1. Addressing Social Determinants of Health through Outdoor Recreation

According to the Centers for Disease Control and Prevention, “Conditions in the places where people live, learn, work, and play affect a wide range of health risks and outcomes. These conditions are known as social determinants of health (SDOH).”

Noah Wilson works with participants during a breakout session

In order to advance health and wellness initiatives via outdoor recreation, participants agreed on the following:

  • Outdoor recreation leaders must address the different social determinants of health in creative ways, such as ensuring that recreation assets are easily accessed from workforce housing
    • In Utah, for example, Governor Herbert’s 2020 budget plan includes an earmark for $30 million to help fund efforts to preserve open space and establish significant community parks which are tied to efficient land use, transit-oriented development and affordable housing
  • Health objectives can be achieved more efficiently with strong, cross-sector partnerships than by individual organizations or offices
    • The best example of this may be found in Colorado, where the Office of Outdoor Recreation partnered with a wide list of stakeholders on the Colorado Outdoor Rx report
    • The Utah office partnered with more than 30 entities to support HCR 4 / Every Kid Outdoors Initiative. Such collaboration resulted in broad support, which in turn will lay the foundation for future awareness and funding for youth outdoor programs.
    • Oregon’s office is working with The Oregon Health and Outdoors Initiative, a coalition driving work around equitable access in the state. To complete this study outlining the $1.4 billion annual savings in health care costs via Oregonians’ participation in outdoor recreation activities, the office collaborated with multiple partners, including Oregon Parks and Recreation Department, which provided staff research time and hired a contractor from Oregon State University
  • There needs to be a common set of practices that groups and organizations can use to address the social determinants of health through outdoor recreation. One possible set of practices could include:
    • Ensuring equitable access to the outdoors
    • Understanding the needs of the population before an outdoor recreation-related intervention is created
    • Creating, or merging, streams of funding from different sectors in order to make an initiative sustainable
    • Lobbying policymakers to make equitable policy change
    • Connecting researchers to the outdoor industry to help track, monitor, and improve new and existing programs
    • Working with local healthcare professionals to improve knowledge and understanding of the role the environment plays in health

Key recommendations from SHIFT:

Break Down Communication Barriers

Significant communication barriers between outdoor recreation, healthcare, and stakeholder communities create friction and undermine collaborative success. Identifying such barriers, and addressing them with a tool like a glossary of common terms, will expedite progress around recreation and health connections.

  • Terminology barriers that exist between the outdoor industry and the health community must be addressed and simplified
    • Blue Cross Blue Shield offers this glossary of health care terms
    • The Colorado Outdoor Rx report has a number of health-care related terms that will help outdoor recreation leaders communicate more effectively with the health care community
  • Similarly, language barriers between different communities must be addressed. The translation of key materials and messages into Spanish, for example, may help convey the health benefits of outdoor recreation initiatives that are applicable to or developed for Latino communities
    • The Recreational Boating & Fishing Foundation launched its Vamos a Pescar brand in 2014 to engage the Latinx audience in fishing and boating. While the Latinx population is fishing in record numbers, only one in four feels represented in the sport. The Vamos A Pescar campaign is continuing to help Latinx families break down perceived barriers to the sport, reeling in the fastest-growing audience with media, education, and a grants program for Latinx communities. In the last year, fishing participation increased by 4%, no doubt aided by the record number of Latinx participants
    • In 2017, the ATA launched “Explora Caza Con Arco,” the Spanish version of the ATA’s popular “Explore Bowhunting” program. Explora Caza Con Arco includes translated how-to resources like those provided in Explore Bowhunting. These resources give Spanish-speaking communities the tools to use public lands and start bowhunting. The ATA offers the program for free to state wildlife agencies, federal-government agencies, and nongovernmental organizations
  • Messaging about the positive connection between outdoor recreation and health must be emphasized 
    • This connection has perhaps been most strongly emphasized by The Confluence Accords, which have enshrined health and wellness as one of their four pillars
    • With Utah’s Office of Outdoor Recreation, the connection is built into its mission: “to ensure all Utahns can live an active and healthy lifestyle through outdoor recreation.”
  • Conferences such as SHIFT that foster communication between partners and peers should be hosted and attended by outdoor recreation leaders 
    • The Utah office holds an annual Outdoor Summit that has an educational health-and-wellness track that engages health care professionals 
    • The Children and Nature Network will have a health care track at its 2019 International Conference in Oakland, CA

