From the inside out to the outside in_ Exploring the

Journal of Outdoor Recreation and Tourism 10 (2015) 70–77

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From the inside out to the outside in: Exploring the role of parks and protected areas as providers of human health and well-being$ Francesc Romagosa a,n, Paul F.J. Eagles b, Christopher J. Lemieux c a Department of Geography and Universitary School of Tourism and Hotel Management, Universitat Autònoma de Barcelona, 08193 Bellaterra, Catalonia, Spain b Department of Recreation and Leisure Studies, University of Waterloo, N2L 3G1 Waterloo, Ontario, Canada c Department of Geography & Environmental Studies, Wilfrid Laurier University, N2L 3C5 Waterloo, Ontario, Canada

art ic l e i nf o

a b s t r a c t

Article history: Received 2 October 2013 Received in revised form 26 June 2015 Accepted 26 June 2015

Research consistently documents positive links between human contact with nature and health and well-being. Recent work has explored the role of visitation to parks and protected areas in providing health and well-being benefits. This conceptual paper identifies the state-of-the-art research findings on this issue from an interdisciplinary perspective. The results reveal increasing understanding of the positive relationships between park and protected area visitation and the associated health and well-being benefits to the visitors. It also establishes the need for better collaboration between park and protected area and health institutions, which will require new and innovative transdisciplinary partnerships in order to better understand salient issues, realign common interests where appropriate, and effectively integrate empirical evidence into relevant policy, planning and management. Recommendations are made for specific knowledge user groups, such as policy makers, social and health professionals, protected areas professionals, and researchers, with the ultimate objective of better linking human health and well-being and protected areas policies to enhance delivery mechanisms for health promotion activities.

Keywords: Parks Protected areas Natural environment Human health Well-being Management Health promotion

Mana ge me nt Implications

   

Visitation to parks and protected areas plays a vital role in human health and well-being. Public health and protected areas' agencies should collaborate more intensively. The “Healthy Parks, Healthy People” program has become paradigmatic. There is a need for further research on the effects of parks visitation on health. & 2015 Elsevier Ltd. All rights reserved.

1. Introduction 1.1. The relationship between human health, well-being and the natural environment The concept of “ecosystem health” has been applied widely in ecology and the environmental sciences over the past 25 years ☆ Francesc Romagosa carried out the writing of the paper during a postdoctoral research stay at the Department of Recreation and Leisure Studies of the University of Waterloo (Ontario, Canada), funded by the Spanish government (José Castillejo fellowship). n Corresponding author. E-mail address: [email protected] (F. Romagosa).

http://dx.doi.org/10.1016/j.jort.2015.06.009 2213-0780/& 2015 Elsevier Ltd. All rights reserved.

(Costanza, Norton, & Haskell, 1992; Lackey, 2001). Environmental degradation (i.e. air and water pollution, forest and wetland destruction, etc.) frequently causes poor human health, while environmental protection (i.e. creation of parks and protected areas, appropriate environmental management, etc.) contributes positively to human health. Hence, the key contributions of ecosystems to human well-being through the provisioning, regulating, cultural, and supporting services are increasingly recognized (Millennium Ecosystem Assessment, 2003). This thinking was documented in The Ottawa Charter for Health Promotion of 1986 (World Health Organization, 1986) which advocated the protection of natural and built environments as well as the conservation of natural resources as essential in any health promotion strategy.

