Journal of Policy Research in Tourism, Leisure & Events, 2013 r Routledge Vol. 5, No. 2, 172-186, hitp:/idx.doi.org/10.1080/19407963.2013.793520 Nature-deficit disorder: evidence, dosage, and treatment Frances E. “Ming” Kuo*"* “Landscape and Human Health Laboratory, Department of Natural Resources and Environmental Sciences, University of Mlinois at Urbana-Champaign, Urbana, IL, USA; "Department of Psychology, University of llinois at Urbana-Champaign, Urbana, IL, USA (Received November 2012; final version received February 2013) Claims have ong becn made of the health-promoting effects of contact with ‘nature’, but these claims have only recently been subjected to rigorous scientific testing. A strong body of evidence is now in hand. An array of studies ranging from rigorous experiments to large-scale epidemiological work has tied nature to health for outcomes ranging from childhood obesity, to immune functioning and rates of physician-diagnosed disease in adults, to longevity in older adults, Moreover, enough evidence has accumulated to begin to answer key questions about the dosage of nature needed to promote health. Do all forms of nature seem to help? Do small bits of nature help, or is some minimum level required for an effect? Similarly, to what extent is an explicit focus on nature necessary — are effects limited to fishing. hiking, gardening, and the like? The evidence to date suggests, broadly, that total exposure is important; all forms and quantities of exposure are helpful; and the greener the better. From these insights into dosage, nine recommendations are drawn for addressing nature deficits at the population level: green everyday places and views; bring green spaces closer: bring green activities and events closer; make spaces and programs fit ncarby users; make green spaces serve multiple activities and uses; support longer visits; reconsider barriers to use; help people start green activities; and help people continue green activities. Keywords: nature; natural environment; green environment; health; public health: trees Resumen Durante mucho tiempo ha habido reivindicaciones sobre los efectos de la promocién de la salud en contacto con Ia ‘naturaleza’, que solo recientemente han sido objeto de un anélisis cientifico riguroso. Ahora se dispone de un fuerte cuerpo de evidencia. Una serie de estudios a partir de rigurosos experimentos epidemiolégicos a gran escala han vinculado ta naturaleza para la salud con resultados que van desde la obesidad infantil, el funcionamiento del sistema inmune y tasas de diagndstico de enfermedades en adultos, y Ia longevidad en adultos mayores, Ademés, se ha acumulado suficiente evidencia para comenzar a dar respuesta a la pregunta clave sobre la dosis de naturaleza necesaria para promocionar la salud. Todas las formas de naturaleza parecen ayudar? Ayudan equefias cantidades de naturaleza o existe un nivel minimo exigido para lograr efectos? De forma similar, en qué medida es necesario una concentracién especifica en la naturaleza — estin los efectos limitados a la pesca, senderismo, “Email: fekuo@illinois.edu {© 2013 Taylor & Prancis174 FE. “Ming” Kuo EA Pb i UALS Se A THE, TA KANT RD, ED AAT FUER ATS) HED AMER ot, RAB: EIR PRIA L, RLY | ARIE. ZAC, BAS Introduction Its a scientific fact that the occasional contemplation of natural scenes of an impressive character .. is favorable to the health and vigor of men .. When Olmsted (1865/1952, p. 502) wrote these bold words in 1865, there was in fact no real scientific evidence for his claim. Olmsted was writing from a conviction borne of his own personal experience and observations — no systematic research had yet examined the impacts of exposure to nature on human health. Nearly 150 years later, however, science has caught up — and more. Using a wide variety of populations, environments, health outcomes, and research designs, scientists have slowly and pains- takingly tested Olmsted’s claim and emerged with an evidence base of which he could only have dreamed, In fact, the findings substantially outstrip Olmsted's claims. Not only are ‘natural scenes of an impressive character’ beneficial, but so are mundane, even meager forms of nature ~ the ‘nature’ that promotes health encompasses far more than wilder- ness. Moreover, not only does nature exposure increase positive indicators of health such as perceived health or well-being, but it also protects against negative health out- comes such as disease and mortality. The notion of “nature-deficit disorder’ (Louv, 2005) captures this well: deprivation of contact with nature leaves us vulnerable to a wide range of negative health outcomes. What have we leamed about nature-deficit disorder and what are the implications for tourism, leisure, and events? This article outlines the evidence, discusses what we know about dosage, and draws implications for ‘treatment’ — recommendations for the shaping of parks and recreation, tourism, and events, ‘Nature and health: overview of