical Activity in Natural Settings (PANS) Deliver Health and Well-Being Benefits Above and Beyond the Benefits of Physical Activity in Indoor or Other Nature-poor Settings?

Physical activity can occur in a variety of contexts, with or without nature contact: people can walk on a forest trail or in a mall, swim in a lake or in a pool, cycle on a Peloton or through a park. Physical activity research, with its roots in exercise science, has typically quantified activity in terms of time (minutes) and intensity (METs, or metabolic equivalents of task), without regard for environmental context.³¹ The metabolic expenditure of over 800 different activities has been quantified.³² Conversely, experimental research on the benefits of nature exposure has typically controlled for physical activity levels, in order to isolate and test the effect of context (the natural environment).³³

The evidence base on the interaction of these 2 variables—the amount of physical activity, and the natural setting of the physical activity—is far more limited than for either individually. The concept of “green exercise” arose in the early 2000s, based on the hypothesis that PANS offers benefits above and beyond those of isocaloric physical activity in non-natural settings.³⁴ Research on green exercise has accumulated in the 2 decades since. In a typical experimental study design, participants exercise in both natural and non-natural settings with equivalent caloric expenditure, and 2 kinds of outcomes are measured before and after each round of exercise: self-reported subjective responses, and objective tests of performance or physiology.

For example, Bailey et al.³⁵ compared the cognitive effects of indoor track and nature trail walks in ten students, using 2 cognitive tests (the Stroop Test and the Backward Digit Span Task) and mobile electroencephalography before and after each walk. Both types of walks yielded improvements, but the nature trail walks led to greater improvement on the Stroop test, significantly higher levels of meditative state on EEG, and greater persistence of these improvements, relative to the indoor track walks. Similarly, Rogerson et al.³⁶ compared the effects of 15 minutes of ergometer cycling in indoor and natural outdoor settings, in a sample of 24 volunteers. They measured directed attention (with the digit span backwards test), mood (with the Profile of Mood States), social interaction (by quantifying conversation with other cyclists while cycling), and self-reported enjoyment of the rides. Directed attention scores worsened during the indoor rides, but improved during natural outdoor rides. Mood remained unchanged in both settings, nor did the indoor and outdoor rides differ with respect to self-reported enjoyment. The natural outdoor rides were associated with significantly greater social interaction than the indoor rides.

Boere at al.³⁷ studied 30 volunteers who took walks in both indoor and outdoor settings. Before and after each walk, subjects completed a visual oddball task, in which repetitive stimuli are irregularly interrupted by a different stimulus, during mobile electroencephalography. The investigators observed improved task performance and an increase in the P300 amplitude, which is associated with attention and working memory, following the outside walk but not the inside walk.

Several systematic reviews of experiments and laboratory studies such as these have been published.^38-42 They converge on several conclusions: that the published studies are highly heterogeneous in study design and outcomes measured, are of low overall quality, and feature considerable risk of bias. There is some suggestion that green exercise may be associated with improved self-reported affect (such as feelings of revitalization and positive engagement, and decreased tension and anger), with greater enjoyment of the activity, and perhaps with lower perceived exertion, compared to indoor exercise, but results for emotion and biological markers have not shown a consistent advantage for green exercise. The available experimental research focuses on short-term outcomes; there is essentially no evidence available comparing long-term (1 year or longer) outcomes of PANS and indoor exercise. Thus, while PANS may be superior to indoor physical activity in at least some respects, the jury is still out.

What are the Correlates of PANS at the Individual and Community Level?

Irrespective of whether PANS is more beneficial than isocaloric indoor physical activity, natural settings may still function as an effective venue for promoting physical activity. Many people like being active in outdoor settings. In 1 study, people who visited local greenspaces at least weekly were 4 times more likely to achieve recommended levels of physical activity than those who never visited.⁴³ A review of 49 greenspace interventions for mental health examined context, mechanism and outcomes to assess what worked, for whom, and in what circumstance.⁴⁴ Optimizing these benefits depends on: a) getting people into natural settings; b) increasing their level of physical activity once they are there; and c) maximizing the benefits that flow from that activity. We address each of these steps below.

What factors are related to increased visits in natural settings?

People contact nature in a range of settings, including public places such as parks, trails, green schoolyards, and community gardens, as well as on private property. Some urban greenspace, such as utility rights-of-way, are “informal” and omitted from official designations.⁴⁵ Parks play an especially important role as most are free and open to all, and widely distributed; accordingly, parks are one of the leading settings for nature contact (even if they are not always fully utilized⁴⁶). Trails and community gardens also provide venues for physical activity. What is associated with visits to such places? A considerable body of evidence helps answer this question. Our discussion follows the social ecological model from the community to the organizational to the individual levels.⁴⁷

At the community level, access is 1 factor related to park visits. If parks are located near where people live, and if the parks are easily reached—without barriers such as busy roadway, fences, or walls, and with convenient public transportation for those who need it—then people visit the parks more frequently.^48-52 The same is true of trails.^53,54 Access to parks and trails varies significantly by geography. According to the CDC’s National Environmental Public Health Tracking network (https://ephtracking.cdc.gov/DataExplorer), 97.3% of people in Illinois live within ½ mile of a park compared to only 29.0% of people in Mississippi.²⁶ Ironically, people in rural areas may have less nearby access to natural areas than people in cities, as much rural land is privately held.⁵⁵

Another dimension of access is cost; people who cannot afford transportation, entry fees, and other costs of a park visit are less likely to visit—a constraint that falls disproportionately on minority communities and on those in poverty.⁵⁶

The neighborhood context also affects park and trail visits. A study in Pittsburgh compared 2 low-income neighborhoods, one of which underwent renovations that improved walkability, reduced incivilities, and improved aesthetics. Increased walkability was associated with a 2.75-fold increase in park visits, while more incivilities and poor esthetics near parks were associated with a nearly 40% reduction in park visits.⁵⁷

Physical features of parks and trails also have an impact on park visits. Facilities such as community centers, playgrounds, fitness equipment, and sports fields; amenities such as benches, shade structures, restrooms, and lighting; paved surfaces and clear signage on trails; natural features such as tree canopy, lawns, and water bodies; overall attractiveness; and good maintenance are all associated with increased visits.^{49,53,54,58-71} Conversely, some features discourage visitation. For example, in a study of trails, tunnels, excessive trailside vegetation and drainage infrastructure, were negatively associated with trail use.⁷² In another study, children, when offered many park features, reported being most eager to visit parks with large adventure playgrounds, giant slides, and interactive areas.⁷³ And in a survey of adolescents in Melbourne, the features identified as most likely to attract them to parks were playground slides, swings, walking and cycling paths, BMX tracks and skate bowls, and the absence of trash and graffiti.⁷⁴ The relative importance of various of these physical features in influencing park and trail visits varies across demographic groups and studies.

Community gardens represent a particular natural setting for physical activity. In addition to the social capital, food security, and environmental benefits they deliver, they are settings for PANS. Gardening can range from light to vigorous physical activity, depending on specific tasks performed (in the range of 2.0 METs for planting and potting, to the range of 5.5 METs for shoveling dirt or mud). A thematic review of 51 studies found that community gardens had a positive impact on reducing body weight and hypertension and increasing physical activity in vulnerable populations.⁷⁵ Three systematic reviews reached differing conclusions with regard to physical activity. The first included 53 studies, with low overall quality, and found mixed results,⁷⁶ the second included 19 studies and found mixed results,⁷⁷ while the third was limited to 8 higher quality studies, and found an association between community gardening and physical activity.⁷⁸ A rigorous randomized trial in Denver, published after those reviews, found an association between community gardening and physical activity.⁷⁹ Factors associated with participation in community gardening include sufficient plots to accommodate those who wish to garden, proximity to home, and a sense of welcoming and belonging (especially for immigrant and refugee populations),⁸⁰ while barriers include legal and policy barriers to the allocation of public land for gardens,⁸¹ as well as potential participants’ time, financial resources, and gardening know-how.^82,83

Programming is a strong correlate of park visits. The parks offer classes, festivals, community services, and other organized activities, people are more likely to visit them. In fact, programming may be an even more important determinant of visits than such factors as perceived threats.^84,85

Public engagement in park and trail design, operation, and oversight is yet another predictor of visits. Communities that feel a sense of ownership, and are actively involved in stewardship of the park or trail, are more likely to use it.⁸⁶

It is not only access, physical features, and programming that are related to park and trail visits; individual and social level factors also matter. People need to feel welcome in a park, to feel a sense of belonging. When this is absent, park visitation declines^87,88—an especially salient factor for members of marginalized communities such as racial and ethnic minorities and immigrants.^89-94 Even if a park is nearby, members of minority communities may be inhibited from visiting due to the racial or ethnic discrimination, lack of knowledge of opportunities, lack of time, and inability to communicate with park employees due to language barriers.^95-98