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This charter appears to be the very first document to delineate an agenda for public health, explicitly connecting human health to nature (Dakubo, 2011). However, as the Canadian Parks Council stated 20 years later, “while a healthy ecosystem is recognized as essential to human health, it seems that the development of programs that use the natural environment as a foundation to promote human health have only been explored in a very preliminary way” (Canadian Parks Council, 2006, p. 1). Humans depend on nature for material needs (food, water, shelter, etc.), as well as psychological, emotional, and spiritual needs (Frumkin, 2001; Katcher & Beck, 1987; Roszak, Gomes, & Kanner, 1995; Suzuki, 1997; Wilson, 1984, 2001). The dependence of humans on nature, and the benefits gained from interacting with the natural environment have recently become emphasized through investigation by several academic disciplines (i.e. environmental sciences to social sciences, and especially by psychology, medicine and public health policy). This research indicates that parks and other forms of protected areas contribute significantly to human health and well-being by providing access to the natural environment, yet it seems that their potential to contribute to health have been unacknowledged and under-utilized (Lemieux et al., 2012; Maller, Townsend, Pryor, Brown, & St. Leger, 2005; Maller, Henderson-Wilson, Pryor, Prosser, & Moore, 2008). This assertion may seem paradoxical since some of the first parks and protected areas were created under the belief that human contact with the natural environment fosters psychological and physical wellbeing and reduces the stress of urban living (Jones & Wills, 2005). 1.2. The present study This paper argues that parks and protected areas constitute a crucial resource for human health and well-being for both individuals and to communities. We apply the concept of health, from the Ottawa Charter, as “a resource for everyday living, which allows us to manage, to cope with and even change our environments” (World Health Organization, 1986). Well-being is defined as “a state of successful, satisfying, and productive engagement with one's life and the realization of one's full physical, cognitive, and social-emotional potential” (Gil & Bedini, 2010, p. 17). This positive approach implicitly understands health and well-being as interdependent concepts. In this paper the term “parks and protected areas” is applied to all types of parks (urban and nonurban) and to all the six categories of protected areas as defined by the International Union for the Conservation of Nature (IUCN) (Dudley, 2008). Thus, we take an expansive approach to categorization of these areas.

2. The role of parks in the provision of human health and wellbeing 2.1. Evidence from the research While parks and protected areas are well-known for their important contribution to the conservation of biodiversity and maintenance and enhancement of ecological integrity (Millennium Ecosystem Assessment, 2003, 2005), their provision of essential ecosystem services, such as clean air, clean water, and carbon sequestration, has not been acknowledged to the same extent (Costanza et al., 1997; Dudley et al., 2011; Naidoo et al., 2008). Their use as spaces for recreation is enormous, but incompletely documented (Hornback & Eagles, 1999; Priskin & McCool, 2006; Stolton, Mansourian, & Dudley, 2010). Parks and protected areas also contribute substantial economic benefits from all of these services, although these are rarely fully recognized and calculated (Dixon & Sherman, 1991; Pabon-Zamora et al., 2008). Yet they also provide an attractive setting for health promotion and the creation of well-being for the human populations that

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access these sites. Stolton and Dudley (2010) identify three ways in which protected areas contribute positively to human health: (1) They provide benefits, such as those that come from conscious management of ecosystems against disease, and those related to management activities that contribute to better health (e.g. provision of clean drinking water, soil stabilization, etc.); (2) they are sources of medicines, both local (drawing primarily on ethnobotanical studies, to show the wide range of values that these areas contain) and global (looking firstly at plants which are used raw or in only lightly processed form and secondly as sources for materials that are components of pharmaceuticals); and, (3) they provide direct health benefits, such as locations for physical exercise and environments for therapeutic activities concerning mental health. Research reveals multiple motivations for visiting and participating in activities provided by protected areas, including satisfaction from the realization of personal values (Kreninchyn, 2006; Lemieux et al., 2012, 2015; Manning, 2011; Manzo, 2003). Protected area values have been classified as intrinsic (e.g., fauna, flora, ecosystems); on-site goods and services (e.g., plant products, animal products, scientific research and knowledge, education); community-oriented (e.g., culture, identity, spiritual meaning, social well-being, bequest for future generations); and individualoriented (e.g., existence, physical health, psychological health, spiritual well-being) (Lockwood, Worboys, & Kothari, 2006). While increasing attention has been paid to on-site goods and services of the natural environment in recent years (i.e., the value of ecosystem services and natural capital) (Anielski & Wilson, 2009; Costanza et al., 1997; Howarth & Farber, 2002), less attention has been given to the community and individual health values and benefits that visitors obtain from visitation to, and experiences provided by, protected areas. Indeed, despite the popularity of protected areas as places to visit for recreation and leisure purposes (e.g., physical activity and relaxation), and the large potential for promoting protected areas as places that support human health and well-being, scant research exists on the diverse perceived health and well-being motivations and benefits associated with visitation, much less about specific management and policy interventions and their effects on subgroups (e.g., youth and the elderly, male and female, disabled people, etc.). Nevertheless, research conducted primarily in the context of urban and suburban parks in developed countries suggests that the social benefits of visiting parks and other forms of protected areas are substantial. A comprehensive literature review conducted to understand better how humans benefit from nature by Maller et al. (2008), found that humans benefitted from the contact with nature in a number of ways, such as viewing natural scenes, being in natural environments, and having contact with plants and animals. Most of these actions in nature can be done in a context of parks and protected areas, mainly because they guarantee a high quality environment, often with good accessibility, infrastructure and services that manage visitation (Eagles, McCool, & Haynes 2002; Eagles & Bushell, 2007). Furthermore, research has also shown that humans are dependent on nature and there are positive links between the natural environment and human health (Kuo, 2010; Nilsson, Baines, & Konijnendijk, 2007). In this sense, a study made by the Health Council of the Netherlands and Dutch Advisory Council for Research on Spatial Planning, Nature and the Environment (2004) highlights the indirect connections that can be made between human health and nature, by looking at how nature influences actions or mechanisms which in turn influence health. These

