Local parks and the health of older adults: results of an exploratory study

Two historic changes that will reshape how local park and recreation services are conceived and funded are taking place. Fundamental changes in health and health care and a simultaneous period of repositioning of park and recreation services have prompted the National Recreation and Park Association, with the assistance and encouragement of the National Recreation Foundation, to take numerous steps to establish linkages with health-related organizations. Additionally, NRPA and NRF have sought to improve understanding of the health benefits of participation in recreation and park services and their ability to reduce medical costs. These steps may have a major impact on the future of the profession.

The health crisis has numerous sources including not only new technology, new funding mechanisms, economic changes, and social values that are less tolerant of the gross differences in the quality of health care, but also a fundamental debate as to what disease is.

During this period of change, preventing rather than treating illness has become increasingly recognized as critical. One recent authoritative study concluded that more than 70 percent of morbidity and mortality in the United States is preventable (Nesse & Williams, 1994). Since approximately $14 of every $100 that changes hands in this country is for "health" purposes, the implications of 70 percent of morbidity and mortality being preventable make prevention an issue that shapes about 10 percent of the total economy.

As the critical human and economic importance of prevention is being realized, public recreation and park services are also in a period of reconceptualization. While local parks are a common feature of American life, currently they are not systematically linked to any policy arena of government.

As many public park and recreation agencies "reposition" themselves for the future, the question arises as to whether such repositioning should gravitate toward the public policy area of "health" or some other policy area, such as "tourism." For local government recreation and park services, in particular, the case for functioning within the public health arena calls for further examination.

Approximately four out of five residents of the United States and Canada use local parks (Godbey, Graefe & James, 1992; Harper, Neider, Godbey & Lamont, 1996). While there may exist the perception that local parks are for younger people, recent nationwide studies show that the vast majority of the American and Canadian public 50 years and older uses local parks. In fact, those most likely to use local parks "frequently" are between the ages of 66 and 75. Among North Americans ages 56-75, more than 60 percent use local parks. Forty-four percent of those 75 and older use local parks. Thus, not only do the majority of people ages 50 and older use local parks, sizable portions use them frequently, and such use continues into old age (Godbey, Graefe & James, 1992; Harper, Neider, Godbey & Lamont, 1996).

While park use is extensive among older adults, this use has only recently been recognized for its relation to health and health policy for older Americans. Although park visitors are viewed as being there for "recreation," there is increasing evidence that such behavior has significant health consequences. For instance, when older park visitors were asked in the surveys cited above what benefits they received from park visitation, their answers most frequently included the chance for exercise and stress reduction.

Given the substantial expenditures for health in the United States, the aging of the population, the consequences of the baby boomers reaching old age, and the massive federal debt, new ways of conceptualizing health care are occurring rapidly. Since the vast majority of public health care expenditures are for older citizens, many new health-promotion and disease-prevention strategies will have to take into consideration the life circumstances (i.e., demographics) and behaviors of older adults.

A Multidimensional Construct

Such reconceptualization will likely emphasize the broader notion of health -- "wellness" -- that assumes health is a multidimensional construct involving social, spiritual, psychological, environmental, educational, and physical components. Additionally, the notion of prevention and personal responsibility for health will grow in importance.

As health policy and health care organizations develop and implement agendas to extend healthy lives and lower health care costs, park and recreation agencies across the country are beginning to utilize the concept of Benefits-Based Management to demonstrate that programs and services contribute to the health of both individuals and communities.

At the municipal level, there are some precedents for state or local health agencies providing guidelines targeted to specific park and recreation facilities or services that have measurable wellness outcomes. The Healthy People 2000 statement of national opportunities, coordinated by the U.S. Department of Health and Human Services, specifically identified increases in community availability and accessibility of physical activity and fitness facilities. These included hiking, biking and fitness trails; public swimming pools; and acres of park and recreation open space (U.S. Dept. of Health and Human Services, 1990).

In summary, public recreation and park agencies are well situated to play a larger part in maintaining and enhancing the health and wellness of the American public, and to be managed to achieve such health benefits. These benefits can and must be measured and analyzed in terms of cost savings in public health expenditures and in ways that involve measurement techniques widely recognized by the medical and health care community.

