- Email: [email protected]
Planning for health: A community-based spatial analysis of park availability and chronic disease across the lifespan
Health & Place 27 (2014) 102–105
Contents lists available at ScienceDirect
Health & Place journal homepage: www.elsevier.com/locate/healthplace
Short Report
Planning for health: A community-based spatial analysis of park availability and chronic disease across the lifespan Gina M. Besenyi a,n, Andrew T. Kaczynski a,b, Sonja A. Wilhelm Stanis c, Ryan D. Bergstrom d, Joseph S. Lightner e, J. Aaron Hipp f a
Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, United States Prevention Research Center, Arnold School of Public Health, University of South Carolina, United States c Department of Parks, Recreation, and Tourism, University of Missouri, United States d Department of Geography, Gustavus Adolphus College, United States e Department of Kinesiology, Kansas State University, United States f Brown School of Social Work, Washington University in St. Louis, United States b
art ic l e i nf o
a b s t r a c t
Article history: Received 28 July 2013 Received in revised form 3 February 2014 Accepted 6 February 2014 Available online 3 March 2014
The purpose of this study was to explore the spatial relationship between park availability and chronic health conditions (CHCs) across age groups in Kansas City, MO. Multinomial logistic regression examined the association between having a park within one-half mile from home and the likelihood of having 0, 1, or 2 or more CHCs. Among respondents aged 40–59, those without a park within one-half mile from home were more than twice as likely to have 2 or more CHCs compared to respondents that had a park nearby. Parks may be an important protective factor for chronic diseases, especially among middle-aged adults among whom access to neighborhood recreational environments may be particularly important. & 2014 Elsevier Ltd. All rights reserved.
Keywords: Parks Recreation Chronic disease GIS
1. Introduction Efforts to promote health and well-being at the population level frequently adopt social ecological models that emphasize the role of community environments in fostering healthy behaviors (Richard et al., 2011; Sallis et al., 2008). Within the built environment, parks are one important community resource that can offer numerous psychological, physical, social, economic, and environmental benefits to residents of all ages (Bedimo-Rung et al., 2005). For example, a growing body of research has examined how parks are associated with physical activity and reduced obesity levels in both children and adults (Kaczynski and Henderson, 2007; Alexander et al., 2013; Wolch et al., 2011). Other studies have documented relationships between access to green space and other health-related outcomes, including mental health (Van Den Berg et al., 2010), morbidity (Maas et al., 2009a), and mortality (Villeneuve et al., 2012). Additionally, users of local park and recreation facilities report fewer visits to a physician (Godbey et al., 1998) and better perceived physical and mental health (Payne et al., 2005), which are
potentially significant indicators of the value of parks within the context of rising health care costs and an aging population. While some limited research has explored how the built environment affects diseases and related risk factors, such as diabetes (Stewart et al., 2011) and high blood pressure (Li et al., 2009), studies specifically about parks have rarely considered these outcomes (Pereira et al., 2012). Moreover, few studies have explored how health outcomes are related to objectively-measured park access across the lifespan (Kaczynski et al., 2009). As the incidence of most major chronic diseases increases with age (Rae et al., 2010), it is important to assess how environmental features, such as parks, differentially impact various cohorts of residents. Given these considerations, the purpose of this study was to examine the spatial relationship between park availability and prevalence of chronic health conditions (CHCs) across adult age groups.
2. Methods 2.1. Study setting and data collection
n
Correspondence to: Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, 800 Sumter – Room 216, Columbia, SC 29208, United States. Tel.: þ1 785 364 4882. E-mail address: [email protected] (G.M. Besenyi). http://dx.doi.org/10.1016/j.healthplace.2014.02.005 1353-8292 & 2014 Elsevier Ltd. All rights reserved.