Perceptions also matter.⁹⁹ When people perceive that a park or trail is safe, nearby, accessible, and of high quality, and that other people (including their friends) use it, they are more likely to use it as well.^99,100 Active marketing of parks has been shown to increase park use, perhaps through positively influencing perception.¹⁰¹ Perceived safety emerges in most studies as a key predictor of park and trail visits, especially for women, seniors, and parents (with respect to their children’s visits).^102,103 In a survey of 3815 adults in 4 U.S. metropolitan areas, people who perceived parks in their communities as safe or very safe had 4.6 times the odds of visiting the parks as those who perceived the parks as unsafe.¹⁰⁴ Interestingly, some users perceive paved trails to be safer than natural-surface trails.¹⁰⁵

Another correlate of visits to parks and greenspace is one’s attitudes and beliefs. Bloemsma et al.,¹⁰⁶ in a longitudinal study of over 3,000 Dutch adolescents, found that people who stated that greenspace was important to them visited parks and greenspaces five to seven times more frequently than those without that belief. A survey of 1,396 people in Singapore, including frequent and infrequent park users and non-users, revealed that “nature orientation,” as reflected by endorsing statements such as “I always think about how my actions affect the environment” and “My relationship to nature is an important part of who I am,” was a stronger determinant of park visitation than any other factor tested (including social norms, accessibility of the parks, and leisure time).¹⁰⁷ And a survey of 516 parents of school-age children in Japan found a strong association between parents’ belief that nature play was beneficial and the frequency of their children’s greenspace visits.¹⁰⁸

It seems intuitive that more visits to parks and trails might be associated with more physical activity—an intuition supported by empirical data.^109-111 But are there ways to strengthen this association? Once people are in natural settings, what factors serve to promote physical activity?

How to Promote Physical Activity in Natural Settings?

Simply having more parkland available is associated with increased park-specific physical activity among young people.¹¹² But as with visits, physical activity in parks and on trails depends in part on facilities and amenities. Correlates of physical activity in parks include sports facilities such as basketball courts and swimming pools; children’s play equipment; paths for walking, jogging, and cycling; natural features such as vegetation, water, and topographical variety; and playing fields.^113-115 A systematic review of interventions to increase park participation and physical activity found evidence supporting playgrounds, safe access to parks, and park renovations and renewal, while noting a risk of bias and issues with study quality.¹¹⁶ On the other hand, elaborate facilities and extensive acreage are not always required; in urban settings, even small pocket parks can promote physical activity, as people walk to them from their homes.¹¹⁷

As climate change intensifies and extreme heat becomes more prevalent, shade is an important predictor of physical activity, not only in parks¹¹⁸ but also in schoolyards^119,120 and in neighborhoods.¹²¹ Trees provide both shade and nature contact, although built shade structures in parks and parklike settings can also reduce temperatures and promote physical activity.¹²²

Neighborhood context also matters for physical activity in natural settings. Auchincloss et al.¹²³ studied a natural experiment—the 2013 construction of a 1.5-mile urban greenway along arterial streets in a poor, high-crime neighborhood in Philadelphia—using systematic observation before and after the construction, both near the greenway and in a comparable comparison neighborhood. There were small increases in MVPA after the greenway was built, but no more than occurred in the comparison neighborhood. The authors concluded that comprehensive improvements to the built and social environment might have been needed to promote physical activity on the greenway.

Organized activities in parks and other urban natural settings, such as yoga classes, volunteer cleanups, organized walks, and sports leagues, are associated with increased physical activity in those settings.^124-129 Park programming for physical activity such as Italy’s “Moving Parks” may be helpful in increasing PANS.¹³⁰ Indeed, the Community Preventive Services Task Force found insufficient evidence that park, trail, and greenway infrastructure alone promote physical activity, but that when combined with additional interventions such as structured programs, they were effective.¹³¹

Importantly, the use of parks and greenspaces for physical activity varies across demographic groups. Males are more likely to utilize these spaces for physical activity than are females.¹³² In a study in Los Angeles parks, with Whites as a baseline, Blacks and English-speaking Latinos were less likely to report park-based physically activity, Spanish-speaking Latinos were equally likely, and Asian/Pacific Islanders more likely (although not with statistical significance).¹³³

Two kinds of natural settings deserve special mention as venues for physical activity: green schoolyard and community gardens. Green schoolyards are schoolyards that have been improved with trees, gardens, and other vegetation; outdoor learning areas; naturalized play equipment; pervious surfaces; and other features. This design approach is grounded in extensive evidence of the benefits of nature contact for children’s health, behavior, and academic achievement.^{15,17,134-137} A systematic review in 2021 summarized numerous observational studies and 6 experimental studies (4 in Europe, 1 in Canada and 1 in the United States). While the results were somewhat mixed, green schoolyards appeared to increase physical activity while reducing sedentary time—a finding corroborated by subsequent studies.^138,139 (In contrast, 1 study found more MVPA on asphalt surfaces than on grassy areas.¹⁴⁰) Features of green schoolyards that promote physical activity include separately demarcated play areas (as opposed to a single continuous space), shade trees, and equipment for climbing and balancing.¹⁴¹ Of note, green schoolyards can double as community parks when school is not in session, if schools execute joint use agreements with city park departments.

The Importance of Nature Connectedness for the Mental Health Benefits of PANS

Once a person goes to a park or greenspace, and once that person engages in physical activity while there, how can the benefits of that physical activity be optimized? Imagine two joggers in a natural setting—one who listens to a podcast through earphones, the other who mindfully “blisses out” on the vegetation and birdsongs. Or imagine two hikers in a natural area, one who feels unfamiliar and uneasy in the surroundings, the other who feels deeply at home and comfortable. Might the same intensity and duration of physical activity, in the same natural setting, be more or less beneficial depending upon differing “receiver” characteristics?

Here the concept of nature connectedness may be relevant. Nature connectedness (also referred to as nature relatedness) refers to the extent to which a person identifies with and feels connected to the natural world.¹⁴² It is a cognitive, affective, and behavioral construct,¹⁴³ operationalized through measures such as the Inclusion of Nature in Self Scale (Schultz, 2001), the Connectedness to Nature Scale¹⁴⁴ (and its brief version¹⁴⁵), the Nature Relatedness Scale¹⁴⁶ (and its brief version¹⁴⁷) and the Attitude Toward Spending Time in Nature Scale.¹⁴⁸ High levels of nature connectedness have been associated with more physical activity and with more time outdoors in both children and adults^149-151 (although not in all studies¹⁵²), with less anxiety,¹⁵³ and with greater life satisfaction and happiness^154-157—perhaps related to, or mediated through, mindfulness while in nature.^158,159 Do people who are more nature-connected benefit more from PANS?

Jenkins et al,¹⁶⁰ in a survey of 262 physically active adults in New Zealand, found a strong association between PANS and eudaimonic well-being (the sense of meaning, purpose, flourishing, self-discovery, and reaching one’s potential)—and found that the association was mediated by nature relatedness (as measured by the Nature Relatedness scale). Other studies of people engaging in PANS, in Portugal,¹⁶¹ Italy,¹⁶² and the U.K.,¹⁶³ also found that greater nature connectedness predicted better outcomes (well-being, psychological restoration, and reduced anxiety, respectively). While the evidence base is sparse, available data suggest that nature connectedness may enhance the benefits of PANS—perhaps suggesting, in turn, that promoting nature connectedness through childhood experiences, education, biophilic environments, and/or other approaches may represent a public health strategy for potentiating the benefits of PANS.^164,165

What Should be Taken Into Account When Promoting PANS in Priority Populations?

Promoting PANS needs to reckon with barriers faces by particular populations. Black, Indigenous, and other People of Color (BIPOC) and immigrant and refugee populations confront historical and current discrimination that can impede their access to natural spaces. People at both ends of the lifespan—children and older adults—bring particular needs, as do people with disabilities.