the evidence The body of evidence establishing the relationship between exposure to nature and health can be thought of as a pyramid, with each successive layer adding stronger, more direct evidence of nature’s role in human health, The first and broadest layer consists of very large body of studies documenting the psychological and subjective impacts of natural environments. Habitat selection theory proposes that organisms should be attracted to settings in which they are most likely to thrive (Orians, 1980). Consistent with the notion that natural settings are important to ‘human thriving, nature in both its wild and tamer forms elicits strong positive responses from people. This “biophilia’ has been confirmed for populations across the globe, from rural to inner city dwellers, from savanna to prairie to the tropics (for review, see Kaplan & Kaplan, 1989). Moreover, both life satisfaction and subjective measures of health are consistently related to access to nature — even after income is taken into account (Vemuri, Grove, Wilson, & Burch, 2011; de Vries, Verheij, Groenewegen, & Spreeuwenberg, 2003, respectively) The next level of evidence ties greenness to healthy functioning — cognitive, affec- tive, and social. Concentration is better after viewing images of green environmentsJournal of Policy Research in Tourism, Leisure & Events 175 (Berto, 2005), and individuals living in greener* buildings perform systematically better on tests of attention than their counterparts randomly assigned to architecturally identical but less green buildings (Kuo, 2001). Similarly, urban public housing res dents randomly assigned to live in relatively green apartment buildings show healthier Patterns of emotional and social functioning than do their peers in barren buildings. Individuals in greener buildings are systematically less aggressive, better able to control their impulses, and better able to address their major life challenges (Taylor, Kuo, & Sullivan, 2002; Kuo, 2001; Kuo, Sullivan, Coley, & Brunson, 1998; Kuo & Sullivan, 2001). The effects of nature on concentration and impulse control have been replicated in children with attention-deficivhyperactivity disorder (AD/HD) (Tayler, Kuo, & Sullivan, 2001), with important implications for their functioning at home, at school, and in social contexts. Another layer of evidence links greenness to important precursors to health. Each of the following is known to be an important factor in health: stress reduction, physical activity, social ties and social support, healing, and immune functioning, Further, each has been tied to exposure to nature. Blood pressure, heart rate, and other physiological indicators of stress decrease rapidly when individuals enter, or are shown images of, forested settings (Park, Tsunetsugu, Kasetani, Kagawa, & Miyazaki, 2010). The avail. ability of both green spaces and recreation areas supports regular physical activity (Li, Fisher, Brownson, & Bosworth, 2005). The presence of parks has been found to be associated with individual's feelings of neighborhood social cohesion (Cohen, Inagami, & Finch, 2008); this finding has been replicated in numerous contexts at a variety of scales. A 1984 study found that patients healed faster with a window view of a natural setting and used fewer analgesics than patients with a view of a brick wall (Ulrich, 1984). Visits to forests have been shown to improve immune functioning as measured by the number and activity of immunity-supporting cells in the blood- stream (Li, 2010). Levels of these cells remained elevated for as much as 30 days afier a forest visit, and did not increase at all during a carefully matched urban visit. The tip of the pyramid comprises studies directly linking greenness with objective ‘measures of health ranging from reduced childhood obesity, to healthier blood glucose levels and lower rates of disease and mortality in adults, to increased longevity in the very old. Table 1 illustrates the diversity of medical outcomes linked with nature in rig- crously controlled studies, A study of over 7000 children in Indianapolis found lower rates of obesity for chil- dren living in greener neighborhoods, controlling for income and housing density (Liu, Wilson, Qi, & Ying, 2007), Subsequent longitudinal research showed smaller increases in body mass index over time in those neighborhoods (Bell, Wilson, & Liu, 2008). Another study found that walks in forests caused a decrease in blood glucose levels in adult diabetic patients that was approximately twice the magnitude expected from exercise alone (Ohtsuka, Yabunaka, & Takayama, 1998). In 2009, Maas et al. conducted the first large-scale geospatial investigation into the greenness-health connection using medical records of disease. Using health data from general practitioners in the Netherlands, Maas and colleagues obtained medical records for over 345,000 individuals, and used the proportion of green space within a 1 km and a3 km radius around each