What is health and how is it determined?
Health is one of life’s most valued assets. Practically all people have it in their ‘top three’ of important life factors. In the 5th Century B.C., a Greek statesman by the name of Pericles stated that ‘Health is that state of moral, mental, and physical wellbeing that enables a person to face any crisis in life with the utmost grace and facility’ (Burn, 1956). However, it is only through research carried out in the latter half of the 20th Century that society has discovered the factors that enhance health. Current theories of disease have become more complex and moved away from single cause explanations to ones in which multiple behavioural, environmental, biological and genetic factors combine over time, resulting in one or more of a number of different diseases (House et al., 1988).
The World Health Organization (WHO) states health is ‘A state of complete physical, mental, and social wellbeing, and not merely the absence of disease or inﬁrmity’ (World Health Organization, 1946). The word ‘health’ is derived from the Greek word ‘hal’ or whole. It is this holistic perspective of health which has emerged in the last 50 years. Nevertheless, it is not possible in reality to achieve the WHO goal. Rene Dubos stated, ‘The concept of perfect and positive health is a utopian creation of the human mind. It cannot become reality because man will never be so perfectly adapted to his environment…It is true that the modern ways of life are creating disease that either did not exist a few decades ago or are now more common than in the past…The utopia of positive health [however] constitutes a creative force because like other ideals, it sets goals and helps medical science to chart its course towards them’ (Dubos, 1965 p. 346).
Dubos (1965) was one of the ﬁrst to explore the interconnections of humans with their environment. Since that time, there has been a great deal of research and the development of models and frameworks about the different factors that shape human life and human health and wellbeing. The physical environment is one of these. Nevertheless, the reductionist approach which has characterised modern science is seen as undermining the capacity to adopt the holistic view which is required to understand and foster optimal outcomes both for humans and the planet.
The Canadian Government produced a major report in 1974, which examined ‘The Health Field Concept’ (Lalonde, 1974). It identiﬁed four key factors that shaped people’s health: genetics; the environments in which they live; lifestyle behaviours; and the provision and accessibility of medical services (Lalonde, 1974). Since that time a major shift has occurred in how health is viewed. It is often called ‘an ecological theory of public health’ and has emanated from such writers as Kickbusch (Kickbusch, 1989a), Antonovsky (Antonovsky, 1984), WHO (World Health Organization, 1986), and recently, the World Bank (Murray and Lopez, 1996). Put simply, it is the recognition that health is inﬂuenced by many factors and most of them are interrelated.
Hancock and Perkins (1985) mapped this ecological perspective in their Mandala of Health. Their model shows that there are three core aspects of health, namely physical, mental, and spiritual, and the various factors that inﬂuence these (Figure 1).
In industrialised countries chronic disease has increasingly replaced acute infectious disease as the major cause of disability and death (House et al., 1988). These types of afﬂictions are often long-term and are potentially much more expensive in terms of health care requirements and cost to the community. Some of the health problems facing society include: disease patterns linked to social inequities and ways of life in industrial societies; health problems that are social rather than medical in nature; health problems that tend to be cumulative, longterm, chronic and not amenable to curative measures; and a general public that is changing its social perception of health risks and is expressing new expectations (Kickbusch, 1989b). In Australia, the Commonwealth and State Governments have been proactive in developing frameworks, strategies, priorities, and tactics to improve people’s quality of life and their longevity. It is often referred to as ‘adding years to life and life to years’.
