Public Land Managers’ Meeting

October 18, 2018 / Andi Gordon

How federal and municipal land managers can incorporate public health objectives into their planning

On Thursday, October 18, public land managers and other stakeholders gathered in an open forum to discuss how to incorporate best practices related to public health outcomes that had been identified during The SHIFT Festival. Municipal park planners as well as USFS, National Park Service and other federal agency representatives were invited to attend. Approximately 80 participants were in attendance for the session, which included a panel discussion followed by a World-café format group discussion. The meeting provided an opportunity for land managers to plan their work, with input from attendees, with health outcomes at the fore.

Panel Discussion

The panel was moderated by Jon Jarvis, Director of the Institute for Parks, People, and Biodiversity at UC Berkeley. Panelists included:

• Ryan Jenkins, Founder, Healthy Parks Healthy Person Tennessee (2018 SHIFT Awards Official Selection)
• Eva Lizette Garcia, Planner, City of Brownsville, TX (2018 Emerging Leader)
• Mona Koh, Community Director, East Bay Regional Parks District (2018 SHIFT Awards Official Selection)
• Farjana Islam, Health and Nature Navigator, United States Forest Service (2018 Emerging Leader)
• Attila Bality, National Park Service Rivers, Trails & Conservation Assistance Program (2018 SHIFT Award Official Selection)
• Diana Allen, MCRP, Chief of Health Promotion, Healthy Parks Healthy People, National Park Service

The panel focused on opportunities for land managers to introduce a generational, socioeconomic and cultural diversity of people to the idea of the outdoors as a place for improving one’s health.

Moderator Jarvis opened the panel by establishing the need for the integration of public health objectives into public land planning. Panelists then discussed ways to improve and leverage a diverse workforce, the power of parks and public lands to increase equitable access, and the attributes of successful “Park Rx” projects and initiatives that were showcased during the Public Lands, Public Health Exhibition Trail.

The panel also touched upon how various land management entities and agencies are responding to broader issues such as a decline in federal funding and climate change with associated sequela such as desertification and increased frequency of extreme events, including wildfires and flooding. 

Ryan Jenkins, Founder, Healthy Parks Healthy Person Tennessee

Ryan Jenkins, the founder of Healthy Parks Healthy Person Tennessee, spoke about the initiative, which aims to create a conduit between the healthcare provider, the individual, and public lands through technology. 

Healthy Parks Healthy Person Tennessee is a partnership between Tennessee State Parks, the Tennessee Department of Health and other state-wide public and private partners. Together, they developed an app that awards points to users for being active outside. The rewards are redeemable at state parks, thereby encouraging frequency of use and encouraging healthy habits. 

Some of the rewards include: 

• free camping 
• two-night cabin stay
• free meal at a Tennessee state park restaurant 
• $20 off at a Tennessee state park gift shop; private hike with a park ranger 
• free game of golf at a Tennessee state park golf course 

Additional items that will be added in the near future include performance shirts, water bottles and backpacks to enhance the user’s experience. 

Healthcare and park prescriptions are connected through the app, which targets a population that otherwise might not be exposed to the outdoors for a variety of reasons, including lack of familiarity with the outdoors, fear of the outdoors, and cost of access. 

The collaborative initiative represented by Healthy Parks Healthy Person Tennessee has the potential to bring a more diverse set of visitors to public lands. With repeated exposure to nature, a user’s health improves over time, a deep connection to the land is fostered and in turn, a sense of stewardship for its utility as a health asset is nurtured.

Eva Lizette Garcia, Planner, City of Brownsville, TX

Eva Lizette Garcia, a City Planner from Brownsville, Texas, brought a unique perspective to the panel. The only representative from a municipality, Garcia described her work with The Lower Rio Grande Valley Active Transportation and Tourism Plan, or “Active Plan,” a 428-mile trail network that will spur economic development and promote healthier lifestyles in the Lower Rio Grande Valley.

In the Lower Rio Grande Valley, which is 85% Latino, 80% of residents are overweight, and 1 in 3 are diabetic. Economically, $250M each year is lost to health care costs in Brownsville. The Active Plan, which links the natural, cultural and historical resources of the region via a network of trails, will serve as a catalyst for healthier lifestyles by providing more safe routes for exercise and outdoor recreation and encouraging locals to hike and bike to destinations.

