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ITALIAN JOURNAL OF PUBLIC HEALTH
IJPH - Year 8, Volume 7, Number 4, 2010
402 FREE PAPERS
Background
People are healthier and living longer if they
live within an attractive natural environment.
[1] Natural green space - our public parks,
woodlands, countryside and even our tree lined
streets - are an opportunity to improve health
and reduce rates of 21st Century diseases. It has
been suggested that people living closer to green
open spaces are more physically active (through
activities such as walking, jogging, cycling) and
are less likely to be overweight or obese [2] as a
result helping to combat rising levels of diseases,
such as diabetes and heart disease. [3]
Studies also indicate that people living within
natural environments and green spaces are
less likely to fall ill due to depression, and
natural green areas help people recover from
chronic stress and concentrate better, [4-6]
having positive effects on mental health. There
is growing evidence that the quality of our
relationship with nature impacts on our mental
health and many research studies have focused
on how urban environments, with some nature
elements, are associated with lower perceived
stress and related to better mental health. Across
processes that include social aggregation, this
probably occurs due to the fact that the human
body involuntarily reacts to natural elements
somehow, whereas built environments seem not
to provoke comparable reactions. [7, 8]
There’s need to give more emphasis to researchers
to find answers about the health benefits of
contact with the natural environment, delivering
health improvements to all communities.
Accordingly, good quality green space needs to
be equally available to everyone in order to cancel
the health gap. The availability of urban green
spaces is an indicator given by the ratio between
Green areas and health outcomes: a systematic review of the scientific
literature
Francesco Di Nardo, Rosella Saulle, Giuseppe La Torre
Department of Public Health and Infectious Diseases, Sapienza University of Rome, Italy
Correspondence to: Giuseppe La Torre, Department of Public Health and Infectious Diseases Teaching Hospital “Umberto I” - 3rd Floor
Radiology Building, University of Rome “Sapienza” Viale Regina Elena 324, 00161 Rome, Italy. E-mail: giuseppe.latorre@uniroma1.it
Abstract
Background: Growing medical evidence shows that access to the natural environment improves health and
wellbeing, prevents disease and helps people recover from illness. Experiencing nature in the outdoors can
help tackle obesity and coronary heart disease. Green areas exert their benefits on both physical and mental
health, promoting physical activity and strengthening the sense of community thus positively influencing
social interaction. Urbanization poses problems through effects such as environmental pollution, accidents,
heat island effects, climate change and a consequent demand for urban green areas.
Material and methods: We performed literature searches of electronic journal databases for studies and
reviews that focused on the relationship between green spaces and health. We looked at the effects on
physical health, mental health, social health, physical activity and well-being in its broadest sense and then
we categorically organized our findings.
Results: We found many contradictory and unexpected results. However, the reported findings were generally
consistent and supported the current view that urban design and the availability of urban green spaces are
key elements of prosperity and individual/collective comfort, so as to influence both the perceived health and
the objective physical conditions in a measurable way. A weak relationship between physical activity levels
and green space availability is observed.
Conclusions: The occasionally contradictory results that emerged in this study suggest that a population’s
response to urban design interventions is often unpredictable. Further research is needed to quantify the
strength of relation between green spaces and urban health, but also to investigate the social and behavioural
aspects which are more difficult to measure and understand.
Key words: green areas, health, well-being
ITALIAN JOURNAL OF PUBLIC HEALTH
IJPH - Year 8, Volume 7, Number 4, 2010
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the area of the municipality dedicated to urban
green spaces and the resident population.
Since 2008, the majority of the human population
lives in urban areas, an unprecedented occurrence
in history, and in developed countries about 75% of
their inhabitants living in dense urban areas. [9, 10]
Urbanization poses problems through effects
such as environmental pollution, accidents, heat
island effects, climate change and a consequent
demand for urban green areas. [11, 12 ]. Green
spaces contribute to regulate urban microclimate
moderating the extreme temperatures, purifying
and filtering air from dust and pollutants and
reducing noise and vibrations.[13]
Green areas represent our natural health heritage
for several human benefits, and their beneficial
effects extend beyond being a cost-effective way
of promoting health. Cost effectiveness, with
substantial life-cost averted savings, and a high
cost benefit ratio are brought about by increases
in physical activity due to access to green areas.