The establishment of Health Promotion and Development Foundations has been just one example of government initiatives. There is now a greater emphasis on working ‘upstream’ (to prevent people ‘falling into’ ill health), than just supplying ‘downstream’ (rescue) services (e.g. medical treatment and rehabilitation). The work done in cardiovascular disease (CVD) prevention through encouraging physical activity, healthy dietary practices, and tobacco reduction programs (e.g. QUIT) are examples of this approach. The ‘upstream’ (health promotion) approach is now happening in most areas of health and is certainly a cornerstone of addressing Australia’s national health priorities (cancer control, injury prevention and control, cardiovascular health, diabetes mellitus, mental health, asthma, and arthritis and musculoskeletal conditions). The environment, however, plays a pivotal role in all of these. Better collection of data and accurate models of future health trends and issues means there can be careful planning for the next 20-30 years. The Victorian Burden of Disease Study (Vos and Begg, 1999) found a number of important changes occurring. This study used similar methods to the WHO/World Bank sponsored Global Burden of Disease study (Murray and Lopez, 1996).
Some key ﬁndings were:
Men have a life expectancy six years shorter than women but the gap is narrowing;
- The gap between the LGA (Local Government Area) with the lowest and
highest life expectancy is seven years in men and four in women. Socio-
economic disadvantage is an important predictor of lower life expectancy;
- The life expectancy of Aboriginal men may be between eight and 18 years shorter than the state average. In women, the gap is estimated to be as large as nine to 18 years;
- Rural residence, especially in the least populated parts of Victoria, is the most important predictor of premature mortality from injuries. Traffic accidents, suicide, machinery accidents, and drowning are the main types of injury responsible for this difference;
- Favourable trends in life expectancy and mortality from many causes have been witnessed in the last two decades. The most favourable trends are observed in deaths from cardiovascular disease and injuries, with a mean annual decline of five percent. Tobacco-related illness in young women, diabetes in older men, drug overdose and suicide in young men show unfavourable trends (Vos and Begg, 1999).
Recent ﬁgures show little change in those ﬁndings.
The WHO/World Bank report identiﬁed cardiovascular disease (CVD) and poor mental health as likely to be the two biggest contributors to disease by the year 2020 (Murray and Lopez, 1996). CVD is currently number one, and will remain so, but poor mental health will rise from position number eight to position number two. The environment has a major inﬂuence on both of these areas. Evidence cited in this report shows that parks and nature can be a signiﬁcant contributor to reducing premature death and disease in these two ﬁelds. Promising evidence is also emerging that positive inﬂuences from park environments, and associated ﬂora and fauna, enhance wellbeing in relation to other health issues.
Parks are one of our most vital health resources. The following sections provide an evidence-based case to support this claim, and suggest that both the health and parks/environment sectors need to act more proactively in collaboration to enrich the role that parks play in improving and sustaining the nation’s (indeed, the world’s) health.
Ecological theory of public health
In response to these changes in the way health is being conceptualised and
managed, researchers and health care professionals are adopting a more holistic approach. Although not always referred to as such, this approach is based on an ecological theory of public health. As mentioned, the concept of an ecological public health has emerged recently in response to a new range of health issues and problems (Chu and Simpson, 1994; Kickbusch, 1989a). Traditional modes of public health seem ill prepared for this new reality and the health risks posed to populations, which has led to a reconsideration of the interdependence between people, their health, and their physical and social environments (Kickbusch, 1989a). It is now known that human health cannot be considered in isolation from physical or social environments (Chu and Simpson, 1994; Wilkinson and Marmot, 2003). In fact, some authors state that the separation of the health of the environment and the health of humans is done at the peril of the human species (Brown, 1996).
In recognition of this, the Ottawa Charter for Health Promotion was developed at an international conference sponsored by the WHO in 1986 (World Health Organization, 1986). The Charter identified the importance of environments supportive of health, stating that the inextricable links between people and their environment are the basis for a socio-ecological approach to health (World Health Organization, 1986). It advocated the protection of natural and built environments as well as the conservation of natural resources as essential in any health promotion strategy. The central theme of the conference, however, was the promotion of health through the maximisation of the health values of everyday settings. Settings are places or social contexts where people engage in daily activities in which environmental and personal factors interact to affect health and wellbeing (Chu and Simpson, 1994). This includes where people learn, live, work, play etc. The consequence for public health policy is to strengthen the
health potential of the settings of everyday life, starting where health is created (Kickbusch, 1989b). Parks are settings that may be health creating (perhaps more so than many other settings) yet their health potential currently often remains unacknowledged and under-utilised.