The Active Plan is being developed to attract visiting cyclists and birders. The resulting economic development—in a county with one of the highest poverty rates in the country—is designed to tap into the rapidly expanding market for “active tourism” to support job creation and small business activity and encourage tourist spending that injects money into local economies.

The Active Plan will connect the population to nature by encouraging access to natural enclaves of pristine habitat within the city. Fish and wildlife tracts complement more developed parks to offer continuous habitat and a more natural experience for users. This urban refuge provides a direct relationship between city dwellers and the flora and fauna of a more holistic and natural ecosystem. 

The importance of a good first experience for a demographic such as Brownsville’s is essential. Access alone does not mean inclusion. For low-income urban populations, “getting out in nature” can seem like a luxury they cannot afford. Programs will be more successful if a municipality provides healthy, outdoor experiences that are low to no cost. 

The City of Brownsville Parks and Recreation Department also offers an affordable afterschool “camp” that provides children with nature experiences in nature. Parents may , but may be unable to offer it due to fear or lack that know-how. Land management programs such as these that offer step-by-step, out-the-door, easy access introductions and connections to the outdoors can provide health benefits to populations that stand to benefit disproportionately from nature contact.

In the vein of collaboration, panelists noted the importance of partnerships. Communities, private and nonprofit programs, religious organizations and governmental entities such as state or national parks can collaborate more effectively when they support and promote one another. Municipalities can provide resources through their large volunteer bases that may overcome language and cultural barriers and break down silos between organizations that are otherwise aligned. Instilling a sense of pride in natural spaces in the user populations also supports their investment in the preservation of natural resources.

Mona Koh, Community Director, East Bay Regional Parks District

California’s East Bay Regional Parks District (EBRPD) offers a good example of a successful collaboration. The EBRPD park system comprises 121,397 acres in 73 parks with 1,250 miles of trails in Alameda and Contra Costa counties. EBRPD’s mission to connect health and nature in public lands has benefited thousands of children and adults who historically have underutilized parks. In 2014, EBRPD and UCSF Benioff Children’s Hospital Oakland (UBCHO) launched the SHINE (Stay Healthy in Nature Everyday) program to bring their underserved patients with chronic illnesses to EBRPD’s parks for health intervention. Every month, EBRPD provides staff, transportation, healthy snacks and a day of outdoor activities for the children and families. The first randomized clinical study on health and nature, conducted by UBCHO in 2015, determined that cortisol levels and feeling of loneliness decreased by 28% and 20% respectively for SHINE participants. Over 100 physicians in UBCHO now prescribe SHINE, and new doctors receive training modules and toolkits. EPRPD has also installed park posters throughout the clinic to connect patients to nature.

Mona Koh, EBRPD’s Community Director, noted that to improve health outcomes in its two-county constituencies (which between them have 2.7 million residents), EBRPD has collaborated with 15 health clinics and 80 multicultural community organizations to educate, motivate, and prescribe nature to under-resourced patients/members to walk in their parks. With their Kids Healthy Outdoors Challenge program, they’ve partnered with 15 school districts, who provide transportation and curriculum books. Annually, 4,000 third grade students and their teachers visit EBRPD’s parks for Nature Study and healthy outdoor experiences. Their signature self-guided Trails Challenge program brings 10,000 people annually to hike EBRPD’s  regional trails.

EBRPD’s 2017 Economic Impact Analysis concluded that they contribute a range of benefits totaling $500M annually to the local economy, including $20M towards healthcare cost savings through the presence of parks, trails, walks and programs.

Farjana Islam, Health and Nature Navigator, United States Forest Service

Farjana Islam, the Health and Nature Navigator at the United State Forest Service (USFS), facilitated discussion regarding her position. Partnering with Unity Health Care and ParkRx America in the Washington, DC area, Farjana is developing pilot programs that foster healthy lifestyles and stewardship for the environment by providing education and exposure to nature. 