This study was part of the Kansas City Parks and Physical Activity Project, a cross-sectional, multi-component investigation of the influence of parks and neighborhoods on physical activity
G.M. Besenyi et al. / Health & Place 27 (2014) 102–105
and health in Kansas City, Missouri (KCMO). The broader Kansas City metropolitan area comprises 15 counties in both Missouri and Kansas and contains over two million people, while KCMO has a population of almost one-half million (459,787) residents from diverse racial/ethnic and socioeconomic backgrounds (City of Kansas City Missouri, 2012). At the time of the study, the city had over 12,000 ac of parkland across 219 parks of all types and sizes (Kansas City Department of Parks and Recreation, 2009). The study protocol was reviewed and approved by the Institutional Review Boards of Kansas State University and the University of Missouri and the study occurred in October–December 2010. Data used for this paper were collected through geographic information systems (GIS) shapefiles and a general population mail survey addressing neighborhood and park issues and health behaviors and outcomes. A parks shapefile and base map shapefiles (state and city boundaries, StreetMap USA layers) were obtained from the KCMO Planning Department. For the survey, with the assistance of a marketing research company (Survey Sampling International, Shelton, CT), an initial cluster random sample of residential addresses geographically-dispersed across KCMO (n ¼3906) was identified. An 11-page self-administered questionnaire was sent to these households using a four-wave, modified Dillman mailing protocol (Dillman, 2000). Of the 3906 questionnaires that were mailed out, 649 were returned by the postal service as undeliverable and 893 were returned completed. This resulted in a 27.4% response rate [893/(3906–649)], which is comparable to other similar studies about parks within the general population (Tilt, 2010; Coombes et al., 2010). The present analyses are based on 583 participants for whom complete data were available for all variables used in this paper (including covariates). 2.2. Measures All parks in the city were visited and audited to determine if they were accessible and useable and an edited GIS parks shapefile was subsequently created. ArcView 10.0 was used to determine the availability of a park (yes or no) within a one-half mile street network buffer of each study participant's home. Within the household survey, respondents were asked to indicate if they currently had any of the following health conditions and were instructed to check all that apply: heart problems (e.g., heart disease, heart attack, high blood pressure), cancer, diabetes, osteoporosis, depression and other mental health concerns, asthma/allergies, disability (please describe), other (please describe). For these chronic diseases, previous research indicates moderate to high percent agreement between self-reported prevalence and practitioner records (Kriegsman et al., 1996). Each participant was subsequently categorized as having 0, 1, or 2 or more CHCs. Finally, participants also provided demographic data, including age (which was subsequently divided into three categories: 18–39, 40–59, and 60 þ years), gender, race/ethnicity, height and weight (used to calculate body mass index), and household annual income.
3. Results Table 1 provides descriptive information regarding characteristics of the sample. Of the 583 respondents, the majority were older, female, and White. The percentage of participants with a nearby park for each of the three age groups was as follows: 18–39 years ¼44.5%, 40–59 years ¼ 36.5%, 60 þ years ¼47.1%. Within the 18–39 age group, 65.8% of participants had 0 CHCs, 26.0% reported 1 CHC, and only 8.1% had 2 or more CHCs, while these percentages were 49.3%, 26.5%, and 24.2% within the 40–59 age group and 28.8%, 36.1%, and 35.1% within the 60þ age group. As shown in Table 2, there were no significant associations between park availability and the number of reported CHCs for the younger (18–39 years) or older (60 þ years) age groups. However, among respondents aged 40–59, those without a park within onehalf mile from home were more than twice as likely to have 2 or Table 1 Descriptive characteristics. Sample characteristic
n
(%)
Total sample
583
100.0%
Age category 18–39 years 40–59 60 þ Mean (SD)
173 219 191 51.7
29.7% 37.6% 32.8% (16.8)
Gender Male Female
226 357
38.8% 61.2%
Body mass index Normal ( o 24.9) Overweight (25.0–29.9) Obese (4 30.0)
210 208 165
36.0% 35.7% 28.3%
Race White Non-white
410 173
70.3% 29.7%
Household income o$25,000 $25,000–$74,999 4$75,000
147 300 136
25.2% 51.5% 23.3%
Park within 1/2 mile Yes No Mean (SD)
247 336 0.59
42.4% 57.6% (0.80)
CHCs 0 1 2þ Mean (SD)
277 172 134 0.91
47.5% 29.5% 23.0% (1.11)
Table 2 Park availability and chronic health conditions (CHCs) across age groups. Park within One-half mile
18–39 years
40–59 years
60 or more years
OR
95% CI
OR
95% CI
OR
95% CI
1 CHC (vs 0 CHCs) Park—Yes Park—No
1.00 0.72
n/a 0.33–1.57
1.00 1.78
n/a 0.89–3.56
1.00 0.52
n/a 0.24–1.11
2þ CHCs (vs 0 CHCs) Park—Yes Park—No
1.00 1.07
n/a 0.30–3.76
1.00 2.28n
n/a 1.05–4.94
1.00 0.84
n/a 0.38–1.86
2.3. Analyses Descriptive statistics were used to examine park availability and CHCs among the full sample and for each age group. We used multinomial logistic regression to analyze the association between having a park within one-half mile and the likelihood of having 0 (reference group), 1, or 2 or more CHCs. Separate tests were conducted for each of the three age categories and all analyses controlled for gender, race/ethnicity, body mass index, and household income. Analyses were conducted in SPSS 17.0 and the significance level was set at p o.05.