Increase the Accessibility and Appeal of the Outdoors for the Broader Community

Historically, outdoor recreation has centered Caucasian users. As the country continues to diversify, the inclusion of other demographics becomes critical to the ability to leverage outdoor recreation as a health-care tool.

2017 Emerging Leader Leandra Taylor (L) speaks with Bob Ratcliffe, Director of Outdoor Recreation and Conservation for the National Park Service, and another participant during the workshop
  • Entry points into the outdoor industry must be made more accessible and appealing to all demographics 
    • Limited access to resources is a commonly cited constraint among racially and ethnically diverse groups. Access manifests itself through financial resources, transportation, and physical access
    • Washington’s Recreation and Conservation Office has worked to define “underserved communities” for grant scoring
    • In Vermont, which is predominantly white, outdoor recreation runs the risk of becoming an upper-class pursuit. The Vermont Outdoor Recreation Economic Collaborative prioritizes the growth of outdoor recreation across all demographics and socioeconomic classes, for example by identifying ways to underwrite public transportation to state parks
    • In King County, Washington, The Center for Leadership in Athletics is collaborating with the Aspen Institute’s national initiative, Project Play, to create a “State of Play” report, which will initiate a regional commitment to reimagining youth sport and addressing inequities in youth access to physical activity through sports, play, and outdoor recreation
    • The Center for Jackson Hole’s Emerging Leaders Program trains a culturally diverse group of young outdoor recreationists to help lead our work at SHIFT and in America

Create recreational opportunities that align with community needs

Different communities have different health care needs. Developing recreational opportunities around them is critical to optimizing health benefits at the community level.

  • The Vermont Outdoor Recreation Economic Collaborative established an outdoor-rec friendly community program, the VOREC Community Grant Program, that allow towns to apply for grant money that can be put toward infrastructure. Bonus points in the selection criteria are given for projects that connect infrastructure to public health.
  • In Utah, the Office of Outdoor Recreation’s Outdoor Recreation Grant was created to help build tourism in communities around the state with the construction and expansion of outdoor recreation amenities, which in turn drive positive public health outcomes. To date, the grant has funded more than 100 projects with total value exceeding $42M.

Emphasize education about and communication around currently available “close to home” programs and resources 

Because ”backyard” recreational opportunities are by definition the most accessible to the largest number of people, they are better positioned to deliver health benefits. Information about them, however, must be readily available to insure they are utilized. 

  • The Check Out Colorado State Parks library loan program is an inter-agency partnership between Colorado Parks and Wildlife, the Colorado Department of Education State Library, and local libraries to enable the general public to explore Colorado’s state parks for free. The program was founded to increase the public’s awareness of Colorado’s State Parks, educate the public about nature, and offer an engaging nature-based recreation experience
  • Utah’s 1000 miles of Family Friendly Trails campaign utilizes a grant program to make bike trails more accessible in communities around the state
  • Colorado’s Colorado the Beautiful initiative seeks to insure that within a generation, every Coloradan will live within 10 minutes of a park, trail, or vibrant green space

Increase access to trailheads and other outdoor recreation opportunities via public transportation 

For under-resourced communities in particular, barriers to access often include transportation (“there is no bus to the trailhead”)