Participants are identified by referral from the Unity Health Care system. The Navigator provides the technical assistance and knowledge to implement the programs. He/She/They are trained in the benefits of nature and health and help patients understand why and how exposure is important; how to advocate for a prescription from their physician; and how to utilize the prescription once it has been received. The program is designed to “meet patients where they’re at” so that a threshold experience may be achieved. 

All programs, but especially the children’s program, is complimented by environmental education that combines functional and well-rounded aspects of wellness such as gardening and cooking while linking consumption (e.g., of a piece of fruit) to the critical role pollinators have and their reliance on healthy lands. 

Additional programs include tree planting efforts and forest bathing walks – the act of being in nature and connecting with it through all of our senses. The latter program is offered to Unity Health Care employees with the intention of closing the loop between health care, employees, patients and communities.

The Health and Nature Navigator is striving to reach bilingual communities and has partnered with Corazón Latino to host themed events and engage populations to partake in citizen science. RioPalooza — a collaboration between Corazón Latino, Fish and Game, Hispanic Access Foundation, and North Bay Adventure – celebrates and shares a variety of outdoor experiences on rivers, including paddling trips and tours, book talks, happy hours, concerts and educational events to promote clean water.

The comprehensive program includes options for people with chronic or terminal illness, patients recovering from surgery, and at-risk youth. The partnership between Barton Health and the USFS provides this at-risk population with guided outings in nature with the safety net of healthcare providers accompanying them.

Diana Allen, MCRP, Chief of Health Promotion, Healthy Parks Healthy People, National Park Service

Diana Allen is the Chief of Health Promotion for the National Parks Service’s (NPS) Healthy Parks Healthy People (HPHP) program, which is based in the Office of Public Health. Healthy Parks Healthy People advances the fact that all parks—urban and wild—are cornerstones of people’s mental, physical, and spiritual health, as well social well-being.

As public land managers look to mainstream parks and public lands as integral elements of healthcare delivery, it can be helpful to take a strategic approach to working collaboratively. The National Park Service has a new Healthy Parks Healthy People 2.0 strategy that launched in the summer of 2018 that promotes parks and public lands as a health resource. Its objective is to bring about lasting change in people’s lifestyle choices ,including their relationship to nature and the outdoors.

Healthy Parks Healthy People has identified a number of projects, programs, and policies for national expansion that have opportunities for health sector engagement. Examples include park prescriptions, Walk with a Doc, fitness challenges, community gardens, and smoke-free parks.

As part of this five-year strategy, the NPS is organizing around two priority areas: access to parks, and volunteerism.

Access to parks is defined by the NPS as actions that make a healthy parks experience to easier, more desirable, and more relatable to all people. This can be accomplished through programs by, for, and with diverse populations; being invitational to populations who use parks infrequently (e.g., minorities, low income, and the disabled communities); and proactively addressing the health needs of select populations (e.g., youth, seniors, active military and veterans).

Volunteerism is the second priority action area. A new NPS Volunteer Health Ambassador program, to be launched in 2019, will engage skills-based volunteers from the sectors of health, hospitality, and tourism to strengthen the connections of parks, people, and health.

Diana concluded her remarks with an invitation for everyone in the room to consider how they might fulfill a role as health ambassador to promote parks as a health resource.

Attila Bality, National Park Service Rivers, Trails & Conservation Assistance Program

Attila Bality is the acting program leader for the National Park Service (NPS) Rivers, Trails & Conservation Assistance Program (RTCA). The program has been engaged with the public health sector for approximately 20 years. In this time, they have worked closely with Active Living by Design, examining the built environment to promote increased physical activity and access to parks and trails. 

Working with academia and national non-profits, RTCA explores the connection between parks, trails and nature. In Albuquerque, NM, the program initiated the Park Rx movement. The work of this program also collaborated with the Centers for Disease Control on two publications: 1. The Parks, Trails & Health Workbook; and 2. Improving Public Health through Public Parks and Trails: Eight Common Measures.  Through these two publications, the NPS is able to emphasize the importance of public health goals for local parks and trails projects and the critical need for baseline and post success measurements that illustrate public health improvements.

