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Impact of Green Space Exposure on Children’s and Adolescents’ Mental Health: A Systematic Review


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In recent years, the interest in the relationship between exposure to green spaces and children’s and adolescents’ mental health has risen. This systematic review aims to provide an overview of observational studies assessing the association between empirical green space exposure with standardized outcome measures of mental health problems, mental well-being and developmental problems in children, adolescents and young adults. The PRISMA statement guidelines for reporting systematic reviews were followed. A PubMed and Scopus search resulted in the inclusion of 21 studies. The evidence consistently suggests a beneficial association between green space exposure and children’s emotional and behavioral difficulties, particularly with hyperactivity and inattention problems. Limited evidence suggests a beneficial association with mental well-being in children and depressive symptoms in adolescents and young adults. These beneficial associations are resistant to adjustment for demographic and socio-economic confounders, which thus may represent independent links. Mediating factors and the variability of this association between different age groups are discussed. From a precautionary principle, evidence up to now demands the attention of policy makers, urban planners and mental healthcare workers in order to protect children’s and adolescents’ mental health in light of rapid global urbanization by providing sufficient exposure to green spaces.
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International Journal of
Environmental Research
and Public Health
Impact of Green Space Exposure on Children’s and
Adolescents’ Mental Health: A Systematic Review
Gert-Jan Vanaken * and Marina Danckaerts
Department of Child and Adolescent Psychiatry, University Psychiatric Centre Leuven, KU Leuven,
3000 Leuven, Belgium
*Correspondence:; Tel.: +32-499-48-09-34
Received: 1 November 2018; Accepted: 24 November 2018; Published: 27 November 2018
In recent years, the interest in the relationship between exposure to green spaces and
children’s and adolescents’ mental health has risen. This systematic review aims to provide
an overview of observational studies assessing the association between empirical green space
exposure with standardized outcome measures of mental health problems, mental well-being
and developmental problems in children, adolescents and young adults. The PRISMA statement
guidelines for reporting systematic reviews were followed. A PubMed and Scopus search resulted in
the inclusion of 21 studies. The evidence consistently suggests a beneficial association between green
space exposure and children’s emotional and behavioral difficulties, particularly with hyperactivity
and inattention problems. Limited evidence suggests a beneficial association with mental well-being
in children and depressive symptoms in adolescents and young adults. These beneficial associations
are resistant to adjustment for demographic and socio-economic confounders, which thus may
represent independent links. Mediating factors and the variability of this association between
different age groups are discussed. From a precautionary principle, evidence up to now demands
the attention of policy makers, urban planners and mental healthcare workers in order to protect
children’s and adolescents’ mental health in light of rapid global urbanization by providing sufficient
exposure to green spaces.
Keywords: green space; mental health; mental well-being; children; adolescents; urban planning
1. Introduction
In recent years, academic interest in a possible relationship between exposure to green spaces
and public health has risen, as can be derived from the number of studies published. In a
systematic review of 12 reviews published between 2010 and 2016, the authors underscored the
beneficial association of exposure to green spaces with all-cause mortality, mortality by cardiovascular
disease and mental health in adults [
]. However only one included review, published in 2015 by
Gascon et al. assessed mental health in children, finding inadequate evidence for such an association [
This incremental interest can be understood firstly, clinically in the light of the rapid global urbanization
dynamic, triggering concerns of a decline of contact with natural green spaces [
], and secondly,
methodologically in the availability of new remote sensing techniques to quantify green spaces using
satellite images [
]. Of course urbanized regions can offer contact with green spaces as well, defined
in this context as urban vegetated spaces such as parks, grasslands, cemeteries, sports and playing
fields and near-road trees [
]. Following these evolutions, the importance of green spaces has also
attracted political interest over the past years. In the United Nation’s Sustainable Development Goals
for instance, member states committed themselves to the following goal, “By 2030, provide universal
access to safe, inclusive and accessible, green and public spaces, in particular for women and children,
older persons and persons with disabilities” [8].
Int. J. Environ. Res. Public Health 2018,15, 2668; doi:10.3390/ijerph15122668
Int. J. Environ. Res. Public Health 2018,15, 2668 2 of 17
Although green spaces seem to be associated with a range of health benefits, particular interest has
arisen for the impact on children’s mental health. One of the main challenges in this field of research
is disentangling the independent role of green space exposure from other confounding variables.