Doing so will often involve collaborative efforts with public health agencies. While educators and professional are now involved in the effort to measure benefits associated with recreation and parks (Driver, Brown & Peterson, 1991), this measurement process must proceed from a paradigm that expresses the outputs or consequences of such services. That paradigm is wellness.

To understand how local parks can serve as part of a preventive approach to health care for the aging baby-boom generation, research must be undertaken that better documents the relationship between local park use and health and wellness among those 50 and olden Such research must include not only self-reports but also measurement techniques -- such as blood pressure, anthropometrics, and body mass index -- which are commonly used by those in the medical and health care profession.

Issues of stress and physical fitness or mobility should be targeted, since the previously mentioned NRPA study found that in self-reports, users of local recreation and park services identified stress reduction and fitness as the two most prevalent individual benefits of participation (Godbey & Blazey, 1983). Whether such self-reports are accurate is a major issue to be addressed by the current research study. An additional concern is whether the existence of health benefits translates into reduced health care costs. Can a case be made that investment in local parks serves to reduce public spending on health costs?

This question is critically important in the process of allocating financial resources to government services. If recreation and parks is merely a market-driven "amenity," it may increasingly be seen as a proprietary function of government that should generate its own income and provide services to those who can -- and will -- pay for them on a fees and charges basis. If, however, local recreation and park services are understood to constitute an investment in the wellness of the local population that ultimately can be demonstrated to save tax dollars in the health care spending stream, they may be thought of as an essential investment in public health in an era of dramatically escalating health care costs.

A Study of Local Park Use and Health of Older Adults

Given the trend toward a wellness model of health care and the important role of parks and recreation agencies in promoting health, the National Recreation and Park Association undertook a study, with the help of the Pennsylvania State University and Cleveland Metroparks, to determine how local park use is related to the health of older adults. Specifically, the study sought to determine:

1) The demographic and health characteristics of older park users and how they differ from those who don't use local parks.

2) The "logistics of use" of older park users -- how often they visit, how they get to the park, length of stay, and with whom they go.

3) What older people do in local parks that may have health consequences.

4) What benefits older park users ascribe to their visit and how such benefits are related to health.

5) How individual blood pressure and stress level are related to park visitation.

6) How older park users differ from nonusers in terms of visits to personal physicians for purposes other than general check-ups.

Methodology

The study used both a questionnaire and a diary to fulfill its purposes. A series of open- and closed-ended questions was used to measure park behavior and associated benefits and logistics of use. Questions about leisure behavior were also included as a basis to examine the relationship between leisure lifestyle and health. Special attention was given to the role of walking as a secondary activity to accompanying park use.

Instrumentation: Several different instruments were used to assess the multidimensional construct of personal health. The "Rand Medical Outcomes Study Health Survey" was selected to measure physical, mental, and social health; activities of daily living; pain; and health perceptions. Symptoms of depression were measured by the Center for Epidemiological Studies' Depression Scale (CESD). Level of social support (the number of people available to provide social support to a respondent, and the degree of satisfaction with social support) was measured with the Social Support Questionnaire. One measure of blood pressure was taken for each respondent as a physiological indicator of health. A variety of demographic information, due to the known influences such variables have on health, was also collected (Markides & Miranda, 1997).

In the second phase of the study, participants were involved in a five-day diary study. The purpose of this phase was to explore the effects of stress on blood pressure, physical activity, leisure behavior, and mood. After receiving training from a researcher, participants conducted multiple blood-pressure checks, provided saliva samples, and completed questionnaires on a daily basis. In addition, several anthropometric readings (i.e., waist and hip circumferences, weight) were obtained on subjects.

Pilot studies: The questionnaire was piloted several times at various park, mall, and grocery-store locations. Each phase of piloting provided the research team with valuable critiques of the questionnaire, which facilitated several major modifications to both the format and content.

