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Among the many benefits provided by plants, “health” stands out as a benefit that is especially highly valued. Over the past decades, people-plant studies have increasingly focused on empirically demonstrating relationships between plants and health. However, there are as yet no consensual standards in the field as to which research findings qualify as evidence for health benefits of plants. In this paper, we first argue that only studies that directly relate exposure to plants and green spaces to health outcomes should be admitted into the evidence base. We then discuss several studies that meet this requirement. An important conclusion is that the experimental evidence base for health benefits of plants seems to be less strong than the evidence provided by observational population studies linking green spaces to public health. Consequently, observational studies deserve more attention from horticultural professionals and other audiences who share an interest in health benefits of plants. However, as living in green areas is often accompanied by certain conditions and lifestyles that promote health, there is still an urgent need for more rigorous studies that allow for a causal interpretation of health effects of plants and green spaces.
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Van den Berg, A. E., & van den Berg, M. M. H. E. (2015). Health benefits of plants and green space:
establishing the evidence base. Acta Horticulturae 1093,19-30.
Health Benefits of Plants and Green Space: Establishing the Evidence Base
Agnes E. van den Berg
Department of Spatial Sciences
University of Groningen
PO Box 800
9700 AV Groningen
The Netherlands
Magdalena M.H.E. van den Berg
Department of Occupational and Public Health and the
EMGO Institute for Health and Care Research
VU University Medical Centre
The Netherlands
Keywords: Human issues in horticulture, landscape, people-plant interaction, pyramid of
evidence, response to nature, green space and health.
Among the many benefits provided by plants, “health” stands out as a benefit
that is especially highly valued. Over the past decades, people-plant studies have
increasingly focused on empirically demonstrating relationships between plants and
health. However, there are as yet no consensual standards in the field as to which
research findings qualify as evidence for health benefits of plants. In this paper, we first
argue that only studies that directly relate exposure to plants and green spaces to health
outcomes should be admitted into the evidence base. We then discuss several studies that
meet this requirement. An important conclusion is that the experimental evidence base
for health benefits of plants seems to be less strong than the evidence provided by
observational population studies linking green spaces to public health. Consequently,
observational studies deserve more attention from horticultural professionals and other
audiences who share an interest in health benefits of plants. However, as living in green
areas is often accompanied by certain conditions and lifestyles that promote health,
there is still an urgent need for more rigorous studies that allow for a causal
interpretation of health effects of plants and green spaces.
Plants provide a myriad of benefits to people, from the provision of food, fibers and
building materials to more intangible benefits such aesthetic pleasure and improvement of
health (Lohr, 2011). These benefits may occur not only with individual plants, but also with
natural environments or “green spaces” such as gardens, parks, forests and other natural
settings. Among the benefits provided by plants, “health” stands out as a benefit that is
especially highly valued in modern society. Health is generally considered the most valuable
asset in life (Schwartz, 1992). Unfortunately, in many parts of the world, this asset is
threatened by developments related to aging populations and unhealthy lifestyles. To relieve
the healthcare burden that derives from these developments, governments and other health
authorities are actively seeking new ways to prevent disease and promote health. Plants have
long since been associated with healing powers, and there is a long tradition of the use of
plants for medical purposes. Plants therefore provide a potentially powerful means to relieve
the healthcare burden of an aging and increasingly unfit population in nations worldwide.
There is a growing awareness and recognition by individuals from many different
professions of the value of scientific evidence for health benefits of plants and green spaces.
This evidence can support policy makers and other key community and health decision
makers in making well-informed decisions on the use of plants and green spaces that optimize
the benefits for the community. In addition, evidence can yield practical guidelines for
horticultural therapy and other interventions that make use of health benefits of plants and
green spaces. In this paper, we sketch a first outline of the main features of an evidence base
for health benefits of plants, including criteria for the inclusion of studies and grading of the
evidence. We also provide an overview of currently available evidence for direct health
benefits of plants from studies with different experimental and observational research designs.
In this overview, special attention is paid to the evidence provided by observational studies of
relationships between green space and health at the population level. Because publications of
these studies have been scattered across different medical and public health journals, this
literature has thus far been relatively inaccessible to horticultural professionals and other
audiences who share an interest in plants and nature. The paper concludes with a discussion of
the strengths and limitations of the current evidence base for health benefits of plants and
green spaces, along with suggestions for future research.
To date, there are no consensual standards in the field of people-plant studies as to which
research findings qualify as evidence for health benefits of plants. In general, the term
“evidence” is used in a very loose manner and the bar for what qualifies as evidence is set
very low.
Following standard guidelines for the evaluation of health research, we propose three basic
criteria for inclusion of research in the evidence base for the effectiveness of plants and green
spaces to improve health (National Institute for Health and Clinical Excellence, 2009).
1. Use of health outcome measures. As a basic rule, only studies that have measured
health outcomes qualify for inclusion into the evidence base for health benefits of plants. But
what constitutes a health measure? Unfortunately, there is not yet a shared understanding in
the field of people-plant studies of what constitutes a health outcome. The concept of health is
typically very broadly interpreted, including not only direct measures of physical and mental
health, but also health-related outcomes such as physical activity, stress or air quality.