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Table 1 A summary of the contribution of parks and protected areas to human health and well-being. (Source: Maller et al., 2008). Component of health/well-being Contribution of parks and protected areas Physical

Mental Spiritual Social Environmental

Provide a variety of settings and infrastructure for various levels of formal and informal sport and recreation, for all skill levels and abilities (e.g. picnicking, walking, dog training, running, cycling, ball games, sailing, surfing, photography, birdwatching, bushwalking, rock climbing, camping, etc.) Make nature available for restoration from mental fatigue; solitude and quiet; artistic inspiration and expression; educational development (e.g. natural and cultural history) Preserve the natural environment for contemplation, reflection and inspiration; invoke a sense of place; facilitate feeling a connection to something beyond human concerns Provide settings for people to enhance their social networks and personal relationships from couples and families, to social clubs and organizations of all sizes, from casual picnicking to events days and festivals Preserve ecosystems and biodiversity, provide clean air and water, maintain ecosystem function, and foster human involvement in the natural environment (Friends of Parks groups, etc.)

actions include (1) recovery from stress and attention fatigue; (2) encouragement of exercise; (3) facilitating social contact; (4) stimulation of development in children; and, (5) stimulation of personal development and a sense of purpose. Looking at these actions with more detail, specific research shows evidence of the positive link between the natural environment, outdoor recreation and human health (Godbey, 2009; Kuo, 2010; Lee & Maheswaran, 2010; Ryan et al., 2010; Townsend & Weerasuriya, 2010). The most obvious include exposure to, and participation in, physical activities such as hiking, swimming, canoeing and other outdoor activities that encourage the green exercise (Pretty, Peacock, Sellens, & Griffin 2005; Pretty, 2011). The most common physical activities are walking and cycling, due to their inexpensive accessibility to the majority of population (de Vries et al., 2011). Several studies found that both the number of recreation facilities and the area of green or open space in a community were significantly related to high levels of walking or physical activity amongst the local population (Kaczynski, Potwarka, & Saelens, 2008; Li, Fisher, Brownson, & Bosworth, 2005). In this sense, Barton, Hine, and Pretty (2009) affirm that the biodiversity and a variety of colors observed in changing seasons in nature contribute to the attractiveness of outdoor spaces and act as an important motivator in sustaining exercise habits. But not all the studies found positive relationships between natural areas and physical activity: a study carried out in the Netherlands, for instance, found that the amount of green space in people’s living environment has little influence on their level of physical activity (Maas, Verheij, Spreeuwenberg, & Groenewegen, 2008). Other studies showed that contact with the natural environment, plants, animals, landscapes, and wilderness, offers a range of medical benefits to visitors, including faster recovery from surgery (Ulrich, 1991) and better pain control (Diette, Lechtzin, Haponik, Devrotes, & Rubin, 2003), reductions and prevention of hypertension, enhanced ability to concentrate (Kuo, 2001), the fulfillment of emotional needs (Lopez-Mosquera & Sanchez, 2012), and lower self-reported stress (Frumkin, 2001; Kaplan, 1995; Kaplan & Kaplan, 1989; Lewis, 1996; Parsons, Tassinary, Ulrich, Hebl, & Grossman-Alexander, 1998). Children with attention and behavioral disorders showed significant improvement after being in contact with nature (Frumkin, 2001; McCurdy, Winterbottom, Mehta, & Roberts, 2010). Another study revealed the importance for children and their parents to engage with beach environments in order to improve their health (Ashbullby, Pahl, Webley, & White, 2013). Research also suggests that exercise is more beneficial, leading to relief of anxiety and depression, when it occurs in natural settings like parks, rather than along urban streets (Bodin & Hartig, 2003; Bowler, Buyung-Ali, Knight, & Pullin, 2010; Hartig, Mang, & Evans, 1991; Thompson Coon et al., 2011). Interestingly, it has been found that the psychological benefits of natural areas increase with an increase in biodiversity (Carrus et al., 2015; Fuller, Irvine, Devine-Wright, Warren, & Gaston, 2007). Furthermore,

