Nearly a decade ago, Dr. Melissa Lem recommended daily “doses” of nature to one of her patients while working for the University of Toronto’s health services.
Lem was initially unsure of the call at the time.
“I thought they would laugh at me. You know that this would seem so ‘crunchy granola’ recommending nature time,” Lem said.
To her surprise, her patient enthusiastically agreed.
“He just nodded his head. ‘I spent a lot more time outside when I was in Vancouver, and I think that is playing a major part in how my symptoms are worsening here in the city,’” Lem recalled the patient saying.
Since that first time prescribing nature, Lem, who is now working in Vancouver as a general practitioner, has taken it a few steps forward.
Nature prescriptions are one of the fastest growing health trends today, and Canada is at the forefront of this advancement. Canada is the second country in the world to be home to a nationwide park prescriptions program, only behind the United States and Park Rx America.
A park prescription is just as it sounds— a doctor’s prescription to take a daily “dose” of nature. There is a wealth of scientific evidence supporting different physical and mental benefits of nature. One example is this study examining cortisol levels in saliva after a self-defined nature experience. Cortisol is an indicator of stress, and the study found that after spending a specified amount of time outside, cortisol levels in participant saliva dropped.
A more qualitative approach on this topic was a study performed in the Canadian Rocky Mountains. The study focused on the effects nature had on people with cognitive and physical disabilities. It monitored 70 people across Western Canada, many of which living with a disability, over the course of several weekends or week long hiking and backcountry trips. The participants were guided with the help of several guides for each individual. Those involved reported improved social connections, a better sense of self, and a return to a childlike connection with nature.
Despite findings like this, Lem and other physicians noticed how those benefits weren’t being leveraged by doctors alongside other beneficial health trends and recommendations, like exercise and eating well.
There are also misconceptions and barriers around nature prescriptions that could slow its adoption, along with the threat of climate change and its possible effects on nature’s health benefits.
PaRx and nature prescriptions in Alberta
Canada’s first national nature prescription program is PaRx, which started in November 2020. This initiative, created by B.C. Parks, is led by Lem as executive director and works to encourage physicians across the country to adopt the policy of prescribing nature.
Lem fell in love with nature when she was a kid and it continues to help her de-stress throughout life. This led her to climate advocacy as she realized that the changing climate was affecting nature around her.
Lem says that linking important issues together is an effectiOkay ve way to create policy change. In PaRx’s case, linking climate change and nature helped its creation.
Another consideration made was the physical risks that come with exercise. Lem wanted to utilize nature prescriptions so anyone could go and experience nature without strenuous physical challenge.
The launch of PaRx happened at an opportune time, providing a silver lining to an otherwise dark period.
“COVID has had a huge effect on our initiative. We’ve heard so much from our public health officers that being outside is good for our health, and to hear that message resonating across the country at the same time we are launching our initiative increased media and health provider interest,” Lem said.
The PaRx initiative has enjoyed early success, hitting the 1,000 prescriber milestone as of October 2021, not even a year since it launched. Lem said that the American equivalent started in 2018 and needed three years to achieve that goal.
Licensed health care professionals who prescribe to PaRx are pledging to hand out nature prescriptions to patients.
Recent partnerships with Parks Canada allow subscribers to PaRx to give their patients national park passes as a means to get out more and complete what their doctor prescribes.
Alberta doctors prescribing nature
Several Alberta doctors are already starting to adopt similar nature prescriptions.
Dr. Clark Svrcek, a family physician, and a member of the Canadian Association of Physicians for the Environment, wanted to get a better feeling for how open patients and other physicians would be to accepting nature prescriptions. So Svrcek started a pilot project where he prescribes nature.
He did this alongside his colleague Dr. Doug Klein, a professor of family medicine at the University of Alberta. Klein practices in Edmonton, while Svrcek is a Calgary doctor. Svrcek first heard of nature prescriptions and formed a general interest in the relation between health and nature when reading The Last Child in the Woods by Richard Louv. The book examined children’s alienation and disconnection from the outdoors.