Apart from the identification of the health value of everyday settings, the Australian Institute of Health and Welfare (AIHW) (1998) identifies holistic wellbeing as a crucial concept for understanding health. AIHW nominates seven dimensions of health: biological and mental wellbeing, social wellbeing, economic wellbeing, environmental wellbeing, life satisfaction, spiritual or existential wellbeing, and ‘other characteristics valued by humans (Australian Institute of Health and Welfare, 1998). Although our understanding of these dimensions is slowly increasing, the majority of health statistics still measure illness or the absence of health. Despite this, much data is accumulating for the positive effects of social relationships on health. It has been demonstrated that social relationships provide a buffer for potentially harmful health effects arising from psychological stress in particular (House et al, 1988). However, the significance of sustainable ecosystems for the dimensions of human health needs greater exploration, as well as inclusion and emphasis in the knowledge base of public health (Brown, 1996). Butler and Friel (2006) highlight a paradox: that the emergence of evidence linking ecological and environmental factors to health outcomes has occurred at the same time as a declining acknowledgement by health promoters of the importance of these factors.
An ecological theory of public health recognises that not only is health itself
holistic and multidisciplinary, but also that a holistic or multidisciplinary
approach is needed to promote and manage health successfully. This requires inventive new efforts in the collaboration between environmental scientists and biomedical researchers on one hand, and between health and environmental policy makers on the other (Wilson, 2001). Our objective for the future should be healthy people in a healthy environment, with healthy relations to that environment (Birch, 1993). In terms of parks, not only do they preserve and protect the environment; they also encourage and enable people to relate to the natural world. For these reasons they have a key role in an ecological approach to health.
Social capital, health and the natural environment
The term ‘social capital’ has become increasingly common in the social science literature over recent years. Though there are variations in the way it is defined, the term generally refers to social structures such as networks, trust, and norms which facilitate co-operation and cohesion in communities, and which result in benefits for community members (Kawachi et al., 1997; Putnam et al., 1993; Coleman, 1988; Bourdieu, 1986). There are, therefore, at least two aspects to social capital: the sources or relational aspects of the capital (i.e. the structures and mechanisms by which it is established and maintained), and the consequences or material aspects of the capital (i.e. the flow-on effects or benefits to community members which result from their membership) (Hawe and Shiell, 2000; Portes, 1998; Wilkinson, 1999)
Recent research suggests that differences in social capital may explain differences in morbidity and mortality within and between different population groups (Kawachi et al., 1997; Putnam, 1995; Runyan et al., 1998; Baum, 1999; Leeder and Dominello, 1999; Lynch and Kaplan, 1997). However, there are differing explanations for the ways in which health is influenced by social capital. Hawe and Shiell (2000) point out that while Kawachi et al. (1997) focus on the relational aspects of social capital, arguing that a large gap between rich and poor people leads to higher mortality through the breakdown of social cohesion, Lynch and Kaplan (1997) offer an explanation based on the material aspects of social capital where income inequality may be a marker for a set of other concrete societal characteristics and policies that influence health. This difference in explanations highlights the fact that the relationships between variables may be complex and multi-directional. Nevertheless, whatever the mechanism by which social capital influences health, there is clear evidence that it does have an effect. At a population health level, Baum (1999) highlights the association between ‘the quality and extent of social interaction and relationships’ and the health of populations. This view is supported by Wilkinson and Marmot (2003 p. 22) who state: ‘Social support and good social relations make an important contribution to health’. However, Wilkinson and Marmot (p. 22) go on to point out that there are two aspects to social support—personal and structural. ‘People who get less social and emotional support from others are more likely to experience less well-being, more depression, a greater risk of pregnancy complications and higher levels of disability from chronic diseases. …The amount of emotional and practical social support people get varies by social and economic status. Poverty can contribute to social exclusion and isolation’. Wilkinson (1999) highlights research by Berkman (1995, in Wilkinson, 1999) and House et al. (1988) which ‘reported death rates two or three times as high among people with low levels of social integration compared to people with high levels’. At an individual level, Baum (1999) reports on a US study by Kawachi et al. (1996, in Baum, 1999) which found that, by comparison with ‘people who had many social ties, those who were socially isolated were 6.59 times less likely to survive a stroke, 3.22 times more likely to commit suicide and 1.59 times less likely to survive coronary heart disease’.