Recent work has shown that where people
have good perceived and/or actual access to
green space they are 24% more likely to be
physically active. ”If this effect was universal
and the population of England was afforded
equitable good access to green space, it is
estimated that life-cost averted saving to the
health service could be in order of £2.1 billion
per annum.” [14]
So better health and wellbeing are two of
the major social and economic benefits we can
secure through good management of the natural
environment in both rural and urban settings.
The high costs of health care means there will be
more emphasis on prevention rather than cure,
encouraging people more interested in their
own health [15] and National and international
policy have to support the inclusion of the natural
environment in holistic health promotion. [16]
Promoting health in urban populations
necessarily involves a strategic leadership,
focusing attention to multi-sectorial strategies
leading to the rise of the ‘Healthy Cities’
movement [17, 18] and investing in programs
for urban population (e.g. increasing green open
areas, reducing traffic encouraging more walking
and cycling movements).
Health Impact Assessment and Environmental
Impact Assessment should always be integrated in
urban planning approaches and therefore need to
become essential parts of future strategies as well.
Methods
We performed literature searches of electronic
journal databases for studies and reviews on
health effects of green spaces, according to
PRISMA criteria. [19]
Databases searched were MEDLINE and
SCOPUS. The keywords used were “green area”,
“green space”, “population”, “quality of life”,
“public health”. Combined searches were carried
out for: green area population quality of life;
green space public health; “green area” AND
“population” AND “quality of life”; “green space”
AND “public health”. The inclusion criteria were
studies and review articles referring to green or
public open spaces with a health perspective,
limited to human studies and published in English.
We excluded studies not pertaining to health and
green areas or public open spaces or published
before 2006. We looked at a health effect in its
broadest sense to cover not just physical health
but also mental health, social health, physical
activity and well-being. This literature review was
completed in October 2010. We also extracted
information from the references of each study
Results
Identification of relevant research
We identified 361 records in the two databases.
278 records were available for screening after
we removed the duplicates. 256 records were
excluded because we judged them not suitable
for the purposes of this study. 7 records were
excluded because not relevant (Figure 1).
The 15 articles reviewed are shown in Table 1.
Considering the study design, one review, one
case-control study, 3 cohort studies and 8 cross-
sectional studies were found.
Benefits on physical health
In their extensive review, Lee and Maheswaran
noted that the availability of green space has been
reported to be independently associated with
increased survival in elderly populations and with
lower stroke mortality. [13, 20, 21]
Many authors agree with these findings: in
a wide interview, Stigsdotter et al. report that
82.1% of respondents living less than 300m from
a green space declared that they had “really good”
or “good” self-rated health compared with 72.4%
among respondents living more than 1km from a
green space. People living more than 1km away
from the nearest green space had lower scores on
the short-form health survey SF-36 and thus poorer
health and health-related quality of life than those
living closer than 1km from green spaces. [22]
The SF-36 is a 36-item instrument that measures
eight dimensions of health (bodily pain; general
health; mental health; physical functioning;
role limitations due to emotional problems;
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role limitations due to physical health; social
functioning; vitality) and was included in the self-
administered questionnaire. [23, 24]
Data used in this study were derived from the
2005 health interview survey and based on a region-
stratified random sample of 21832 adult Danes. [25]
Data were collected by means of face-to-face
interviews in the respondent’s home. In this
study, all types of nature environments were
grouped into one variable, called “green space”.
Maas investigated the relationship between
perceived health and different types of green
space: according to her survey, in areas where
90% of the environment around the home is
green, only 10.2% of the residents feel unhealthy,
as compared with areas in which 10% of the
environment is green, where 15.5% of the
residents feel unhealthy. [26]
Moreover, her analysis showed that there
seems to be a positive relationship between
perceived general health and both agricultural
green (1km: β =0.004, SE=0.000/3km: β =0.004,
SE=0.001) and natural green areas(1km: β=0.004,
SE=0.001/3km: β =0.006, SE=0.001) in a person’s
living environment. However, urban green within
a 3km radius around the home seemed to be
negatively related to people’s health (β = -0.008,
SE=0.002), and this unexpected phenomenon,
in the author’s opinion, is probably caused by
the fact that urban green can only be found in
urban areas that have a lower total amount of
green space. Other findings were that people
with secondary education level benefit most
from green space and that people who are highly
educated only benefit from green space in strong
and moderate (only just significant within a 1km
radius) urban areas. These analyses suggest that
the lower educated groups are more sensitive to
the characteristics of the physical environmental.