“So prior to the last year, long have I spoken with patients about the benefits of the outdoors. One of the things that I will talk about in addition to all the usual things like the Canada Food Guide, is that idea of getting outside as much as possible and spending a good chunk of everyday outdoors no matter what the weather,” Svrcek said.
Svrcek and Klein both stress the importance of getting children outdoors to improve their health, and Klein points to his interest in pre-diabetic conditions like metabolic syndrome as a starting point. He began focusing on ways to limit the potential for the condition appearing later in life by getting children outdoors more.
Because of those introductions to the idea, Svrcek and Klein soon began championing the use of nature prescriptions in Alberta. They hope that this practice will be added into routine health care or even schooling in a field that can be slow to change.
“For schools over the last couple of years, I don’t think it’s been a great time for them to be innovative. But teachers know the benefits, and literature is catching up with that in universities. It is going to take a while for that shift to change in the medical field, for these ideas to get a wider acceptance,” Klein said.
For the patients involved, Svrcek and Klein ask them to spend half an hour a day outside, three times a week for six months. The patients are asked to keep a weekly logbook of their time spent outside, what they did, and what enabled them to get outside.
Though none of Svrcek’s and Klein’s patients who are participating in the pilot project have a common condition, Svrcek said people suffering from mental health issues like depression should get special attention for nature prescribing.
Klein and Svrcek reported many patients being onboard for such an idea and many lamenting the end of their pilot period.
“You know, they’ve been in the study for six months, and the six months is up and they’re asking, ‘why are we done? Can I keep doing this? Can I keep filling out a logbook,’” Svrcek said.
“We say ‘if you enjoy being outside that much, keep going and keep doing it. And find that nature in your backyard or your city.’”
Nature prescription misconceptions
The pilot project received a small grant from the University of Alberta and is just beginning to wrap up with research results expected later this summer. Despite the enthusiasm from many patients, Svrcek said that there are barriers for people who try to use park prescriptions and some people, no matter how willing, will not be able to fulfill their prescription. One example he gave was isolation and not having a partner to go outside with. He noted that going by yourself discourages people from going out and fulfilling their prescription.
Lem also notes there are common misconceptions with the idea of what will fulfill a nature prescription and hopes PaRx will rectify these misconceptions and help people see that nature time does not need to be a grand adventure.
“One question people tend to ask is ‘where is my nature prescription?’ We want to get across that this is whenever you’ve had a meaningful experience in nature,” Lem said.
“That’s when you get the health benefits. It doesn’t have to be in the deep woods or the side of a mountain. You can find nature in your local neighbourhood park.”
Svrcek also has hopes for creating more organized initiatives that will help people get more time outdoors and alleviate the problem of isolation and loneliness. This includes a patient and community focused care approach where doctors and patients have more one-on-one time that will ultimately facilitate discussions about the importance of nature for our health.
“I’d love to be able to carve out an afternoon a week where I invite my patients to go on a walk in Fish Creek provincial park. We meet and go for a bit of a stroll and just have some general conversation and enjoy the outdoors together,” Svrcek said.
“We could talk about some of those health benefits in an organized program. Then they can literally see somebody like me walk the talk.”
This ties into a physical aspect as some groups who need outdoor time the most will have the hardest time gaining access.
Sonya Jakubec is a nurse and professor at Mount Royal University and a member of the Canadian Association of Nurses for the Environment. She has paid specific attention to individuals with disabilities and those going through palliative and end-of-life care.
Jakubec said that many of the individuals she has worked with need nature, but the big experiences like going out to the mountains are not an option due to mobility or the stage of care an individual is at.
An added emphasis on the outdoors not being a pure wilderness experience is something that Jakubec hopes catches on in community and patient-focused care. It is especially important for nature prescriptions.
“It is a misconception that traps some people from filling their nature prescriptions, that they view it as something that has to be grand and complicated. When you don’t feel well, the last thing you may want to do is head outside,” Jakubec said.
“Even though it is beneficial, imagine being in a cycle of palliative care treatments and appointments, a nature prescription could be off-putting.”
