Date Published: February 15, 2018
Publisher: Public Library of Science
Author(s): Nooshin Razani, Saam Morshed, Michael A. Kohn, Nancy M. Wells, Doug Thompson, Maoya Alqassari, Amaka Agodi, George W. Rutherford, Omid Beiki.
Exposure to nature may reduce stress in low-income parents. This prospective randomized trial compares the effect of a physician’s counseling about nature with or without facilitated group outings on stress and other outcomes among low-income parents.
Parents of patients aged 4–18 years at a clinic serving low-income families were randomized to a supported park prescription versus independent park prescription in a 2:1 ratio. Parents in both groups received physician counseling about nature, maps of local parks, a journal, and pedometer. The supported group received additional phone and text reminders to attend three weekly family nature outings with free transportation, food, and programming. Outcomes measured in parents at baseline, one month and three months post-enrollment included: stress (using the 40-point Perceived Stress Scale [PSS10]); park visits per week (self-report and journaling); loneliness (modified UCLA-Loneliness Scale); physical activity (self-report, journaling, pedometry); physiologic stress (salivary cortisol); and nature affinity (validated scale).
We enrolled 78 parents, 50 in the supported and 28 in the independent group. One-month follow-up was available for 60 (77%) participants and three-month follow up for 65 (83%). Overall stress decreased by 1.71 points (95% CI, -3.15, -0.26). The improvement in stress did not differ significantly by group assignment, although the independent group had more park visits per week (mean difference 1.75; 95% CI [0.46, 3.04], p = 0.0085). In multivariable analysis, each unit increase in park visits per week was associated with a significant and incremental decrease in stress (change in PSS10–0.53; 95% CI [-0.89, -0.16]; p = 0.005) at three months.
While we were unable to demonstrate the additional benefit of group park visits, we observed an overall decrease in parental stress both overall and as a function of numbers of park visits per week. Paradoxically the park prescription without group park visits led to a greater increase in weekly park visits than the group visits. To understand the benefits of this intervention, larger trials are needed.
Chronic, unbuffered stress among low-income parents and children has been recognized as a contributing factor to health outcome disparities . Low-income parents describe intense and daily stressors arising from difficulties in providing for their families’ basic needs such as food and housing; moreover, these are compounded by discrimination, immigration, and mental health issues [2, 3]. Low-income families can be socially isolated and may lack access to community-based buffers for these stressors . With more than 46.7 million people living in poverty in the United States, innovative, community-based means of dealing with stress are needed in this population .
We randomized 78 child-parent pairs, 50 in the supported group and 28 in the independent group (Fig 1). Of the enrolled parents, 68 (87%) were women, the mean age was 38, 95% were non-white, and the majority (68%) lived below 200% of the federal poverty line. Of the enrolled children, 40 (51%) were male, with average age of 8.8 years (SD 3.1 years), and 59 (76%) of the children had at least one chronic illness. Participants in the supported and independent park prescriptions groups did not differ significantly except for self-reported mental health by parents, which was rated poorer in the supported park prescriptions group (p = 0.01) (Table 1). Overall study completion rate was high (10% lost to any follow up; Fig 1). Of 50 enrollees in the supported park prescription group, 56% attended at least one outing and 44% attended two or more. Because few participants turned in their pedometry recordings (23%; Fig 1) these data were not analyzed.
In this prospective clinical trial of 78 low-income parents, we report a significant decrease in stress, as well as improvement in park visits, loneliness, physical activity, physiologic stress and nature affinity over the three months of the trial. Our study showed that park prescriptions are a promising tool for addressing stress in low-income parents, a population at high need for community-based supports for stress. Future research should include a controlled trial comparing a park prescription as we have described to no intervention.