Sampling strategy: The sample for the study consisted of park and non-park users, at least 50 years of age, living in the Cleveland metropolitan area. Because of the length of the instrument (16 pages) and the personal nature of the questions, a random sample was not possible. Consequently, the research team used several different sites and data-collection strategies to achieve a diverse sample that closely reflected the demographic profile of the Cleveland area. Furthermore, non-park users were selected as a comparison group to examine differences in leisure behavior, perceived leisure benefits, and health status between park users and non-park users.

Permission was granted to collect data at all Cleveland Metroparks areas, six Rini Rego Stop-N-Shop Marketplace stores, and three malls (Parma Town, Great Lakes, and Richmond). While these sites were carefully selected to achieve a diverse sample, they provided limited access to African-Americans, people 80 and older, and those with lower functional health status. Further research indicated that a private social service agency called Golden Age Centers of Greater Cleveland (GAC) attracted the type of population needed to make the sample more demographically representative. GAC operates 15 senior centers in the area that provide many services, such as hot-meal programs, counseling, health and wellness programs, leisure and recreation programs, and transportation, to sustain independence.

A total of 1,506 questionnaires was completed, with a response rate of 45 percent. Although approximately 300 people were interested in the diary, time constraints only permitted the involvement of 129.

Findings

The findings of this exploratory study supported the contention that local parks should be regarded as a health service. Specifically, the major findings were:

1. Older visitors to Cleveland Metroparks sites were diverse in terms of their socioeconomic status, age, and ethnicity.

2. Park use was extensive among older Cleveland residents. In general, more than one-third of respondents reported visiting local park areas (e.g., general park areas, playgrounds) frequently, and more than half (53 percent) visited these areas occasionally. Specific to Cleveland Metroparks, 15 percent of all respondents visited a Cleveland Metroparks site 52 to more than 100 times per year, 10 percent visited 26-51 times, and 18 percent visited 12-26 times. As the average park visit lasted about two hours, parks provide an appreciable amount of time per year in which older citizens are likely to be physically active.

3. The majority of park users older than 50 were physically active during their visit. In terms of on-site behaviors in Cleveland Metroparks, more than two-thirds used the parks for moderate or high levels of physical activity. More specifically, about 16 percent enjoyed a high level of physical activity (e.g., jogging, bicycling, hiking), 51 percent had a moderate level (e.g., walking 21-45 minutes, biking, hiking or swimming for less than 30 minutes), 17 percent had a low level (e.g., playing with grandchildren, walking 20 minutes or less), 13 percent were sedentary, and the remaining three percent were just driving though the park (and perhaps should not be counted as users). The average visitor spent approximately half of his or her time walking.

4. Older visitors who were active in the parks were healthier than sedentary users and non-users on a number of measures (see Table 1). Active park users were less likely to be overweight (as measured by body mass index, a computation of weight and height) than those with longer park stays who used the parks for passive activities or did not use the park at all. For those 65 and older, the level of physical activity was the most important positive predictor of body mass index.

TABLE 1. RELATIONSHIP OF LEVEL OF PHYSICAL ACTIVITY AND GENERAL HEALTH AMONG PARK USERS

                                       General Health

                              Excellent    Very good       Good
                                % (N)        % (N)         % (N)

Sedentary Activity             12 (18)      33 (47)       33 (47)
Low Physical Activity          11 (20)      37 (69)      343 (62)
Moderate Physical Activity     13 (73)      38 (215)      35 (199)
High Physical Activity         19 (33)      39 (67)       30 (51)

                                        General Health

                                Fair        Poor
                                % (N)       % (N)       Total

Sedentary Activity             17 (25)      5 (7)        144
Low Physical Activity          17 (31)      2 (3)        185
Moderate Physical Activity     12 (68)      1 (7)        562
High Physical Activity          17 (7)      2 (1)        170

5. The benefits that older local park users ascribed (in their own words) to their visits are clearly health related. Among visitors ages 50 and older who are moderately or highly active during their park visits, the most frequently reported benefits were related to exercise, renewal (i.e., stress relief, a clear mind, or a refreshed, better mood), nature, and health. Those who undertook light physical activity reported exercise, nature, and social benefits most frequently. Sedentary park users mentioned renewal, nature, and social benefits most frequently. Renewal was a theme that ran through the identified benefits of all those older users of parks. In summary, older park users attributed benefits to their visits that are directly related to personal health (see Table 2).