BIPOC and immigrant/refugee populations, and those who are poor, confront longstanding inequities in available resources, compounded by ongoing discrimination. Parks, playgrounds, and other greenspaces are farther from home, smaller in area, and of poorer quality, than in White and/or affluent neighborhoods.^166-168 Street tree canopy is similarly maldistributed.¹⁶⁹ However, nature contact may deliver disproportionate health benefits to these populations—a phenomenon that has been called the “equigenic effect,” as it functions to reduce health disparities.^170,171 Accordingly, it is especially important to address inequities in nature access, if PANS is to be promoted in marginalized populations. However, improving nature-poor neighborhoods with parks and greenspace may have the unintended consequence of driving up housing prices and property taxes, a phenomenon known as green gentrification; this can result in displacing members established communities.¹⁷² Strategies for equitably improving nature access while avoiding displacement include documenting disparities in greenspace access through mapping, prioritizing the provision of greenspace to areas of relative deprivation; actively engaging communities in the design and stewardship of parks; maintenance to keep public greenspaces safe and inviting; inclusive facility design and programming; connectivity of greenspaces to where people live, through transit and pedestrian/bicycle infrastructure, and anti-displacement policies such as affordable housing provision to minimize disruption caused by green gentrification.^173,174

Children can engage in PANS both in designated playgrounds in schoolyards and parks, and in unstructured natural areas. Indeed, a systematic review of the benefits of nature contact for children identified physical activity as the pathway most strongly supported by evidence.¹⁷ Factors that help get children outdoors and physically active include parents who prioritize nature contact,¹⁰⁸ ample nearby parks and greenspace,^112,175,176 safe routes to parks and greenspaces,¹⁷⁵ perceived safety within the parks and greenspaces,¹⁷⁷ and programmatic initiatives to encourage outdoor activity, including initiatives that engage parents as well as children.^178,179 The evidence on what features of outdoor playgrounds best promote physical activity in children is mixed. A systematic review of studies on playground designs found that playground markings, game equipment, or a combination of the two, were not associated with children’s physical activity levels, but that physical structures such as climbing equipment was.¹⁸⁰ A later meta-analysis of studies of playground interventions and physical activity found that interventions such as the use of multicolored markings and a sporting playground zonal design did increase physical activity, but only to a small degree.¹⁸¹ Evidence suggests that schoolyard features including ample grassy fields, less crowding, shade from trees, and distinct play zones are associated with more physical activity.¹⁴¹

Older adults face several challenges when spending time in nature, including uneven and rough walkways, risk of falls, cognitive decline, dehydration and safety concerns. A systematic review of older adults’ preferences for parks and open space found that needs included more seating options, age-friendly programming, clean rest rooms and easily navigable paths.¹⁸² Although parks are safer and more easily accessible than more undeveloped natural areas, studies in the United States have found that very few older adults use parks, especially when compared to cities in East Asia.¹⁸³ A “walk-along” interview study of older adults in Melbourne parks found that top priorities determining visits included a well-maintained, peaceful and attractive environment with established trees, gardens and birdlife; ample seating; pleasant paths; toilets; cafés; water features; shade/shelter; facilities for grandchildren; and the presence of other people. Features most valued for physical activity included walking paths, organized activities, and fitness equipment.^184,185 A key motivator of park visits for older adults is social connections,^186-188 so amenities that facilitate social contact, such as shaded benches, as well as programming such as gardening classes, may encourage park visits among older adults.

Indoor nature may represent an opportunity to promote physical activity among older adults in institutional settings, even if only light activity. However, a systematic review of indoor nature interventions found that while indoor gardening and horticulture programs were effective in promoting cognition, psychological well-being, social outcomes, and life satisfaction, physical activity did not emerge as a benefit.¹⁸⁹

People with disabilities, including mobility limitations, visual disabilities, and others, confront physical barriers to visiting parks and greenspaces, such as steps, slopes, inaccessible transport, and inaccessible bathrooms.¹⁹⁰ However, social and institutional barriers such as unwelcoming social activities, cultural events, place branding and stigma may be as important.^191,192 These barriers impede visits.¹⁹³ Solutions include careful design of facilities to permit use by people with disabilities^194,195—but also programming that actively engages people with disabilities, building on strengths and contributions they may make.¹⁹⁶

What can Health Professionals do to Promote PANS?

An immediate option for health professionals is to integrate PANS promotion into clinical practice. An emerging therapeutic approach is to “prescribe” nature contact to patients, known as “NatureRx” or “ParkRx.” In these initiatives, health professionals recommend or refer patients to spend more time in nature. Nature prescription programs have varied greatly with respect to the health professional role (prescriber or recommender), the ways in which prescriptions are provided (written or verbal), the content of the prescriptions (specific parks, activities, and “doses” vs general recommendations), the integration with other aspects of health care such as medical records, and follow-up. Reviews have noted that the available studies are small, heterogeneous in design, and methodologically limited, but have suggested that nature prescriptions may have some efficacy.^197-199 It may be difficult for the individual clinician to implement park prescriptions; system-wide programs facilitated by executive leadership may be needed. Further research is needed to determine what forms of nature prescriptions are effective.

Health professionals can also promote PANS by engaging in this behavior themselves. Such modeling has been shown to be effective in promoting healthy behaviors.^200,201 It has the added benefit of promoting the health and well-being of health professionals themselves.

Third, health professionals can engage in community efforts to promote outdoor spaces. These range from “Walk With a Doc” programs to serving on the boards of local park conservancies or outdoor recreational groups. Such efforts can also be undertaken at the institutional level; health institutions can partner with community groups to promote the creation and use of parks and greenspaces. The Perelman School of Medicine at the University of Pennsylvania has worked to promote tree equity in Philadelphia,²⁰² and the M.D. Anderson Cancer Center in Houston has supported that city’s Be Well Communities initiative, in which promoting PANS is a central element (https://www.mdanderson.org/research/research-areas/prevention-personalized-risk-assessment/be-well-communities.html).

Fourth, health professionals can work to direct health funds toward the creation and maintenance of parks and greenspaces. This may occur in any of several ways: inclusion of park equity in Community Health Needs Assessments, followed by community investments to rectify documented deficits or inequities; directing Medicaid funds to parks and greenspace as a social determinant of health, pursuant to Medicaid waivers; and directing funds from health care conversion foundations (also known as health legacy foundations) to parks and greenspaces.²⁰³

Conclusion

Both physical activity and spending time in nature provide a myriad of health benefits. While some evidence exists around short-term benefits additive benefits around PANS, longer term studies are needed. Several factors affect how often people spend time in PANS including access, physical features, neighborhood context and programming. Similar factors affect the extent to which people are physically active once in natural settings, and still other factors may affect the level of benefit they experience once physically active. Specific barriers in BIPOC communities and among children, older adults, and people with disabilities may inhibit time spent in PANS. Health professionals can help increase their patients’ time spent in nature through prescription programs, modeling, and other programmatic activities. Promoting PANS is a potentially powerful way to promote 2 important health behaviors simultaneously.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Jay Maddock

Howard Frumkin

References

Ruegsegger

Booth

. Health benefits of exercise. Cold Spring Harb Perspect Med. 2018;8(7):a029694. doi:10.1101/cshperspect.a029694.

Warburton

DER

Bredin

SSD

. Health benefits of physical activity: a systematic review of current systematic reviews. Curr Opin Cardiol. 2017;32(5):541-556. doi:10.1097/hco.0000000000000437.

Reiner

Niermann

Jekauc

Woll

. Long-term health benefits of physical activity – a systematic review of longitudinal studies. BMC Publ Health. 2013;13(1):813. doi:10.1186/1471-2458-13-813.

Gasana

O'Keeffe

Withers

Greaves

. A systematic review and meta-analysis of the long-term effects of physical activity interventions on objectively measured outcomes. BMC Publ Health. 2023;23(1):1697. doi:10.1186/s12889-023-16541-7.

Janssen

LeBlanc

. Systematic review of the health benefits of physical activity and fitness in school-aged children and youth. Int J Behav Nutr Phys Act. 2010;7(1):40. doi:10.1186/1479-5868-7-40.

Liu

Wang

et al. Time-dependent effects of physical activity on cardiovascular risk factors in adults: a systematic review. Int J Environ Res Public Health. 2022;19(21):14194. doi:10.3390/ijerph192114194.

Nieman

Wentz

. The compelling link between physical activity and the body’s defense system. J Sport Health Sci. 2019;8(3):201-217. doi:10.1016/j.jshs.2018.09.009.

Nuzum

Stickel

Corona

Zeller

Melrose

Wilkins

. Potential benefits of physical activity in MCI and dementia. Behav Neurol. 2020;2020:7807856. doi:10.1155/2020/7807856.

Chekroud

Gueorguieva

Zheutlin

et al. Association between physical exercise and mental health in 1·2 million individuals in the USA between 2011 and 2015: a cross-sectional study. Lancet Psychiatr. 2018;5(9):739-746. doi:10.1016/s2215-0366(18)30227-x.

10.

Peluso

Guerra de Andrade

. Physical activity and mental health: the association between exercise and mood. Clinics. 2005;60(1):61-70. doi:10.1590/s1807-59322005000100012.

11.

Singh

Olds

Curtis

et al. Effectiveness of physical activity interventions for improving depression, anxiety and distress: an overview of systematic reviews. Br J Sports Med. 2023;57:1203-1209. doi:10.1136/bjsports-2022-106195. bjsports-2022-106195

12.

Piercy

Troiano

Ballard

et al. The physical activity guidelines for Americans. JAMA, J Am Med Assoc. 2018;320(19):2020-2028. doi:10.1001/jama.2018.14854.

13.

Piercy

Bevington

Vaux-Bjerke

Hilfiker

Arayasirikul

Barnett

. Understanding contemplators' knowledge and awareness of the physical activity guidelines. J Phys Act Health. 2020;17(4):404-411. doi:10.1123/jpah.2019-0393.

14.