In general, two types of health outcome measures can be distinguished (College of
Emergency Medicine UK., 2012; Van den Berg et al., 2012). First, clinical and patient
centered health outcome measures cover objective and subjective measures of patient
functioning, such as symptom severity, mortality, hospital days, medication use, discomfort
(pain, nausea), physiological responses, and patient satisfaction. Second, public health
measures give an indication of the health status of a population. These indicators include
measures based on birth and death statistics, such as mortality rates and life expectancy,
measures of the prevalence and incidence of disease and illness (also called morbidity rates),
measures of self-reported general, mental and physical health, and measures of health-related
quality of life.
2. Focus on exposure to plants and green spaces. A second criterion is that health
outcomes must be directly linked to the exposure variable of interest, i.e. plants and other
natural elements and settings. A major implication of this criterion is that evaluations of
nature-assisted therapies, such as horticultural or wilderness programs, are excluded from the
evidence base for health benefits of plants unless they include a control group that receives a
non-natural intervention that is identical to the nature-based intervention except for the
exposure to plants or green space. In a similar way, population studies that link green space to
health do not count as evidence for health benefits of plants unless they use some form of
statistical control to disentangle the influences of green space from other variables that
typically co-occur with the presence of green space, such as the higher socio-economic status
of greener neighborhoods. In general, only studies that tap into the unique contribution of
plants and green spaces to health outcomes qualify as evidence for health benefits of plants.
A much-debated issue in the literature on people-plant relationships is whether
exposure to “plastic plants” and other imitations of nature (e.g., photos or videos of natural
landscapes) provides a valid way to study health benefits of plants and green spaces (De Kort
et al., 2006). As yet only few studies have compared people’s (psychophysiological)
responses to real and virtual nature, with somewhat mixed findings (Kahn et al., 2008;
Felsten, 2009; Kjellgren and Buhrkall, 2010). Therefore, we suggest to exclude studies using
photos and other simulations of plants and green space from the evidence base for health
benefits of plants and green spaces, unless more evidence for the validity of such studies
should become available.
3. Comparison of health outcomes over time and/or across locations. A third basic
inclusion criterion is that a study should compare health outcomes over time, e.g. by means of
pre- and post intervention measures, or across locations that differ in the presence of plants or
green space. Following this criterion, opinion surveys, post-occupancy evaluation studies,
focus groups or other non-comparative studies do not qualify as evidence for health benefits
of plants. This is not to imply that such studies cannot convey useful information on the use of
plants for health purposes, only that this information does not count as evidence for the
effectiveness of plants to promote health or prevent or cure disease.
The above three criteria only outline the minimum requirements for the admission of
studies into the evidence base for health benefits of plants. Additional criteria, such as
publication in a peer-reviewed journal may be set to increase the strength of the evidence
base. However, given the limited availability of studies, it seems premature to set stringent
inclusion criteria. Instead, the most pressing issue is to establish consensual guidelines for
separating relevant from non-relevant research findings.
Studies that merit inclusion into the evidence for health benefits of plants may vary
significantly in research method or design and the strength of the evidence provided. In
general, research studies can be broadly classified as experimental or observational. In
experimental studies, the investigator controls the assignment of participants to a (“green”)
intervention or exposure, which is often but not always performed randomly. In observational
studies, the investigator “observes” phenomena or outcomes in general or specific populations
without specifically assigning an intervention or treatment. Experimental study designs are
generally considered to provide stronger evidence than observational designs, but this applies
only when the experiment includes a control group that is not exposed to the intervention or
treatment of interest. Uncontrolled experiments or intervention studies provide weaker
evidence than most observational studies, except for case series that observe the medical
histories of single patient or exposure groups.
The hierarchy in the strength of evidence provided by different study designs can be
graphically represented as a pyramid, with the weakest (uncontrolled) designs residing at the
bottom and the strongest (controlled) designs residing at the top. Figure 1 gives an example of
a pyramid with six levels of evidence that apply to research on health benefits of nature. This
pyramid presents only a summary and simplification of all the study designs that are available
for studying health benefits of nature. For more detailed classifications, see Ho et al. (2008)
and The National Institute for Health and Clinical Excellence (2009).
Figure 1. Pyramid of evidence. RCT = Randomized Controlled Trial; NRCT = Non-
Randomized Controlled Trial
The bottom level of the pyramid is formed by “before-and-after studies” that measure
health outcomes before and after a green intervention or exposure. For example, Raanaas,
Patil and Hartig (2010) investigated the effects of a 4-week indoor plant intervention on self-
report measures of health, well-being and emotion in coronary and pulmonary patients before,
during, and after the intervention. Due to the lack of a control group it is not possible to
determine whether any effects observed are due to the plants or to other causes such as
general distraction or spontaneous recovery of the patients. Before-and-after studies therefore
generally provide weak evidence of causality.