Intuitively most attention was paid to the role of socio-economic status, as this factor predicts mental
health and may influence where families eventually end up living. In 2009, Maas and colleagues
published a landmark study linking data of residential land use to medical diagnoses in primary care
settings for approximately 345,000 Dutch patients from different age groups [
]. Patients living in
the greenest environments were significantly less frequently diagnosed with a range of physical and
mental disorders after adjustment for the most probable socio-economic and demographic confounders,
compared to their counterparts living in the least green neighborhoods. Remarkably, the strongest
associations were found for psychiatric conditions, particularly in children [9]. Since then, a growing
number of studies have assessed those associations between green space and children’s and adolescents’
mental health. As mentioned earlier, Gascon et al. conducted the first systematic review on this specific
topic, in 2015, considering the results of the four existing observational studies as inadequate evidence
at the time for a causal relationship between green spaces and children’s mental health [
]. More
recently, in 2017, McCormick published another systematic review in this domain [
]. With a broader
scope on children’s mental well-being and school functioning, including 12 articles in the review, the
author concluded that access to green space was associated with improved mental well-being and
cognitive development of children. However, it should be noted that heterogeneity in study design
was significant and sufficient replication research was not systematically available at the time of review.
As global urbanization progresses, more than ever, children, adolescents and young adults are
coming to age in neighborhoods dominated by built environments. At the same time, mental health
problems in these age groups put a significant burden on these individuals and their life course, their
families and society as a whole. Since the research line that sheds a light on the interplay of these
dynamics expanded rapidly in recent years, there is a need for a new overview of the existing evidence
to guide urban planning and public health policy. This paper aims to provide such an attempt at
answering the question if an association between green space exposure and children’s and adolescent’s
mental health and neurocognitive development exists and which domains of these outcome concepts
are possibly involved in particular.
2. Materials and Methods
2.1. Search Strategy
This systematic review was conducted following the Preferred Reporting Items for Systematic
reviews and Meta-Analyses (PRISMA) statement guidelines [
]. The literature search was carried
out using two frequently used search engines, PubMed and Scopus. Following an exploratory
phase to identify the essential aspects in this domain of research, the following keywords were
selected: Keywords related to green space (“green space”, greenspace, greenness) combined with
keywords related to mental health and neurocognitive development (“mental health”, “well-being”,
development *) and with keywords related to childhood and adolescence (child *, adolescen *, infan *,
“young adult *”, youth). The asterisk (*) acts as a truncation symbol to detect various results composed
of a single string of text, e.g. ‘child *’ detects terms as ‘children’ and ‘childhood’. On 2 March 2018,
the last search was conducted. The title and abstract provided the information for a first screening
of the given articles. Following this first screening, full articles were read to decide on inclusion
for this systematic review. References of the included studies were taken into account to identify
additional articles.
2.2. Selection Criteria
The selection criteria for inclusion that all studies needed to fulfill were: (a) The article described
an original research study; (b) the article was written in English; (c) the article was published in a
Int. J. Environ. Res. Public Health 2018,15, 2668 3 of 17
peer-reviewed scientific journal; (d) the study had an observational design, interventional designs were
excluded; (e) green space exposure was analyzed empirically either by objective methods based upon
land cover maps or remote sensing data, or by subjective methods using standardized questionnaires;
(f) green space exposure was assessed in residential or school surroundings; (g) mental health and
neurocognitive development were assessed using standardized instruments or through existing
medical records or databases; (h) the study focused primarily on children, adolescents or young adults
with an age limit of 25 years, articles primarily focusing on adults over 25 years of age and were
excluded even when the study population existed in part of participants under the age of 25 and (i) no
restriction on publication date was put in place.
2.3. Data Collection and Evaluation of Evidence
Following the methodology used in a previous systematic review on green space and mental
health by Gascon et al. [
], we extracted the ensuing basic characteristics, methodological features and
outcome results of the studies included in our systematic review: Author, year of publication, country,
study design, study population, sample size, exposure assessment, outcome assessment, confounding
factors and main results. These extraction processes were conducted manually.
As children’s mental health and development are broad concepts, with a multitude of existing
methods to capture these concepts, the available evidence for any impact of exposure to green
spaces was evaluated based on the studied outcome parameter. These outcome parameters were
divided into three categories, i.e., (1) emotional and behavioral difficulties; (2) mental well-being and
(3) neurocognitive development. The evaluation of evidence for an association between green space
exposure and any studied outcome parameter was based on the number of studies finding a beneficial
association in comparison to the total number of studies assessing this parameter.
3. Results
3.1. Literature Search Results
The literature search using the described keywords yielded 89 results in PubMed and 197 results
in Scopus, as presented in Figure 1. A first screening based on title and abstract resulted in 48 articles
after the elimination of duplicates. After full-text read-through, 21 studies were selected for inclusion.
No additional articles fitting the predefined criteria were detected via the references.