When the effects of the amount of green space
were analysed for different age groups in the
different degrees of urbanity, it seemed that the
relationship was most consistent for the elderly,
who benefitted from green space in all urban areas.
Only the elderly and the youth seemed to benefit
from green space in strongly urban areas. [26]
Contrary to expectations, an observational study
on a population of 1546405 living in 1009 small
urban areas in New Zealand found no relationship
between availability of total green space and
cardio-vascular disease (CVD) mortality and no
evidence that CVD mortality was inversely related
to the availability of either total or usable green
space, suggesting that the relationships between
green space and health may vary according to
national, societal or environmental contexts. [27]
In an observational study, conducted during
2003–2004 on 1895 participants living in urban
areas of Adelaide, Australia, those who perceived
their neighbourhoods to have the highest degree
of greenness (the items included the following
attributes: access to a park or nature reserve;
Figure 1. Study selection flow diagram.
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IJPH - Year 8, Volume 7, Number 4, 2010
Author Year Study type Sample Main results
Lee &
Maheswaran
[5]
2010 Review 35 articles
It is difficult to establish a significant association between the
availability of urban green spaces and both physical and mental
health because of the complexity of this relationship and the bias,
the weak statistical evidence and the confounding factors found
in many articles. Usage of green areas for recreational physical
activities depends on many determinants such as gender, age,
individual motivation, personal barriers, lack of time, perceived safety,
unpredictable weather, number of facilities and features, accessibility,
maintenance and safety.
Stigsdotter et
Al. [17] 2010 Cross-sectional
study
21832 living in
Denmark
People living less than 300m from a green space declare better
perceived physical and mental health than people living more distant.
People living more than 1km away from a green space have 1.42
higher odds of experiencing stress. People suffering from stress are
likely to use green spaces to reduce stress.
Maas et Al.
[21] 2006 Cross-sectional
study
250782 living in
The Netherlands
In areas with a higher percentage of green space people report better
perceived health; lower educated groups are more sensitive to the
physical environmental characteristics.
Richardson
et Al. [22] 2010
Observational
study
(cohort study)
1546405 living in
New Zealand
There is no significant relationship between availability of total green
space and cardiovascular mortality.
Sugiyama et
Al. [23] 2008
Observational
study
(case – control
study)
1895 living in
Australia
People who perceive their neighbourhoods to have the highest degree
of greenness have 1.37 higher odds of reporting better physical health
and 1.60 higher odds of reporting better mental health.
Richardson &
Mitchell [26] 2010
Observational
study
(cohort study)
28600000 living
in the United
Kingdom
In areas with a higher percentage of green space the risk of death
from cardiovascular and respiratory disease decreases for men but
not for women.
van den Berg
et Al. [31] 2010 Cross-sectional
study
4529 living in
Denmark
Access to green spaces positively affects stress and mental health.
Green spaces provide as a buffer against stressful life events. This
moderating effect was found for green space within 3km, but not for
green space within 1km from home.
Guite et Al.
[37] 2006 Cross-sectional
study
2696 living in the
United Kingdom
There are significant relations between poor mental health and
neighbour noise, feeling over-crowded in the home and being
dissatisfied with access to green open spaces; there are significant
relations between poor vitality and poor access to community
facilities and feeling unsafe to go out in the day.
Maas et Al.
[44] 2009 Cross-sectional
study
10089 living in
The Netherlands
The availability of green spaces in the living environment is positively
related to the feelings of loneliness and shortage of social support,
especially for children, for the elderly, and for people with a lower
economic status; feelings of loneliness and shortage of social support
partially mediate the relation between green space and overall health.
Hillsdon et Al.
[51] 2006 Cross-sectional
study
4950 living in the
United Kingdom
There is no evidence of significant relationships between recreational
activity and access to green spaces.
Kaczynski et
Al. [53] 2008
Observational
study
(cohort study)
380 living in
Canada
Parks with more features were more likely to be used for physical activity
and the availability of walkable paths has the strongest relationship
with park use for physical activity purposes; size and distance are not
significant predictors of a park being used for physical activity.
Cohen et Al.
[54] 2006 Cross-sectional
study
1556 living in
the U.S.A. (only
females)
Adolescent girls who live near more parks engage in 4%–6% extra
nonschool metabolic equivalent–weighted moderate/vigorous
physical activity. The relation between physical activity and green
spaces is stronger for parks with amenities that are conducive to
walking and with active features.