The next three steps up the pyramid consist of controlled observational studies. First,
in cross-sectional studies, both exposures and outcomes are measured at a single point in time,
and the prevalence of the outcome is compared among those with and without exposure to
plants and green spaces. For example, Maas Verheij, Groenewegen, De Vries, &
Spreeuwenberg (2006) showed that the amount of green space in residential neighborhoods is
related to self-reported health of residents of these neighborhoods. Because attractive, green
neighborhoods tend to attract wealthier and thus healthier people, cross-sectional studies
typically use some form of statistical control for the influence of socio-economic background
variables. However, causal influences of green space on health cannot be established with
cross-sectional methods because self-selection cannot be completely ruled out.
Cohort or longitudinal studies provide a more rigorous type of epidemiological studies
in which groups of people are followed (retrospectively or prospectively) over time to identify
potential risk or preventive factors for certain diseases or outcomes. Because events are
measured in a temporal sequence, causes can be more easily distinguished from effects. For
“Before-and-after study”
Retrospective Cohort
Prospective Cohort
example a retrospective cohort study by Bell and colleauges (2008) found that economically
disadvantaged children and youth in greener settings were less likely to increase their BMI
scores over two years compared to their counterparts in less green neighborhoods.
At the top levels of the pyramid we find the controlled experimental studies. In these
types of studies, the investigator assigns participants to (green) experimental and (non-green)
control conditions. If participants are assigned by chance, the experiment is classified as a
“randomized controlled trial”, the “gold standard” of medical research. Using chance to
assign people to conditions that differ on selected variables means that the groups will be
similar and that causal inferences can be drawn on the influence of the variables. For example,
Park and Mattson (2008, 2009) found that patients who were randomly assigned to recovery
in hospital rooms with ornamental plants displayed better medical and psychological
responses than patients in similar rooms without plants. Despite their significant strength,
controlled experimental studies also have important limitations. They are typically expensive,
time consuming, and designed to answer questions about the effectiveness of a specific
intervention for specific groups. Thus, controlled experiments are usually very narrow in
scope and may be inappropriate to address questions on the often long and complicated causal
chains in general populations (Victora et al., 2004).
In the next two paragraphs, we will summarize the currently available evidence for
direct health benefits of plants and green spaces from experimental and observational studies.
This summary is not a comprehensive review. It highlights some of the studies that meet the
criteria outlined above and it is mainly intended to give an impression of the size and strength
of the evidence base.
Experimental evidence for health benefits of plants and green space mainly comes
from two lines of research: (1) evaluations of the effects of horticultural and other nature-
assisted therapies (e.g., gardening and wilderness programs) in various patient groups (see for
reviews Elings, 2006; Annerstedt and Währborg, 2011), and (2) controlled laboratory or field
experiments in which healthy participants are exposed to natural or built settings (see for
reviews Van den Berg, 2005; Bowler et al., 2010). Both lines of research have typically
reported findings that support the relevance of nature as a resource for health and well-being.
However, following the criteria outlined above, these findings do not qualify as direct
evidence for health benefits of nature. Evaluations of nature-assisted therapies typically
include no control group, or only a passive control group that receives no therapy.
Consequently, the effects of the therapy cannot be disentangled from the effects of other
variables, such as individual counseling and group activities, and thus do not provide direct
evidence for a link between plants and health. Controlled laboratory and field experiments
provide more direct, causal evidence for positive effects of plants and green spaces on healthy
individuals. However, most of these studies have used health-related outcome variables such
as physical activity levels (Thompson Coon et al., 2011) or psycho-physiological responses
(Van den Berg et al., 2007; Bringslimark et al., 2009; Park et al., 2010) instead of direct
health outcome measures. Therefore, this line of research also provides only indirect evidence
for health benefits of plants.
Only a few random controlled trials in patient populations provide direct evidence for
health benefits of plants and green space. Among these studies is a series of clinical trials in
which patients were randomly assigned to rooms with and without potted plants after
thyroidectomy, appendectomy, or hemorrhoidectomy surgery (Park and Mattson, 2008,
2009). These trials show, among other things, that patients in rooms with plants have shorter
hospital stays and need fewer intakes of postoperative pain medication than patients in rooms
without plants. A longitudinal study in a Norwegian rehabilitation center examined the health
benefits of bedroom views of nature among coronary and pulmonary patients (Raanaas et al.,
2012). Patients were quasi-randomly assigned to rooms with an unobstructed view onto
mountains and a valley, or to rooms with only a partial view to nature or a fully blocked view
that was dominated by buildings. The results show that an unobstructed natural view
positively affected the mental health of men and the physical health of women. In addition,
pulmonary patients with an unobstructed natural view showed greater improvement in mental
health than coronary patients with such a view.
Outside the health-care setting, a random cross-over trial among children diagnosed
with ADHD revealed that the children perform better on an attention test after a 20-minute
guided walk in a park than after a walk in a more urban downtown or residential
neighborhood (Faber Taylor and Kuo, 2009). Another random cross-over trial demonstrated
that individuals diagnosed with major depressive disorder display better cognitive and
emotional functioning after walking in a park than after walking in a built setting (Berman et
al., 2012). Furthermore, a longitudinal cross-over study among healthy office workers in
Norway revealed a 23 percent decrease in symptoms such as coughing or a horse throat
during periods when foliage plants were added to their offices (Fjeld et al., 1998).
In sum, although many experimental studies have demonstrated positive effects of
plants and green spaces on people, only few of these studies provide strong and direct
evidence for health benefits of plants. Consequently, observational studies could make an
important contribution to the evidence base for health benefits of plants.