Panelists also noted a California program that features a collaboration between the United States Forest Service (USFS) and a local hospital:

In 2016, Barton Health, a not-for-profit health care facility, partnered with Lake Tahoe Basin Management Unit, South Lake Tahoe’s local USFS branch, to host cooperative Wellness Outings: guided walks that promote nature as medicine by teaming patients with a U.S. Forest Service ranger and physicians or nurses from Barton Health for guided outings in the national forest. In South Lake Tahoe, CA, a town of less than 22,000 people, hundreds have participated in the Wellness Walks, including the general public and target audiences such as the chronically ill, those recovering from surgery, and at-risk youth.

The collective impact of land managers in the “nature as a social determinant of health” movement is significant. The panel provided a “conversation within a conversation” regarding the ways that land managers of various kinds can work to protect the land at the same time they are promoting opportunities connecting people with nature for the benefit of their health.

WORLD CAFÉ

World Café table discussions are a way to synthesize input from a large group through facilitated small group discussions. Key points from preset questions were synthesized across the larger group to more efficiently capture the insights from the individual discussions. The World Café allowed the comprehensive means to include discussion on pre-determined, specific topics to inform and identify more specific issues from a number of people. Facilitators synthesized the café high-points, providing the foundation and reference for this summary document.

Below are the preset questions followed by a summary of collaborative dialogue. The questions covered how land managers may prepare for a new demographic user group focused on accessing lands and space for the specific purpose of health. Additional questions focus on opportunities and challenges as well as example of best practices and looking forward to how emerging technologies may influence programs moving forward.

PREPARING FOR A NEW DEMOGRAPHIC

How can public land managers better prepare to receive a health-focused public or to satisfy a park prescription?

Central to supporting health-focused public land use is the ability of land managers to provide a more inviting experience for and to the population.

From a practical standpoint, the readiness of the infrastructure to receive users cannot be overlooked. Providing picnic benches, bathrooms, and trails will require attention to the Americans with Disabilities Act and various cultural needs. Understanding that spaces may be utilized in different ways (e.g., picnics for Latinx families vs hiking) is vital to design and programmatic success. Education and understanding is bi-directional: public lands may provide a vehicle for emphasizing these spaces as a cultural resource.

With an influx of interested and engaged users, land managers can also identify opportunities for environmental education and public land stewardship. Visiting “patients” could be educated, for example, about why and how forests are managed to maintain healthy ecosystems or how wildfire in some cases is beneficial for the overall health of the forest. 

Such education could in turn be developed into community participation. Walkability assessments could provide input regarding trail accessibility. Agency level programs that include social science as well as the protection of biological and natural resources could assist in behavior change and the encouragement of positive habits.  

Consideration may also be given to self-guided opportunities that could be bolstered by new technologies such as Agents of Discovery, an educational mobile gaming platform that uses augmented reality to get youth active, and apps such as Track Trails, an expanding network of trails that feature self-guided brochures and signs as well as incentives for tracking adventures.

A common theme during the panel and World Café was the importance of engaging and collaborating on multiple levels. Some examples included collaboration with local health communities via health fairs or hospital events. Consideration could be given to the elimination of park entrance fees for those with park prescriptions in order to expand access and remove barriers.

The preparation for accepting this new health-focused population is not without challenges—for example, staffing shortfalls can handicap sustainable operations and maintenance. However, given the momentum and interest in the health benefits of nature contact, it also represents great opportunities. Hiring community members for specific and emerging roles and / or developing volunteer programs that engage a culturally diverse membership may strengthen efforts to connect with the public. This will also provide a component of the workforce necessary for long-term program viability while gaining support for and ensuring the protection of our natural spaces and places. 

A robust volunteer program must consider that the public’s level of knowledge and abilities may vary widely from entry level to expert. Just as volunteers may have a range of abilities, so too will visitors. Land managers could consider offering different levels of trails (e.g., green, blue, black) that target different capabilities and interests that are available to and aligned with the broader community needs. 

Outcomes-focused management should align with recreation area management while addressing the following questions: 

1. Who are you planning for?
2. Why are you planning this? 

Collaborating internally and externally to answer these questions is critical, as is partnering with cities and non-profits, in particular to support access and quality entry-level experiences.