Jones &
Hillsdon [55] 2010 Cross-sectional
study
6821 living in the
United Kingdom
Reported frequency of green space use declines with increasing distance
of green spaces from home. People living closer to the type of green
space classified as a “formal park” are more likely to achieve the physical
activity recommendation and less likely to be overweight or obese.
Maas et Al.
[56] 2008 Cross-sectional
study
4899 living in
The Netherlands
No relationship between the amount of green space in the living
environment and whether or not people meet recommendations for
physical activity. People living in a greener environment spend more
time at cycling for commuting purposes and gardening.
Abercrombie
et Al. [61] 2008 Cross-sectional
study
833 census
block groups in
Maryland and
Washington DC,
U.S.A.
Mixed-race neighbourhoods have a higher number of parks, regardless
of income. Low- and middle-income groups living in mostly-white
block groups and high-income groups living in mostly-minority block
groups have the lower access to public parks. Private facilities are
inversely related to the percent of children in the block groups.
Table 1. List of studies in this review.
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access to bicycle or walking paths; presence
of greenery; presence of tree cover or canopy
along footpaths and presence of pleasant natural
features) had approximately 40% higher odds of
belonging to the better physical health category
(measured with the short-form health survey
SF-12), compared with those who reported the
lowest degree of greenness. [28, 29]
To identify the perceived greenness of
a neighbourhood, five questions from the
Neighbourhood Environment Walkability Scale
were used. [30]
The level of association did not change
substantially after controlling for age, education,
work status, household income and marital status.
After further adjusting for walking as a means
of recreation, social coherence and local social
interaction, the association between greenness and
physical health became non-significant (p=0.06). In
this model, recreational walking was a significant
predictor of participants’ physical health but neither
social coherence nor local social interaction was
associated with physical health. [28]
Richardson and Mitchell found gender differences
when studying the relationships between urban
green space and health. In their study, carried out
in the UK, the risk of cardiovascular and respiratory
disease mortality decreased with increasing green
areas for males (p < 0.001), and was lowest for the
greenest wards (cardiovascular disease: incidence
rate ratio (IRR) 0.95, 95% CI 0.91-0.98; respiratory
disease: IRR 0.89, 95% CI 0.83-0.96). Thus, males
living in the greenest urban wards in the UK had
a 5% lower risk of cardiovascular disease mortality
and 11% lower risk of respiratory disease mortality
than those in the least green wards. In contrast,
no association with urban green space was found
among females for cardiovascular and respiratory
mortality. [31]
The authors considered the possibility that
the lack of association between green space and
cardiovascular disease and respiratory disease
mortality for women might reflect the fact that
women tend to die from these diseases at older
ages than men.
Benefits on mental health
It’s clear from Lee’s review that physical
and social features of the environment affect
behaviour somehow. [13, 32]
Studies in different groups such as students,
inner city girls, and workers reported associations
between green space and several psychological,
emotional and mental health benefits. [33, 34]
The possibility to access green spaces also
positively affects stress and quality of life. [22, 35-37]
The presence of green vegetation and the
formation of neighbourhood social ties in urban
areas significantly contribute to residents’ sense
of safety and adjustment. [38]
However, much of the literature on the
psychological benefits of green space tended to
be qualitative or from grey literature sources, the
quality of which varied. There is generally a lack
of robust evidence for the link between mental
health, well-being and green space but this may
be due to the inherent difficulties in quantifying
non-physical health benefits. [13]
According to Stigsdotter’s survey, respondents
that more often visited green spaces reported
less stress. Furthermore, the longer the distance
of the respondents’ homes from the nearest
green space, the more stress was reported. The
association between stress and distance to green
spaces remained even after adjusting for potential
confounders. As a result, Danes living more than
1km away from a green space resulted as having
1.42 higher odds of experiencing stress than those
living less than 300m from a green space. [22]
An analysis of the association between stress and
visits to green spaces showed that respondents
who do not report stress have 1.57 (95% CI 1.40–
1.76) higher odds of visiting a green space at
least a few days a week than those reporting
stress. The reasons for visiting green space differed
significantly whether the respondents were stressed
or not. A higher percentage of stressed respondents,
compared to those not stressed, reported that the
most important reasons for visiting green spaces
were to “reduce stress/relax” and to “obtain peace
and quiet without noise”. The results also showed
that the more often respondents visited green
spaces, the less stress they experienced. [22]
These results are also in line with findings from
previous studies. [28, 29]
Sugiyama et al. state that those who reported
the highest degree of greenness in their survey
had almost twice the odds of being in the
better mental health category, compared with
those who perceived little greenness in their
neighbourhood. After adjusting for the socio-
demographic variables, the strength of the
association between the highest degree of
greenness and mental health was attenuated but
nonetheless remained significant. The amount of
recreational walking undertaken and the social
coherence were significant predictors of the
mental health score. [28]