103
The reference group for the multinomial logistic regression analysis was 0 CHCs. All analyses controlled for gender, race/ethnicity, body mass index, and household annual income. n
p o .05.
104
G.M. Besenyi et al. / Health & Place 27 (2014) 102–105
more CHCs compared to 0 CHCs than those who had a park nearby (OR ¼2.28, CI ¼ 1.05–4.94).
4. Discussion Although past research has largely supported the link between green space and physical activity or reduced obesity, the present investigation extended this notion to highlight the relationship between parks and self-reported presence of a range of chronic diseases. We found that for middle-aged adults having a park within one-half mile was associated with a reduced likelihood of having multiple CHCs. This finding might be explained by other studies that have reported positive relationships between access to parks and diverse outcomes that may be intermediary mechanisms for disease prevention, such as recreational and transportrelated physical activity (Kaczynski and Henderson, 2008), psychological restoration (Hipp and Ogunseitan, 2011), stress relief (Hansmann et al., 2007), improved air quality (Yang et al., 2005), social interaction (Maas et al., 2009b), and collective efficacy (Cohen et al., 2008). For middle-aged adults in particular, this may be a sensitive period in the life course (Ben-Shlomo and Kuh, 2002) where access to recreational resources is particularly influential in mitigating the development or expression of CHCs. For example, research indicates that although physical activity declines across the lifespan, relationships between the neighborhood environment and physical activity are modified by age (Van Cauwenberg et al., 2011). Specifically, Ranchod et al. (2014) found that greater density of recreational facilities within 1 mile was associated with a less pronounced decline in physical activity among middle-aged and older adults. They concluded that improved access to recreational facilities enabled middle to older age adults the ability to maintain physical activity levels as they age. An increased awareness of their growing susceptibility to CHCs and retention of functional abilities for park utilization may explain why parks were particularly significant for this age group. The findings of this study have several practical implications for the fields of urban planning, public health, and parks and recreation management. For example, neighborhood and community planning efforts should integrate parks and open space within walking distance (e.g., one-half mile) of residents to facilitate proximal opportunities for physical activity, stress mitigation, social bonding, and psychological restoration that may attenuate the effects of other deleterious environmental features (e.g., food environment, traffic, pollution) on chronic disease rates (Lee and Maheswaran, 2011; Sallis et al., 2012). This proximity to healthpromoting green space may be especially important for middleaged adults with increased stress-related factors (e.g., familial responsibilities, busy careers) and for whom the prospect of chronic health issues is more imminent (Fan et al., 2012; Soldo, 1996; Wang et al., 2007). Public health professionals should facilitate and coordinate efforts by multiple agencies (e.g., recreation, social services, planning, economic development, medical experts) to advocate for and promote parks and open spaces to both internal and external audiences (Blanck et al., 2012). Finally, parks and recreation departments would be wise to view their resources as integral components of the community health care system and to adopt a broader mission of promoting well-being for all ages that focuses on ultimate outcomes related to reduced rates of morbidity and mortality (Payne, 2002). This study was subject to several limitations that provide fertile ground for future research. For example, although one-half mile is a theoretically-reasonable distance within which to examine park availability and this threshold created a relatively even distribution within the current sample, using other sizes of buffers may produce different results. Further, this study only examined the