CHALLENGES of CLIMATE CHANGE

Recognizing the challenge of climate change, what are the opportunities to proactively anticipate and address impacts on public and environmental health?

The impacts of climate change are numerous and already affecting populations of all kinds without bias. Some examples include but are in no way limited to: extreme weather events, land, air and water degradation (algae blooms, drought, air pollution, wildfires, melting glaciers, ocean acidification, rise in ocean and waterway temperatures, rise in sea levels and changes to climate), environmental injustice, and rising global temperatures. The results include population displacement and migration of humans and animals, loss of infrastructure, loss of biodiversity and loss of life.

Land managers can address some of these issues through mitigation of greenhouse gas emissions and adaptation to the impacts of climate change strategies as follows:

• Restoration of watersheds
• Protect corridors for wildlife migration
• Predict changes in visitation patterns
• Collaboration and partnerships with scientists, firefighters, etc.
• Increase tree canopy in parks, streets, green spaces
• Engage the public in tree planting events that empower communities
• Develop a migration plan that accounts for people moving away from the coasts
• Consider broader messaging, such as “reducing your footprint” while in parks
• Environmental education for youth

TOOLS AND OPPORTUNITIES

What are some of the tools and opportunities for land management agencies to work at the community level to create threshold experiences?

“Threshold experiences” can be defined as the experiential encounter that creates the drive and know-how to continue advancing knowledge and incite the motivation to continue challenging oneself. Aptly for a conference held in Jackson Hole, WY, learning to ski was used as an analogy. A person may begin learning on a bunny hill, with used equipment and no experience, but a positive encounter with the activity would encourage a desire to invest in better equipment, continued learning, and moving on to more technical terrain.

Identification of trail difficulty with a significant offering of easy trails that are readily accessible is an important aspect in creating that threshold experience. Feeling safe is also important and may be supported by the availability of local ambassadors, nature guides, and navigators to coach, connect, and empower people. This has the side-effect of modeling exemplary behavior and monitoring and educating those that may stray from this vision.

Free or very low cost gear rentals, akin to shared bike programs, may offer a solution to what can be a formidable but not insurmountable barrier. Hiking is one activity with minimal equipment needs to get started. Advertising and marketing for low cost cabin rentals (within USFS lands) is an example of providing infrastructure for those who may not have the means to purchase a tent or sleeping bag in order that they might have a desired or desirable overnight outdoor experience.

Working with local municipal recreation and education agencies can offer various programs such as citizen science projects that can speak to a different type of user and may provide a necessary link to champion stewardship. Creating the atmosphere for all people to thrive within natural places is an important component to this end. Opportunities for all ages and ability developed in tandem with health messaging could insure a future where the land and the people may thrive. Inspiring and connecting youth with the concepts of nature and health is critical to a sustainable future. They are the future leaders of our public lands. Some ideas to inspire include:

• Provide 4^th and 5^th graders nationwide with free passes to federal public lands;
• Provide programs that utilize free public lands access with integrated STEAM (an educational approach to learning that uses Science, Technology, Engineering, the Arts and Mathematics as access points for guiding student inquiry, dialogue, and critical thinking) learning 
• Engage 6-8^th graders with immersion experiences;
• Provide curriculum that includes responsible fishing, hunting and archery skills with an emphasis on safety and integrated with STEAM;
• Provide curriculum associated with food production, systems and nutrition
• Address food security in combination with nature access:
  • Provide food card if you walk to the farmers market (in compliment to SNAP farmers market programs);
  • Host farmers markets in parks;
  • Provide local transit passes for people buying food at farmer’s markets.

Examples abound for ways to encourage people to have a quality outdoor experience. Employers could provide prescriptions for employees and / or offer outings as a bonus. Grassroots efforts may include hosting family campouts or nature nights. These events could be coordinated with local stargazing organizations for an educational and “wow-ing” experience. At a community level, health fairs may be held within local parks to address a combination of objectives. Outings can be planned that have free transportation to parks for the day with planned and open events that include park staff.