person’s postal code to predict the incidence of disease. The study controlled for socioeconomic status, age, gender, education, population density, and work status. Maas et al. found that green spaces within 1 km of the home were associated with a lower incidence of disease in 15 of the 24 disease categories. Many of the health176 FE, “Ming” Kuo Table 1. Effects of nature deprivation on medical outcomes, Medical outcome Effect of nature deprivation Immune functioning 28% decrease” Childhood obesity 15% increase in disproportionate weight gain? Healing from surgery 9% longer recovery times® Cancer 10% increase in incidence® High blood pressure 6% increase in incidence® Cardiac disease 18% increase in incidence Coronary heart disease 27% increase in incidence® Musculoskeletal complaints 26% increase in incidence® Depression 33% increase in incidence* Anxiety disorder 44% increase in incidence® Upper respiratory tract infection 24% increase in incidence* Bronchiolitis/pneumonia 9% increase in incidence® Asthma, COPD 30% increase in incidence* Migraine/severe headache 18% increase in incidence® Vertigo 26% increase in incidence’ Infectious disease of intestinal canal 27% increase in incidence® Medically unexplained physical symptoms 20% increase in incidence® Acute urinary tract infection 20% increase in incidenc Diabetes mellitus 25% increase in incidence® Mortality among older adults 13% increase" Note: COPD = chronic obstructive pulmonary disease “Li 2010), estimated across multiple measures based on Li's graphs "Bell etal. (2008) SUrich (1984) “Li, Kobayashi, and Kawada (2008), estimated across multiple measures based on ther graphs. Maas tal. (2009). "Takano et al. (2002), outcomes showing a systematic link to greenness in that study are of particular concem in the US population — blood pressure, cardiac disease, and coronary heart disease: anxiety disorders and depression; and asthma and diabetes — to name a few. The strength of the greenness-health links were less pronounced at a radius of 3 km, but ho case was proximity to greenness linked to more disease. The strongest effects of greenness were seen in slightly urban areas, and the relationship disappeared in highly urban areas, where major sources of greenness — street trees, yards, and gardens — are not captured by land cover classifications. The relationship between green space and health was strongest among children and older adults — segments of the population with high rates of health issues. A longitudinal study of over 3000 older citizens — 74 years old and above ~ in Tokyo found that access to green, walkable paths and spaces significantly protected against mortality independent of age, sex, marital status, socioeconomic status, and initial health status (Takano, Nakamura, & Watanabe, 2002). A number of follow-up studies examining mortality as a function of residential greenness have now beenJournal of Policy Research in Tourism, Leisure & Events 177 conducted; while few are as rigorous as the Takano et al.’s work, and not all show sig- nificant effects, the overall pattern seems to hold. One notable study in the UK using mortality records for a population of 40 million revealed consistent findings for mor- tality rates, showing substantially reduced mortality for greener areas; in that study, greenness accounted for fully half of the income-based disparities in mortality (Mitchell & Popham, 2008), At this time, decades of research points to contact with nature as a key contributor in human health, The convergence of findings across different investigators, countries, research participants, types of studies, forms and exposures of nature, and measures of health is remarkable (for a fuller review, see Kuo, 2010). The available evidence strongly suggests that nature deficits have serious, wide-ranging consequences. How ‘might policies in recreation, tourism, and events help address this deficit? Dosage In addressing nature deficits, the question of dosage arises — what kinds of nature exposure are effective, at what intervals, in what form? A review of the scientific litera- ture on nature deficits yields three general themes: (1) maximize minutes; (2) all forms, all doses help; and (3) the greener, the better. Maximize minutes To allocate public dollars efficiently, policy-makers need to know what dosage vari- ables are most important in addressing nature deficits — intensity of exposure? fre- quency? duration? total time? If, for example, intensity and duration of exposure are most important, then the ideal dosage would consist of wildemess experiences and extended visits to highly natural settings — fishing weekends, camping trips, ete, — and in that case our policy priorities in terms of human health would be fo invest energy and money in conserving and protecting large tracts of wildemess, providing urban areas with major parks, and educating the public on the benefits of extended nature experiences. By contrast, if frequency and total time of