Sandifer, Sutton-Grier, and Ward (2015) found strong evidence linking biodiversity with production of ecosystem services and between nature exposure and human health, although acknowledged that much more research is needed on mechanisms of causation. These findings are relevant because the level of biodiversity in protected areas is usually higher than non-protected areas (Mulongoy & Chape, 2004). 2.2. Specific parks and protected areas approach The published studies largely focus on urban and suburban parks, and very few have been conducted within the specific context of protected areas; therefore, a prominent gap exists within the literature. Furthermore, most studies focused primarily on the benefits associated with attention restoration and physical activity in natural environments, and ignored other aspects that affect both individual and collective health and well-being. Maller et al. (2008) first adopted this broader perspective and summarized the contribution of parks and protected areas to five different components of health and well-being (physical, mental, spiritual, social and environmental) (see Table 1). A recent study from Spain (Europarc-España, 2013) complements the work of Maller et al. (2008). The work in Spain found that parks and protected areas: 1. Offer diverse opportunities for recovery of diseases, convalescences and ailments associated to different stages of a person’s life, particularly those related with cardiovascular (high blood pressure, obesity) and bony (osteoporosis) problems; 2. can foster healthy eating habits through consumption of local products (promotion of proximity products, quality brands associated to protected areas and local products); 3. provide unrepeatable personal experiences that promote improved self-esteem because many activities involve difficulty and pose symbolic goals; and, 4. provide opportunities to work with children, teenagers, and senior in creating healthy life habits and promoting physical exercise. The US National Park Service (2013, p. 2) defines park health resources as “programs, facilities, and environments (natural and cultural) that, when used by visitors, can provide demonstrable and often distinctive physical, mental, and social health benefits”. Programs exist with educational and recreation elements. Increasingly, healthy and local foods are being offered. Differentiation between the human health and well-being benefits between protected natural areas (e.g., national/provincial/ state parks) and urban parks can be made. Protected natural areas can generally provide more types of human health and well-being benefits than the ones that can be provided by urban parks (Table 2), despite the fact that urban parks have the key attribute of

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Table 2 Human health and well-being considerations for protected natural areas and urban parks. Health and well-being considerations

Main human health and well-being benefits

Protected natural areas, such as national parks  Places of high biodiversity, and they are among the healthiest ecosystems (good environmental state). Consequently, Environmental well-being they become appropriate environments to provide resources for health and human well-being.

 Social need for connection with nature can be better granted by protected areas taking into account that they are

Environmental well-being

representative from the natural environment. In fact, natural areas have historically been seen in many cultures as “therapeutic landscapes” (Gesler, 1992).

 Good provision (in comparison with natural non-protected areas) of infrastructures and services that manage visitation.

Physical well-being Social well-being

 Generally protected areas (especially those with limited accessibility) offer calm, serenity, and silence, and are per- Psychological well-being ceived as restorative places.