TECHNOLOGY

What is the role of technology?

With technology at our fingertips and the ability to connect from almost everywhere, we have the opportunity to utilize existing platforms and / or develop applications that may assist land managers in their efforts to promote healthy exposures to nature while also protecting it. 

Storytelling and crowdsourcing is already quite popular with Instagram, and Facebook abounds with scenes of nature. However, incentivizing the process with games and rewards may provide the means to gather meaningful data that can support the growing body of evidence on nature and health. Using biotrackers, providers may “view” information for helping individuals make healthy decisions given habits and objective measures. While there may be outstanding privacy issues, the concepts are promising. Additional considerations include the scalability of incentives.

Other tools may provide the motivation for learning and exploring through “gamification” within the recreation process. QR codes may link to historical, ecological or other facts within the area.

Google maps are a nearly ubiquitous resource for way finding that is elevated in its utility by skilled geographical information system users for professionals to conduct research and make better decisions.

Various apps for mobile devices offer positional tracking that may be used with or without a cell signal and include trail maps than can record your movement such as: REI Hiking Project App, All Trails, GAIA GPS. This blog recently ranked some of the best.

PARTNERSHIPS AND BEST PRACTICES

Where have really good partnerships on public health been established?

Some examples of quality partnerships include:

• Parks and Recreation departments working in coordination with Health Departments
• Boys and Girls Club and community health professionals collaborating on bus programs to support transportation and access to nature
• College students and Park Service collaborating on Parks Rx. This successful program could be resurrected but currently lacks funding
• Health providers and community outdoor event organizers collaborating for funding and co-promotion of events and activities
• Collaboration among State and Federal public lands to support park access for youth (e.g., expanding the Every Child in the Park fourth grade park pass to include state parks as well as national parks)
• Peer to peer partnerships and cross-sector conferences among the research, health, and public land manager community

What are the best practices?

Once again, a common theme pointed to collaboration and involvement of all stakeholders. Joint planning is vital in identifying shared needs and goals for outdoor places while leveraging health impact assessments and other outcome measures. These efforts act as an important tool for programmatic funding including providing available staff, gear, etc. A mutual trust with individuals and other partners such as the community, private, nonprofit and government entities will insure long-term viability of nature and health programs. However, universal accessibility and safety in such places is requisite.  

The following describes some innovative programs, policies and initiatives that serve as best practices:

• California Department of Public Health’s Health in All Policies (HIAP), which supports incorporating health, equity and sustainability into decision-making across sectors and policy areas
• “Work swap” to see what is working well and exchange ideas among health care providers, outdoor program staff, educators, and others
• San Gabriel National Monument has a mandate for a transit plan that supports access to the outdoors and is an example of “transit-to-trails” initiatives that connects urban areas to public lands. 
• Trust for Public Lands’ ParkScore mapping which ranks the 100 largest U.S. cities based on how accessible parks are. This encourages city planners and decision-makers to support access to quality parks.
• Institute for the Golden Gate has extensive resources on ParksRx and is a knowledge hub and communication infrastructure for public land managers and organizations looking to support health and nature activities. 
• Library programs that support a nature smart library accessible in multiple languages.
• Physical therapy in outdoor settings requires partnerships with facilities and transit operators for access.
• Hospital emergency departments’ reporting requirements may include outdoor recreation components

CONCLUSION

The Land Manager’s Meeting provided an open forum for the discussion of successful initiatives at the intersection of land management and public health. 

Land managers from all sectors expressed interest in developing innovative programs that offer nature-based exposures to a diverse demographic. With various promotions for improving public health through nature contact on the rise, utilization of public lands is expected to increase. Caring for the land is essential, as healthy lands are essential to reaping health benefits from nature-based experiences. 

As user days increase, educating new populations about the importance of protecting the resource that provides the benefits is critical to sustainable conservation efforts. 

Collaborations are vital to advancing public health objectives while sustaining thriving ecosystems. Partnering with health care systems and other champions of nature-based experiences can educate people on how their own health and the health of the land is a bi-directional flow. Innovative programs that champion nature-based experiences for health and that improve access to and familiarity with our public lands must also encourage conservation.