Nature-based biopsychosocial resilience: An integrative theoretical framework for research on nature and health.

Nature-based solutions including urban forests and wetlands can help communities cope better with climate change and other environmental stressors by enhancing social-ecological resilience. Natural ecosystems, settings, elements and affordances can also help individuals become more personally resilient to a variety of stressors, although the mechanisms underpinning individual-level nature-based resilience, and their relations to social-ecological resilience, are not well articulated. We propose 'nature-based biopsychosocial resilience theory' (NBRT) to address these gaps. Our framework begins by suggesting that individual-level resilience can refer to both: a) a person's set of adaptive resources; and b) the processes by which these resources are deployed. Drawing on existing nature-health perspectives, we argue that nature contact can support individuals build and maintain biological, psychological, and social (i.e. biopsychosocial) resilience-related resources. Together with nature-based social-ecological resilience, these biopsychosocial resilience resources can: i) reduce the risk of various stressors (preventive resilience); ii) enhance adaptive reactions to stressful circumstances (response resilience), and/or iii) facilitate more rapid and/or complete recovery from stress (recovery resilience). Reference to these three resilience processes supports integration across more familiar pathways involving harm reduction, capacity building, and restoration. Evidence in support of the theory, potential interventions to promote nature-based biopsychosocial resilience, and issues that require further consideration are discussed.

Transfemoral amputation and prosthesis provision in Tanzania: Patient and provider perspectives.

Background: The burden of disability because of traumatic limb amputation, particularly transfemoral amputation (TFA) is disproportionately carried by low- and middle-income countries. The need for improved access to prosthesis services in these settings is well-documented, but perspectives on the burden imposed by TFA and the challenges associated with subsequent prosthesis provision vary among patients, caregivers and healthcare providers. Objectives: To examine the burden of TFA and barriers to prosthesis provision as perceived by patient, caregiver and healthcare professional, at a single tertiary referral hospital in Tanzania. Method: Data were collected from five patients with TFA and four caregivers recruited via convenience sampling, in addition to 11 purposively sampled healthcare providers. All participants participated in in-depth interviews regarding their perceptions of amputation, prostheses and underlying barriers to improving care for persons with TFA in Tanzania. A coding schema and thematic framework were established from interviews using inductive thematic analysis. Results: All participants noted financial and psychosocial burdens of amputation, and perceived prostheses as an opportunity for return to normality and independence. Patients worried about prosthesis longevity. Healthcare providers noted significant obstacles to prosthesis provision, including infrastructural and environmental barriers, limited access to prosthetic services, mismatched patient expectations and inadequate coordination of care. Conclusion: This qualitative analysis identifies factors influencing prosthesis-related care for patients with TFA in Tanzania which are lacking in the literature. Persons with TFA and their caregivers experience numerous hardships exacerbated by limited financial, social and institutional support. Contribution: This qualitative analysis informs future directions for research into improving prosthesis-related care for patients with TFA in Tanzania.

Outdoor Transmission of SARS-CoV-2 and Other Respiratory Viruses: A Systematic Review.

BACKGROUND: While risk of outdoor transmission of respiratory viral infections is hypothesized to be low, there are limited data on SARS-CoV-2 transmission in outdoor compared to indoor settings. METHODS: We conducted a systematic review of peer-reviewed papers indexed in PubMed, EMBASE, and Web of Science and preprints in Europe PMC through 12 August 2020 that described cases of human transmission of SARS-CoV-2. Reports of other respiratory virus transmission were included for reference. RESULTS: Five identified studies found a low proportion of reported global SARS-CoV-2 infections occurred outdoors (<10%) and the odds of indoor transmission was very high compared to outdoors (18.7 times; 95% confidence interval, 6.0-57.9). Five studies described influenza transmission outdoors and 2 adenovirus transmission outdoors. There was high heterogeneity in study quality and individual definitions of outdoor settings, which limited our ability to draw conclusions about outdoor transmission risks. In general, factors such as duration and frequency of personal contact, lack of personal protective equipment, and occasional indoor gathering during a largely outdoor experience were associated with outdoor reports of infection. CONCLUSIONS: Existing evidence supports the wide-held belief that risk of SARS-CoV-2 transmission is lower outdoors but there are significant gaps in our understanding of specific pathways.