  • Helena, Montana, has a free trail shuttle connecting mountain bikers to Helena’s numerous trails. Sponsored in part by Blue Cross Blue Shield Montana, the Trailrider Program provides service 5 days a week for bikers, hikers, and runners, and is “priceless” to the community. From 2015 to 2017 the number of riders more than doubled from 1,568 to 3,387 riders
  • In Maine, both the Recreational Trails Program and Land and Water Conservation Fund programs have incorporated the idea of proximity as a key scored component of the application, encouraging investments in outdoor recreation amenities that have a higher probability of being used based on proximity to that user population
  • Made possible by a service partnership with the Seattle Department of Transportation, Trailhead Direct is a Seattle-based pilot project sponsored by King County Parks and Metro’s Community Connections program that seeks to ease vehicle congestion, reduce safety hazards and expand access to hiking destinations along I-90. Trailhead Direct is currently expanding by providing transit van service from South Seattle and Capitol Hill

Engage Healthcare Providers and Nature Contact Researchers 

Healthcare providers have a vested interest in advancing public health objectives and priorities, which in turn are informed by research. Participants agreed that both providers and researchers alike represent natural allies with whom stakeholders in the outdoor recreation community can and should collaborate.

Collaborate with hospitals to incorporate outdoor recreation

Though participants agreed on this point, few examples of state offices that are currently doing so are available. 

  • Wyoming, North Carolina and Oregon offices have begun such work by entering data related to parks and trails into the national Parks Rx America database, which enables physicians to prescribe outings to parks in the Parks Rx system
  • An example of a hospital incorporating outdoor recreation into its program may be found in South Lake Tahoe, California. Though California does not have an office of outdoor recreation, Barton Health is partnering with the local United States Forest Service to create Wellness Outings that expedite the recovery of patients by taking them on guided walks on USFS land

Seek funding through Medicaid

One of the few good examples of this may be found in Colorado. As noted above, the Colorado State Medicaid system is increasingly focused on value-based care. Colorado’s Office of Outdoor Recreation convened multiple partners to develop the Colorado Outdoor and Health Collaborative. The Collaborative provided planning guidance and helped Rocky Mountain Health Plans, a Regional Accountable Entity, create a recreation referral program. This program represents one of few State Medicaid accountable care organizations in the country that are able to refer Medicaid enrollees from clinics to subsidized recreation opportunities while providing reimbursement for the participating recreation and medical practices as part of a population health management plan.

Develop communication around best practices

Participants agreed that communication regarding the health benefits of outdoor recreation should be developed around the “Eight Common Measures that connect park and trail planning to public health goals proposed by NPS and CDC:

  1. PROXIMITY: Percentage of the population (city/county/state/national) living within a half mile of a public park or trail corridor boundary.
  2. WALKING ACCESS: Percentage of the population (city/county) with less than a half-mile walk route to a public park or trail entrance.
  3. PARK CONNECTIVITY: The ratio of the number of people with less than a half-mile walk route to a public park or trail entrance to the number of people living within a half mile of that specific park or trail corridor boundary.
  4. LAND AREA: Percentage of land area designated as public parks or trails.
  5. PHYSICAL ACTIVITY: Percentage of users engaged in sedentary, moderate, or vigorous physical activity at a specific facility area.
  6. VISITATION: Annual number of visits to a specific facility area.
  7. FREQUENCY: Average number of visits to a specific facility area by an individual during a period of time.
  8. DURATION: Average time spent at a specific facility area by an individual

Best practices for addressing social determinants of health through outdoor recreation

Increase Representation 

Outdoor recreation must be accessible and relevant to all communities if the health benefits are to be distributed equitably. State offices will often need to invest disproportionately to engage historically underrepresented or under-resourced communities in order to achieve equitable distribution.  

