Researchers’ Meeting

October 18, 2018 / Andi Gordon

Background: In 2017, Howard Frumkin et al proposed an influential research agenda on nature contact and health, identifying principal domains of research and key questions that, if answered, would provide the foundation for evidence-based public health interventions. 

From Oct. 16-18 in Jackson, WY, The 2018 SHIFT Festival convened a broad cross-section of professionals from the research, health care, conservation, land management and outdoor recreation communities to explore the connection between public health and time spent outside, with a goal of leveraging the health benefits of nature to strengthen the argument for its preservation. On Oct. 18, in the afternoon of the Festival’s final day, a Researchers’ Meeting invited participants to discuss the state of the research on the topic, using the 2017 Frumkin et al research agenda as the discussion’s starting point. 

Objectives: The goal of the researchers’ meeting was to explore progress to date on the 2017 research agenda, including knowledge gaps and how and with whom to fill them. As the meeting occurred at the conclusion of SHIFT, it was informed by the Festival’s proceedings, as well as by best practices highlighted during the event.

Discussion: For two hours, approximately three dozen professionals working on the health benefits of nature contact gathered in an open forum to share their respective work. Participants discussed the seven domains of the 2017 research agenda, as well as the challenges inherent in measuring some of the domains’ definitions given the state of the science. Insights provided by specific examples complemented and became catalysts for broader conversations, ideas and questions related to the topic.  

Conclusions: The meeting generated animated conversation, including on details that need to be clarified for each domain. Participants agreed that the empirical evidence for nature’s positive impact on health is mounting, and that large-scale studies and funding are necessary to attain critical mass for the adoption of nature as a social determinant of health. There was consensus among participants that compelling storytelling and the economic quantification of the benefits and positive impacts of nature and health will assist in securing more consistent funding for additional research. They also agreed that the preservation of our natural places is essential to ensuring that this valuable and low-cost health intervention is available for future generations.

Additional agreement was reached on some of the factors necessary to persuade institutional healthcare to adopt nature as a tool for improving public health. Challenges common to the funding of research and to the importance of connectivity and timing related to research projects were also identified.

Perhaps most importantly, the meeting facilitated multiple new connections and provided a solid foundation for future collaborations among individuals who are engaged or interested in nature contact and its impact on human health.

OVERVIEW

Healthcare spending in the US is estimated at $3.5 trillion/year which represents nearly 20% of the US GDP. Put another way, for every 5 dollars generated in the US economy, 1 dollar goes towards healthcare. The healthcare insurance industry uses research to inform their reimbursement standards, but large population studies on the connection between time spent in nature and human health are difficult to find and to conduct.   

The 2017 research agenda identified seven areas of focus critical for the provision of evidence that in turn will be necessary for public health interventions. The authors concluded that although significant evidence regarding nature contact and its range of human health benefits was already available, much remained unknown. They furthermore proposed that a robust research effort, guided by a focus on key unanswered questions, had the potential to yield high-impact, consequential public health insights.

Presented by REI, the October 18 Researchers’ Meeting at SHIFT was facilitated by Josh Lawler, a co-author of the 2017 research agenda and Co-Director of The University of Washington’s Center for Creative Conservation. The meeting was co-facilitated by Marc Berejka, Director of Community and Government Affairs with REI, one of the principal funders of The University of Washington’s work on the matter. 

The public meeting began with a round of introductions by the participants, who briefly described their backgrounds. (An incomplete list of participants, who were not required to register for the meeting, may be found here.) Researchers, clinicians, public and private sector employees, non-profit representatives, and healthcare industry professionals were all in attendance. 

Following introductions, Josh Lawler led a review and brief discussion of the key questions and principle domains of research identified in the 2017 research agenda, using the presentation found here.

Lawler noted that if the research sector were to answer the questions identified in the 2017 agenda, the authors feel it would provide the evidence necessary to insure public health interventions with a nature component are funded at a mainstream level. 

The discussion of the domains generated extensive conversation regarding details that participants felt needed additional clarification. The seven domains, and some of the questions participants felt needed to be addressed for each, included:

1. Mechanistic Biomedical Studies (which explores how nature improves human health, e.g., by facilitating psychological pathways, enhanced immune function, social connections, increased physical activity and improved air quality):
   1. What are the biomedical effects of nature contact? 
   2. What is the beneficial interaction? 
   3. What are the psychological changes? How are they to be measured (e.g., cortisol, HR, cytokines, anxiety, depression and stress scales)?
   4. What effects do awe and wonder have? 
   5. How does the social connection of being in nature improve people’s health (e.g., via enhanced immune function)? 
2. Exposure Science (which develops quantitative and qualitative methods and metrics for measuring what counts as “nature contact” and the constitution of a meaningful “dose”):
   1. What constitutes “nature”—that is, what is the exposure? Is it a picture? Is it looking through a window or having indoor plants? 
   2. How is the exposure measured? 
   3. What is the dose (e.g., duration, proximity)? 
   4. How is a dose measured (i.e., via contact with or connectedness to nature)? 
3. Epidemiology of Health Benefits (which examines the health outcomes of time spent in nature [e.g., reducing pain, stress or the risk of cancer], examples of innovative approaches for measuring them, and what we know about “dose”):
   1. What are the associations of nature and health? 
   2. What are the outcomes? 
   3. How is it measured? 
   4. What is the target population? 
4. Diversity and Equity Considerations (which underscore the need to account for cultural differences and inequities in understanding the nature-health connection, e.g., unequal access to nature, different ways of valuing it, different effects of nature, and “green gentrification”):
   1. How accessible are the dose and exposure? 
   2. Where and what are the differences to access? 
5. Technology (which looks at how technologies that mediate the nature experience affect health outcomes, and whether they have the same or different health benefits as being in real natural places):
   1. Can virtual reality supplement the outdoors? 
   2. Can “apps” help insure exposure? 
6. Economic and Policy (which refers to cost-benefit analyses of ecosystem services [e.g., health benefits and avoided medical costs] and related policy implications for conservation and planning):
   1. What is the cost-benefit of ecosystem services? 
   2. How can nature be valued? 
7. Implementation Science (which develops and evaluates the tools and actions for optimization of nature benefit delivery, e.g., best practices for the design of parks, trails and schools):
   1. What tools are being used? 
   2. What are current best practices? 

Research, Practice and Policy

During the meeting, participants agreed that the benefits provided by nature include opportunities for climate change mitigation, better air quality, promotion of active lifestyles and increased physical activity, social cohesion, improved mental health, more effective learning, and reductions in stress and illness.

A number of researchers, including social scientists, cognitive psychologists, ecologists and neuroscientists, discussed their work, which included: 

• surveys of National Park visitors; 
• studies assessing cognitive function, changes in mood, and restorative responses;
• landscape architecture design preferences; 
• post-traumatic stress disorder responses with exposure to nature

Additional discussion touched on existing data, including the importance of contact with the outdoors as an important factor in the development of vision for children. 

Attendees from the non-profit sector provided overviews of some of their programs, which are designed to positively impact health and well-being via increased access to, experience of and connection with nature. For example, The Wounded Warriors in Action Foundation provides hunting and fishing opportunities to our nation’s Purple Heart recipients. John McDaniel, its Founder and CEO, noted that the organization sees and hears the positive effects of nature contact among its participants—work that could be bolstered by a collaborative and engaged community that actively shares outcomes on nature contact and health.

Clinicians in the room discussed the importance of identifying measurable improvements on program participants. Researchers offered suggestions for ways to optimize questions, for example by reframing a question such as “Does the program work? Yes/No” to include ways to capture the “how” and “why” of its performance, which in turn would help address some of the questions highlighted during the discussion of the research agenda. 

Such collaboration across sectors, between researchers and clinicians, was an underlying theme of the SHIFT in general and the meeting in particular, and participants agreed it was essential for collective advancement. The point was reinforced when a health insurance representative noted the importance of reporting the cost savings to payers when communicating study, program or performance results for prescriptions of nature. 

Several states that were beginning to include public health objectives in revisions of their State Comprehensive Outdoor Recreation Plans (SCORP) had representatives in attendance as well. (SCORP plans are prepared to satisfy the requirements of the Land and Water Conservation Fund.) Noting that policies initiated by SCORPs can drive institutional change, and that research informs policy, these representatives highlighted the opportunity for early adopters to use public health benefits to advance the case for outdoor recreation. They furthermore observed that for this to happen, messaging from both the health care and outdoor recreation sectors needs to be consistent, well defined, and intentional about its recipients.

Common Theme: What drives change?

While the principal research domains provided the discussion’s foundation, the conversations soon turned practical. Researchers seek answers related to the domains, but for clinicians, non-profits and perhaps especially for healthcare industry payers, the domains are often abstract.

Questions that arose in this discussion included the following:

• How can researchers inform clinicians and others “in the field” of their progress?
• What is needed to insure that such a transfer of information occurs? 
• What outcomes related to nature and health will provide the evidence necessary for the funding of public health initiatives to occur? 

The positive effects of nature and health that are clear for many were especially evident for meeting participants. “They get it,” said Marc Berejka of REI, which recently granted the University of Washington $1 millon to further its studies on the subject. But for others, such as insurance companies, policy makers or health care providers, for whom the benefits are not as readily apparent, researchers and clinicians must accurately and effectively convey, share and publicize results that demonstrate the positive effects of nature contact on health.

To do this, participants agreed that the research community must answer some of the following questions:

• What are the confounding variables? From a research perspective, this means controlling for age, gender, location—some of the questions that make the domain questions both vague and huge
• What are the biggest levers for change? Is it the research outcomes, marketing, policies, or “buy in” by a health payor?
• What measures and metrics should be used? (i.e., are they physiologic, such as cortisol measures?)
• What are the quantifiable outcome measures (e.g., reduced emergency department visits)?
• What is the best way to insure inclusion of all stakeholders?
• What are the pre/post medical costs of interventions that include nature as a prescription?