exposure are most impor- tant, then providing natural elements, views, and microgreen spaces in everyday places, — home, work, school, and the daily commute ~ might provide the greatest health benefits most efficiently. While many questions remain as of the time of this writing, the available evidence strongly points to the importance of frequency and total time of exposure. First, some of the strongest, most striking effects of green settings have been found for ‘captive audi- ences’ — individuals and populations with limited mobility, and therefore maximum exposure to the setting under study: prisoners (Moore, 1981-1982), patients recovering from surgery (Ulrich, 1984); public housing residents (Kuo, 2001), and children or older adults (Maas et al., 2009), In each of these cases, a surprisingly small dose of nature — a view of a few trees (Kuo, 2001; Moore, 1981-1982; Ulrich, 1984), or perhaps a larger percentage of green space within 1 km of home (Maas et al., 2009) — yields systematic differences in an important outcome (specifically, healtheare demands, hospital discharge rates, cognitive functioning and effective management of one’s major challenges, and rates of physician-diagnosed disease). It appears that total time of exposure to nature — even extremely limited forms — plays a critical role in health and well-being.178 FE. “Ming” Kuo Along the same lines, consistent with the idea that the greenness of the everyday environment, with its frequent, extended exposures, rather than one’s access to green spaces farther afield, scientists have found that it is the greenness of the near-home environment that is the strongest predictor of health and other outcomes. In the Nether. lands, research on greenness and rates of disease, the strongest links between greenness and health were found closest to home — within | km, or roughly a 10-minute walk; by contrast, the greenness within a 3 km radius of home was less predictive of health (Maas et al., 2009). Even more striking are smaller scale studies that compare outcomes for residents of the same neighborhood. Two Chicago public housing residents may live in the same cluster of apartment buildings, but itis the one in the greener building that performs better on tests of concentration and reports meeting her life challenges more proactively ~ the fact that both residents live within a mile of spectacular green areas on Lake Michigan is not enough to overcome the benefits of having a view of trees and grass from home (Kuo, 2001). Together, these findings suggest that total time of exposure is the key, and that access to even some of the best large-scale urban green spaces in the world does not obviate the need for greenness in an individual’s everyday views and settings, Thus, to maximize the health benefits of nature, a key policy goal may be to ‘maximize minutes’ — to shape our communities so as to maximize the total minutes of nature exposure in residents’ everyday lives All forms, all doses help Ifnature deficits are best addressed by maximizing minutes of exposure, a logical next question is, “... exposure to what?" Do the benefits of nature accrue for all forms of nature? Are soccer fields, forest preserves, or expanses of prairie all effective in addres= sing nature deficits? Do the benefits obtain for relatively urban, everyday forms of nature, or is immersion in a ‘natural environment’ necessary’? The scientific literature on dosage suggests that nature helps in every form, and in every dose. Researchers have examined ‘exposure to nature’ in every conceivable form, from wildemess trips (Hartig, Mang, & Evans, 1991), to prairie restoration volunteering (Miles, Sullivan, & Kuo, 1998), to soccer fields and other “everyday” forms of nature (Faber Taylor & Kuo, 2011), to inner city apartment views of urban nature (Kuo, 2001) and have found benefits across the board, although findings for the benefits of indoor plants has been mixed (Bringslimark, Hartig, & Patil, 2009). In a nationwide study of children with AD/HD, both rural and inner city parents reported that their child’s symptoms abated after playing in ‘relatively green’ settings ~ even though what constitutes a ‘relatively green’ setting in an inner city is likely to differ substantially from what constitutes a ‘relatively green’ rural setting. In the same study, benefits were found for a whole variety of green activities, ranging from ‘nature activities’ such as hiking and fishing and climbing trees, to non-nature activities such as reading in a shady backyard or playing basketball in a neighborhood park (Kuo & Faber Taylor, 2004). Just as leafy green vegetables are beneficial regardless of whether they appear in salad, lasagna, or smoothies, exposure to greenness seems to help in every form, Moreover, benefits are seen for nature in every amount. Even the smallest doses make a difference, whether that dose is described in terms of duration, or the natural. ness of the setting. In one study, as little as