Silva

Matos

Gonçalves

. Nature and human well-being: a systematic review of empirical evidence from nature-based interventions. J Environ Plann Manag 2023;1-58. doi:10.1080/09640568.2023.2227761.

15.

Wen

et al. Greenspace and health outcomes in children and adolescents: a systematic review. Environ Pollut. 2022;314:120193. doi:10.1016/j.envpol.2022.120193.

16.

Gianfredi

Buffoli

Rebecchi

et al. Association between urban greenspace and health: a systematic review of literature. Int J Environ Res Public Health. 2021;18(10):5137. doi:10.3390/ijerph18105137.

17.

Fyfe-Johnson

Hazlehurst

Perrins

et al. Nature and children’s health: a systematic review. Pediatrics. 2021;148(4):e2020049155. doi:10.1542/peds.2020-049155.

18.

Twohig-Bennett

Jones

. The health benefits of the great outdoors: a systematic review and meta-analysis of greenspace exposure and health outcomes. Environ Res. 2018;166:628-637. doi:10.1016/j.envres.2018.06.030.

19.

Jimenez

DeVille

Elliott

et al. Associations between nature exposure and health: a review of the evidence. Int J Environ Res Public Health. 2021;18(9):4790. doi:10.3390/ijerph18094790.

20.

Wilson

. Biophilia. Cambridge, Mass: Harvard University Press; 1984. 157.

21.

Yao

Zhang

Gong

. The effect of exposure to the natural environment on stress reduction: a meta-analysis. Urban For Urban Green. 2021;57:126932. doi:10.1016/j.ufug.2020.126932.

22.

Kaplan

. The Experience of Nature: A Psychological Perspective. New York: Cambridge University Press; 1989.

23.

Huang

Lin

. The relationship between urban green space and social health of individuals: a scoping review. Urban For Urban Green. 2023;85:127969. doi:10.1016/j.ufug.2023.127969.

24.

Kuo

. How might contact with nature promote human health? Exploring promising mechanisms and a possible central pathway. Front Psychol. 2015;6:1093. doi:10.3389/fpsyg.2015.01093.

25.

Calogiuri

Chroni

. The impact of the natural environment on the promotion of active living: an integrative systematic review. BMC Publ Health. 2014;14:873. doi:10.1186/1471-2458-14-873.

26.

Lackey

Tysor

McNay

Joyner

Baker

Hodge

. Mental health benefits of nature-based recreation: a systematic review. Annals of Leisure Research. 2021;24(3):379-393. doi:10.1080/11745398.2019.1655459.

27.

Astell-Burt

Hartig

Putra

IGNE

Walsan

Dendup

Feng

. Green space and loneliness: a systematic review with theoretical and methodological guidance for future research. Sci Total Environ. 2022;847:157521. doi:10.1016/j.scitotenv.2022.157521.

28.

Gómez

Baur

JWR

Hill

Georgiev

. Urban parks and psychological sense of community. J Leisure Res. 2015;47(3):388-398. doi:10.1080/00222216.2015.11950367.

29.

Kabisch

Korn

Stadler

Bonn

, eds. Nature-based Solutions to Climate Change Adaptation in Urban Areas: Linkages between Science, Policy and Practice. Cham, Switzerland: Springer; 2017.

30.

Hoefer

. The Multiple streams framework: understanding and applying the problems, policies, and politics approach. J of Pol Practice Research. 2022;3(1):1-5. doi:10.1007/s42972-022-00049-2.

31.

Sylvia

Bernstein

Hubbard

Keating

Anderson

. Practical guide to measuring physical activity. J Acad Nutr Diet. 2014;114(2):199-208. doi:10.1016/j.jand.2013.09.018.

32.

Ainsworth

Haskell

Herrmann

et al. 2011 Compendium of Physical Activities: a second update of codes and MET values. Med Sci Sports Exerc. 2011;43(8):1575-1581. doi: 10.1249/MSS.0b013e31821ece12.

33.

Bratman

Hamilton

Hahn

Daily

Gross

. Nature experience reduces rumination and subgenual prefrontal cortex activation. Proc Natl Acad Sci U S A. 2015;112(28):8567-8572. doi:10.1073/pnas.1510459112.

34.

Pretty

Peacock

Sellens

Griffin

. The mental and physical health outcomes of green exercise. Int J Environ Health Res. 2005;15(5):319-337. doi:10.1080/09603120500155963.

35.

Bailey

Allen

Herndon

Demastus

. Cognitive benefits of walking in natural versus built environments. World Leisure Journal. 2018;60(4):293-305. doi:10.1080/16078055.2018.1445025.

36.

Rogerson

Gladwell

Gallagher

Barton

. Influences of green outdoors versus indoors environmental settings on psychological and social outcomes of controlled exercise. Int J Environ Res Public Health. 2016;13(4):363. doi:10.3390/ijerph13040363.

37.

Boere

Lloyd

Binsted

Krigolson

. Exercising is good for the brain but exercising outside is potentially better. Sci Rep. 2023;13(1):1140. doi:10.1038/s41598-022-26093-2.

38.

Noseworthy

Peddie

Buckler

et al. The effects of outdoor versus indoor exercise on psychological health, physical health, and physical activity behaviour: a systematic review of longitudinal trials. Int J Environ Res Public Health. 2023;20(3):1669. doi:10.3390/ijerph20031669.

39.

Lahart

Darcy

Gidlow

Calogiuri

. The effects of green exercise on physical and mental wellbeing: a systematic review. Int J Environ Res Public Health. 2019;16(8):1352. doi:10.3390/ijerph16081352.

40.

Mnich

Weyland

Jekauc

Schipperijn

. Psychosocial and physiological health outcomes of green exercise in children and adolescents—a systematic review. Int J Environ Res Public Health. 2019;16(21):4266. doi:10.3390/ijerph16214266.

41.

Thompson Coon

Boddy

Stein

Whear

Barton

Depledge

. Does participating in physical activity in outdoor natural environments have a greater effect on physical and mental wellbeing than physical activity indoors? A systematic review. Environ Sci Technol. 2011;45(5):1761-1772. doi:10.1021/es102947t.

42.

Zhang

Cao

Zhang

. Psychological benefits of green exercise in wild or urban greenspaces: a meta-analysis of controlled trials. Urban For Urban Green. 2022;68:127458. doi:10.1016/j.ufug.2022.127458.

43.

Flowers

Freeman

Gladwell

. A cross-sectional study examining predictors of visit frequency to local green space and the impact this has on physical activity levels. BMC Publ Health. 2016;16:420. doi:10.1186/s12889-016-3050-9.

44.

Masterton

Carver

Parkes

Park

. Greenspace interventions for mental health in clinical and non-clinical populations: what works, for whom, and in what circumstances? Health Place. 2020;64:102338. doi:10.1016/j.healthplace.2020.102338.

45.

Biernacka

Kronenberg

Łaszkiewicz

Czembrowski

Amini Parsa

Sikorska

. Beyond urban parks: mapping informal green spaces in an urban–peri-urban gradient. Land Use Pol. 2023;131:106746. doi:10.1016/j.landusepol.2023.106746.

46.

Evenson

Williamson

Han

McKenzie

Cohen

. United States’ neighborhood park use and physical activity over two years: the National Study of Neighborhood Parks. Prev Med. 2019;123:117-122. doi:10.1016/j.ypmed.2019.03.027.

47.

Sallis

Cervero

Ascher

Henderson

Kraft

Kerr

. An ecological approach to creating active living communities. Annu Rev Publ Health. 2006;27(1):297-322. doi:10.1146/annurev.publhealth.27.021405.102100.

48.

Zhao

Yin

Chi

. Park access affects physical activity: new evidence from geolocated Twitter data analysis. J Urban Des. 2023;28(3):316-335. doi:10.1080/13574809.2022.2118698.

49.

Giles-Corti

Broomhall

Knuiman

et al.

Increasing walking: how important is distance to, attractiveness, and size of public open space?

Am J Prev Med. 2005;28(2 Suppl 2):169-176. doi:10.1016/j.amepre.2004.10.018.

50.

Lee

Mancus

Yuen

Wolff

Jenkins

. What are the factors associated with neighborhood park visits and health in Alabama? A cross-sectional study using a path model. Int J Environ Health Res. 2022;32(7):1542-1553. doi:10.1080/09603123.2021.1897533.

51.

Huang

Guo

. How do travel distance and park size influence urban park visits? Urban For Urban Green. 2020;52:126689. doi:10.1016/j.ufug.2020.126689.

52.

Łaszkiewicz

Kronenberg

Mohamed

Roitsch

De Vreese

. Who does not use urban green spaces and why? Insights from a comparative study of thirty-three European countries. Landsc Urban Plann. 2023;239:104866. doi:10.1016/j.landurbplan.2023.104866.

53.

Starnes

Troped

Klenosky

Doehring

. Trails and physical activity: a review. J Phys Act Health. 2011;8(8):1160-1174. doi:10.1123/jpah.8.8.1160.