TABLE 2. OVERALL BENEFITS ASCRIBED TO PARK USE

Benefit                       Frequency    Percent

Exercise                         395          48
Renewal                          171          21
Nature                           134          16
Health                            49          6
Social                            24          3
Enjoy                             19          2
Other                             17          2
Learn                             8           1
Activity Itself                   7           1
Reflect                           4           1
Total                            828         100

6. Among the more important findings of this study is that active park use was negatively related to visits to a physician for reasons other than check-ups (see Table 3). Even after controlling for age, income, and health status, park users were significantly less likely to have a recent physician visit. Those who engaged in more park visits or more strenuous activities, and those who felt better as a result of visiting the park, were less likely to have visited a physician. Additionally, respondents who had better access to a park were less likely to have a physician visit. These negative relations with visits to a physician were quite pronounced, indicating a strong relation between park access, use and benefits, and lower rates of physician visits. This study indicates that park and recreation use may help reduce physician visits. Similarly, values that emphasize leisure may reduce the probability of a physician visit. [Because of the importance of this issue, a separate analysis has been undertaken by Dr. Stephen Foreman, Health Policy and Administration, Penn State University, 1998.]

TABLE 3. FREQUENCY OF PHYSICIAN VISITS FOR ANYTHING OTHER THAN A CHECK-UP AMONG PARK USERS

                                      General Health

                                 Less than         Six mos.
Level of physical activity      6 mos. ago      to 1 yr. ago
among park users                   % (N)            % (N)

Sedentary Activity                72 (104)         18 (26)
Low Physical Activity             69 (127)         17 (32)
Moderate Physical Activity        62 (348)         23 (131)
High Physical Activity           159 (100)         23 (38)

                                      General Health

                                   Between         Between
Level of physical activity      1-5 yrs. ago    5-10 yrs. ago
among park users                    % (N)           % (N)

Sedentary Activity                 8 (11)           3 (4)
Low Physical Activity             10 (19)           1 (2)
Moderate Physical Activity         9 (51)           2 (12)
High Physical Activity             8 (14)           4 (6)

                                      General Health

                                  Can't
Level of physical activity       Remember
among park users                   % (N)            Total

Sedentary Activity                0 (0)              145
Low Physical Activity             2 (3)              184
Moderate Physical Activity        3(18)              560
High Physical Activity           6 (10)              168

7. Level of physical activity in the park was the strongest predictor of lower diastolic blood pressure, and was a stronger predictor than age, general level of physical activity, or level of education. While only a small amount of variation was accounted for in the equation, because multiple factors potentially influence health, this finding warrants further investigation.

8. In terms of a person's perceived general health, frequency of park visits was positively associated with better health, as was frequency of vigorous exercise in the last two weeks, a higher level of general activity, higher levels of formal education, and higher levels of social support.

9. Results of the diary study indicated that those with higher stress stayed at the park an average of 30 minutes longer than those who reported lower stress during the diary session. Further analysis indicated, however, no significant difference in activity type or frequency of park visits between the two groups to explain this finding. Nevertheless, longer park stays were predictive of lower scores on the daily stress inventory.

These results add to the strength of the hypothesis that people use the park as a means of moderating their stress.

The Practical Significance

Approximately 30 percent of the U.S. population reports having no leisure-time physical activity (LTPA), a rate that increases with age. It is also well documented that the prevalence of disease increases in those who are sedentary. This study indicates a positive association between park use and health among older adults.

While it is likely that adults in better health are more likely to use parks, it also seems likely that the use of parks is an important factor in maintaining or enhancing personal health. Most current concepts of health assume that, within the limits of one's genetic endowment, one's personal behaviors play an important role in determining the extent to which optimal health is achieved. Because local parks are accessible to the majority of older Americans, generally impose no fees or charges for admission, and lend themselves to a variety of pleasurable uses that result in physical activity and stress reduction, these facilities should rightly be thought of as part of the health care system.