In the early 2000’s, research groups in the Netherlands (De Vries et al., 2003) and
Japan (Takano et al., 2002) demonstrated for the first time direct relationships between green
space in the living environment and public health. In the Dutch cross-sectional study, data on
three health outcomes (perceived general health, mental health and number of health
complaints) from a random sample of more than 10,000 people were linked to land-use data
on the amount of green space in their living environment. Results show that, after controlling
for socioeconomic and demographic characteristics, residents with a high percentage of green
space in a 1 or 3 km radius around their home reported better general and mental health and
fewer health complaints than those with a low percentage of green space around their home.
Relationships between green space and health were stronger among lower socioeconomic
status groups, the elderly, and others who stay home during the day, suggesting that the
impact of green space on health is related to the amount of exposure to the local environment.
Takano et al. (2002) examined the five year survival rate of a cohort of more than
3000 seniors living in a highly urbanized area of Tokyo. They found a significant association
with the self-reported amount of walkable green streets and spaces near the residence: older
people who perceived their neighborhood as greener and easier to walk in lived longer (13 %
higher odds for survival) independent of age, sex, social economic status and other potential
In the past ten years, the findings of these pioneering studies have been replicated and
extended in different countries with various objective and self-reported indicators of green
space and health. Thus far, however, this emerging literature has not received much attention
in the field of people-plant studies. Below, we will discuss some of the key studies and their
The Vitamin G Research Program
The initial publication of the Dutch research group (De Vries et al., 2003) has been
followed up by a series of cross-sectional studies that were conducted as part of the large-
scale Vitamin G (where G stands for Green) program in the Netherlands (for overviews of this
program, see Groenewegen et al., 2006; Groenewegen et al., 2012). In one of these studies,
the Vitamin G team looked at people’s health as assessed by doctors (Maas et al., 2009b).
Among other things, they found that having more green space within a one-kilometer radius
of the home is linked to a reduced risk of depressive symptoms and anxiety. For another
study, the Vitamin G team visited 80 Dutch neighborhoods to collect primary data on
residents’ health and green space quantity and quality indicators such as absence of litter,
accessibility, and colorfulness (Van Dillen et al., 2011). Results show that people’s self-
reported general and mental health is positively related to both the quantity and the quality of
the green space around their homes. In addition to the Vitamin G research program, many
other observational studies have been carried out in different countries. These studies can be
roughly divided into three groups according to the principal health outcome: general health
outcomes, specific health outcomes, and mortality rates (Van den Berg and Maas, 2012).
Green space and general health
Using census data for the entire population, a cross-sectional study in the UK showed
that a higher proportion of green space in an area is associated with better population health,
especially in suburban lower income areas (Mitchell and Popham, 2007). A recent
longitudinal study in the UK demonstrated that moving to greener urban areas was associated
with sustained mental health improvements in all three postmove years (Alcock et al., 2013).
Other cross-sectional as well as longitudinal UK studies have found that individuals report
significantly better general health and mental health when living nearer the coast (Wheeler et
al., 2012; White et al., 2013). These latter findings indicate that health benefits are not
exclusive to “green spaces”, but may also occur with “blue spaces”.
A cross-sectional study in Australia showed that residents who perceive their
neighborhood as highly green have better odds of physical and mental health compared with
those who perceive it as not so green (Sugiyama et al., 2008). Another cross-sectional study in
Denmark revealed relationships between distance to green space and health and health-related
quality of life (Stigsdotter et al., 2010). A study in 75 neighborhoods in the city of
Amsterdam, the Netherlands, showed that dissatisfaction with neighborhood green space was
associated with a higher risk of fair to poor self-rated health (Agyemang et al., 2007). A
comparative study in a “green” and “grey neighborhood in Belgium with similar socio-
demographic, housing and spatial conditions found that residents of the green neighborhood
reported higher levels of general health, bodily functioning and happiness. However, only the
difference in happiness was significant (Van Herzele and De Vries, 2011). A Norwegian
study examined relationships between indoor plants and health using cross-sectional survey
data from 385 office workers (Bringslimark et al., 2007). After controlling for gender, age,
and other factors the number of indoor plants proximal to a worker’s desk was significantly
related to reduced sick leave.
Green space and specific health outcomes
A cross-sectional study in the U.S. showed lower asthma prevalence among children
living in areas with more street trees (Lovasi et al., 2008). Several studies in the U.S. and
Spain have found a reduced risk of adverse pregnancy outcomes such as low birth weight in
greener residential areas, especially among mothers with lower education (Donovan et al.,
2011; Dadvand et al., 2012a; Dadvand et al., 2012b). In Australia, access to green public open
spaces was found to be associated with a more healthy cardiometabolic profile (Paquet et al.,
Green space and mortality
Mitchell and Popham (2008) obtained mortality records of all deaths registered in
England from the working-age population in a 5-year period. After adjustment for potential
confounders and area-level income-deprivation index, they found that mortality rates
decreased as the greenness of an area increased. Thus, residents of greener areas had a lower
risk of dying before their retirement age. The relationship between mortality and green space
was stronger for lower-income areas, suggesting that the provision of green space can reduce
income-related health inequalities. Another study by the same research group observed
significantly lower risk of all-cause mortality (excluding external causes) in small urban areas
with more than 60% green space (Mitchell et al., 2011).