spatial relationship between park availability and prevalence of CHCs. Future studies should explore additional park characteristics (e.g., size, features, usage) that have been shown to be related to park use and physical activity (Kaczynski et al., 2008; Sugiyama et al., 2010). Additionally, our index of CHCs may not have been comprehensive and other indicators of health status may be relevant as well. However, previous research has shown strong agreement between self-reported chronic diseases and objectively measured health, especially among well-known diseases (Haapanen et al., 1997; Kehoe et al., 1994). Our study did not account for self-selection of living closer to a park, although some research indicates this is not a serious issue with respect to parks and health behaviors such as physical activity (Kaczynski and Mowen, 2011). Likewise, our cross-sectional design does not permit causal inferences about the relationship between park availability and disease outcomes. However, GIS methods are a valid way to explore correlational relationships and are becoming a popular practice within public health research for understanding relationships between population-level health and the environment (Barnard and Hu, 2005). Still, future research should explore underlying psychological, social, or physiological mechanisms that may explain the association between parks and health outcomes. As well, this study focused only on adults. However, research indicates that the social and economic impact of parks may be even more significant for preventing the development of risk factors related to diabetes, heart disease, and depression amongst youth and adolescents (Flynn et al., 2006; Nwobu and Johnson, 2007). Future research should explore the relationship between exposure to park availability early in life and long-term effects on CHCs. Finally, this study was conducted within a single, Midwestern city among respondents who were mostly older, female, and White. To increase generalizability, replicating these analyses in other settings (e.g., more or less dense urban locations, rural areas) and across a range of participants (e.g., gender, age, socioeconomic status) would be beneficial. Despite these limitations, this is one of the first studies to examine the association between park availability and a variety of CHCs. Within healthy community planning efforts, parks may be an important protective factor for chronic diseases, especially among middle-aged adults for whom access to neighborhood recreation environments may be particularly influential.
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Contents lists available at ScienceDirect
Health & Place journal homepage: www.elsevier.com/locate/healthplace
Short Report
Planning for health: A community-based spatial analysis of park availability and chronic disease across the lifespan Gina M. Besenyi a,n, Andrew T. Kaczynski a,b, Sonja A. Wilhelm Stanis c, Ryan D. Bergstrom d, Joseph S. Lightner e, J. Aaron Hipp f a
Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, United States Prevention Research Center, Arnold School of Public Health, University of South Carolina, United States c Department of Parks, Recreation, and Tourism, University of Missouri, United States d Department of Geography, Gustavus Adolphus College, United States e Department of Kinesiology, Kansas State University, United States f Brown School of Social Work, Washington University in St. Louis, United States b
art ic l e i nf o
a b s t r a c t
Article history: Received 28 July 2013 Received in revised form 3 February 2014 Accepted 6 February 2014 Available online 3 March 2014
The purpose of this study was to explore the spatial relationship between park availability and chronic health conditions (CHCs) across age groups in Kansas City, MO. Multinomial logistic regression examined the association between having a park within one-half mile from home and the likelihood of having 0, 1, or 2 or more CHCs. Among respondents aged 40–59, those without a park within one-half mile from home were more than twice as likely to have 2 or more CHCs compared to respondents that had a park nearby. Parks may be an important protective factor for chronic diseases, especially among middle-aged adults among whom access to neighborhood recreational environments may be particularly important. & 2014 Elsevier Ltd. All rights reserved.