Spiritual well-being

Urban and suburban parks  High levels of accessibility for a large number of people.

Social well-being

 Good provision of facilities and infrastructure.

Physical well-being

p. 74) state that “protected area managers throughout the world are increasingly being encouraged to see the areas they manage enjoyed as ‘outdoor gyms’. Although this is clearly not a strategy for all protected areas, in particular those with fragile environments or where animal populations include species which represent a danger to human life, for many managers and policy makers the need to link protected areas and health is becoming clear.” Many examples of good practices have been developed and implemented in the use of the outdoors and the natural environment for the purpose of improving human health and well-being (Bell, van Zon, Van Herzele, & Hartig, 2011; Drakou, De Vreese,

good accessibility and infrastructure and facilities provision.

3. Applied projects and studies in parks and protected areas Until recently, health-policy circles showed little interest in the benefits of health and well-being supplied by the natural environment in general, and even less benefits from parks and protected areas. However, recent initiatives indicate that a renewed appreciation for nature as a curative phenomenon (but also preventive and contributing to enhance the quality of life) is emerging in the health care sector. Increasingly, park and protected area circles wish to engage the health sector. Stolton and Dudley (2010,

Table 3 Comparison of the international “Healthy parks” reported programs. Program

Country

Promoter institution

Year of start

Healthy Parks, Healthy People

Australia

Parks Victoria

1999

Main outcomes

 Alliances with the local health sector and universities  Organization of international congresses on this issue and creation of HPHP Global to help spreading the message globally

Healthy by Nature

America's Great Outdoors Initiative

Healthy Parks, Healthy People US

Canada

Canadian Parks Council

2006

United States of America

Government of U.S.A.

2010

United States of America

National Park Service

 Development of different healthy living programs by the provincial park agencies

 Raise awareness of the value and benefits of natural areas, such as using them as a way to improve the health and well-being of society

2010

 Development of the Strategic Action Plan (2011), based on (1) demonstration projects; (2) research and evaluation; (3) communications and education, and; (4) alignment and synergy

 Development of HPHP Science Plan (2013), establishing research needs Monitor of Engagement with the Natural Environment

United Kingdom

Health and protected areas in Spain Spain

Natural England

2012

 Provide baseline and trend data on how people use the natural environment in England

Europarc-Spain

2013

 Identify the benefits that protected areas provide to human health and well-being

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Lofthus, & Muscat, 2011; Senior & Townsend, 2010). However, almost all of them have been implemented in urban and suburban parks. In this section, we will present some examples of programs or studies that are explicitly connected to parks and protected areas in a wider sense. We will pay attention to cases from Australia, Canada, United States, United Kingdom, and Spain (Table 3), as examples of actions in this field. The most internationally-acknowledged program communicating the importance of parks and the natural environment for human health and well-being to governments and the community is the Australian “Healthy Parks, Healthy People” (Maller et al., 2005, 2008). It was initially developed in 1999 by Parks Victoria, the agency in charge of the management of the protected areas in the State of Victoria in Australia, and it is based on the assertion that individual and collective health depends on a healthy parks system, and that a healthy parks system is integrally linked to the value placed on it by the community (Healthy Parks Healthy People Global, 2011). The program, still currently in operation, is based on three main pillars. First, there is a search for alliances with the health sector at the local level that permit to deliver a variety of projects and programs (i.e. the State Health Department, the Royal Australian College of General Practitioners, Asthma Victoria, the National Heart Foundation, Arthritis Victoria, the program’‘Active in Parks’, and additional funding by the Medibank private partner) (Active in Parks, 2014). Second, an emphasis targeted research (Senior & Townsend, 2010; Townsend & Weerasuriya, 2010). Third, dissemination of information on actions and research results is emphasized. Examples include Maller et al. (2008), and the First International Congress on Healthy Parks in 2010 (Healthy Parks Healthy People, 2014). The Canadian Parks Council (2006) produced its strategy “Healthy by Nature”. This document was a response to mounting evidence of increasing obesity, type 2 diabetes, and the general Pan-Canadian Healthy Living Strategy endorsed by Canada Health Ministers in 2005 (Senior & Townsend, 2010). This Canadian national program carried five key messages, simply expressed as (1) parks for your health; (2) parks for your family; (3) parks for your soul; (4) parks for your community; and (5) parks for your environment (Canadian Parks Council, 2006). Since then, several provincial park agencies in Canada have embraced the Healthy by Nature concept and are contributing to healthy living programs in their jurisdictions (e.g., Alberta, British Columbia, Manitoba, and Ontario). In the United States, America's Great Outdoors initiative, approved in 2010, aimed to raise awareness of the value and benefits of natural areas, such as using them as a way to improve the health and well-being of society (Government of U.S.A., 2011). The National Park Service (NPS) published its strategic action plan “Healthy Parks, Healthy People US” (National Park Service, 2011), a document inspired by the 2010 congress that took place in Australia. The plan provides for creative exploration of health and well-being within the context of sustainability, across four priority areas: (1) demonstration projects and nodes of innovation; (2) research and evaluation; (3) communications and education, and; (4) alignment and synergy. Recently the NPS produced a science plan containing research needs in this field (National Park Service, 2013). Since 2010, regional initiatives were initiated in the United States. One example is the “Healthy Parks, Healthy People: San Francisco”, a partnership between park agencies and the health care sector of that Californian city (Institute at the Golden Gate, 2013). The repositioning of recreation and parks in the USA as a health and wellness service has also been fueled by the National Recreation and Park Association (NRPA), which initiated numerous partnerships with organizations such as Centers for Disease Control and Prevention, National Cancer Institute, and others (Godbey, Caldwell, Floyd, & Payne, 2005).