With the situation changing from year to year, Jakubec hopes that palliative care continues to evolve to meet the needs of patients. Jakubec stresses that every person is different and may need specific methods of outdoor care. That could mean none at all.
Jakubec noted that in some of her research, some palliative patients reported losing hope when being outside because that may be the last time they have that experience.
With that in mind, Jakubec said that caregivers should evaluate on an individual basis what type of outdoor care someone requires.
“Some people used to be outdoorsy, but toward the end of life, they can’t do what they used to do. And that means they don’t want to interact with nature. They’ll say, ‘If I can’t climb that big peak, then I’m out,’” Jakubec said.
“For others, they know they have limitations, but they do what they can. Everyone is different in what they want to try. When it comes to caregivers, professionals and family. It starts with understanding and listening.”
Climate change and nature prescriptions
However, all of these problems and triumphs associated with nature prescriptions won’t matter if an even bigger existential threat renders the health outcomes of nature meaningless.
Thinking back to the beginning of the pandemic, Lem remembered how climate change reared its head in Western Canada.
“I remember early on in the pandemic; I was thinking this is really going to affect my patients’ mental health when the lockdowns started happening. Initially, I didn’t notice much of a change,” Lem said.
“It was that summer when the smoke rolled in that people’s mental health started deteriorating. Part of it was that nowhere felt safe.”
Studies have shown that environmental stress can directly relate to how beneficial nature health outcomes will be. Catherine Reining was a student at Wilfrid Laurier University when she performed her thesis on environmental integrity and its connection to the benefits of nature.
Her research conducted at an Ontario provincial park found that if an individual perceived a location to have less environmental integrity, they would get fewer health benefits. Reining said that as climate change gets worse, the problem will become more noticeable in a shorter time frame.
“As our climate changes, we are going to see ecosystems adapting or disappearing. There’s this whole idea of last chance tourism with popular places that people are trying to see before they disappear. Like glaciers, for example, and that will add even more pressure,” Reining said.
“This will trickle to the human population as we see the health concerns that come along with climate change. Like a greater risk of asthma because of air quality. Because of that, we’ll need those natural environments even more, so there is that cycle.”
Because of that, there needs to be an effort for creating new protected space. Parks need to continue growing to combat climate change, as Christopher Lemieux, the research chair in environmental geography at Wilfrid Laurier University, said.
Lemieux has worked on several studies analyzing how humans interact with protected spaces and what benefits are associated with them. He said policy needs to look towards expanding these areas.
“We often don’t need to look far to realize that there are many natural solutions readily available to us. But we need to commit to protecting and restoring nature the best we can to maximize its potential in an uncertain future,” Lemieux said over an email interview.
A recent example of creating new protected areas is the Nature Conservancy of Canada announcing a new conservation site in southwestern Alberta, the 303-hectare area known as Chapel Rock.
Lemieux also said that park prescriptions, which have been picking up steam in other provinces like Manitoba, could be a great way to get people aware of how climate change affects them. With such high enrollment in these programs, the awareness could be elevated to new heights.
“The power of the health community will bring a lot of much needed attention to the health of the planet. From this awareness, people will adopt more pro-environmental behaviours and, hopefully, use nature to their advantage by accessing it and wanting to protect more of it,” Lemieux said over an email interview.
This sentiment is another one of Lem’s base goals and hopes for PaRx and the park prescriptions movement in general. Lem said connections with the Canadian Association of Physicians for the Environment, which she is a member of, will fundamentally aid PaRx.
“Compared to other park prescriptions, we bring a real knowledge of climate change and the wish to take action through this initiative,” Lem said.
“People who are more connected to nature across a life span are more likely to protect it. And this goes beyond conservation. You’ll protect something you love.” PaRx’s latest partnership with Parks Canada was announced on January 31, 2022. The partnership allows physicians who prescribe to PaRx to hand out national park passes to patients so they can fill out their nature prescriptions. It demonstrates how the idea of nature prescriptions is continuing to grow and gain credibility.
For Melissa Lem, it is a far cry from that first nature prescription she handed out nearly a decade ago.