Association of neighborhood parks with child health in the United States.

While there is evidence that parks support pediatric health, there have been no national studies looking at both physical and mental health. We assessed whether the presence of a neighborhood park is associated with pediatric physical or mental health across the U.S. using a nationally representative cross-sectional random sample of American children ages 0-17. Caregivers reported on the park presence in their child's neighborhood and the child's physical activity, screen-time, sleep, weight, and diagnosis of anxiety, depression, or attention deficit hyperactivity disorder (ADHD). Covariates included child and family sociodemographics and, for 29 states, neighborhood urbanicity. Caregivers reported on 49,146 children (mean age 9.4 years; 49% female). There were 11,791 (24%) children living in neighborhoods lacking a park; children in non-urban locations (aOR 2.19, 95% CI 1.40-1.67) or below the federal poverty level (aOR = 1.48, 95%CI 1.38-1.58) had higher odds of lacking a park. Irrespective of sociodemographics, children lacking parks were more likely to be physically inactive (aOR1.36, 95% CI 1.24, 1.48), have excessive screen-time (aOR = 1.19, 95% CI 1.14, 1.25), or obtain inadequate sleep (aOR = 1.23, 95% CI 1.18, 1.29). Children without parks were more likely obese (aOR = 1.32, 95% CI 1.21, 1.43), overweight (aOR 1.25, 95%CI 1.17, 1.33), or diagnosed with ADHD (aOR 1.20, 95% CI 1.12, 1.29), but not more anxious or depressed (aOR = 1.04, 95%CI 0.97, 1.11). Associations between parks and pediatric physical and mental health suggests that the provision of neighborhood parks could represent a low-cost childhood health intervention.

Screening for Park Access during a Primary Care Social Determinants Screen.

While there is evidence that access to nature and parks benefits pediatric health, it is unclear how low-income families living in an urban center acknowledge or prioritize access to parks. METHODS: We conducted a study about access to parks by pediatric patients in a health system serving low-income families. Adult caregivers of pediatric patients completed a survey to identify and prioritize unmet social and economic needs, including access to parks. Univariate and multivariate analyses were conducted to explore associations between lack of access to parks and sociodemographic variables. We also explored the extent to which access to parks competed with other needs. RESULTS: The survey was completed by 890 caregivers; 151 (17%) identified "access to green spaces/parks/playgrounds" as an unmet need, compared to 397 (45%) who endorsed "running out of food before you had money or food stamps to buy more". Being at or below the poverty line doubled the odds ( Odds ratio 1.96, 95% CI 1.16-3.31) of lacking access to a park (reference group: above the poverty line), and lacking a high school degree nearly doubled the odds. Thirty-three of the 151 (22%) caregivers who identified access to parks as an unmet need prioritized it as one of three top unmet needs. Families who faced competing needs of housing, food, and employment insecurity were less likely to prioritize park access (p < 0.001). CONCLUSION: Clinical interventions to increase park access would benefit from an understanding of the social and economic adversity faced by patients.

The Association of Knowledge, Attitudes and Access with Park Use before and after a Park-Prescription Intervention for Low-Income Families in the U.S.