54.

Reed

Ballard

Hill

Berrigan

. Identification of effective programs to improve access to and use of trails among youth from under-resourced communities: a review. Int J Environ Res Public Health. 2020;17(21):7707. doi:10.3390/ijerph17217707.

55.

Frost

Goins

Hunter

et al. Effects of the built environment on physical activity of adults living in rural settings. Am J Health Promot. 2010;24(4):267-283. doi:10.4278/ajhp.08040532.

56.

Zanon

Doucouliagos

Hall

Lockstone-Binney

. Constraints to park visitation: a meta-analysis of north American studies. Leisure Sci. 2013;35(5):475-493. doi:10.1080/01490400.2013.831294.

57.

Richardson

Ghosh-Dastidar

Collins

et al. Improved street walkability, incivilities, and esthetics are associated with greater park use in two low-income neighborhoods. J Urban Health. 2020;97(2):204-212. doi:10.1007/s11524-019-00416-7

58.

Sugiyama

Francis

Middleton

Owen

Giles-Corti

. Associations between recreational walking and attractiveness, size, and proximity of neighborhood open spaces. Am J Public Health. 2010;100(9):1752-1757. doi:10.2105/AJPH.2009.182006.

59.

Song

Newman

Huang

. Factors influencing long-term city park visitations for mid-sized US cities: a big data study using smartphone user mobility. Sustain Cities Soc. 2022;80:103815. doi:10.1016/j.scs.2022.103815.

60.

Zhang

Feng

Shi

et al. Health promoting green infrastructure associated with green space visitation. Urban For Urban Green. 2021;64:127237. doi:10.1016/j.ufug.2021.127237

61.

Grilli

Mohan

Curtis

. Public park attributes, park visits, and associated health status. Landsc Urban Plann. 2020;199:103814. doi:10.1016/j.landurbplan.2020.103814.

62.

Mertens

Van Cauwenberg

Veitch

Deforche

Van Dyck

. Differences in park characteristic preferences for visitation and physical activity among adolescents: a latent class analysis. PLoS One. 2019;14(3):e0212920. doi:10.1371/journal.pone.0212920.

63.

Zhang

Zhou

. Recreational visits to urban parks and factors affecting park visits: evidence from geotagged social media data. Landsc Urban Plann. 2018;180:27-35. doi:10.1016/j.landurbplan.2018.08.004

64.

Rung

Mowen

Broyles

Gustat

. The role of park conditions and features on park visitation and physical activity. J Phys Act Health. 2011;8 Suppl 2(Suppl 2):S178-S187.

65.

Van Puyvelde

Deforche

Mertens

et al. Park features that encourage park visitation among older adults: a qualitative study. Urban For Urban Green. 2023;86:128026. doi:10.1016/j.ufug.2023.128026.

66.

Dobbinson

Simmons

Chamberlain

et al. Examining health-related effects of refurbishment to parks in a lower socioeconomic area: the ShadePlus natural experiment. Int J Environ Res Public Health. 2020;17(17):6102. doi:10.3390/ijerph17176102

67.

Johansen

Reynolds

Wolch

et al. The association of trail features with self-report trail use by neighborhood residents. J Phys Act Health. 2020;17(7):1-8. doi:10.1123/jpah.2019-0347.

68.

McNeill

Murguiaa

Nguyen

Taylor

. Walking trail use among a sample of black, white, hispanic, and asian adult walkers. J Phys Act Health. 2015;12 Suppl 1(Suppl 1):S31-S39. doi:10.1123/jpah.2013-0391.

69.

Orstad

McDonough

Klenosky

Mattson

Troped

. Correlates of trail use for recreation and transportation on 5 Massachusetts trails. J Phys Act Health. 2016;13(8):845-853. doi:10.1123/jpah.2015-0457.

70.

Orstad

Szuhany

Tamura

Thorpe

Jay

. Park proximity and use for physical activity among urban residents: associations with mental health. Int J Environ Res Public Health. 2020;17(13):4885 doi:10.3390/ijerph17134885.

71.

Cohen

Talarowski

Han

et al. Playground design and physical activity. Am J Prev Med. 2023;64(3):326-333. doi:10.1016/j.amepre.2022.10.012.

72.

Reynolds

Wolch

Byrne

et al. Trail characteristics as correlates of urban trail use. Am J Health Promot. 2007;21(4 Suppl):335-345. doi:10.4278/0890-1171-21.4s.335.

73.

Veitch

Ball

Flowers

Deforche

Timperio

. Children’s ratings of park features that encourage park visitation, physical activity and social interaction. Urban For Urban Green. 2021;58:126963. doi:10.1016/j.ufug.2020.126963.

74.

Veitch

Salmon

Deforche

et al. Park attributes that encourage park visitation among adolescents: a conjoint analysis. Landsc Urban Plann. 2017;161:52-58. doi:10.1016/j.landurbplan.2016.12.004.

75.

Malberg Dyg

Christensen

Peterson

. Community gardens and wellbeing amongst vulnerable populations: a thematic review. Health Promot Int. 2020;35(4):790-803. doi:10.1093/heapro/daz067.

76.

Hume

Grieger

Kalamkarian

D’Onise

Smithers

. Community gardens and their effects on diet, health, psychosocial and community outcomes: a systematic review. BMC Publ Health. 2022;22(1):1247. doi:10.1186/s12889-022-13591-1.

77.

Kunpeuk

Spence

Phulkerd

Suphanchaimat

Pitayarangsarit

. The impact of gardening on nutrition and physical health outcomes: a systematic review and meta-analysis. Health Promot Int. 2020;35(2):397-408. doi:10.1093/heapro/daz027.

78.

Lampert

Costa

Santos

Sousa

Ribeiro

Freire

. Evidence on the contribution of community gardens to promote physical and mental health and well-being of non-institutionalized individuals: a systematic review. PLoS One. 2021;16(8):e0255621. doi:10.1371/journal.pone.0255621.

79.

Litt

Alaimo

Harrall

et al. Effects of a community gardening intervention on diet, physical activity, and anthropometry outcomes in the USA (CAPS): an observer-blind, randomised controlled trial. Lancet Planet Health. 2023;7(1):e23-e32. doi:10.1016/S2542-5196(22)00303-5.

80.

Goralnik

Radonic

Garcia Polanco

Hammon

. Growing community: factors of inclusion for refugee and immigrant urban gardeners. Land. 2022;12(1):68. doi:10.3390/land12010068.

81.

Mikulec

Diduck

Froese

Unger

MacKenzie

. Legal and policy barriers to community gardening in winnipeg, Canada. Can J Urban Res. 2013;22(2):69-89.

82.

Diaz

Webb

Warner

Monaghan

. Barriers to community garden success: demonstrating framework for expert consensus to inform policy and practice. Urban For Urban Green. 2018;31:197-203. doi:10.1016/j.ufug.2018.02.014.

83.

Delshad

. Community gardens: an investment in social cohesion, public health, economic sustainability, and the urban environment. Urban For Urban Green. 2022;70:127549. doi:10.1016/j.ufug.2022.127549.

84.

Cohen

Han

Derose

et al. The paradox of parks in low-income areas: park use and perceived threats. Environ Behav. 2016;48(1):230-245. doi:10.1177/0013916515614366.

85.

Cohen

Han

Derose

et al. Neighborhood poverty, park use, and park-based physical activity in a Southern California city. Soc Sci Med. 2012;75(12):2317-2325. doi:10.1016/j.socscimed.2012.08.036.

86.

Derose

Marsh

Mariscal

Pina-Cortez

Cohen

. Involving community stakeholders to increase park use and physical activity. Prev Med. 2014;64:14-19. doi:10.1016/j.ypmed.2014.03.019.

87.

Fernandez

Shinew

Stodolska

. Effects of acculturation and access on recreation participation among Latinos. Leisure Sci. 2015;37(3):210-231. doi:10.1080/01490400.2014.991436.

88.

Sharaievska

Stodolska

Shinew

Kim

. Perceived discrimination in leisure settings in Latino urban communities. Leisure/Loisir. 2010;34(3):295-326. doi:10.1080/14927713.2010.521319.

89.

Rishbeth

Blachnicka-Ciacek

Darling

. Participation and wellbeing in urban greenspace: ‘curating sociability’ for refugees and asylum seekers. Geoforum. 2019;106:125-134. doi:10.1016/j.geoforum.2019.07.014.

90.

Powers

Lee

Pitas

Graefe

Mowen

. Understanding access and use of municipal parks and recreation through an intersectionality perspective. J Leisure Res. 2020;51(4):377-396. doi:10.1080/00222216.2019.1701965.

91.

Biernacka

Łaszkiewicz

Kronenberg

. Park availability, accessibility, and attractiveness in relation to the least and most vulnerable inhabitants. Urban For Urban Green. 2022;73:127585. doi:10.1016/j.ufug.2022.127585.

