Risk management in suburban forest recreation areas: A retrospective analysis of illness cases

Abstract

Participating in forest recreation activities sometimes involves risks that result in illnesses and/or injuries. One important risk factor is participants’ preexisting medical conditions, which may lead to illness incidents. Little has been studied about the relationship between participants’ illnesses and their preexisting medical conditions, and, from a risk management perspective, that is crucial information with which to identify vulnerable groups for preventing incidents. Finding answers can help the site managers of Xitou Nature Education Area (XNEA) in Taiwan (R.O.C.) in risk management planning. Therefore, we retrospectively analyzed emergency medical service records between July 2012 and June 2018 that included each patient’s age, sex, date, time, preexisting health conditions, and illness contracted. Of the 276 patients assessed, 56.2% were female. More than half (55.4%) had preexisting medical conditions. The most common symptom was dizziness (47.8%). Most health-related events occurred in the morning and during summer months. Elderly visitors (≥60 years) were the most vulnerable to illness. More men than women encountered syncope. Participants with high blood pressure had a higher risk of dizziness, respiratory problems, and syncope. Individuals with diabetes were vulnerable to weakness. Visitors with cardiac-related problems were likely to have chest pain or tightness in their chest. Preexisting medical conditions constitute an inherent risk in visitors, and this association with the occurrence of illness during forest recreation confirmed higher risks in specific patient groups. This epidemiological study describes the characteristics of illnesses and identifies the at-risk groups to facilitate future risk management planning for forest recreation in XNEA.

Introduction

Forest recreation is continuously gaining attention with a growing number of tourists (Gstaettner et al., 2019). Literature highlights engaging in outdoor recreation has a variety of benefits on health and wellbeing, such as improvement in self-esteem, as well as mental, physical and social functioning (Hartig et al., 2014; Kaplan, 1995; Korpela et al., 2017; Plummer, 2005; Swarbrick et al., 2004). Nevertheless, exploring nature and wilderness areas inevitably entails risks that may threaten health and safety (Kuenzi and McNeely, 2008). Managing risk to ensure visitor health and safety is considered an obligation of all outdoor recreation and tourism sites (Keirle, 2002; Spengler and Hronek, 2011). This is a complicated process because risk involves the complex interrelationships between humans and between humans and nature (Brown, 1998; Rayner, 1987). Researchers have proposed many risk management models in order to maintain the safety of visitors (Brown, 1998; Spengler and Hronek, 2011). One of the simplest models containing the basic components of all risk management models is composed of four cyclical steps: risk identification (list of risks), risk evaluation (likelihood of risks), risk treatment (control measures), and risk implementation (risk monitoring and review) (Eagles et al., 2002; Spengler and Hronek, 2011). From a risk management perspective, risk identification and evaluation are fundamental steps that rely on past experience and include recognizing potential groups as well as determining a tolerable level of risk for participants (Barton, 2007; Ewert, 1984; Spengler and Hronek, 2011). Therefore, it is imperative to learn from the past by obtaining essential data and analyzing prior events (Dickson and Gray, 2012; Goode et al., 2016; Spengler and Hronek, 2011).

Incident analysis involving past experience not only enables managers to understand the effects of the context of an incident but also provides clues regarding risk sources (Dickson and Gray, 2012). These risk sources are the interactions of participant characteristics (e.g. sex, age, health, and fitness), physical environments (e.g. terrain, infrastructure, and weather), and equipment (e.g. clothing, camping equipment, and shoes) (Brown, 1998; Haddock, 2013; Haddock et al., 1993). Visitors with preexisting medical conditions can be classified as unstable, and their health is at risk of worsening during an excursion (Greuters et al., 2009; Schutz et al., 2014). Hence, wilderness medical physicians strongly recommend maintaining good health (Auerbach, 2015). This does not imply that people with chronic illnesses should avoid natural areas; however, they should recognize their limitations, including their medical histories, before engaging and should wisely select their own level of engagement (Auerbach, 2015; Grant et al., 1996; Haddock, 2013). Forest recreation practitioners should thus first consider participants’ health in terms of their preexisting medical conditions for risk management. Furthermore, eliminating all risk from outdoor recreation is impossible, therefore, sharing responsibility with visitors is a strategy for risk management (Dickson and Gray, 2012; Eagles et al., 2002; Sadler, 2004). In conclusion, site managers should understand visitors’ characteristics that may lead to incidents and communicate risk information to travelers, who then must assume responsibility for recognizing the inherent risk and their personal well-being (Department of Conservation and Land Management, 1998; Dickson and Gray, 2012; Eagles et al., 2002; Grant et al., 1996; Rickard, 2014). Tourists should be self-reliant and know their own limitations for a safe and satisfying outdoor recreation experience (Brandenburg and Locke, 2017; Gstaettner et al., 2018; Haddock, 2013; Skaros, 1998).

Studies have reported numerous instances of illnesses in wilderness areas (e.g., Forrester and Holstege, 2009; Heggie and Heggie, 2004; Spano et al., 2018; Stella-Watts et al., 2012). However, few have traced whether visitors’ medical conditions are related to the medical problems encountered. In order to develop useful risk management strategies and plans, further research is required to determine vulnerable conditions and the contributing factors that result in illness incidents among participants (Haegeli and Pröbstl-Haider, 2016). To this end, shifting from descriptive analysis to medical history analysis is necessary for understanding to whom, in what circumstances, and how a medical problem occurs (Drupsteen and Guldenmund, 2014; Shanmugam and Maffulli, 2008). Furthermore, as a popular forest recreation destination Xitou Nature Education Area’s (XNEA) management team expected to have a better understanding of patients’ profiles for planning risk management planning and reducing incidents in the future. Located in the middle of Taiwan, XNEA is one of the most popular forest recreation destinations and visitors can easily visit XNEA from Taiwan’s second largest city, Taichung, via a 90-minute shuttle (The Experimental Forest et al., 2018). The suburban forest recreation destination, XNEA, provides visitors a pleasant natural environment with well-organized recreation facilities; as a result, the tourist arrivals are nearly 2 million per year (Wang et al., 2011). A rising need for ensuring visitors’ health and safety was proposed to XNEA’s management team. The analysis of patients’ rescue reports was considered an approach to identify vulnerable groups. Additionally, understanding the relationship between visitors’ encountered illnesses and their preexisting medical conditions can help destination managers improve their risk management plan. Therefore, the three objectives of this study were: (1) to report encountered illness characteristics in the Xitou Nature Education Area (XNEA), (2) to examine the association between visitors’ preexisting medical conditions and illnesses encountered in XNEA by using a retrospective review approach, and (3) to identify high-risk groups to determine which visitors to target to increase health awareness and to aid destination managers in improving risk management planning.