Keywords: Parks Recreation Chronic disease GIS
1. Introduction Efforts to promote health and well-being at the population level frequently adopt social ecological models that emphasize the role of community environments in fostering healthy behaviors (Richard et al., 2011; Sallis et al., 2008). Within the built environment, parks are one important community resource that can offer numerous psychological, physical, social, economic, and environmental benefits to residents of all ages (Bedimo-Rung et al., 2005). For example, a growing body of research has examined how parks are associated with physical activity and reduced obesity levels in both children and adults (Kaczynski and Henderson, 2007; Alexander et al., 2013; Wolch et al., 2011). Other studies have documented relationships between access to green space and other health-related outcomes, including mental health (Van Den Berg et al., 2010), morbidity (Maas et al., 2009a), and mortality (Villeneuve et al., 2012). Additionally, users of local park and recreation facilities report fewer visits to a physician (Godbey et al., 1998) and better perceived physical and mental health (Payne et al., 2005), which are
potentially significant indicators of the value of parks within the context of rising health care costs and an aging population. While some limited research has explored how the built environment affects diseases and related risk factors, such as diabetes (Stewart et al., 2011) and high blood pressure (Li et al., 2009), studies specifically about parks have rarely considered these outcomes (Pereira et al., 2012). Moreover, few studies have explored how health outcomes are related to objectively-measured park access across the lifespan (Kaczynski et al., 2009). As the incidence of most major chronic diseases increases with age (Rae et al., 2010), it is important to assess how environmental features, such as parks, differentially impact various cohorts of residents. Given these considerations, the purpose of this study was to examine the spatial relationship between park availability and prevalence of chronic health conditions (CHCs) across adult age groups.
2. Methods 2.1. Study setting and data collection
n
Correspondence to: Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, 800 Sumter – Room 216, Columbia, SC 29208, United States. Tel.: þ1 785 364 4882. E-mail address: [email protected] (G.M. Besenyi). http://dx.doi.org/10.1016/j.healthplace.2014.02.005 1353-8292 & 2014 Elsevier Ltd. All rights reserved.
This study was part of the Kansas City Parks and Physical Activity Project, a cross-sectional, multi-component investigation of the influence of parks and neighborhoods on physical activity
G.M. Besenyi et al. / Health & Place 27 (2014) 102–105
and health in Kansas City, Missouri (KCMO). The broader Kansas City metropolitan area comprises 15 counties in both Missouri and Kansas and contains over two million people, while KCMO has a population of almost one-half million (459,787) residents from diverse racial/ethnic and socioeconomic backgrounds (City of Kansas City Missouri, 2012). At the time of the study, the city had over 12,000 ac of parkland across 219 parks of all types and sizes (Kansas City Department of Parks and Recreation, 2009). The study protocol was reviewed and approved by the Institutional Review Boards of Kansas State University and the University of Missouri and the study occurred in October–December 2010. Data used for this paper were collected through geographic information systems (GIS) shapefiles and a general population mail survey addressing neighborhood and park issues and health behaviors and outcomes. A parks shapefile and base map shapefiles (state and city boundaries, StreetMap USA layers) were obtained from the KCMO Planning Department. For the survey, with the assistance of a marketing research company (Survey Sampling International, Shelton, CT), an initial cluster random sample of residential addresses geographically-dispersed across KCMO (n ¼3906) was identified. An 11-page self-administered questionnaire was sent to these households using a four-wave, modified Dillman mailing protocol (Dillman, 2000). Of the 3906 questionnaires that were mailed out, 649 were returned by the postal service as undeliverable and 893 were returned completed. This resulted in a 27.4% response rate [893/(3906–649)], which is comparable to other similar studies about parks within the general population (Tilt, 2010; Coombes et al., 2010). The present analyses are based on 583 participants for whom complete data were available for all variables used in this paper (including covariates). 2.2. Measures All parks in the city were visited and audited to determine if they were accessible and useable and an edited GIS parks shapefile was subsequently created. ArcView 10.0 was used to determine the availability of a park (yes or no) within a one-half mile street network buffer of each study participant's home. Within the household survey, respondents were asked to indicate if they currently had any of the following health conditions and were instructed to check all that apply: heart problems (e.g., heart disease, heart attack, high blood pressure), cancer, diabetes, osteoporosis, depression and other mental health concerns, asthma/allergies, disability (please describe), other (please describe). For these chronic diseases, previous research indicates moderate to high percent agreement between self-reported prevalence and practitioner records (Kriegsman et al., 1996). Each participant was subsequently categorized as having 0, 1, or 2 or more CHCs. Finally, participants also provided demographic data, including age (which was subsequently divided into three categories: 18–39, 40–59, and 60 þ years), gender, race/ethnicity, height and weight (used to calculate body mass index), and household annual income.