While the relationship between social capital and health has been the subject of considerable research and reflection, the relationship between social capital and the biophysical environment is only now beginning to be explored. Hawe and Shiell (2000) highlight the lack of exploration of place-level effects within the literature on social capital, but even they do not specifically refer to the effects of place in terms of biophysical environments. More recently, the role of parks and open spaces in building social capital through recreational activities has been highlighted. For example, DeGraaf and Jordan (2003) draw attention to the opportunity available to professionals working in park management and in recreation and leisure services to promote development of social capital.
Where the link between social capital and the biophysical environment has been explored (Cavaye, 1999; Pretty and Ward, 2001; Pretty and Smith, 2003) the work has largely focused on the impacts of varying levels and types of social capital on environmental management, rather than on the contribution of biophysical environments to social capital. One strand of work linking social capital and the environment has been the work of the Civic Practices Network on ‘civic environmentalism’. However, like the previous example, this also links social capital and the environment in a unidirectional ‘social capital environmental improvement’ model.
Anecdotal evidence, however, suggests that engagement in civic environmentalism (through groups such as Friends of Parks) has spin-off social capital benefits in addition to the benefits that such groups were originally designed to achieve. One of the key elements of social capital is ‘civic engagement’. Putnam (1995) states that dense networks of interaction probably broaden participants’ sense of self, developing the ‘I’ into the ‘we’. Yet, Putnam (1995) observes, America (like many other nations) is experiencing a decline in civic engagement and social connectedness. One of the factors associated with this decline has been ‘the technological transformation of leisure’ (Putnam, 1995). If we consider the anecdotal evidence, and Putnam’s (1995) observations, in the light of Frumkin’s (2001) evidence of the effects of wilderness experience in increasing capacity for cooperation and trust, it seems likely that human interactions with nature through parks may have significant capacity for building social capital.
Emerging empirical evidence confirms the potential for spin-off social capital benefits of civic environmentalism indicated by anecdotal evidence (Townsend, 2006; Moore, Townsend and Oldroyd, 2007). Research by Selman (2001), however, exploring the potential for environmental management projects to contribute to the growth of social capital, suggests that although this potential exists, it may be compromised by the pressures of life in modern society. A study of a local ‘friends of parks’ group in Melbourne found, like Selman, that relatively few young families are involved in such groups (Townsend and Maller, 2003). However, where young families were involved, significant social benefits were found to flow from that involvement, including the widening of their social networks and ‘the increase in confidence in .. .children as a result of interaction with other people in the community’ (Townsend 2006 p. 116). In another Australian study which compared volunteer members of land management groups associated with the Trust for Nature and matched controls, it was found that members of the groups both experienced and contributed to higher levels of social capital than the controls (Moore, Townsend and Oldroyd 2007). It is interesting to note the ‘symbiotic’ relationship between social and natural capital. As one benefits the other it could be worthwhile to investigate the facilitative role that parks could play in linking one to the other. This area needs exploration.
Healthy parks, healthy people
The health benefits of contact with nature in a park context
A review of relevant literature
School of Health and Social Development Faculty of Health, Medicine, Nursing and Behavioural Sciences
© Deakin University and Parks Victoria 2008
Authors Dr. Cecily Maller Associate Professor Mardie Townsend Associate Professor Lawrence St Leger Dr Claire Henderson-Wilson Ms Anita Pryor Ms Lauren Prosser Dr Megan Moore