A recent study in New Zealand found no association between green space and 10-year
mortality rates (Richardson et al., 2010). Another study by Richardson and colleagues,
conducted in the U.S., found that mortality from all causes was even higher in greener areas
(Richardson et. al, 2012). This study was performed at the geographical scale of whole cities
with a total population of 43 million people. The authors of both studies argue that their
results are country-specific: the variation in green space availability in New Zealand may be
too small to find a relation and in the U.S. greater car-dependency related to urban sprawl as
compared to West-European countries may obscure the potential health benefits of green
In sum, observational - mostly cross-sectional studies - indicate that access to plants
and green spaces may promote health and protect people from the negative health
consequences of living in poverty. However, to gain more insight into the causality of the
relationships, there is a need for more rigorous, prospective study designs that follow large
numbers of people with different exposures to green space over longer periods of time. To
obtain a more balanced picture of both the positive and negative impacts of plants on health,
future studies should also allow for the detection of possible health risks of plants and green
space, such as the development of allergies due to sensitization to pollens and other natural
substances (Cariñanos and Casares-Porcel, 2011).
In this paper we have outlined the evidence base for health benefits of plants and green
spaces. We have argued that only studies that speak directly to a relationship between plants
and health should qualify as evidence for health benefits of plants, and we have proposed
some basic criteria for inclusion and grading of evidence. We have also highlighted some of
the currently available evidence for health benefits of plants from studies with experimental
and observational designs. An important conclusion is that the experimental evidence base for
health benefits of nature does not seem to be very strong. Although experimental research has
generally demonstrated positive effects of plants and nature-based activities on people, only
few of studies have employed proper designs and measures that enable the identification of a
direct link between plants and health. In the past ten years, an increasing number of
observational studies have provided important complementary evidence for health benefits of
plants at the population level. However, as living in green areas is often accompanied by
certain conditions and lifestyles that promote health, there is still an urgent need for more
rigorous studies that allow for a causal interpretation of health effects of plants and green
spaces. To advance the evidence base for health benefits of plants, we propose three potential
research directions. First, there currently exists a large body of experimental studies on
nature-assisted therapy and restorative effects of nature that only indirectly provides evidence
for health benefits of nature. By implementing some changes in the study design, future
studies in these domains would qualify more directly for inclusion in the evidence base. For
example, evaluations of nature-assisted therapies could include control groups that receive a
non-nature therapy, or experimental studies on restorative effects of viewing or visiting nature
could more often use patient samples instead of healthy volunteers. In general, when
designing an experiment, investigators should become more aware of the potential relevance
of their study to the evidence base for health benefits of plants and green spaces.
A second direction for future research pertains to the need for more rigorous
prospective designs to assess the long-term health effects of exposure to plants to support
well-informed decisions on the use of plants and green spaces in public health policy and
practice. Finally, there is still little evidence on the mechanisms underlying relationships
between plants and health. While many studies have demonstrated links between green space
and possible mechanisms, such as stress, physical activity or social cohesion, only few studies
have conducted mediational analyses to determine whether these mechanisms can explain
relationships between green space and health (see for example Maas et al., 2008; Maas et al.,
2009a; Van Herzele and De Vries, 2011). Conducting more of these studies can lead to a
better understanding of the pathways by which plants may lead to better health, which can be
used to optimize the use of plants and green spaces for the benefits of the community.
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Prospective Cohort
... A large body of research addresses human-plant-nature interactions and includes contributions from medicine, public health, human nutrition, social science, and environmental psychology (Bratman et al., 2015b;Bringslimark et al., 2009;de Vries et al., 2003;Dorn et al., 2018;Goldman, 2014;Kaplan and Kaplan, 1989;Simon, 2014) as well as early work in this field by horticulturists (Lohr and Relf, 2000;Lohr et al., 1996;Relf, 1990Relf, , 1992Relf and Lohr, 2003;Shoemaker et al., 1992). Recent research has been summarized here to provide an overview of the physical, mental, and social benefits of human interaction with plants, nature, and green environments (Bowler et al., 2010;Cameron, 2014;de Vries et al., 2013;Hartig et al., 2014;Keniger et al., 2013;Lohr, 2011;Thompson, 2011; van den Berg and van den Berg, 2015). Additional research explores crop breeding, traditional food production, and economics, as well as public health and consumer perspectives (Bliss, 1999;Goldman, 2014;Hansson et al., 2018;Patil et al., 2014). ...
... Researchers who work in the humanplant-nature arena but were trained in fields outside horticulture often publish using ''nature'' and ''natural'' terminology that includes both natural and built environments and does not always exclude artificial elements (Hartig et al., 2014). An example of this terminology challenge is the current debate about the inclusion of film, video, or images of nature, as well as the use of artificial plants, in nature research (van den Berg and van den Berg, 2015). Published works often lack clear articulation of the specific plants or the environment in which they are located (Keniger et al., 2013). ...