  • Collaborate across boundaries 
    • Engaging across socioeconomic, cultural and demographical divides requires collaborations with stakeholders and industries that might not be typical partners. In order to reach communities that have historically been underrepresented, state offices of outdoor recreation will often need to partner with organizations, programs and initiatives that have earned a preexisting level of authentic trust with them.
  • Support diverse role models and leaders within the outdoor industry
    • The predominant narrative of who’s outside in outdoor recreation today remains a stereotype: predominantly white, middle class, fit, “bad ass,” good-looking people. Offices of outdoor recreation can help close the gap between the current and the ideal participant by promoting people of color, LGBTQ+ and other marginalized community members as emblematic outdoor recreationists
      • At the 2018 Outdoor Retailers Summer Market in Denver, NativesOutdoors, the Colorado Commission of Indian Affairs (CCIA), and the Colorado Outdoor Recreation Industry Office convened a one-day summit of tribal leaders and organizations around Colorado to focus on and discuss the current state and pathways for public lands management, outdoor recreation, and the opportunities for collaboration with the tribes
      • At the 2017 SHIFT Festival, the “Gotta See It to Be It” project convened social media influencers to discuss the influence of social media on who we expect to see outside, and how grassroots mediums can challenge the prevailing narrative of the outdoor recreation community. The initiative sparked Diversify Outdoors, which created a network of social media innovators committed to positive disruption in the space. Where relevant, outdoor rec leadership positions can consider working with members of this group who are operating in their states

Develop programs for underserved communities 

  • Through its Rewilding Project, REI has collaborated closely with the National Forest Foundation and The Wilderness Society to improve access to and enhance outdoor recreation infrastructure at the San Gabriel Mountains National Monument, which is located within an hour’s drive for 10 million people in the greater Los Angeles area. The initiative has restored and rerouted trails and increased access by linking urban trails and developing public transportation from the city to the mountains.
  • In Michigan, the Outdoor Adventure Center in downtown Detroit created an innovative destination that provides hands-on options for Metro Detroit youth and families to experience and learn about the abundance of outdoor recreation opportunities in Michigan. The project was catalyzed by Governor Engler and overseen by the Department of Natural Resources. In 2016, its first full year of operation, the OAC saw 100,000 visitors

Ensure a Consistent Framework

A set of standards is necessary in order to maximize impact. Standardization allows gains to be measured, areas of need to be improved, and clearly defines objectives and goals. This set of standards should include why the work is being undertaken (including a comprehensive list of benchmarks to be achieved), how the work will be done (with clearly stated standards for partnership), and what the improvements will mean for the populations that will receive the change (such as improvements in medical outcomes). Finally, the framework should be evidence-based, replicable, and scalable to ensure lasting change. 

Examples that could serve as the basis for an outdoor recreation and public health framework include the following:

  • Incorporate health measures and benefits into outdoor recreation planning through processes like the Statewide Comprehensive Outdoor Recreation Plan (SCORP plans are prepared to satisfy the requirements of the Land and Water Conservation Fund)
    • Washington’s SCORP states, “Conserving green space and providing diverse recreation opportunities improves a community’s mental, social and physical health and safety. Through greater collaboration with public health agencies and healthcare providers, outdoor recreation providers can leverage support for improving outdoor recreation opportunities while improving community health and reducing medical costs.”
    • Vermont’s SCORP has a GIS analysis component that will help generate more data and visuals around public health objectives 
    • One of the outcomes of Maine’s SCORP process, which is informed by Rural Active Living Assessment tools, is to develop a georeferenced GIS layer that will enable comparisons between the existence of outdoor recreation infrastructure and known health disparities
  • Replicate previously successful frameworks, such as the Safe Routes to School National Partnership, a national non-profit that advances policy change and catalyzes support for healthy, active communities, starting with walking and bicycling to school 

Key allies that state outdoor recreation leadership positions need to work with in order to address social determinants of health through outdoor recreation 

Again and again, participants noted the potential of cross-sector collaboration to help achieve outcomes that outdoor recreation leaders would not be able to achieve alone.