We conducted secondary data analyses of pooled data from a clinical trial that prescribed park visits to children and their caregivers in a low-income, urban setting. Data were collected at the prescribing visit (baseline) and at one and three months of follow up from 78 families. Family characteristics were identified at baseline; regression models were used to explore changes during follow up in associations of park use with knowledge, attitudes and perceived access to parks. At baseline, park users differed from non-users in demographics, knowledge of park locations, attitudes about the value of park visits, but not affinity for nature. Park users were also more likely than non-users to feel that their neighborhood was safe for children to play in. Changes in knowledge of park locations, nature affinity, and perceived access to parks were each significantly associated with increased park use by families at one and three months after the park prescription. Adjusting for age, gender, race, poverty, and US birth, increases in knowing the location of parks were associated with an increase of 0.27 weekly park visits (95% CI 0.05, 0.49; p = 0.016); increases in feeling a caregiver had money to visit parks were associated with 0.48 more weekly park visits (95% CI 0.28, 0.69; p < 0.001); increases in perceived money for park outings were associated with 0.24 increased park visits per week (95% CI 0.05, 0.42; p = 0.01); each unit increase in nature affinity was associated with 0.34 more weekly park visits (95% CI 0.09, 0.59; p = 0.007). In other words, knowing where to go, valuing nature, and having time, and money contributed to increased likelihood of visiting a park. We discuss in terms of health behavior theory how demographics, knowledge, attitudes and perceived barriers to park use can inform park prescription interventions.

Clinic and park partnerships for childhood resilience: A prospective study of park prescriptions.

INTRODUCTION: Pediatricians need community resources for childhood stress. We examined the association of weekly park visits and resilience amongst children receiving a park prescription at a clinic for low-income families. MATERIALS AND METHODS: A prospective longitudinal clinical trial was conducted amongst children ages 7-17 at a safety-net primary care clinic with measures at zero, one and three months out. Parents reported their child's park visits per week, baseline ACE score, their own stress (PSS10) and coping; children reported resilience (Brief Resiliency Scale) and stress (PSQ8-11 scale). RESULTS: Enrolled children (N = 54; mean (sd) age 10.3 (2.4) years), had a median (IQR) ACE score of 2 (1, 4). Child resilience improved with each one-day increase in weekly park visits (0.04 points, 95% CI 0.01, 0.08) at every level of ACEs. Child stress partially mediated this relationship. CONCLUSION: Parks are a community resource for pediatric resilience; park prescriptions may be a way to deal with pediatric stress.

Effect of park prescriptions with and without group visits to parks on stress reduction in low-income parents: SHINE randomized trial.

INTRODUCTION: Exposure to nature may reduce stress in low-income parents. This prospective randomized trial compares the effect of a physician's counseling about nature with or without facilitated group outings on stress and other outcomes among low-income parents. MATERIALS AND METHODS: Parents of patients aged 4-18 years at a clinic serving low-income families were randomized to a supported park prescription versus independent park prescription in a 2:1 ratio. Parents in both groups received physician counseling about nature, maps of local parks, a journal, and pedometer. The supported group received additional phone and text reminders to attend three weekly family nature outings with free transportation, food, and programming. Outcomes measured in parents at baseline, one month and three months post-enrollment included: stress (using the 40-point Perceived Stress Scale [PSS10]); park visits per week (self-report and journaling); loneliness (modified UCLA-Loneliness Scale); physical activity (self-report, journaling, pedometry); physiologic stress (salivary cortisol); and nature affinity (validated scale). RESULTS: We enrolled 78 parents, 50 in the supported and 28 in the independent group. One-month follow-up was available for 60 (77%) participants and three-month follow up for 65 (83%). Overall stress decreased by 1.71 points (95% CI, -3.15, -0.26). The improvement in stress did not differ significantly by group assignment, although the independent group had more park visits per week (mean difference 1.75; 95% CI [0.46, 3.04], p = 0.0085). In multivariable analysis, each unit increase in park visits per week was associated with a significant and incremental decrease in stress (change in PSS10-0.53; 95% CI [-0.89, -0.16]; p = 0.005) at three months. CONCLUSION: While we were unable to demonstrate the additional benefit of group park visits, we observed an overall decrease in parental stress both overall and as a function of numbers of park visits per week. Paradoxically the park prescription without group park visits led to a greater increase in weekly park visits than the group visits. To understand the benefits of this intervention, larger trials are needed. TRIAL REGISTRATION: ClinicalTrials.gov NCT02623855.