... The lack of clear definitions of the environments in which humanplant-nature interactions take place also diminishes the opportunity to explain the specific mechanisms of effect (Keniger et al., 2013;Thompson, 2011). The value of clarity and precision in describing plants and environments while conducting research was presented concisely by van den Berg and van den Berg (2015) in a summary from a People Plant Council Symposium. These researchers stated that ''only studies that directly relate exposure to plants and greenspaces to health outcomes should be admitted into the evidence base.'' ...
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Many fields of research converge to assess the impact of plants on human health, well-being, and nutrition. However, even with a recent history of horticulturists contributing to human–plant interaction work, much of the current research is conducted outside the context of horticulture and specifically outside of consumer horticulture (CH). To connect CH to research being conducted by other disciplines that explore the role of plants in improving human quality of life, a workshop was held on 1 Aug. 2018 in Washington, DC, at the American Society for Horticultural Science (ASHS) annual conference. The workshop focused on current food science, nutrition, and crop-breeding efforts to enhance nutrition and flavor, and human health and well-being research related to nature and plant interactions in an increasingly urban population. Following these presentations regarding potential research linkages and collaboration opportunities, a facilitated discussion identified ways to improve future CH research and foster collaborative work. Action items identified included connecting research and vocabulary to help cultivate an interest in plants in younger generations; supporting awareness of collaborative opportunities with health, nutrition, urban planning, and public health practitioners; ensuring CH is known to administrators; and taking responsibility for initiating communication with colleagues in these areas.
... A few staff members made negative comments regarding the hassle with the maintenance of the plants, and about plants making the ward darker, busier, and messier. These findings strengthen the evidence base for the benefits of interior plants (Bringslimark et al., 2009;Van den Berg & Van den Berg, 2015) and extend current knowledge by examining a reduction in functional decline as a thus far unidentified benefit of greening. ...
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This research examined whether greening of a geriatric ward may reduce the hospital-induced decline in the independent functioning of elderly patients as measured by changes from admission to discharge in the KATZ-ADL6 and physician assessments at discharge. Using a quasi-experimental design with 4 months of pre- and post-tests, the functional decline in a sample of 54 hospitalized geriatric patients was found to be lower after greening than before greening for both measures. Moreover, an evaluative survey among 15 staff members showed that they appreciated the greening, and believed it to support patient well-being.
Recent years have witnessed a growth in research on urban green spaces given their significance to human wellbeing and environmental management. This paper explores the perceived health benefits of urban green areas by drawing on the experiences of 95 participants sampled from three urban communities in the Kumasi Metropolis of Ghana. It is a qualitative study employing a cross-sectional design. The paper argues that participants’ perceptions straddle physical and non-physical dimensions of health. From the physical perspective, the participants revealed that green spaces improved physical activity and reduced incidence of cardiovascular diseases and high blood pressure. The non-physical health benefits included improved attention, reduced stress and positive emotions such as happiness. The findings of this paper call for broad-based multi-sectoral approach to managing green spaces in urban Ghana.
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This article presents a pilot study investigating the multidimensional diversity of cemeteries as an important element of cultural heritage and green infrastructure within the urban landscape. We studied the state and diversity of nature, perceptions, and activities of visitors. As religion is an important aspect that differentiates cemeteries from each other, we studied a sample of four multi-confessional urban cemeteries in Łódź (Poland) and Leipzig (Germany) by using site observation and a questionnaire survey. We found that cemeteries are far undervalued as public green resources that can perform important functions in sociocultural life and the mental well-being of the general public, as the perceptions of silence- and contemplation-seeking visitors tell us. The perception of cemeteries depends on the level of secularization, varying from a sacrum sphere up to specific recreational and touristic opportunities; findings that should be considered by town planners when optimizing the cultural ecosystem services of green spaces.
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Background: Despite considerable efforts, health disparities between people with high and low socioeconomic status (SES) have not changed over the past decades in The Netherlands. To create a culture of health and an environment in which all people can flourish, a shift in focus is needed from disease management towards health promotion. The Bolk model for Positive Health and Living Environment was used as a tool to guide this shift. This study aimed to describe how this model was used and perceived by stakeholders in a case study on an integrated health promotion approach for residents with low SES. Methods: An instrumental case study was undertaken in Venserpolder, a neighborhood in Amsterdam South East of approximately 8500 residents. A participatory action approach was used that allowed continuous interaction between the residents, health care professionals, researchers, and other stakeholders. The Bolk model is a tool, based on the conceptual framework of positive health, that was developed to guide health promotion practice. Its use in the case study was evaluated by means of semistructured interviews with stakeholders, using qualitative directed content analyses. Results: The Bolk model was found to be a useful tool to identify and map the needs and strengths of residents with low SES. The model facilitated the development and implementation of eight health promotion pilots by transforming the needs and strengths of residents into concrete actions carried out by responsible actors in the neighborhood. Although the Bolk model seemed to be accepted by all stakeholders, the shift towards positive health thinking appeared to be more embodied by local professionals than by residents. Adjustments were proposed to enhance the applicability of the model in a multicultural setting, to increase its cultural sensitivity and to use language more familiar to residents. Conclusions: The Bolk model for positive health and living environment seems to be promising in the guidance of health promotion practices in Amsterdam South East. Further research and development are needed to improve its cultural sensitivity and to investigate its applicability in a broader range of public health settings.