Government

Collaboration across agency and jurisdictional boundaries can reach new audiences, communities and stakeholders. It can also provide access to funding mechanisms that otherwise might not be available to state offices acting independently.

  • Local and state-level health departments
  • Public health agencies, such as the Centers for Disease Control
    • The Maine Bureau of Parks and Lands has partnered with Maine Center for Disease Control to utilize the Rural Active Living Assessment data set specifically to generate positive health outcomes. The end goal of this analysis will be recommendations within Maine’s SCORP that encourage investments in outdoor recreation facilities that are proximate to populations that will directly benefit from that project, and or to fit identified needs for outdoor recreation investments and therefore will have a greater probability of being enjoyed by the public.
  • Parks and recreation departments 
    • In the Southeast Side of Chicago, the Big Marsh Bike Park, which provides a variety of trail choices and programs including BMX, mountain biking, and Cyclo-cross on 40 acres of existing slag fields where good habitat restoration was difficult and cost prohibitive, was made possible by a collaboration between the Chicago Park District, SRAM and the Friends of Big Marsh
    • Oregon’s office of outdoor recreation worked with Oregon Parks and Recreation Department, which provided staff research time for the report on the health benefits of outdoor recreation
    • Michigan is connecting existing bike paths to create the Iron Belle Trail, a 2,000-mile-long biking and hiking route between the tip of the Upper Peninsula all the way to Belle Isle in Detroit. The trail, which is 70 percent complete, will eventually pass through hundreds of municipalities. In the fall of 2018, Genesee County Parks & Recreation helped open a new section of barrier-free, non-motorized trail that extends the existing Iron Belle Trail from Genesee and Stanley roads another 2.25 miles to Vassar road.
  • Transportation departments
    • The Tennessee Department of Transportation’s Multimodal Access Grant is a state-funded program created to support the transportation needs of transit users, pedestrians and bicyclists through infrastructure projects that address existing gaps along state routes. Multimodal Access projects are state-funded at 95 percent with a 5 percent local match. Total project costs must not exceed $1 million. Applications are accepted once each year.
    • In Wisconsin, the East Central Wisconsin Regional Planning Commission works with public health departments and nonprofit partners to identify shared values to support active living and integrate public health into transportation plans
    • The Minnesota Department of Transportation and Department of Health have partnered together over the years to advance health equity through such initiatives as health impact assessments and Minnesota Walks, one of the first statewide pedestrian planning frameworks in the country that recognizes health and walking as transportation planning priorities.
  • Local, state and federal elected leaders 
    • Utah’s office is working with Governor Herbert on Healthiest Next Generation Initiative, which seeks to improve all areas of children’s health in early learning settings, schools and communities
    • The Rhode Island Outdoor Recreation Council, created by Governor Gina M. Raimondo and composed of government, community and industry leaders, was Vice-Chaired by Director of Health Dr. Nicole Alexander-Scott, MD, MPH. In the Council’s final report, Dr. Alexander-Scott notes, “Our wealth of outdoor recreational spaces provide ideal opportunities to get people physically active and play an important role in fostering healthy lifestyles. The Council’s report also recognizes the unique challenges faced by under-resourced communities in developing and maintaining these spaces, and provides recommendations to support the kind of programming and infrastructure that will facilitate greater use by all Rhode Islanders.”
    • In Wyoming, Governor Matthew H. Mead’s call for the development of an Outdoor Recreation Task Force in 2016 to generate recommendations for improving Wyoming’s outdoor recreation industry led to the Wyoming Task Force on Outdoor Recreation Report. The report notes that outdoor recreation can “provide mental, spiritual and physical health and wellness and quality time for families and individuals.”
    • In 2019 in New Mexico, Gov. Michelle Lujan Grisham is supporting Senate Bill 462, which was co-sponsored by Rep. D. Wonda Johnson (D) and Sen. Steven Neville (R) and would set aside $1.6 million to establish the Outdoor Recreation Division within the Economic Development Department