five minutes spent at a coastline is reported to have substantial benefits (Barton & Pretty, 2010). College students whose dormitoryJournal of Policy Research in Tourism, Leisure & Events 179 room view includes even a small percentage of green fare better than their counterparts with none (Tennessen & Cimprich, 1995). In public housing, courtyards with a bit of tree cover have better outcomes than courtyards with none (Kuo et al., 1998). There is evidence that indirect contact with a green outdoor setting helps ~ numerous studies have found benefits for indoor views of urban green space (Kaplan, 2001). Finally, there is some indication that even dormant vegetation may confer health and other benefits — the work in the Netherlands examines the impacts of nearby green space year-round, in settings where vegetation is dormant most of the year (Maas et al., 2009); similarly, research on tree cover in Chicago public schools suggest that aca- demic achievement may be boosted even by trees that are dormant for the majority of the school year (Kuo, in progress). It appears that even the smallest bit of “Vitamin G’ (a metaphor for exposure to natural settings) helps. The greener, the better From the findings above, it would seem that even tiny doses of nature, and very urban forms of nature are beneficial, and that the key variable in health benefits from nature may be total time of exposure. Does it follow, then, that from a human health perspec- tive, we can dispense with creating and maintaining larger, more distant green spaces — forest preserves, metropolitan parks, national parks? (Obviously, there are many reasons to create and maintain such spaces other than human health — including protect- ing wildlife habitat and biodiversity, our national heritage, and the experiences of beauty and awe that such spaces afford.) In fact, the evidence suggests that even from the sole perspective of maximizing human health, our larger, wilder green spaces play an important role, While there are benefits for even small doses of nature, the evidence also suggests that — all other things being equal - the bigger the dose, the greater the benefits.” In the study of college students’ dorm room views, not only was a bit of green in the view better than none, but the greener the view, the better the student’s cognitive functioning (Ten- nessen & Cimprich, 1995). Similarly, ina study of apartment courtyards in an inner city public housing development, each additional increment of tree cover was associated with greater benefits (Kuo et al., 1998). Further, extended exposures to wilderness ‘may be particularly helpful. A two-night, three-day stay in a forested area was sufficient to enhance immune functioning for an entire month. While green is good, more is gen- erally better. Taken together, these three themes suggest that Vitamin G works much like a water- soluble vitamin. Because our bodies cannot store water-soluble vitamins, it is necessary that we take them in as part of our everyday diet. Similarly, for Vitamin G, it does not suffice to visit Yosemite once a year, or even Central Park every weekend. Vitamin G needs to be part of our daily activity diet. Fortunately, Vitamin G is helpful in a wide range of forms and doses — we can eat breakfast at a window with morning light; drive (or bike!) to work along tree-lined streets; and garden, catch a local soccer match, or read in a backyard hammock on the weekend. Recommendations If we were to shape leisure, tourism, and events to treat nature-deficit disorder, what might that entail? Here are nine suggestions for helping residents increase their daily intake of Vitamin G.180 FE. “Ming” Kuo (1) Green everyday places and views. Because daily exposure is so important to health and healthy functioning, and because even mundane, urban forms of nature are helpful, perhaps one of the most important routes to treating nature-defieit disorder is to green the places, paths, and views in people's daily lives. Greening for public health must include greening residential areas, workplaces, and schools, as well as the transportation corridors to and from those places. Because they are part of the Public realm, street trees in right-of-ways might be a major component of such an initiative. Shrubs, flower plantings, planter boxes, and green roofs could be used to bring Vitamin G to a community’s vertical and horizontal surfaces without requiring the purchase of land, Such greening efforts would pay dividends not only in terms of a more healthy citi- zenry, lowering healthcare costs and reducing health-related productivity losses, but also in terms of a more attractive community. Tourist dollars might follow, and Outdoor events such as festivals and block parties might benefit from more attractive Public spaces and neighborhoods, enlivening a community socially and economically, (2) Bring green spaces closer. Immediate access to green spaces is likely to substan tally address nature deficits. To grasp