In the United Kingdom, Natural England, a governmental institution encourages people to enjoy their surroundings. In accordance with its national strategy “Healthy Lives, Healthy People” (Natural England, 2012), Natural England commissioned a survey called Monitor of Engagement with the Natural Environment to provide baseline and trend data on how people use the natural environment in England (Natural England, 2012). Even though its mandate was not specific to parks and protected areas, it was an important step in acknowledging the relationship between visitors to green spaces, health and well-being in England. Also in Europe, a recent study by the Spanish office of Europarc, with support from the Spanish Government and the regional government of Castilla y Leon, aimed to identify the benefits that protected areas provide to human health and well-being (Europarc-España, 2013). It is a first step in this field in Spain.

4. Conclusions and policy recommendations This paper shows increasing understanding of the positive relationships between park and protected area visitation and the associated health and well-being benefits to the visitors. It is becoming increasingly clear that better connections between parks and protected areas and health institutions are required to support public health promotion initiatives that are of mutual interest. Indeed, a consensus has emerged about the importance of parks and protected areas in providing space in support of health and well-being both at an individual and a community level. However, as Maller et al. (2008, p. 21) aptly pointed out several years ago, and is still highly relevant today, parks still “need recognition for the essential role they play in preserving, maintaining, and promoting the health of the humans, as well as that of their environment.” As a result, we conclude by outlining some specific conclusions and recommendations for policy makers, social and health professionals, protected areas and conservation professionals, as well as researchers and academics. Policy makers should consider increased linkage of health and well-being policies to protected areas, as a delivery mechanism for health promotion activities, where appropriate. In other words, they should begin to acknowledge and integrate parks and protected areas as a positive health resource. Lemieux et al. (2015) provide useful recommendations for such a linkage in the Province of Alberta in Canada. Generally speaking, policy makers should help implement and coordinate the recommendations described below for other professionals, especially giving support to further research in this field. Social and health professionals should be encouraged to develop awareness of the various roles that parks and other forms of protected areas can play in health policy and health promotion, and to develop partnerships with protected area managers to implement health-related activities. It may be beneficial to examine how contact with nature in parks can be used as a preventative measure. Eventually, programs should address the needs of health-related stakeholders (i.e., health professionals, sport and education organizations), as well as specific user groups (e.g., children, teenagers, seniors and disabled). As Lemieux et al. (2015) pointed out, outreach programs focused on connecting, in particular, youth and newcomers to nature, may be beneficial. The results of the study by Lemieux et al. (2015) revealed that more frequent visitors tend to be of better physical health, and perceive greater well-being benefits and outcomes associated with protected area visits. This finding has important implications, as nonpark users may be unable to get to parks (i.e., due to physical constraints), or are unaware of the benefits, and a well-designed outreach program can help support the benefits of ongoing park visitation.