92.

Das

Fan

French

. Park-use behavior and perceptions by race, hispanic origin, and immigrant status in Minneapolis, MN: implications on park strategies for addressing health disparities. J Immigr Minor Health. 2017;19(2):318-327. doi:10.1007/s10903-015-0339-1.

93.

Powers

Webster

Agans

Graefe

Mowen

. Engagement, representation, and safety: factors promoting belonging and positive interracial contact in urban parks. Urban For Urban Green. 2022;69:127517. doi:10.1016/j.ufug.2022.127517.

94.

Tedeschi

Heino

Jämsä

Klemettilä

. The multidimensionality of urban nature: the well-being and integration of immigrants in Finland. Urban For Urban Green. 2022;74:127645. doi:10.1016/j.ufug.2022.127645.

95.

Franzini

Taylor

Elliott

et al. Neighborhood characteristics favorable to outdoor physical activity: disparities by socioeconomic and racial/ethnic composition. Health Place. 2010;16(2):267-274. doi:10.1016/j.healthplace.2009.10.009.

96.

Stodolska

Shinew

Acevedo

Izenstark

. Perceptions of urban parks as havens and contested terrains by Mexican-Americans in Chicago neighborhoods. Leisure Sci. 2011;33(2):103-126. doi:10.1080/01490400.2011.550220.

97.

Wang

Brown

Liu

. The physical and non-physical factors that influence perceived access to urban parks. Landsc Urban Plann. 2015;133:53-66. doi:10.1016/j.landurbplan.2014.09.007.

98.

Stodolska

Shinew

Camarillo

. Constraints on recreation among people of color: toward a new constraints model. Leisure Sci. 2020;42(5-6):533-551. doi:10.1080/01490400.2018.1519473.

99.

Park

. Psychological park accessibility: a systematic literature review of perceptual components affecting park use. Landsc Res. 2017;42(5):508-520. doi:10.1080/01426397.2016.1267127.

100.

Ries

Voorhees

Roche

Gittelsohn

Yan

Astone

. A quantitative examination of park characteristics related to park use and physical activity among urban youth. J Adolesc Health. 2009;45(3 Suppl):S64-S70. doi:10.1016/j.jadohealth.2009.04.020.

101.

Richardson

Han

Williamson

Cohen

Park

. Park marketing strategies, park conditions, and park use: a longitudinal national study of parks. J Phys Act Health. 2019;16(12):1154-1162. doi:10.1123/jpah.2018-0426.

102.

Talal

Santelmann

. Visitor access, use, and desired improvements in urban parks. Urban For Urban Green. 2021;63:127216. doi:10.1016/j.ufug.2021.127216.

103.

Derose

Han

Park

Williamson

Cohen

. The mediating role of perceived crime in gender and built environment associations with park use and park-based physical activity among park users in high poverty neighborhoods. Prev Med. 2019;129:105846. doi:10.1016/j.ypmed.2019.105846.

104.

Lapham

Cohen

Williamson

et al. How important is perception of safety to park use? A four-city survey. Urban Stud. 2016;53(12):2624-2636. doi:10.1177/0042098015592822.

105.

Reed

Morrison

Arant

C-A

. Profile differences of users of paved versus natural-surface trails. J Phys Act Health. 2009;6(1):112-118. doi:10.1123/jpah.6.1.112.

106.

Bloemsma

Gehring

Klompmaker

et al. Green space visits among adolescents: frequency and predictors in the PIAMA birth cohort study. Environ Health Perspect. 2018;126(4):047016. doi:10.1289/ehp2429.

107.

Sia

Tan

Kim

KBH

. Use and non-use of parks are dictated by nature orientation, perceived accessibility and social norm which manifest in a continuum. Landsc Urban Plann. 2023;235:104758. doi:10.1016/j.landurbplan.2023.104758.

108.

Truong

Nakabayashi

Hosaka

. Parents’ orientation is more important for children’s visits to greenspaces than the availability of spaces and time. Landsc Urban Plann. 2023;235:104738. doi:10.1016/j.landurbplan.2023.104738.

109.

Veitch

Rodwell

Abbott

Carver

Flowers

Crawford

. Are park availability and satisfaction with neighbourhood parks associated with physical activity and time spent outdoors? BMC Publ Health. 2021;21(1):306. doi:10.1186/s12889-021-10339-1.

110.

Evenson

Cho

Rodríguez

Cohen

. Park use and physical activity among adolescent girls at two time points. J Sports Sci. 2018;36(22):2544-2550. doi:10.1080/02640414.2018.1469225.

111.

Hughey

Wende

Stowe

Kaczynski

Schipperijn

Hipp

. Frequency of neighborhood park use is associated with physical activity among adults in four US cities. J Phys Act Health. 2021;18(5):603-609. doi:10.1123/jpah.2020-0540.

112.

Stewart

Verma

Rajbhandari

Antonakos

Colabianchi

. Park area and physical activity among children and adolescents: findings from the healthy communities study. J Phys Act Health. 2023;20:792-798. doi:10.1123/jpah.2022-0420.

113.

Liu

Chen

Yan

. Identifying park spatial characteristics that encourage moderate-to-vigorous physical activity among park visitors. Land. 2023;12(3):717. Available from: https://mdpi-res.com/d_attachment/land/land-12-00717/article_deploy/land-12-00717-v2.pdf?version=1679465285

114.

Stewart

Moudon

Littman

Seto

Saelens

. The association between park facilities and duration of physical activity during active park visits. J Urban Health. 2018;95(6):869-880. doi:10.1007/s11524-018-0311-1.

115.

El-Kholy

Moustafa

Abou El-Ela

MAS

. Urban park design and children’s physical activity levels: an investigation of design characteristics of green areas and playgrounds. J Eng Appl Sci. 2022;69(1):93. doi:10.1186/s44147-022-00152-x.

116.

Wheeler

Zuo

. The effectiveness of interventions to increase participation and physical activities in parks: a systematic review of the literature. Int J Environ Res Public Health. 2022;19(19):12590. doi:10.3390/ijerph191912590.

117.

Cohen

Marsh

Williamson

et al. The potential for pocket parks to increase physical activity. Am J Health Promot. 2014;28(3 Suppl):S19-S26. doi:10.4278/ajhp.130430-QUAN-213

118.

Kabisch

Kraemer

. Physical activity patterns in two differently characterised urban parks under conditions of summer heat. Environ Sci Pol. 2020;107:56-65. doi:10.1016/j.envsci.2020.02.008

119.

Lanza

Alcazar

Durand

Salvo

Villa

Kohl

. Heat-resilient schoolyards: relations between temperature, shade, and physical activity of children during recess. J Phys Act Health. 2023;20:134-141. doi:10.1123/jpah.2022-0405

120.

Pfautsch

Wujeska-Klause

Walters

. Outdoor playgrounds and climate change: importance of surface materials and shade to extend play time and prevent burn injuries. Build Environ. 2022;223:109500. doi:10.1016/j.buildenv.2022.109500.

121.

Tabatabaie

Litt

Carrico

. A study of perceived nature, shade and trees and self-reported physical activity in denver. Int J Environ Res Public Health. 2019;16(19):3604.

122.

Buller

English

Buller

et al. Shade sails and passive recreation in public parks of Melbourne and Denver: A randomized intervention. Am J Public Health. 2017;107(12):1869-1875. doi:10.2105/ajph.2017.304071

123.

Auchincloss

Michael

Kuder

Shi

Khan

Ballester

. Changes in physical activity after building a greenway in a disadvantaged urban community: a natural experiment. Prev Med Rep. 2019;15:100941. doi:10.1016/j.pmedr.2019.100941

124.

Cohen

Han

Derose

Williamson

Marsh

McKenzie

. Physical activity in parks: a randomized controlled trial using community engagement. Am J Prev Med. 2013;45(5):590-597. doi:10.1016/j.amepre.2013.06.015

125.

Ward Thompson

Roe

Aspinall

. Woodland improvements in deprived urban communities: what impact do they have on people's activities and quality of life? Landsc Urban Plann. 2013;118:79-89. doi:10.1016/j.landurbplan.2013.02.001

126.

King

Litt

Hale

Burniece

Ross

. ‘The park a tree built’: evaluating how a park development project impacted where people play. Urban For Urban Green. 2015;14(2):293-299. doi:10.1016/j.ufug.2015.02.011.

127.

Cranney

Phongsavan

Kariuki

et al. Impact of an outdoor gym on park users’ physical activity: a natural experiment. Health Place. 2016;37:26-34. doi:10.1016/j.healthplace.2015.11.002.

128.

Han

Cohen

Derose

Marsh

Williamson

Loy

. Effectiveness of a free exercise program in a neighborhood park. Prev Med Rep. 2015;2:255-258. doi:10.1016/j.pmedr.2015.03.010

129.