Design and evaluation of a park prescription program for stress reduction and health promotion in low-income families: The Stay Healthy in Nature Everyday (SHINE) study protocol.

BACKGROUND: Contact with nature improves human health; stress reduction is a mediating pathway. Stay Healthy in Nature Everyday (SHINE) is a stress reduction and health promotion intervention for low-income families at an urban Federally Qualified Health Center. We plan to evaluate two service-delivery models for SHINE and present here the intervention design and evaluation protocol. METHODS: Behavioral change theory and environmental education literature informed the intervention. Outcomes were selected after review of the literature and field tested procedures to determine what was feasible and ethical in a busy clinic serving vulnerable populations. DESIGN: We designed a randomized controlled trial to examine two levels of intensity in behavioral counseling about the health benefits of nature. Dyads consisting of a caregiver and a child aged 4 to 18 who access our pediatric primary care center are eligible. All dyads receive a pediatrician's recommendation to visit parks to experience nature and written resources (a "park prescription"). The intervention group receives added case management and an invitation to three group outings into nature with transportation, meals and activities provided. Primary outcomes measured at baseline, one month and three months post-enrollment are caregiver stress measured by PSS-10 score and salivary α-amylase; secondary outcomes are park prescriptions adherence, physical activity recorded by pedometer and journaling, loneliness, family cohesion and affinity to nature as measured by a validated scales. Both groups receive incentives to participation. DISCUSSION: Our intervention represents a feasible integration of recent research findings on the health benefits of nature and primary care practice.

Neighborhood Characteristics and ADHD: Results of a National Study.

OBJECTIVE: We examined the association of neighborhood social and physical characteristics with ADHD, accounting for individual and family factors. METHOD: The 2007 National Survey of Child Health, a nationally representative data set, was used (N = 64,076). Three neighborhood scales were generated: social support, amenities, and disorder. Logistic and ordinal logistic regressions were conducted to examine the association of these scales with ADHD diagnosis and severity while adjusting for individual and family characteristics. RESULTS: Eight percent had a child with ADHD: 47% described as mild, 40% moderate, and 13% severe. In adjusted models, lower neighborhood support was associated with increased ADHD diagnosis (odds ratio [OR] = 1.66 [1.05, 2.63]) and severity (OR = 3.74 [1.71, 8.15]); neighborhood amenities or disorder were not significantly associated. Poor parental mental health was associated with ADHD prevalence and severity. CONCLUSION: Neighborhood social support is a potential area of intervention for children with ADHD and their caregivers. Research challenges and opportunities are discussed.

High HIV prevalence in a respondent-driven sampling survey of injection drug users in Tehran, Iran.

Iran is facing unprecedented dual drug use and HIV epidemics. We conducted a cross-sectional survey to obtain HIV prevalence and risk behavior data from injection drug users (IDU) in Tehran. We used respondent-driven sampling (RDS) to recruit IDU through successive waves starting with 24 "seeds," conducted anonymous face-to-face interviews and HIV testing and counseling, and used RDSAT to adjust data. During 44 weeks, 1,726 study referral coupons resulted in 645 (37 %) IDU referrals, of whom 548 (85 %) were enrolled. From those enrolled, 84 % were incarcerated, 47 % employed, 55 % single, 27 % under 30 years of age, and 26 % homeless. The adjusted HIV prevalence was 26.6 % (95 % confidence interval 21.3-32.1), and was higher among certain IDU subgroups (e.g., those who sharing injection paraphernalia). Our estimates of HIV prevalence were higher than some other estimates; however, repeated surveys using similar methodology are needed to monitor the trend of HIV epidemic over time.

Injection drug use in Rural Iran: integrating HIV prevention into iran's rural primary health care system.