Recreational walking and social coherence
were associated with mental health scores and
perceived greenness remained an independent,
significant predictor of mental health. This
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suggests that the relationship between
perceived greenness and mental health is not
totally attributable to walking or to social
cohesion. One potential factor explaining this
“unaccounted” path may be the restorative
effects of green or natural environments. The
finding suggests that neighbourhood green
spaces are conducive to better health, in so far
as they are walkable, especially in the case of
physical health. [28]
Other authors confirm that the availability of
green or natural environments is associated with
adults’ perceptions of better health. [26, 39-41]
In a study on 2696 adults living in wards with
high levels of deprivation and with different
range of environmental features in Greenwich,
U.K., Guite et al. found significant relationships
between poor mental health and: neighbour
noise (OR 2.71, 95% CI 1.48, 4.98), feeling
over-crowded in the home (OR 2.22, 95% CI
1.42, 3.48), being dissatisfied with access to
green open spaces (OR 1.69, 95% CI 1.05, 2.74),
confirming an association between the physical
environment and mental well-being across a range
of domains. [42]
These authors also found significant
relationships between poor vitality and: poor
access to community facilities (OR 1.92, 95% CI
1.24, 3.00), feeling unsafe to go out in the day
(OR 1.58, 95% CI 1.00, 2.49). [42]
Selection of the wards was based on the ward
Index of Multiple Deprivation. [43]
Measures to assess satisfaction with the physical
environment were based on the five domains of
Chu’s model. [44]
Mental health was measured by SF-36 version
2. [45-47]
Benefits on social health
Social capital is positively influenced by green
spaces which provide a meeting place for users to
develop and maintain neighbourhood social ties.
[13, 38, 48, 49]
Social interaction enhances personal and social
communication skills. [38, 50]
Moreover, it is also probable that exposure
to green spaces may have an impact on urban
socioeconomic health inequalities. [51]
However, studies found that inner city and poor
populations are less likely to report participation
in outdoor recreation activities. [50, 52]
Teenagers living in disadvantaged
neighbourhoods, for example, lacked access to
parks they considered safe and were therefore
less likely to participate in physical activities than
teens in more affluent neighbourhoods. [53]
Another study noted that people in low-income
households were more likely to adopt low levels
of activity and were least well served by affordable
facilities. [54]
Wealthy residents, on the other hand, were
more likely to live in close proximity to facilities
of any type. [54]
Socioeconomic differentials in physical inactivity
are consistent with socioeconomic gradients in
many health outcomes and may represent a key
pathway through which socioeconomic status
affects health. [55]
The unequal distribution of green space could
account for some of the cross-cultural and
socioeconomic variations in their use. Even if access
to green space appears to be implicitly linked with
levels of deprivation, confounding factors such as
individual lifestyles cannot be discounted since
they could have socioeconomic links. [13]
A study from Maas showed a relation between
loneliness and distance from the closest green
area in strongly urban municipalities. People
with more green space within a 1km radius
around their home experience less shortage of
social support. This relation was apparent for
children (in a 1 and 3km radius), young adults
(1 and 3km), adults (3km), elderly (3km), lower
educated people (1 and 3km) and people with a
low income (1 and 3km). [49]
However, people experiencing less loneliness
and shortage of social support did not have
more contact with neighbours or friends in the
neighbourhood and they didn’t receive more
social support. This suggests that the relationship
between green space and social contacts has
more to do with the fact that green spaces can
strengthen sense of community by means of place
attachment and place identity of its residents,
than with real contacts with neighbours. [49]
It is of notice that this author revealed how the
feelings of loneliness and lack of social support
appear to partially mediate the relationship
between green space and self-perceived health
(1km: z = 6.26, p<0.001 / 3km: z = 7.43,
p<0.001), number of health complaints (1km: z
= -6.22, p<0.001 / 3km: z = 7.36, p<0.001) and
self-reported propensity to psychiatric morbidity
(1km: z = -5.57, p<0.001 / 3km: z = 6.89,
p<0.001). [49]
Physical activity and green space
From Lee and Maheswaran’s review, it is clear
how the usage of green areas for recreational
physical activities purposes depends on many user
determinants. Factors such as gender (with males
using parks more than females), age (negatively
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affecting only the elder), high individual motivation
(positive attitude towards the process of being
physically active and partaking in physical activity
with a significant other), personal barriers (with
overweight people and people suffering from
poor health or disabilities using parks less than
others) and lack of time; perceived safety (affecting
especially females) all appear to influence the use
of green areas. [13]
Environmental determinants such as
unpredictable weather (keeping people from
using parks), number of facilities and features
(being positively related to park usage), and
accessibility (maintenance and safety) are
important factors that also influence the level of
physical activity and green space use. [13]
From a survey involving 4950 participants
residing in the city of Norwich who completed
a physical activity questionnaire it resulted that
males had higher levels of recreational physical
activity (mean of 8.43 h per week) compared
with females (mean of 5.84 h per week) and this
difference was statistically significant (p<0.001).