Cohen

Golinelli

Williamson

Sehgal

Marsh

McKenzie

. Effects of park improvements on park use and physical activity: policy and programming implications. Am J Prev Med. 2009;37(6):475-480. doi:10.1016/j.amepre.2009.07.017

130.

Toselli

Bragonzoni

Dallolio

et al. The effects of park based interventions on health: the Italian project “moving parks. Int J Environ Res Public Health. 2022;19(4):2130. doi:10.3390/ijerph19042130

131.

Community Preventive Services Task Force . Physical Activity: Park, Trail, and Greenway Infrastructure Interventions to Increase Physical Activity. Atlanta: Centers for Disease Control and Prevention; 2021. Available from: https://www.thecommunityguide.org/content/tffrs-physical-activity-park-trail-greenway-infrastructure-interventions-increase-physical-activity

132.

Derose

Han

Williamson

Cohen

. Gender disparities in park use and physical activity among residents of high-poverty neighborhoods in Los Angeles. Wom Health Issues. 2018;28(1):6-13. doi:10.1016/j.whi.2017.11.003

133.

Derose

Han

Williamson

Cohen

RAND Corporation . Racial-ethnic variation in park use and physical activity in the city of Los Angeles. J Urban Health. 2015;92(6):1011-1023. doi:10.1007/s11524-015-9994-8

134.

Lohr

Krause

McClelland

et al. The impact of school gardens on youth social and emotional learning: a scoping review. J Adventure Educ Outdoor Learn. 2021;21(4):371-384. doi:10.1080/14729679.2020.1838935.

135.

Johnstone

Martin

Cordovil

et al. Nature-based early childhood education and children's social, emotional and cognitive development: a mixed-methods systematic review. Int J Environ Res Public Health. 2022;19(10):5967. doi:10.3390/ijerph19105967.

136.

Browning

MHEM

Rigolon

. School green space and its impact on academic performance: a systematic literature review. Int J Environ Res Public Health. 2019;16(3):429. doi:10.3390/ijerph16030429.

137.

Jin

Hua

Jiang

et al. Effect of outdoor activity on myopia onset and progression in school-aged children in northeast China: the Sujiatun Eye Care Study. BMC Ophthalmol. 2015;15:73. doi:10.1186/s12886-015-0052-9.

138.

van Dijk-Wesselius

Maas

van Vugt

van den Berg

. A comparison of childre’s play and non-play behavior before and after schoolyard greening monitored by video observations. J Environ Psychol. 2022;80:101760. doi:10.1016/j.jenvp.2022.101760.

139.

Fernandes

Ubalde-López

Yang

et al. School-based interventions to support healthy indoor and outdoor environments for children: a systematic review. Int J Environ Res Public Health. 2023;20(3):1746. doi:10.3390/ijerph20031746.

140.

Hazlehurst

Wolf

Simmons

et al. Physical activity and social interaction assessments in schoolyard settings using the system for observing outdoor play environments in neighborhood schools (SOOPEN). Int J Behav Nutr Phys Act. 2023;20(1):94. doi:10.1186/s12966-023-01483-5.

141.

Raney

Daniel

Jack

. Impact of urban schoolyard play zone diversity and nature-based design features on unstructured recess play behaviors. Landsc Urban Plann. 2023;230:104632. doi:10.1016/j.landurbplan.2022.104632.

142.

Restall

Conrad

. A literature review of connectedness to nature and its potential for environmental management. J Environ Manage. 2015;159:264-278. doi:10.1016/j.jenvman.2015.05.022.

143.

Schultz

. Inclusion with nature: understanding the psychology of human-nature interactions. In: Schmuck

Schultz

, eds. The Psychology of Sustainable Development. New York: Kluwer; 2002:61-78.

144.

Mayer

Frantz

. The connectedness to nature scale: a measure of individuals’ feeling in community with nature. J Environ Psychol. 2004;24(4):503-515. doi:10.1016/j.jenvp.2004.10.001.

145.

Navarro

Galharret

J-M

Olivos

et al. The brief version of the “connectedness to nature scale”: factorial structure and invariance study across seven European cities. Ecopsychology. 2022;14(3):190-199. doi:10.1089/eco.2021.0058.

146.

Nisbet

Zelenski

Murphy

. The nature relatedness scale: linking individuals' connection with nature to environmental concern and behavior. Environ Behav. 2009;41(5):715-740. doi:10.1177/0013916508318748.

147.

Nisbet

Zelenski

. The NR-6: a new brief measure of nature relatedness. Front Psychol. 2013;4:813. doi:10.3389/fpsyg.2013.00813.

148.

Maddock

Suess

Bratman

et al. Development and validation of an attitude toward spending time in nature scale. Ecopsychology. 2022;14(3):200-211. doi:10.1089/eco.2022.0017.

149.

Puhakka

Pyky

Lankila

et al. Physical activity, residential environment, and nature relatedness in young men-A population-based MOPO study. Int J Environ Res Public Health. 2018;15(10):2322. doi:10.3390/ijerph15102322.

150.

Molina-Cando

Escandón

Van Dyck

et al. Nature relatedness as a potential factor to promote physical activity and reduce sedentary behavior in Ecuadorian children. PLoS One. 2021;16(5):e0251972. doi:10.1371/journal.pone.0251972.

151.

Dillon

Lee

STH

. Green spaces as healthy places: correlates of urban green space use in Singapore. Int J Environ Res Public Health. 2023;20(17):6711. doi:10.3390/ijerph20176711.

152.

Teixeira

Gabriel

Martinho

et al. Connectedness to nature does not explain the variation in physical activity and body composition in adults and older people. Int J Environ Res Public Health. 2021;18(22):11951. doi:10.3390/ijerph182211951.

153.

Martyn

Brymer

. The relationship between nature relatedness and anxiety. J Health Psychol. 2016;21(7):1436-1445. doi:10.1177/1359105314555169.

154.

Zelenski

Nisbet

. Happiness and feeling connected: the distinct role of nature relatedness. Environ Behav. 2014;46(1):3-23. doi:10.1177/0013916512451901.

155.

Pritchard

Richardson

Sheffield

McEwan

. The relationship between nature connectedness and eudaimonic well-being: a meta-analysis. J Happiness Stud. 2020;21(3):1145-1167. doi:10.1007/s10902-019-00118-6.

156.

Cervinka

Roderer

Hefler

. Are nature lovers happy? On various indicators of well-being and connectedness with nature. J Health Psychol. 2012;17(3):379-388. doi:10.1177/1359105311416873.

157.

Martin

White

Hunt

Richardson

Pahl

Burt

. Nature contact, nature connectedness and associations with health, wellbeing and pro-environmental behaviours. J Environ Psychol. 2020;68:101389. doi:10.1016/j.jenvp.2020.101389.

158.

Richardson

Hamlin

Butler

Thomas

Hunt

. Actively noticing nature (not just time in nature) helps promote nature connectedness. Ecopsychology. 2022;14(1):8-16. doi:10.1089/eco.2021.0023.

159.

Sadowski

Böke

Mettler

Heath

Khoury

. Naturally mindful? The role of mindfulness facets in the relationship between nature relatedness and subjective well-being. Curr Psychol. 2022;41(8):5358-5373. doi:10.1007/s12144-020-01056-w.

160.

Jenkins

Lee

Houge Mackenzie

Hargreaves

Hodge

Calverley

. Nature-based physical activity and hedonic and eudaimonic wellbeing: the mediating roles of motivational quality and nature relatedness. Front Psychol. 2022;13:783840. doi:10.3389/fpsyg.2022.783840.

161.

Loureiro

Veloso

. Exercício Físico Outdoor, Bem-Estar e Conectividade com a Natureza. Psico. 2014;45(3):299-304.

162.

Sella

Meneghetti

Muffato

et al. The influence of individual characteristics on perceived restorativeness and benefits associated with exposure to nature in a garden. Front Psychol. 2023;14:1130915. doi:10.3389/fpsyg.2023.1130915.

163.

Lawton

Brymer

Clough

Denovan

. The relationship between the physical activity environment, nature relatedness, anxiety, and the psychological well-being benefits of regular exercisers. Front Psychol. 2017;8:1058. doi:10.3389/fpsyg.2017.01058.

164.

Yue

Chen

. Direct, indirect, and vicarious nature experiences collectively predict preadolescents' self-reported nature connectedness and conservation behaviors. PeerJ. 2023;11:e15542. doi:10.7717/peerj.15542.

165.

Alves

Betrabet Gulwadi

Nilsson

. An exploration of how biophilic attributes on campuses might support student connectedness to nature, others, and self. Front Psychol. 2021;12:793175. doi:10.3389/fpsyg.2021.793175.

166.

Klompmaker

Hart

Bailey

et al. Racial, ethnic, and socioeconomic disparities in Multiple measures of blue and green spaces in the United States. Environ Health Perspect. 2023;131(1):017007. doi:10.1289/EHP11164.

167.