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The outdoor environment offers an important platform for engaging older adults from a variety of social, cultural and ethnic orientations for the purpose of improving or maintaining their physical and mental health as well as facilitating their social and cultural connections. Using a multidisciplinary lens, this study looks at the requirements and potential of a more inclusive landscape design that acknowledges different modes of health, recovery and rehabilitation, drawing from both the past and the future and providing suggestions on how more efficient and culturally appropriate ways of maintaining health and social connectivity can be achieved in later life.
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With growing strain on mental health services, greenspace interventions could be a promising addition to current health and social care provisions as they have the potential to be widely accessible for people within their own communities and used alongside a variety of treatment plans. Despite promising progress in greenspace research, the underlying mechanisms and processes of greenspace interventions are still unclear. Without knowing these it is impossible to understand why programmes work and how best to replicate them. To address this gap this review uses realist methodology to synthesise the international evidence for greenspace interventions for mental health in both clinical and non-clinical populations. Forty-nine full text articles are included in the review and the underlying contexts, mechanisms, and outcomes of the interventions identified and refined into an original overriding theory under three themes of Nature, Individual Self, and Social Self. The interaction of these three factors represents a new conceptual framework for greenspace interventions for mental health and shows what works, for whom, and in what circumstances. The findings of this review are not only theoretically novel but they also have practical relevance for those designing such interventions including the provision of recommendations on how to optimise, tailor and implement existing interventions.
Technical Report
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A conceptual model was developed, describing the short-term, medium and long-term effects of plants on the indoor climate and the health and well-being of people. The model was tested by means of intervention research at three companies and eight homes for the elderly. The effect of plants on the physical indoor climate was measured with sensors, the effect on the health and well-being of employees with questionnaires. In principle, a ‘Before After Control Impact’ approach was used at the locations. A control room and an intervention room were selected for each location. After a pre-measurement, plants were placed in the intervention room and up to three post-measurements were conducted. At the companies, significant effects were found on relative humidity (up), attractiveness of the workplace (more attractive), state of mind (more positive), satisfaction with own functioning (higher) and sickness absence reporting (less). The need for recovery after a working day showed a reversed effect (rising). No significant effects were found for the other variables in the model. Similar effects were not observed in the homes for the elderly. Possible reasons for the latter are: the small number of employees working in the same room (i.e., living room for clients), a low willingness amongst these employees to participate in the study (high work pressure), a high mobility amongst employees and working and working in both the intervention and the control room.
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The idea that contact with nature is healthy appears so intuitively valid, that for a long time, people felt no need to demonstrate or quantify nature's contribution to their health and well‐being. This chapter provides a brief introduction to the concepts of health and nature. Within environmental psychology, the term nature is generally used to denote a broad category of natural environments and features of those environments, such as single trees or plants. A more recent line of research has investigated the relationship between access to green space in the living environment and public health. The chapter discusses four main mechanisms: improvement in air quality, stimulation of physical activity, facilitation of social cohesion, and stress reduction. The scientific research and insights discussed in the chapter provide a scientific base for the formal acceptance and better practical use of health benefits of nature in policy and practice.
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Indoor plantings are widely used in building environments though little is known regarding the way office workers respond to indoor foliage plants. The objective of the present study was to assess the effect of foliage plants in the office on health and symptoms of discomfort among office personnel. A cross-over study with randomised period order was conducted; one period with plants in the office and one period without. A questionnaire consisting of 12 questions related to neuropsychological symptoms, mucous membrane symptoms and skin symptoms was distributed among the 51 healthy subjects who participated in the study. It was found that the score sum of symptoms was 23% lower during the period when subjects had plants in their offices compared to the control period. (Mean score sum was 7.1 during the period without plants vs. 5.6 during the period with plants.) Complaints regarding cough and fatigue were reduced by 37 and 30%, respectively, if the offices contained plants. The self-reported level of dry/hoarse throat and dry/itching facial skin each decreased approximately 23% when plants were present. Overall, a significant reduction was obtained in neuropsychological symptoms and mucous membrane symptoms, while skin symptoms seemed to be unaffected by the presence of plants. The results from this study suggest that an improvement in health and a reduction in symptoms of discomfort may be obtained after introduction of foliage plants into the office environment.
A myriad of benefits of plants that have been documented by research are presented in this paper, along with a discussion of possible mechanisms. Plants, which are essential for our survival, provide food, fiber, building material, fuel, and pharmaceuticals. Plants also produce intangible benefits for people, such as improving our health. These benefits occur with scenes of nature, individual plants indoors, gardens outdoors, parks, and forests. The understanding of the role of trees, in particular, in promoting both human and ecological health is increasing. Plants make our surroundings more pleasant, and they help us feel calmer. They contribute to cleaner, healthier air, thus improving our well-being and comfort. Plants have been associated with reduced stress, increased pain tolerance, and improved mental functioning in people. Human responses to plants appear to be both learned and innate. Some studies suggest genetic components to the responses. Some primates are known to detect subtle differences in leaf color, selecting to eat those leaves with the highest nutritive value; people also respond more positively to plants of some colors than to others. Most people in the world now live in urban areas. These areas are typically devoid of plants, resulting in concerns over children being raised in such unnatural areas. These impacts will also be examined.