Participants aged 60–70 years were the most
active age group (mean of 7.54 h activity per
week). Those aged 40–50 reported a mean of 5.95
h of activity per week, those aged 50–60 reported
a mean of 6.49 h per week and those aged 70
or over reported a mean of 7.34 h per week. In
general, the older age groups were more active
than the younger ones (p<0.001). Significant,
positive associations with recreational physical
activity were also found for education (p<0.001),
Townsend Index (p<0.001) and car ownership
(p<0.001). There was no significant relationship
between recreational physical activity and self-
reported health problems. [56]
Parks were evaluated with a tool containing
69 items grouped into eight themes as follows:
accessibility, maintenance, recreational facilities,
amenity provision, signage and lighting, landscape,
usage, and atmosphere. Sixty-one green spaces
in Norwich were surveyed using the tool.
Unexpectedly, participants with the best access
to high-quality large green spaces actually reported
significantly lower levels of activity compared with
those with the poorest access, suggesting that
some factors not directly measured but related
to local environments may be determinants of
activity. Furthermore, the neighbourhood measures
of access to green spaces showed non-significant
associations with recreational physical activity. [56]
No studies have reported a positive association
between access to green space and overall
levels of physical activity, and one has even
reported an inverse relationship. [57]
An observational study from Kaczynski et al.
showed that only the number of features is
a significant predictor of a park being used
for physical activity (OR = 1.45; 95% CI =
1.09, 1.82; p=0.03), while park size and distance
to participants’ homes didn’t seem to play an
important role and were not considered significant
predictors. Parks that were used for physical
activity had an average of 5.86 facilities and 6.57
amenities, compared with only 2.74 facilities and
4.00 amenities in parks that were not used for
physical activity. [58]
The presence of paved trails (OR = 32.41;
95% CI = 3.27, 320.36; p=0.01), unpaved trails
(OR = 7.11; 95% CI = 1.40, 36.12; p=0.02), and
wooded areas (OR = 6.75; 95% CI = 1.40, 31.90;
p=0.02) were significantly related to park-based
physical activity when examined independently.
However, when they examined these 3 variables
concurrently, only the presence of a paved trail
was a significant predictor of some physical
activity occurring within the park. Indeed, parks
with a paved trail were almost 26 times more
likely to be used for physical activity than parks
without a paved trail (OR = 25.93; 95% CI = 2.15,
312.51; p=0.01). [58]
A study including 1556 grade 6 girls from U.S.
showed that the presence of parks was associated
with higher levels of non-school metabolic
equivalent–weighted moderate-to-vigorous physical
activity (MEMVPA, a measure accounting for the
volume and intensity of activity) among adolescent
girls. It also suggested that this relationship holds
for proximity, number, and the type of parks, as
well as specific park amenities. [59]
The authors made girls wear accelerometers
for 6 days to measure MEMVPA. Trained staff
used a checklist to document the presence of
facilities and amenities at each park, including
passive amenities, such as drinking fountains,
restrooms, and areas with shade, and active
amenities like basketball courts, multipurpose
fields, playgrounds, and tennis courts.