3. Results Table 1 provides descriptive information regarding characteristics of the sample. Of the 583 respondents, the majority were older, female, and White. The percentage of participants with a nearby park for each of the three age groups was as follows: 18–39 years ¼44.5%, 40–59 years ¼ 36.5%, 60 þ years ¼47.1%. Within the 18–39 age group, 65.8% of participants had 0 CHCs, 26.0% reported 1 CHC, and only 8.1% had 2 or more CHCs, while these percentages were 49.3%, 26.5%, and 24.2% within the 40–59 age group and 28.8%, 36.1%, and 35.1% within the 60þ age group. As shown in Table 2, there were no significant associations between park availability and the number of reported CHCs for the younger (18–39 years) or older (60 þ years) age groups. However, among respondents aged 40–59, those without a park within onehalf mile from home were more than twice as likely to have 2 or Table 1 Descriptive characteristics. Sample characteristic
n
(%)
Total sample
583
100.0%
Age category 18–39 years 40–59 60 þ Mean (SD)
173 219 191 51.7
29.7% 37.6% 32.8% (16.8)
Gender Male Female
226 357
38.8% 61.2%
Body mass index Normal ( o 24.9) Overweight (25.0–29.9) Obese (4 30.0)
210 208 165
36.0% 35.7% 28.3%
Race White Non-white
410 173
70.3% 29.7%
Household income o$25,000 $25,000–$74,999 4$75,000
147 300 136
25.2% 51.5% 23.3%
Park within 1/2 mile Yes No Mean (SD)
247 336 0.59
42.4% 57.6% (0.80)
CHCs 0 1 2þ Mean (SD)
277 172 134 0.91
47.5% 29.5% 23.0% (1.11)
Table 2 Park availability and chronic health conditions (CHCs) across age groups. Park within One-half mile
18–39 years
40–59 years
60 or more years
OR
95% CI
OR
95% CI
OR
95% CI
1 CHC (vs 0 CHCs) Park—Yes Park—No
1.00 0.72
n/a 0.33–1.57
1.00 1.78
n/a 0.89–3.56
1.00 0.52
n/a 0.24–1.11
2þ CHCs (vs 0 CHCs) Park—Yes Park—No
1.00 1.07
n/a 0.30–3.76
1.00 2.28n
n/a 1.05–4.94
1.00 0.84
n/a 0.38–1.86
2.3. Analyses Descriptive statistics were used to examine park availability and CHCs among the full sample and for each age group. We used multinomial logistic regression to analyze the association between having a park within one-half mile and the likelihood of having 0 (reference group), 1, or 2 or more CHCs. Separate tests were conducted for each of the three age categories and all analyses controlled for gender, race/ethnicity, body mass index, and household income. Analyses were conducted in SPSS 17.0 and the significance level was set at p o.05.
103
The reference group for the multinomial logistic regression analysis was 0 CHCs. All analyses controlled for gender, race/ethnicity, body mass index, and household annual income. n
p o .05.
104
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more CHCs compared to 0 CHCs than those who had a park nearby (OR ¼2.28, CI ¼ 1.05–4.94).