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Table 4 Summary of US National Park Service HPHP research agenda (Source: National Park Service, 2013). Identifying and evaluating park health resources What are visitors' baseline levels of health prior to and post utilization of park health resources? What park health resources are most conducive to physical and mental health? Where are the resources located? What are the health values of these resources? Are different resources associated with specific park settings and types? What combination (type/intensity) of park health resources results in the maximum health benefits? Documenting physical activity in parks What health resources for physical activities are available, and where are they located? What is the extent of physical activity in national parks? What are the different classifications of physical activity within park settings? What is the duration and intensity of physical activity undertaken by visitors? Do parks help visitors meet their daily recommendations for physical activity? Do park visits contribute to future changes in healthy lifestyle behaviors? Understanding the link between park-going and mental health and wellbeing Which park resources and activities promote mental health and well-being? What are the specific mental health and well-being benefits of parks? What are constraints to park use and access to health resources that promote mental health and well-being? Evaluating nutrition and nutritional information in parks What food/beverages are available, and how nutritious are these items? What are the constraints to regulating the quality of food available in parks? What are the financial implications of regulating the quality of food sold by park vendors? How do park users respond to an inventory of healthy choices and constraints on non-nutritious foods in park food outlets? What is the baseline nutritional knowledge and preferences of park visitors, and are there significant differences between the general population’s nutritional knowledge and preferences? Can nutritional signage mitigate concerns about availability of healthy/unhealthy foods? How can NPS policy lead to increased nutritional offerings? Improving health education/communication in parks What are park agency health education resources? What communication strategies are used and preferred by visitors? How do use and preference of health education/communication strategies vary by categories of visitors such as age and group composition? Do education programs lead to healthier decision-making at parks and at home that is consistent with national guidelines for physical activity and diet? Do certain types of interpretive programs lead to a reduction of perceived constraints to park health resources? Can interpretive programs designed for specific populations result in higher interactions with park health resources? Developing and using program evaluation tools What are the current methods and tools used for evaluation of park health resources and programs? How effective are these tools in evaluation for health resources and programs in each park? Are current and future health programs amenable to sound evaluation and monitoring? Additional areas of research What park resources/experiences are considered inspirational to staff and visitors? How do social relationships mediate interaction with park resources? Do visitors retain healthy lifestyles when returning to home communities? How does the ecological health of the park influence physical, mental, and social health of visitors? What role do parks play in public health policy? Do policies in parks act as interventions to promote healthy lifestyles? What is the return of investment of park based disease prevention strategies?

Protected areas planners and managers should integrate human health and well-being objectives in their planning and management actions, in addition to ecological objectives. They should also develop health communication strategies and promote them to health professionals and the public at large. Furthermore, they may also