the impact of ‘nature at the doorstep’, imagine a young family living a few doors down from a duck pond, or the office staff of a small company having a shady area with picnic tables for lunch. With nature so near, informal green activities such as taking the kids to feed the ducks at the pond before dinner, and brown bag get-togethers over the pienic table, can become daily or near-daily rituals Even an added block of distance between home and green space, or office and green Space, may turn a daily outing into a weekly, or rare, occurrence. The importance of nearby green space is heightened for individuals with limited mobility — parents with small children, frail older adults, individuals with disabilities, and low-income individ uals with limited transportation options — but is likely to be a key factor in health for al individuals, It is important to note that green spaces ‘at the doorstep” can be either public or private in nature. In many neighborhoods and work places, private green space already exists close by and can serve this function. In some places, however especially urban, low-income areas — itis lacking, In such places, public green space can play a crucial role; indeed, it is likely that some portion of the health problems associated with urban, low-income areas is attributable to nature-deficit disorder, Indeed, Mitchell and Popham’s (2008) findings on income-disparities in mortality suggest that pethaps as much as half of income-disparities in health might be attribu. table to nature deficits. Itis also important to note that providing immediate access to green spaces does not require sprawl, Because all doses of nature are helpful, and even very urban forms of nature are helpful, there is no call for single-family homes surrounded by large expanses of turf ot private green space. All that is needed is ready access to green views and a bit of green space. Apartment buildings, clustered housing, and the Dutch tradition of shared open spaces are all compatible with daily doses of green space while economizing on land. () Bring green activities and events closer to people; distribute them in space. ‘Green time” comprises specific green activities; whether itis walking or feeding the ducks or gardening or reading in a hammock, any sustained exposure to nature is likely to involve more than simply standing in a place with green views and elements Providing immediate access to green spaces will have limited health benefits if there is nothing to do in those spaces and therefore nothing to hold people in them,Journal of Policy Research in Tourism, Leisure & Events 181 Programming and activity infrastructure are key here. Concerts in the park, neigh- borhood potlucks, cooperative child-care arrangements centered around a playground, birthday parties in the pavilion, early morning tai chi classes in the park ~ all green outdoor activities lend health benefits and can be supported through programming and infrastructure. Moreover, the evidence here suggests that park districts should con- sider bringing green activities as close to users as possible to maximize participation This entails holding events in neighborhood green spaces or in schoolyards ot in green outdoor areas in work environments where feasible. Offering multiple small, nearby events may promote health more than offering a single, distant event because their convenience is likely to attract more residents per capita Following this logic, scattering soccer fields across a landscape may be preferable to building a single large sports complex with a dozen fields. Distributing the same number of fields across several neighborhoods allows for shorter transportation times for players and expands access to those who are transportation-limited, Physically siting a single field within a larger park might also create more opportunities for casual games, a sense of ownership and familiarity among the park users, and higher ibility, which might in turn allow for more community-building game attendance as well as higher enrollment rates in the sport, Rather than standing vacant whenever games and practices are unscheduled, a neighborhood athletic field invites and accom- modates casual use. Such well-used, shared green spaces could provide each small resi- dential area with an outdoor living room of sorts. These smaller, more ubiquitous green spaces should complement, not detract from the attractions and benefits of larger parks. A medium-sized or large park offers experiences that small parks simply cannot, A larger community can support a large complex with a dozen fields, providing opportunities for soccer tournaments. Larger parks can also offer quite hikes ‘away from it all’, and provide space for large-scale gatherings and celebra- tions, weekend farmer’s markets and flea markets. A variety of different, and differently sized parks, can widen the palette of possible green activities and experiences to appeal to diverse individuals, and encourage