4. Discussion Although past research has largely supported the link between green space and physical activity or reduced obesity, the present investigation extended this notion to highlight the relationship between parks and self-reported presence of a range of chronic diseases. We found that for middle-aged adults having a park within one-half mile was associated with a reduced likelihood of having multiple CHCs. This finding might be explained by other studies that have reported positive relationships between access to parks and diverse outcomes that may be intermediary mechanisms for disease prevention, such as recreational and transportrelated physical activity (Kaczynski and Henderson, 2008), psychological restoration (Hipp and Ogunseitan, 2011), stress relief (Hansmann et al., 2007), improved air quality (Yang et al., 2005), social interaction (Maas et al., 2009b), and collective efficacy (Cohen et al., 2008). For middle-aged adults in particular, this may be a sensitive period in the life course (Ben-Shlomo and Kuh, 2002) where access to recreational resources is particularly influential in mitigating the development or expression of CHCs. For example, research indicates that although physical activity declines across the lifespan, relationships between the neighborhood environment and physical activity are modified by age (Van Cauwenberg et al., 2011). Specifically, Ranchod et al. (2014) found that greater density of recreational facilities within 1 mile was associated with a less pronounced decline in physical activity among middle-aged and older adults. They concluded that improved access to recreational facilities enabled middle to older age adults the ability to maintain physical activity levels as they age. An increased awareness of their growing susceptibility to CHCs and retention of functional abilities for park utilization may explain why parks were particularly significant for this age group. The findings of this study have several practical implications for the fields of urban planning, public health, and parks and recreation management. For example, neighborhood and community planning efforts should integrate parks and open space within walking distance (e.g., one-half mile) of residents to facilitate proximal opportunities for physical activity, stress mitigation, social bonding, and psychological restoration that may attenuate the effects of other deleterious environmental features (e.g., food environment, traffic, pollution) on chronic disease rates (Lee and Maheswaran, 2011; Sallis et al., 2012). This proximity to healthpromoting green space may be especially important for middleaged adults with increased stress-related factors (e.g., familial responsibilities, busy careers) and for whom the prospect of chronic health issues is more imminent (Fan et al., 2012; Soldo, 1996; Wang et al., 2007). Public health professionals should facilitate and coordinate efforts by multiple agencies (e.g., recreation, social services, planning, economic development, medical experts) to advocate for and promote parks and open spaces to both internal and external audiences (Blanck et al., 2012). Finally, parks and recreation departments would be wise to view their resources as integral components of the community health care system and to adopt a broader mission of promoting well-being for all ages that focuses on ultimate outcomes related to reduced rates of morbidity and mortality (Payne, 2002). This study was subject to several limitations that provide fertile ground for future research. For example, although one-half mile is a theoretically-reasonable distance within which to examine park availability and this threshold created a relatively even distribution within the current sample, using other sizes of buffers may produce different results. Further, this study only examined the
spatial relationship between park availability and prevalence of CHCs. Future studies should explore additional park characteristics (e.g., size, features, usage) that have been shown to be related to park use and physical activity (Kaczynski et al., 2008; Sugiyama et al., 2010). Additionally, our index of CHCs may not have been comprehensive and other indicators of health status may be relevant as well. However, previous research has shown strong agreement between self-reported chronic diseases and objectively measured health, especially among well-known diseases (Haapanen et al., 1997; Kehoe et al., 1994). Our study did not account for self-selection of living closer to a park, although some research indicates this is not a serious issue with respect to parks and health behaviors such as physical activity (Kaczynski and Mowen, 2011). Likewise, our cross-sectional design does not permit causal inferences about the relationship between park availability and disease outcomes. However, GIS methods are a valid way to explore correlational relationships and are becoming a popular practice within public health research for understanding relationships between population-level health and the environment (Barnard and Hu, 2005). Still, future research should explore underlying psychological, social, or physiological mechanisms that may explain the association between parks and health outcomes. As well, this study focused only on adults. However, research indicates that the social and economic impact of parks may be even more significant for preventing the development of risk factors related to diabetes, heart disease, and depression amongst youth and adolescents (Flynn et al., 2006; Nwobu and Johnson, 2007). Future research should explore the relationship between exposure to park availability early in life and long-term effects on CHCs. Finally, this study was conducted within a single, Midwestern city among respondents who were mostly older, female, and White. To increase generalizability, replicating these analyses in other settings (e.g., more or less dense urban locations, rural areas) and across a range of participants (e.g., gender, age, socioeconomic status) would be beneficial. Despite these limitations, this is one of the first studies to examine the association between park availability and a variety of CHCs. Within healthy community planning efforts, parks may be an important protective factor for chronic diseases, especially among middle-aged adults for whom access to neighborhood recreation environments may be particularly influential.
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