Effects of an indoor plant intervention in a Norwegian rehabilitation center were assessed in a quasi-experiment. During a 2-year period, coronary and pulmonary patients (N = 282) completed self-report measures of health, subjective well-being, and emotion on arrival, after 2 weeks, and at the end of a 4-week program. The intervention involved the addition of indoor plants for the second year. On average, patient physical and mental health improved during the program, but the addition of plants did not increase the degree of improvement. Subjective well-being did, however, increase more in patients who went through their program after the addition of plants, although the effect was only apparent in the pulmonary patients. The patients reported more satisfaction with indoor plants and the interior generally after the intervention. Room for the intervention to affect outcomes may have been limited by the well-designed interior and the center's location in a scenic mountain area, but these favorable features of the context apparently did not negate the potential for indoor plants to contribute to patient well-being.
Using various medical and psychological measurements, this study performed a randomized clinical trial with surgical patients to evaluate if plants in hospital rooms have therapeutic influences. Ninety patients recovering from an appendectomy were randomly assigned to hospital rooms with or without plants. Patients in the plant treatment room viewed eight species of foliage and flowering plants during their postoperative recovery periods. Data collected for each patient included length of hospitalization, analgesics used for postoperative pain control, vital signs, ratings of pain intensity, pain distress, anxiety, and fatigue, the State-Trait Anxiety Inventory Form Y-1, the Environmental Assessment Scale, and the Patient's Room Satisfaction Questionnaire. Patients in hospital rooms with plants and flowers had significantly fewer intakes of postoperative analgesics, more positive physiological responses evidenced by lower systolic blood pressure and heart rate, lower ratings of pain, anxiety, and fatigue, and more positive feelings and higher satisfaction about their rooms when compared with patients in the control group. Findings of this research suggested that plants in a hospital environment could be noninvasive, inexpensive, and an effective complementary medicine for patients recovering from abdominal surgery.
Medical and psychological measurements of surgical patients were tested to determine the influence of plants and flowers within hospital rooms. Eighty female patients recovering from a thyroidectomy were randomly assigned to either control or plant rooms. Patients in the plant room viewed 12 foliage and flowering plants during their postoperative recovery periods. Data collected for each patient included length of hospitalization, analgesics used for postoperative pain control, vital signs, ratings of pain intensity, pain distress, anxiety and fatigue, the State-Trait Anxiety Inventory Form Y-1, the Environmental Assessment Scale, and the Patient's Room Satisfaction Questionnaire. Patients in hospital rooms with plants and flowers had significantly shorter hospitalizations, fewer intakes of analgesics, lower ratings of pain, anxiety, and fatigue, and more positive feelings and higher satisfaction about their rooms when compared with patients in the control group. Findings of this research suggest the therapeutic value of plants in the hospital environment as an effective complementary medicine for surgical patients.
This study investigated the associations between the accessibility, greenness, size, and type (active vs. passive) of public open spaces (POS) and clinical risk markers for cardiometabolic diseases and whether such associations could be explained (mediated) by physical activity and psychological well-being. Adult participants (n = 3754) provided clinical, self-reported, and residential location data. Cardiometabolic risk was defined as the sum of six anthropometric and biochemical risk markers. POS accessibility was defined as the number and proportion of POS within a 1000-m road distance from participants’ residences. Greenness, size and type were respectively defined as the median Normalised Difference Vegetation Index, median size, and proportion of POS with a sporting land use for all accessible POS. Physical activity and psychological well-being were self-reported. Associations were tested using Poisson regression models accounting for spatial clustering of observations and participants’ age, gender, education, income and area-level socioeconomic disadvantage. The number and proportion of POS were not found to be statistically significantly related to cardiometabolic health; however, greenness, size, and type (active) of available POS were inversely related to cardiometabolic risk. The association between POS and cardiometabolic health was partially mediated by physical activity. Psychological well-being was not implicated in the associations tested. These results suggest that the characteristics, not the number or proportion, of locally accessible POS are related to cardiometabolic health and, to some degree, physical activity. Maintaining or improving the quality of locally available POS might be a more effective urban design strategy to support cardiometabolic health than efforts to increase the accessibility of POS.
Analysis of English census data revealed a positive association between self-reported health and living near the coast. However that analysis was based on cross-sectional data and was unable to control for potential selection effects (e.g. generally healthier, personality types moving to coastal locations). In the current study we have used English panel data to explore the relationship between the proximity to the coast and indicators of generic and mental health for the same individuals over time. This allowed us to control for both time-invariant factors such as personality and compare the strength of any relationship to that of other relationships (e.g. employment vs. unemployment). In support of cross-sectional analysis, individuals reported significantly better general health and mental health when living nearer the coast, controlling for both individual (e.g. employment status) and area (e.g. green space) level factors. No coastal effect on life satisfaction was found. Although individual level coastal proximity effects for general health and mental health were small, their cumulative impact at the community level may be meaningful for policy makers.