Schools and school officials

  • Tennessee School Health Coordinators Office, which connects physical, emotional and social health with education, is working with Healthy Parks Healthy Person Tennessee to share the benefits of getting outdoors with more students across the state.
  • In Globeville, Elyria, and Swansea (“GES”) in the greater Denver region, a collaborative process between local governments and civil society identified Garden Place Academy Elementary School as a high priority location for tree planting. Together, TNC and the City and County of Denver Forestry Division donated 55 trees to be planted around the schoolyard and nearby homes. The trees will offer long-term benefits of shade that will cool city streets, reduce air pollution, and encourage outdoor activity in the neighborhood.
  • Free Forest School —a 2018 SHIFT Award Official Selection—supports parents and teachers in integrating outdoor emergent learning opportunities with traditional classroom instruction, and partners with school districts, cities, and community organizations to increase access to nature play for children who face the greatest barriers.

Non-profits

As noted in the Colorado report, “the outdoor industry is poised to … take a lead role in improving public health through outdoor activities. Specifically, outdoor and environmental education nonprofits and socially-conscious outdoor guides and outfitter businesses … can become change agents in a growing outdoor prescription movement that aims to improve public health through the great outdoors…. Through partnering with healthcare providers, outdoor recreation service providers have the opportunity to spread the healing power of adventure.” Offices of outdoor recreation can collaborate with such progressive nonprofit organizations to expedite the movement’s growth.

  • In Oregon, the Office of Outdoor Recreation partners with the nonprofit coalition Oregon Health and Outdoors Initiative to improve health and the environment for all Oregonians by increasing access to and engagement with nature among communities experiencing inequities
  • Colorado partnered with a number of nonprofit organizations, including the Willamette Partnership, The Trust for Public Land and The Nature Conservancy, on its Colorado Outdoor Rx report
  • True North Treks, LEAP Therapeutic Wilderness Program, and Project Healing Waters are examples of the growing number of non-profit organizations that harness the power of outdoor recreation to improve physical and mental health for various populations. 

Community Leaders

Community leaders can serve as champions, bridging cultural divides and delivering messages to their members with authenticity and trust. Identifying and collaborating with such leaders allows outdoor recreation leadership positions to advance agendas more effectively than they would be able to do on their own.

Land Agencies

Land agencies such as USDA Forest Service and US Fish & Wildlife Service are logical partners for the advancement of public health agendas. Once areas of mutual interest are ascertained, collaborations are able to proceed on multiple levels and fronts. 

  • Land-use planners
    • Vermont Forests, Parks and Recreation works with the Vermont Department of Transportation, through which federal highway administration funding for Recreation Trails is administered in grants
    • Parks Rx: Your Prescription to Better Health is a nature-based, healthy living prescription that allows providers to prescribe outdoor physical activity to their patients via a searchable online database of more than 100 Birmingham, Alabama, parks. The collaborative effort partners with the Freshwater Land Trust, Birmingham Park and Recreation and the Centers for Disease Control and Prevention, among others
    • The Land Trust Alliance advocates for trails as ways to promote an active, healthy lifestyle and support the local economy by providing opportunities for outdoor recreation to residents and visitors
  • Private landowners
    • In Vermont, which is 90% private land, funding that comes from LWCF and Recreation Trails Program is predominantly channeled through recreation-related nonprofits and divided between public and private lands. Increasingly, bonus points are given for projects that skew directly to health.
    • Though Maine is roughly 94% privately owned land, the state enjoys a legacy of public access to private lands for outdoor recreation as long as the land is not posted. As more people from “away” move to the state, this public use of private land is stressed in two ways, by those who move there and promptly post their land prohibiting access, and by those who move to Maine but aren’t aware of or comfortable with the concept. As a result, Maine Inland Fisheries and Wildlife has identified landowner relations as a major initiative
  • Public land stewards and agencies

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