any given individual to partake of multiple green activities. Multiple green activities are, in tum, likely to be an effective way of addressing nature deficits. (4) Make spaces and programs fit nearby users. Placing green spaces and green activities near potential users is a necessary, but not sufficient, step in addressing nature-deficit disorder. Parents in an area with no playgrounds, or cyclists in an area with only playgrounds, are for all intents and purposes living in an area without green space. For a space to best combat nature-deficit disorder, it should accommodate the desired green activities of the people who live or work or study nearby. In residential areas, this approach to shaping shared green spaces might yield a palette of green spaces, each of slightly different character, corresponding to the needs of those living (or working) nearest. Certainly, every green space cannot be a complete microcosm of the larger green environment, nor should a small space attempt to accommodate more uses than its footprint allows. But the resulting variety might have a number of benefits. By focusing on the uses most desired within a particu- lar neighborhood, parks and recreation facilities might reinforce the uniqueness of neighborhoods and strengthen sense of community within neighborhoods. A diverse palette of public neighborhood parks might give residents reason to visit other parks as well as their own, increasing their total Vitamin G intake. Finally, a diverse palette of green spaces might also appeal to tourists by broadening the recreational ‘opportunities a community has to offer.r 182 FE. “Ming” Kuo (G) Make parks serve multiple activities and uses. Within-park diversity of uses can only amma the same purpose as between-park diversity. A park with multiple uses sat only appeals to different users, but also gives a single user multiple reason visit —an after dinner walk today, a visit with the toddler to the slide tomorrow, and barbequing on the weekend. Parks can serve a wide array of activities: chess ond checkerboards; WAI and outlets at stations would support working and surfing at the park in pleasant intertet much as ice cream vendors and a snack kiosk might attract hemen visitors, Hours of access might be extended. Morning yoga classes or bind watching sessions mut be allowed, or even offered, as might night-time activities such we bonfires, star Bazine: and camping. In extending hours of access and operation, i may be helpful to Alon me forms of recreation (¢.g. noisy parties) to specific times ot day, while still allowing for other green activities, The infrastructure for longer stays would be important to consider. Clean, open ible fora parent and toddler to stay longer. The infastreorce for shared meals ~ grils, prenie tables, trash cans, and shelters ~ can encourage longer events such as family reunions and barbeques, (0) Reconsider barriers to use: rules and fees. Many rules and prohibitions are well intentioned, but unnecessarily limit the potential for green activity within a park and therefore discourage use of green space. Many Prohibited activities could be made less disruptive if given specific support. Skate parks, for example, take an otherwise Gisruptive form of reereation and tum it into a structed activity that is spatially iso- lated so as to keep skateboarders from endangering other users. Consider: are the inles against ‘leaving the path’, taking nothing. bet memories, and climbing on Tutural or human structures absolutely necessary? Might exceptions be made from ‘ime to time, allowing children and adults to engase witl me space on their own terms? Fees also limits the access to green places and activitie While ai or once-a-year vi Se antithetical to using parks and public green space for Public health purposes, For some green activites, such as tennis, fishing, or camping, equipment costs are a Parret. Equipment rental or loan programs can allo People to try an activity, such as tennis, without sinking hundreds of dollars ints tennis rackets. Rental programs can also allow individuals to participate casually if they do not intend to play often Snough to make purchasing equipment worthwhile, Furthermore, equipment rentalsJournal of Policy Research in Tourism, Leisure & Events 183 but they also need a repertoire of green activities they enjoy. Parks and recreation departments can help widen individuals’ green physical activity repertoires by offering classes, and also by helping individuals discover activities or activity partners. For example, adults interested in bird watching might be able to consult the parks depart- ment website for the hours of the neighborhood bird watching outings. Parks websites and bulletin boards might work to gather information on neighborhood clubs and local groups sharing an interest in doubles tennis or adult soccer or taichi, and use their bul- letin boards and websites as clearing houses for such information, (9) Help people continue green