Major opium trafficking routes traverse rural Iran, but patterns of drug use and HIV infection in these areas are unknown. In 2004, Iran's Ministry of Health integrated substance use treatment and HIV prevention into the rural primary health care system. Active opium or heroin users (N = 478) were enrolled in a rural clinic. Participants received counseling for abstinence from substances, or daily needle exchange and condoms. On enrollment, 108 (23%) reported injecting; of these, 79 (73%) reported sharing needles. Of 65 participants tested for HIV, 46 (72%) tested positive. Participants who received daily needle exchange/condoms stayed in the program longer than those who did not (AOR 2.08, 95% CI 1.1-3.88). This project demonstrates that HIV risks exist in rural Iran and suggests the innovative use of Iran's rural health care system to extend prevention and treatment services to these populations.

HIV risk behavior among injection drug users in Tehran, Iran.

AIMS: Iran faces parallel human immunodeficiency virus (HIV) and injection drug use epidemics; more than 62% of known HIV cases occur among injection drug users (IDU). We conducted a formative study of IDU in Tehran to explore risk behavior in the wake of the recent harm reduction efforts. PARTICIPANTS AND DESIGN: Key informant interviews (n = 40), focus group discussions (nine groups of IDU, n = 66) and a review of existing published and unpublished literature were conducted. Participants included IDU, physicians, policy makers, police, IDU advocates and their families. IDU were diverse in gender, education, income and neighborhood of residence. Interviews were transcribed and analyzed using grounded theory. A typology of IDUs in Tehran, categorized according to self-defined networks as well as HIV risks, is presented. This categorization is based on the groups identified by IDUs, compared to those identified by other key informants, and on a secondary data review. FINDINGS: Homeless, female, young IDU and users of a more potent form of heroin were identified as having increased risks for HIV. Participants described shortening transitions from smoked opium to injected opiates. Whereas a majority of participants considered needle sharing less common than previously, sharing continues in locations of group injection, and in states of withdrawal or severe addiction. System-wise barriers to harm reduction were discussed, and include the cost or stigma of purchasing needles from pharmacies, over-burdened clinics, irregular enforcement of laws protecting IDU and lack of efforts to address the sexual risks of IDU. CONCLUSIONS: This research is one of the first to describe a diversity of IDU, including women and higher socio-economic class individuals, in Tehran. While efforts in harm reduction in Iran to date have been notable, ongoing risks point to an urgent need for targeted, culturally acceptable interventions.

Insights from a survey of sexual behavior among a group of at-risk women in Tehran, Iran, 2006.

Despite high rates of HIV among male injection drug users, the sexual behaviors of at-risk women in Iran remain unknown. A questionnaire on HIV knowledge and risk behavior was administered in a Tehran nongovernmental organization targeting runaways and other women seeking safe haven. Half (total N = 50) were less than 24 years old; baseline HIV knowledge was high. The few who acknowledged using illicit substances said they used "frequently." Nonresponse rates to questions regarding sexual behavior were high (12 of 50). Half admitted a history of sexual activity; 40% of those reported their first sexual contact with someone other than their husband; three people had multiple partners. Three women reported a history of rape. Zero (97.5% one-sided confidence interval [CI] = 0, 0.17) of 35 women tested positive for HIV or syphilis. This study documents the existence of sexual behavior in a population of Iranian women, represents one of the first attempts at sexual research in the Iranian context, and highlights challenges in surveying this vulnerable group.

How well do trends in HIV prevalence in young people reflect HIV incidence? Results from 10 years of HIV serosurveillance in San Francisco.

Trends in HIV prevalence among young populations (15-24 years) are held to approximate trends in HIV incidence. Using the Serological Testing Algorithm for Recent HIV Seroconversion (STARHS) to estimate HIV incidence, we were able to demonstrate that this assumption was true for young patients at San Francisco's public sexually transmitted infection clinic from 1989 to 1998. However, the trend in prevalence among young people did not mirror trends in incidence in the overall population.