Parks, as opposed to other facilities, should be prioritized for health-promotion purposes, since natural environments allow for "restorative experiences," which facilitate the clearing of "residual clutter" from the mind, allow for quiet contemplation, and help to recover the directed attention that is required to complete work (Kaplan & Kaplan, 1989).

The continued promotion of park facilities and programs to older populations, as well as partnerships with social service and health organizations, will help garner additional support for parks and recreation as an essential component of health care. Some innovative examples of programs designed to meet this goal are already in place. Consider the following:

1) Cleveland Metroparks offers special monthly "breakfast in the park" programs that combine physical activity (a walk before breakfast) and a congregate meal, providing opportunities for socialization in a natural environment. Other interpretive programs, such as bird watching and plant identification, are specifically geared toward facilitating both education and physical activity among older adults.

2) The Foothills Park District in Lakewood, Colorado, teamed up with Kaiser Permanente to establish a program that will refer Kaiser clients who have undergone breast surgery to the park district's "Active Options" fitness and wellness program. This program, open to all Foothills customers ages 62 and older, features a discounted fitness pass, which includes unlimited facility usage, unlimited aerobic and strength training classes, individual fitness evaluations, and newsletters.

3) The California Department of Health Services hired a parks and recreation professional to develop collaborative relationships between parks and recreation and public health departments (Seeley, 1997).

Moving Into the Health Arena

These initiatives, and others like them, are helping to move parks and recreation into the health arena. Other issues to consider in developing publicity/promotional campaigns and partnerships include perceptions of safety and transportation. Many older people (especially those in urban areas) may be afraid to leave their homes to participate in physical activity. Promotion of parks as "safe havens" for enjoyable leisure activity may help overcome this constraint. Transportation is another common barrier to park use. Recreation and park agencies might consider partnerships with senior centers, assisted-living facilities, and other social service organizations to aid with transportation needs.

Of course, many park and recreation agencies themselves may deal with resource limitations for additional programs. However, there is substantial funding available for applied research and programs focused on optimizing mobility, health, and general quality of life among the older population. For more information on funding opportunities, visit the following Web sites:

National Institutes of Health www.nih.gov/

National Institutes of Aging www.nih.gov/nia/

Retirement Research Foundation fdncenter.org./grantmaker/rrf/index. html

AARP's Andrus Foundation www.andrus.org

Given our aging population, the increasing importance of local parks to the health of older adults seems evident. This needs to be more clearly articulated in health policy and in the development of collaborative strategies to minimize health care costs.

References

Driver, B.L., Brown, R and Peterson, G. 1991. The Benefits of Leisure. State College: Venture Publishing.

Foreman, S. 1998. The Relationship between Visit to a Physician and Visits to Local Parks Among Older Adults. University Park, Pa: Penn State University.

Godbey, 6. and Blazey, M. 1983. Old People in Urban Parks: An Exploratory Investigation, Journal of Leisure Research, 15(3): 229-45

Godbey, G., Graefe, A. and James, S. 1992. The Benefits of Local Recreation and Park Services: A Nationwide Study of the Perceptions of the American Public. Ashburn, VA: NRPA.

Harper. J., Neider, D., Godbey, G. and Lamont. D. 1996. The Use and Benefits of Local Government Recreation and Park Services in Edmonton, Alberta. Winnipeg: Health, Leisure and Human Performance Institute, University of Manitoba.

Kaplan, R. and Kaplan, S. 1989. The experience of nature: A psychological perspective. Cambridge: Cambridge University Press.

Markides, K. and Miranda, M. (eds.). 1997. Minorities, aging, and health. Thousand Oaks, CA: Sage Publications.

Nesse, R. and Williams, G. 1996. Why We get Sick -- The New Science of Darwinian Medicine. New York: Vintage Books.

Seeley, A. 1997. Recreation as preventive health care. California Parks and Recreation, 53 (3), p. 7.

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