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want to consider developing health activities and ensure access to these by the public (i.e. integrating health more fully into visitor education, interpretation, and outreach programs in protected areas) and consider developing and integrating health and wellbeing indicators in park program evaluations and follow-up documents (e.g., “state of the park” reporting). Such initiatives do not necessarily have to be the sole responsibility of the protected area managers, but can be developed in association with other organizations working in the protected area field. Many of these initiatives will only be successful if a cooperative approach is developed between parks and health and well-being organizations. The ever increasing separation of urban populations from nature may be an opportunity for land use managers to create new protected areas closer to urban areas, or for park agencies to improve the parks facilities and accessibility in order to foster public health activities in these sites. Indirectly, these actions may facilitate the public use of protected areas and constitute one strategy to make them socially and economically profitable due to the different uses. In this sense, this is a win–win operation, beneficial both for protected areas (a way to generate profile and income) and society (a way to improve health and well-being). It should be noted that some types of visitor use in parks and protected areas can negatively affect the environment, as well as the quality of visitor experiences, unless well-managed (Eagles et al., 2002). This reveals the need for appropriate land use planning and management actions, followed by monitoring, in protected areas. One of the key objectives of that policy should be to avoid negative effects on the health and well-being of visitors that could be produced if there were crowding problems or conflicts among visitors (different recreational demands sharing a same place). For instance, the motorized use of natural areas is likely to be in increasing conflict with activities linked with experiencing peace and quietness and solitude (Bell, Tyrväinen, Sievänen, Pröbstl, & Simpson, 2007). Apart from this, there can also exist other general constraints to visiting parks as a health resource, such as park characteristics (size, facilities, accessibility, and safety), and other social characteristics (age, gender, socio-economic status, ethnicity, etc.) (National Park Service, 2013). A major problem for park managers is a lack of finance to implement management needs (Eagles, 2002, 2003, 2014; Eagles & Hillel, 2008). It is crucial to include the value of the health benefits of contact with the natural environment in the business case regarding funding and priorities. It is also essential that mechanisms be developed for the health sector to contribute sufficient finance to enable program development and implementation. In this regard, protected area agencies should consider strengthening its social science component in order to promote research to improve understanding, planning, management and decision-making pertaining to human health and wellbeing and conservation-related issues (Lemieux et al., 2015). Finally, researchers and academics can help better understand the impact of conservation initiatives on the human health and livelihoods of communities. This should be a top research question for conservation and health policy. As Lemieux et al. (2012, p. 82) noted, “increased levels of health research can help protected area practitioners and public health authorities more systematically address the health potential of protected areas, and better ensure that informed decisions are made in all areas of the health system including treatment, prevention, public program and policy development”. Furthermore, academics should also incorporate integrated teaching on this field in health, recreation, and tourism courses. According to Maller et al. (2008), research should be focused on (a) collecting further empirical evidence demonstrating the health and well-being benefits of contact with nature; (b) exploring new opportunities for application of the health and well-being benefits of contact with nature by investigating nature-based interventions to address

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existing and emerging health problems; and (c) exploring opportunities for using the health and well-being benefits of contact with nature as a preventive ‘upstream’ health measure. Lemieux et al. (2015) also emphasize that the health and well-being benefits received by visitors within different landscape and biodiversity contexts is a critical research gap. For example, how areas with high biodiversity or ecological integrity affect human health and well-being differ from areas with lower biodiversity and ecological integrity (i.e., areas subjected to various sources of anthropogenic stresses) both within and between parks is an area requiring further empirical examination. More recently, the US National Park Services Healthy Parks Healthy People Science Plan identified three general research goals, in this case specifically related to parks and protected areas: (1) demonstrate that parks and public lands are sources of health benefits; (2) inform the design and implementation of effective park policies, programs, facilities, and environments related to health; and, (3) quantify the health benefits of park experiences as a benchmark to improve the health impact of parks (National Park Service, 2013). In relation to the latter, if motivations, expectations and perceived benefits of visitors are better known, it will be much easier to give advice on the management of parks and protected areas and the related public health policies. Interestingly, apart from those general research goals, the NPS Science Plan proposes a set of research topics and related questions to be addressed (National Park Service, 2013) (Table 4). All of these research questions may be appropriate much beyond the National Parks in the USA. They could constitute a good way to refine the research initiatives in the field of health and well-being globally. Overall, the policy and management interventions that could be developed and implemented to support an integrated approach to biodiversity conservation and human health and well-being remain critical research gaps. However, in an era characterized by rapid socio-economic and environmental transformation, it will be increasingly important for protected area agencies and professionals to identify and implement programs that are society-oriented, and to develop outreach strategies that communicate this relevance to elected officials, key decision-makers, and the public. Addressing human health and well-being in the context of protected areas and their management will require the full involvement of agencies and organizations that have a stake in measurement and improvement; local, state, and federal agencies as well as community health centers, physician practices, environmental non-government organizations and others will all have a key role to play. While the task ahead is large and complex, better integration of the parks and protected areas and human health sectors holds enormous potential that can lead to better biodiversity and human health and wellbeing outcomes and the overall enhancement of societal understanding and acceptance of park and protected areas’ role in society.

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