activities: increasing enjoyment and addressing gaps. Once green activities are established in a person’s routines, the next challenge is maintenance. In the press of busy lives, itis all too easy for leisure pursuits to be squeezed out. Parks departments can help people maintain established green routines by adding value to them. Classes and clinics can help individuals gain competence, making a green activity — whether it be fishing or golf — more fun, Partner-finding programs can help runners find running buddies or form marathon training groups — the social nature of the activity then helps sustain interest and motivation over long periods of time, Tournaments can add interest, as well, by giving individuals goals and bench- marks for their progress. Similarly, tracking programs can celebrate experience and achievement much like electronic games or summer reading programs do ~ “You've won 10 tennis games ~ congratulations!” or *You've identified all of the ten most common Illinois birds ~ you're ready to become an intermediate bird watcher!” Parks departments can also help troubleshoot breaks in a green activity routine related to weather or injury, helping individuals maintain or alter their routine as needed. Winter serves as a barrier to many common uses of green space, such as sports, jogging, and use of playgrounds. By interrupting the normal seasonal use of rec- reational spaces, winter creates stopping points where individuals end their healthy physical activities for a season. Many will be too busy to resume at the next season, or will not make it through the physical adjustment back to physical activity after a sedentary winter. Parks departments can endeavor to help individuals continue their green activities through the winter months, whether by allowing and enabling winter activities such as sled hills and cross-country ski courses, or by ensuring the continued usability of existing spaces during the winter. Similarly, regular joggers on a jogging trail might be encouraged to continue if signs informed them that the trail would be salted or plowed for use during winter, or if they knew they could check the status of the trail on the web before starting out. Conctusi The importance of green recreational opportunities and events has never been so clear. The striking, large impacts of even brief exposures to nature on such diverse outcomes as concentration (Berto, 2005; Kuo, 2001), immune functioning (Li, 2010), and aggtes- sion (Kuo & Sullivan, 2001) suggest that modem life leaves most individuals with a nature deficit. Furthermore, the costs of this nature deficit, in terms of the personal, household, and societal costs of substantially higher rates of disease, are immense. Take, for example, the annual heathcare costs and lost productivity associated with the common cold in the USA ~ $40 billion a year (Fendrick, Monto, Nightengale, & Sames, 2003), or the annual costs of cancer care in the USA — over $120 billion (Mar- iotto, Yabroff, Shao, Feuer, & Brown, 2011). As Table 1 shows, the available data184 PE, “Ming” Kuo suggest that addressing nature deficits at the population level would reduce the common cold (upper respiratory tract infections) by 24% and cancer rates by roughly 10%, with an estimated savings of over $20 billion for these two diseases alone. The suggestions here provide some ideas of how we might go about treating this deficit, but the question of how to most effectively and efficiently address nature- deficit disorder in an increasingly urban and technology-centered age may be our next great public health challenge. Acknowledgements ‘The author thanks the Editors of this Special Issue for their invitation to submit a contribution and for their thoughtful comments on an earlier version of the manuscript. This manuscript also benefited from specific suggestions from Christopher Krassa, Starlyn Robinson, Joanna Miscier. wicz, and Doreen Tseng; the author is grateful for their ideas and attention to improving this work. Finally, she thanks the TKF Foundation for their encouragement in investigating the relationship between green space and health; that encouragement provided the impetus for the literature search forming the basis of Table 1 in this article. Notes 1. Nature-deficit disorder is not a medical diagnosis for much the same reasons as there is no ‘activity-defict disorder’ — while the human body's need for regular physical activity has been thoroughly established (Warburton, Nicol, & Bredin, 2006). The effects of inactivity are too diverse and varied to capture in a single disorder. 2. In this paper, the ‘green’ in ‘green buildings” refers to the level of surrounding vegetation, not to sustainability measures. 3. Note, however, that Barton and Pretty (2010) compared exposures of different durations, and found the greatest effects for a five-minute exposure to a water view; however, the other exposures were for other views. 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