Given the broad range of questions, it is clear that a diverse and collaborative effort is essential to find answers. SHIFT and the researcher’s meeting provided a clear example of this collaborative spirit.

Common Challenges: Funding, Connectivity, Timing 

Many participants lamented the lack of funding for the topic (REI was the only funder in the room) and subsequent difficulty of managing operational costs. This theme rang true for researchers and non-profits alike. Historically there has been a paucity of funding available for nature and health, especially compared to the funding available for environmental research proper.  

The presence of researchers who had been granted National Institute of Health Research Project Grants to conduct work in this area provided some hope. (R01 grants—the NIH’s original and historically oldest grant mechanism—provides support for health-related research and development based on the NIH’s mission). The sharing of this experience underscored the importance of ongoing connection between stakeholders and the need for a way to share research, ideas, successes and failures, which would significantly advance the opportunity for others to achieve their goals.

One objective of the meeting was to improve connectivity among those working at the intersection of nature and health. Participants agreed connectivity is essential to coordinated efforts moving forward. Finding a way to stay connected with current (and past) research, as well as with the community as a whole, emerged as a common theme. 

It was clear from the ideas generated by this energetic and passionate community that they wanted a way to continue the conversation. Ideas to stay connected included:

• An online platform (website) connect those interested in the topic, attract support (philanthropic and otherwise) and serve as a comprehensive database / repository of research
• Social media outlets
• The creation of a professional society dedicated to nature and health
• A newsletter or journal (virtual or paper) to disseminate topical information 
• A yearly conference

For now, participants offered additional resources for published research, including: 

• International Journal of Environmental Research and Public Health 
• The Lancet Planetary Health Journal
• Children & Nature Network’s Research Library
• ParkRx’s Resources
• Landscape Architecture Foundation 
• Active Living Research 
• Institute of the Golden Gate

Participants agreed that improved connectivity could be helpful in many ways. For example, connecting researchers and non-profits with universities and high schools could help engage students and the next generation of leaders. It also could help with the timing of research projects. Applications to institutional review boards take time and the timing of projects is often not coordinated with or known by fellow researchers. The asynchronous nature of this situation makes baseline data difficult to collect and outcome measures difficult to quantify.

What next?

One participant said of the meeting, “It was a good group of smart people; it was the right people to discuss the issues (of nature and health); and it was the right format.” But what’s next? What incremental steps are necessary to transition institutional health towards the prescription and preservation of nature as a critical component of human health – akin to shelter, food and clothing?

An over-arching consensus was that the meeting was necessary and welcomed by those in attendance. The people in the room all felt strongly that the outdoors is good for your health, and that, while the evidence for this point is mounting, it remains peripheral to the mainstream institutional thought, disjointed, concealed or otherwise difficult to access. What does or will it take to convince the broader public that nature is important to our health and therefore must be managed as a precious resource? How can the early adopters, innovators and thought leaders at the forefront of “Nature Rx,” who understand nature’s importance to public health, strengthen and clarify this message? 

Participants noted lack of funding and limited collaboration and communication among researchers and practitioners as obstacles to wide-spread adoption. Compelling storytelling and quantification of the benefits and positive impacts of nature and health will assist in securing more consistent funding for additional research. 

This meeting provided a first step to understanding some of the opportunities and challenges that lie ahead for various stakeholders. Participants agreed that continuing the conversation is vital to the cause, as is finding funders to underwrite research and leveraging policy to drive change at the societal level. Stories that illustrate nature’s ability to relieve suffering must be elevated if the understanding of the value of nature interventions is to become embedded in the institutional health paradigm. 

Simultaneously, the preservation of the natural places in which health benefits can be accessed and achieved is essential to the movement’s success.

The importance of a nature and health movement was clear to all of the passionate people in the room. Each participant represented both a pocket of expertise from a different part of the country and an advocate for the movement. Although the pockets are currently fragmented, and as a result lack the critical mass necessary to illuminate a clear path forward, the participants’ diversity highlighted the breadth, complexity and potential of the movement to positively affect health and wellbeing and preserve nature at the same time. Protecting our natural places is essential to ensuring that this valuable and low-cost health intervention is preserved.

1. Frumkin et al 2017. Nature Contact and Human Health: A Research Agenda. Environmental Health Perspectives.
2. U.S. national health expenditure as percent of GDP from 1960 to 2018. Accessed 1/24/19. https://www.statista.com/statistics/184968/us-health-expenditure-as-percent-of-gdp-since-1960/
3. Oregon State Comprehensive Outdoor Recreation 2013-2017. Accessed 12/14/18. https://www.oregon.gov/oprd/PLANS/docs/scorp/2013-2018_SCORP/2013-2017_Oregon_SCORP.pdf.