A study on 6821 adults examining the association
between objectively measured access to green
space, frequency of green space use, physical
activity, and the probability of being overweight
or obese in the city of Bristol, England, showed
that people living further from urban green spaces
were less likely to visit them than those nearby,
and this effect was particularly strong for formal
green spaces. Respondents living further from
green spaces were also less likely to meet guideline
physical activity levels and more likely to be
overweight or obese, even after adjustment for the
walkability of respondent’s neighbourhoods, their
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socioeconomic status, and area deprivation. [60]
Some disparities became apparent during the
examination of access by green space type: mean
distances were 2207m for young people’s green
areas, 1758m for formal, 1082m for sports, 570m
for natural, and 481m for informal green space
types. About 30% of respondents lived within
300m of informal and natural green spaces, but
only less than 10% lived within 300m of young
people’s and sports green spaces. [60]
Maas et al. investigated whether physical activity
(in general but also, in particular, walking and
cycling during leisure time and for commuting
purposes, sports and gardening) is an underlying
mechanism in the relationship between the
amount of green space in people’s direct living
environment and self-perceived health. They
found no significant relationship between the
percentage of green space and meeting the public
health recommendations for physical activity.
Quite surprisingly, findings show that people walk
less often during leisure time when there is more
green space in their direct living environment.
This relationship is as large in a 1km radius as
in a 3km radius around one’s home. They also
showed that people spend less leisure time on
walking when there is more green space in a 3km
radius around their home. People with 20% green
space in a 3km radius around their home walked
approximately 250 minutes per week for leisure,
whereas people with 80% green space in a 3km
radius around their home walked approximately
190 minutes per week during leisure time. [61]
There is also a negative relationship between
the percentage of green space in a 1km radius
around the living environment and whether or
not people cycle during leisure time.
There is no significant relationship between
the percentage of green space and walking for
commuting purposes: people with more green
space around their homes do not walk more often
for commuting purposes and do not walk for
commuting purposes for a longer period. However,
Authors observed an effect in people cycling for
commuting purposes: they were likely to spend
more time on it if they had a higher percentage of
green space in their living environment, and this
was apparent both in a 1km and 3km radius. People
with 20% green space in a 1km radius around their
home cycle approximately 120 minutes per week
for commuting purposes, while people with 80%
green space in a 1km radius around their home
cycle approximately 170 minutes per week for
commuting purposes. [61]
People with a higher percentage of green space
in a 1km radius around their home also garden
more often: people with 20% green space in a 1km
radius around the home garden approximately
180 minutes per week, whereas people with 80%
green space in a 1km radius around their home
garden 265 minutes per week. [61]
In the authors’ opinion, the finding that people
with more green space in their living environment
less often walk or cycle is probably due to the fact
that in greener living environments, facilities are
further away and people more often use a car
to reach them. Furthermore, green spaces are
usually more available outside the strongly urban
areas, where the chances of parking a car near
home are much higher.
Despite the well documented health disparities
showing how low-income populations and
those from ethnic and racial minority groups
have shorter life spans, higher rates of chronic
diseases, less access to (and lower quality of)
health care and lower quality of life than wealthy
and non-Hispanic white populations, income and
racial disparities don’t affect access to public
parks in the U.S., as confirmed by Abercrombie
et al. who reported that the expected deprivation
of recreation facilities in low-income and high-
minority areas was not found in their study for
private or public facilities. [62-66]
Authors expected private companies to
concentrate in areas where ability to pay is better,
but their results weren’t totally surprising: other
studies conducted in Scotland and Australia found
even greater access to recreation resources in
disadvantaged communities. [67, 68]
Number and size of parks were positively related
to the percent of children in the block group,
suggesting that park placement decisions were
somewhat sensitive to providing access to children.
The possibility that families with children may choose
to move near parks shouldn’t be miscalculated.
However, the number of private facilities resulted
to be inversely related to the percent of children in
the block group, indicating that business decisions
won’t serve children properly. [66]
Discussion
In our review of the most updated literature
regarding the relationships between green spaces
and wellness, we found many contradictory and
unexpected results. That said, the reported findings
in studies were generally consistent and supported
the current view that urban design and the
availability of urban green spaces are main elements
of prosperity and individual/collective comfort, so
as to influence both the perceived health and the
objective physical conditions in a measurable way.