Rigolon

. A complex landscape of inequity in access to urban parks: a literature review. Landsc Urban Plann. 2016;153:160-169. doi:10.1016/j.landurbplan.2016.05.017.

168.

Nesbitt

Meitner

Girling

Sheppard

SRJ

. Who has access to urban vegetation? A spatial analysis of distributional green equity in 10 US cities. Landsc Urban Plann. 2019;181:51-79. doi:10.1016/j.landurbplan.2018.08.007.

169.

Schwarz

Fragkias

Boone

et al. Trees grow on money: urban tree canopy cover and environmental justice. PLoS One. 2015;10(4):e0122051. doi:10.1371/journal.pone.0122051.

170.

Rigolon

Browning

McAnirlin

Yoon

. Green space and health equity: a systematic review on the potential of green space to reduce health disparities. Int J Environ Res Public Health. 2021;18(5):2563. doi:10.3390/ijerph18052563.

171.

Mitchell

Popham

. Effect of exposure to natural environment on health inequalities: an observational population study. Lancet. 2008;372:1655-1660.

172.

Cole

HVS

Garcia Lamarca

Connolly

JJT

Anguelovski

. Are green cities healthy and equitable? Unpacking the relationship between health, green space and gentrification. J Epidemiol Community Health. 2017;71(11):1118-1121. doi:10.1136/jech-2017-209201.

173.

Hughey

Stewart

Zeidler

Shulaker

Bray-Simons

Yip

. Key park equity policies: toward a 10-minute walk park equity policy framework. San Francisco: Trust for Public Land; 2023. Available from: https://10minutewalk.org/wp-content/uploads/2023/07/062223_10-Minute-Walk_Policy_Framework-FINAL.pdf.

174.

Chapple

Loukaitou-Sideris

Miller

Zeger

. The role of local housing policies in preventing displacement: a literature review. J Plann Lit. 2022;38(2):200-214. doi:10.1177/08854122221137859.

175.

Gemmell

Ramsden

Brussoni

Brauer

. Influence of neighborhood built environments on the outdoor free play of young children: a systematic, mixed-studies review and thematic synthesis. J Urban Health. 2023;100(1):118-150. doi:10.1007/s11524-022-00696-6.

176.

Zhang

C-Q

Lai

Kwan

M-P

. Park and neighbourhood environmental characteristics associated with park-based physical activity among children in a high-density city. Urban For Urban Green. 2022;68:127479. doi:10.1016/j.ufug.2022.127479.

177.

Truong

Nakabayashi

Hosaka

. How to encourage parents to let children play in nature: factors affecting parental perception of children's nature play. Urban For Urban Green. 2022;69:127497. doi:10.1016/j.ufug.2022.127497.

178.

Larouche

Kleinfeld

Charles Rodriguez

et al. Determinants of outdoor time in children and youth: a systematic review of longitudinal and intervention studies. Int J Environ Res Public Health. 2023;20(2):1328. doi:10.3390/ijerph20021328.

179.

Lee

E-Y

Bains

Hunter

et al. Systematic review of the correlates of outdoor play and time among children aged 3-12 years. Int J Behav Nutr Phys Act. 2021;18(1):41. doi:10.1186/s12966-021-01097-9.

180.

Escalante

García-Hermoso

Backx

Saavedra

. Playground designs to increase physical activity levels during school recess: a systematic review. Health Educ Behav. 2014;41(2):138-144. doi:10.1177/1090198113490725.

181.

Pfledderer

Kwon

Strehli

Byun

Burns

. The effects of playground interventions on accelerometer-assessed physical activity in pediatric populations: a meta-analysis. Int J Environ Res Public Health. 2022;19(6):3445. doi:10.3390/ijerph19063445.

182.

Levy-Storms

Chen

Loukaitou-Sideris

. Older adults' needs and preferences for open space and physical activity in and near parks: a systematic review. J Aging Phys Act. 2018;26(4):682-696. doi:10.1123/japa.2016-0354.

183.

Maddock

. Why Communities Should be Designing Parks for Older Adults. Melbourne: The Conversatoin. 2017. Available from: https://theconversation.com/why-communities-should-be-designing-parks-for-older-adults-67626.

184.

Veitch

Flowers

Ball

Deforche

Timperio

. Designing parks for older adults: a qualitative study using walk-along interviews. Urban For Urban Green. 2020;54:126768. doi:10.1016/j.ufug.2020.126768.

185.

Veitch

Ball

Rivera

et al. What entices older adults to parks? Identification of park features that encourage park visitation, physical activity, and social interaction. Landsc Urban Plann. 2022;217:104254. doi:10.1016/j.landurbplan.2021.104254.

186.

Yung

EHK

WKO

Chan

EHW

. Elderly satisfaction with planning and design of public parks in high density old districts: an ordered logit model. Landsc Urban Plann. 2017;165:39-53. doi:10.1016/j.landurbplan.2017.05.006.

187.

Kemperman

Timmermans

. Green spaces in the direct living environment and social contacts of the aging population. Landsc Urban Plann. 2014;129(0):44-54. doi:10.1016/j.landurbplan.2014.05.003.

188.

Enssle

Kabisch

. Urban green spaces for the social interaction, health and well-being of older people— an integrated view of urban ecosystem services and socio-environmental justice. Environ Sci Pol. 2020;109:36-44. doi:10.1016/j.envsci.2020.04.008.

189.

Yeo

Elliott

Bethel

White

Dean

Garside

. Indoor nature interventions for health and wellbeing of older adults in residential settings: a systematic review. Gerontol. 2020;60(3):e184-e199. doi:10.1093/geront/gnz019.

190.

Lepoglavec

Papeš

Lovrić

Raspudić

Nevečerel

. Accessibility of urban forests and parks for people with disabilities in wheelchairs, considering the surface and longitudinal slope of the trails. Sustainability. 2023;15(10):7741. doi:10.3390/su15107741.

191.

Wojnowska-Heciak

Suchocka

Błaszczyk

Muszyńska

. Urban parks as perceived by city residents with mobility difficulties: a qualitative study with in-depth interviews. Int J Environ Res Public Health. 2022;19(4):2018. doi:10.3390/ijerph19042018.

192.

Seeland

Nicolè

. Public green space and disabled users. Urban For Urban Green. 2006;5(1):29-34. doi:10.1016/j.ufug.2006.03.001.

193.

Corazon

Gramkov

Poulsen

Lygum

Zhang

Stigsdotter

. I would really like to visit the forest, but it is just too difficult: a qualitative study on mobility disability and green spaces. Scand J Disabil Res 2019;21:1-13. doi:10.16993/sjdr.50.

194.

Kopeva

Maslovskaia

Ivanova

Zaitseva

. Adaptation of parks for people with disabilities in hill terrain of vladivostok. IOP Conf Ser Mater Sci Eng. 2021;1079(2):022025. doi:10.1088/1757-899X/1079/2/022025.

195.

Zhang

Huang

Wang

. Accessibility improvement and renewal of urban park green space for the elderly and the disabled. Forests. 2023;14(9):1801. doi:10.3390/f14091801.

196.

Abbott

Porter

. Environmental hazard and disabled people: from vulnerable to expert to interconnected. Disabil Soc. 2013;28(6):839-852. doi:10.1080/09687599.2013.802222.

197.

Nguyen

P-Y

Astell-Burt

Rahimi-Ardabili

Feng

. Effect of nature prescriptions on cardiometabolic and mental health, and physical activity: a systematic review. Lancet Planet Health. 2023;7(4):e313-e328. doi:10.1016/S2542-5196(23)00025-6.

198.

Adewuyi

Knobel

Gogna

Dadvand

. Health effects of green prescription: a systematic review of randomized controlled trials. Environ Res. 2023;236(Pt 2):116844. doi:10.1016/j.envres.2023.116844.

199.

Kondo

Oyekanmi

Gibson

South

Bocarro

Hipp

. Nature prescriptions for health: a review of evidence and research opportunities. Int J Environ Res Public Health. 2020;17(12):4213. doi:10.3390/ijerph17124213.

200.

Oberg

Frank

. Physicians' health practices strongly influence patient health practices. J R Coll Physicians Edinb. 2009;39(4):290-291. doi:10.4997/JRCPE.2009.422.

201.

Frank

Dresner

Shani

Vinker

. The association between physicians’ and patients’ preventive health practices. CMAJ (Can Med Assoc J). 2013;185(8):649-653. doi:10.1503/cmaj.121028.

202.

Gotschall

Zhao

Wilson

et al. Philadelphia towards Racial and Environmental Equity (Philly TREEs): how a medical school can advance health equity through urban forestry in Philadelphia, PA, USA. Lancet Planet Health. 2023;7(9):e777-e783. doi:10.1016/s2542-5196(23)00173-0.

203.

Easterling

McDuffee

. Social determinants of health: how are health conversion foundations using their resources to create change? Washington: Health Affairs Forefront. 2018. doi:10.1377/forefront.20180313.6738.