In a darkened room at CHOP Primary Care, Cobbs Creek, physician Chris Renjilian set up a projector and debriefed doctors, nurses, and other staff on a new intervention that the office will begin offering to patients in its care.
The medical breakthrough in question? Prescription-strength outdoor play.
“As primary-care pediatricians, one of our goals is to help children get more active. The American Academy of Pediatrics recommends 60 minutes a day of outside play,” he said. “This is something we already spend a lot of time screening for and talking to families about.”
Now, they’ll actually be able to prescribe it, in the form of customized, detailed action plans that are tailored to connect kids with Philadelphia’s park system at a time when children are spending far less time in nature than doctors say is needed for healthy development of motor skills, social competence, problem-solving abilities, and even eyesight. It’s an antidote to the plague psychologist Richard Louv described as nature-deficit disorder.
The initiative, called NaturePHL, is a collaboration between CHOP, the Schuylkill Center for Environmental Education, Philadelphia Parks & Recreation Department, and the National Forest Service.
Launching in August in the form of a pilot program at CHOP’s primary-care offices in Cobbs Creek and Roxborough, NaturePHL will be a standard part of all check-ups for kids age 5 to 12, integrated right into their electronic medical records.
Every patient will be screened, given a brief message about the importance of outdoor play, and referred to a new website, NaturePHL.org, that provides a guide to local parks. Some — perhaps those struggling with obesity or attention-deficit disorder — will get more comprehensive counseling; a detailed park prescription for an outdoor activity such as a hike, a scavenger hunt, or a visit to a playground; and a referral to a “nature navigator.” That’s a community health worker who will help create a detailed plan, figure out how to overcome barriers to getting outside, or even join the patient on a park visit.
It’s not the first park-prescription program: Similar ones have launched around the country, including one in Washington, D.C., created by a network of community health centers and the National Park Service that reported a 22-minute average boost in weekly activity.
The Philadelphia organizers intend to undertake the most comprehensive study yet of whether such programs work and how best to undertake them. They hope to analyze whether the program will lead doctors to talk about the importance of outdoor play more, whether kids in the program actually spend more time outdoors, and what effect, if any, it has on their health and well-being.
“There really isn’t any research out on parks-prescription programs, their effectiveness and their impact on health,” said Michelle Kondo, a scientist with the National Forest Service. “We’re still figuring out what’s important to measure and what you can quantify.”
It might involve using GPS trackers to check whether kids are complying with the prescriptions, or monitoring changes in a patient’s heart rate, blood pressure, cortisol levels (which indicate stress), core strength, and attention.
Until now, she said, “these studies have been done with college students, for example, taking them on a bus ride out to the forest and hooking them up to machines as they sit or walk in the forest — not often with urban residents in their own neighborhoods.”
Renjilian was a pediatric resident at CHOP when he began talking about the idea with staff at the Schuylkill Center.
“The story of NaturePHL is really a story of shared goals. Philadelphia parks advocates want to encourage use of green space,” he said. “And I think a lot of pediatricians struggle because they know they have a responsibility to talk to their patients and families about physical activity and physically active play, but that’s really hard to do. We fall short in giving advice that is efficient, but also sufficiently personal, local, and specific. There’s a knowledge gap there. Most pediatricians don’t live in the same neighborhoods as their patients, and we’re very aware of that.”
NaturePHL aims to fill that gap with a website that maps Philadelphia parks and lists such features as playgrounds, bathrooms, swimming pools, and wheelchair accessibility. Mary-Grace Gorman of the Parks & Recreation Department said the hope was that a new demographic would also get connected to activities and programs the department was already running in city parks.
As Renjilian presented the initiative to CHOP staff, physician Nicole Jaffe asked what organizers expected, based on focus groups, to be the most common question. “Are the parks on here screened for safety? That’s the biggest concern I get from my patients, and if I’m endorsing it,” Jaffe said, “I want to know that there is a low probability of something going down there.”
There’s no simple answer, though. “What is safe?” Renjilian asked.
The hope is that the website will help families evaluate that. A team from the Schuylkill Center has been conducting “park audits” to list the features of each park, and the center plans to add photos and a forum for user reviews and user-submitted photos.
“The idea is, maybe if you can see what the park looks like, you might think it’s safer,” said Elisa Sarantschin, the NaturePHL program coordinator for the Schuylkill Center.
Although the website was designed in collaboration with CHOP, Sarantschin hopes that the general public will look to it as a resource and that pediatricians in other health systems around the city can begin introducing the program to patients over the next several years.
Kondo is thinking even bigger. “The Forest Service would also like to be part of providing tools to other cities and other groups wanting to start parks-prescription programs.”
Such nationwide initiatives have shown success in the past. One, Reach Out and Read, targeted literacy by providing a brief message from a pediatrician, along with a new book, to young children during checkups. Researchers found that the result was children’s language development advanced by three to six months.
Wedging these conversations into a 15-minute pediatrician visit may be challenging, but the hope is, if there’s a patient whose body-mass index has been creeping up over several visits, the doctor might set aside a couple of minutes to talk about options.
“We’re the ones who are going to have to do this. This has to be practical,” Renjilian told the group at CHOP. “But for kids with obesity, other than telling them to go outside, there was nothing to give them. Now we have NaturePHL.”