At any rate, establishing a causal relationship
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between green spaces and health was difficult
and reviews done so far have often been based
on contradictory or weak studies. Even after
socioeconomic factors are controlled for, the
possibility of confounding factors cannot be
excluded. [13]
Overall, people with more green space in their
living environment feel healthier, experience
a lower number of health complaints and have
lower self-rated propensity for psychiatric
morbidity. [14, 49]
Even if the relationship between green spaces
and physical health is often hard to prove, since
it is necessary to identify phenomena which
exert their effects over long periods of time, we
can safely state that male cardiovascular disease
and respiratory disease mortality rates decrease
with increasing green space, but no significant
associations were found for women. [31]
On the other hand, it isn’t much easier to
measure the effects that green spaces have on
mental health, given that data are usually self-
reported and not quantitative. However, we
found strong associations between the physical
environment and mental well-being across a wide
range of domains.
The Literature provides evidence for an
association between health-related quality of life
and distance from one’s private home to the
nearest green space and also supports a positive
association between use of green spaces and relief
from stress: the more often people visit green
spaces, the less stress they experience. [13, 28, 42]
Additionally, our findings suggest that the longer
the distance one’s home is from the nearest green
space, the more stress people experience. [28, 42]
In line with this, the reasons for visiting green
spaces differ significantly depending on whether
or not people experience stress: subjects reporting
stress state reasons for visiting green spaces that
are connected to mental restoration, while those
not affected from stress mostly demand physical
challenges and mental strength. [13, 28, 42]
The most important factors operating
independently on mental health appear to be
neighbourhood noise, sense of over-crowding
in the home, sense of overcrowding in the
escape facilities like green spaces and community
facilities, and fear of crime. [13, 36, 39]
Not only does the availability of green spaces
positively affect the levels of stress, but people
actively seek for nature when stressed also. A
bright (though dramatic) example is provided
by Lazaroff, who reported a marked increase in
the number of visits of green spaces following
the attacks on the World Trade Centre in 2001,
according to the national parks authorities. [69]
As said, a growing number of studies show that
contacts with nature have beneficial mental health
effects. Research has found strong evidence for a
positive relationship between exposure to nature
and restoration from stress and attention fatigue,
but studies have also shown that green spaces
have indirect effects on mental well being like
serving as a buffer against the health impacts of
stressful life events. [36]
A buffer is a moderating variable decreasing
the association between an independent variable
and an outcome variable and explains in which
way or under which conditions the independent
variable affects the outcome variable.
At the same time, as we observed that feelings
of loneliness and shortage of social support
partially mediate the relationship between green
space and overall health, it appears evident
that the amount of green space in the living
environment is positively related to the feelings
of loneliness and shortage of social support,
especially for children, for the elderly, and for
people with a lower economic status, affecting
both the individual well-being and the entire
social order by means of improving attachment
and social coherence. [42, 49]
Regarding physical activity, common sense
may suggest an association with the availability
of green spaces but, from the literature, the
evidence for the link between physical activity
levels and green space availability appears to
be weak or less clear-cut, while there is strong
evidence of the health benefits deriving from
physical activity. [13, 58-61]
It has been estimated that physical inactivity
causes 1.9 million deaths globally each year. [70]
Adults don’t reach the recommended level of
physical activity, which is at least 30 minutes
of moderate activity on five or more days per
week. [70-72]
Even tough several studies support the view that
green spaces promote physical activity, offering
opportunities for valuable exercise such as walking
and cycling, further studies are needed to evaluate
the nature of these significant relationships.
Green spaces may affect people’s attitude towards
physical activity in other ways, although these
mechanisms are not always clear. [58-61]
Further research is needed to quantify the
strength of association between green spaces and
urban health, but also to investigate the psycho-
social and economic dimensions that are more
difficult to measure. [22]
Moreover, we have to recognise that detailed
scientific knowledge is important and needed
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to implement environmental programs with the
overall aim of protecting the human population
from environmental related diseases. [73]
In this context, there is increasing evidence
on the functional role of urban green to monitor
and improve urban air quality - even with the
use of Geographical Information System (GIS)
that in recent years has been in widespread
use for public health purposes - and, as a direct
consequence, quality of life in populations in
urban areas. [74, 75]
Limitations of this study
The occasionally contradictory results of this
study prove that a populations’ response to urban
design interventions is often unpredictable. Many
unexpected results probably occurred because of
the differences in population habits, geographical
locations, measures and definitions of green space
as well as self-report measures of “well-being”.
Many studies presented in this review- focusing on
physical health outcomes- deal with perceived rather
than objective health conditions documented, thus
limiting our capability to evaluate the real impact
that green spaces have on health.
Measuring the real amount of physical activity
is complex and often neglected. Self-reported
data might be unreliable, since informal physical
activity is also an important component of the
overall activity levels.
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