3.2. Study Characteristics and Methods
As presented in Table 1, more than half of the included studies were published in 2016 or later
(n= 12), while the earliest publication matching the inclusion criteria only dates back to 2013. Eleven
of the selected studies were conducted in Europe, others were conducted in North America (n= 6)
and Oceania (n= 4). Twelve studies had a cross-sectional design, seven studies were longitudinal
and two studies were ecologically designed, i.e., relying on exposure and outcome data at the district
instead of the individual level [
]. The sample size of the examined populations ranged between
72 [
] and approximately 3,000,000 participants [
]. Exposure to green space was measured in the
majority of studies with at least one objective parameter. Land cover maps providing data on land
use (n= 10) or remote sensing data based on satellite images providing the Normalized Difference
Vegetation Index (NDVI) (n= 9) and derivations, were the most commonly used objective green space
parameters. The NDVI is a parameter based on the difference in reflected visible and infrared light
between green spaces and the built environment. One study used geolocation data obtained by study
participants wearing digital watches with GPS-functionality [
]. Two studies assessed green space
exposure solely with a subjective parameter, i.e., the score on a questionnaire gauging time spent in
green spaces or the distance to the nearest green space [
]. Seven studies combined objective and
subjective parameters in the exposure assessment.
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Int. J. Environ. Res. Public Health 2018, 15, x 4 of 17
Figure 1. Search results. Figure based on Preferred Reporting Items for Systematic reviews and Meta-
Analyses (PRISMA) guidelines by Moher et al. [11].
The majority of studies (n = 16) assessed green space exposure only in the residential
neighborhood of children or adolescents, two studies measured exposure exclusively in the school
environment while three studies combined residential and school exposure to green spaces.
Mental health outcome was assessed by a range of different instruments. Eight studies used the
parent-based version of the Strengths and Difficulties Questionnaire (SDQ), while one study relied
on the SDQ filled out by multiple informants [17]. Eight studies relied on other standardized
questionnaires. Computerized neuropsychological tests were used to assess aspects of
neurocognitive development in three studies. Medical records and derived prevalence data provided
an outcome measure in two studies. Outcome results were described heterogeneously as the
percentile change in average score on a given test, the odds ratio, the rate ratio or the beta coefficient
of correlation. Associations that are presented in Table 1 or described below always consist of
significant and confounder-adjusted associations, unless stated otherwise. All studies assessed at
least one measure of the socio-economic status (SES), i.e., family income, parental education and/or
parental employment, except for two studies [14,15]. Adjustments for ethnicity, parental mental
health and neighborhood socio-economic status (nSES), i.e., safety, walkability, house value, average
household income of the neighborhood, were conducted less systematically, as presented in Table 1.
PubMed search
(n = 89)
Additional records
identified through
(n = 0)
Records identified
(n = 286)
Full-text articles
assessed for eligibility
(n = 48)
Full-text articles
(n = 27)
Studies included in
systematic review
(n = 21)
Scopus search
(n = 197)
Records screened after
removal of duplicates
(n = 208)
Excluded records based
on title/abstract
(n = 160)
(n = 78)
Figure 1.
Searchresults. Figure based on Preferred Reporting Items for Systematic reviews and Meta-Analyses
(PRISMA) guidelines by Moher et al. [11].
The majority of studies (n= 16) assessed green space exposure only in the residential neighborhood
of children or adolescents, two studies measured exposure exclusively in the school environment while
three studies combined residential and school exposure to green spaces.
Mental health outcome was assessed by a range of different instruments. Eight studies used
the parent-based version of the Strengths and Difficulties Questionnaire (SDQ), while one study
relied on the SDQ filled out by multiple informants [
]. Eight studies relied on other standardized
questionnaires. Computerized neuropsychological tests were used to assess aspects of neurocognitive
development in three studies. Medical records and derived prevalence data provided an outcome
measure in two studies. Outcome results were described heterogeneously as the percentile change in
average score on a given test, the odds ratio, the rate ratio or the beta coefficient of correlation.
Associations that are presented in Table 1or described below always consist of significant and
confounder-adjusted associations, unless stated otherwise. All studies assessed at least one measure of
the socio-economic status (SES), i.e., family income, parental education and/or parental employment,
except for two studies [
]. Adjustments for ethnicity, parental mental health and neighborhood
socio-economic status (nSES), i.e., safety, walkability, house value, average household income of the
neighborhood, were conducted less systematically, as presented in Table 1.
Int. J. Environ. Res. Public Health 2018,15, 2668 5 of 17
Table 1. Study characteristics, methodology and results.
Author, Year,
Design N, Age Exposure Data
Exposure Concept
Confounders Adjusted for
in Model Significant Results in Adjusted Model
Aggio et al., 2015,
Scotland [15]
5–6 years questionnaire residence walking time to
nearest GS SDQ no adjusted model in publication (Not adjusted) more than 20 min walking
time to GS associated with higher scores
on TDS.
Amoly et al., 2014,
Spain [18]
7–10 years NDVI,
questionnaire residence,
average greenness
(100 m, 250 m, 500 m);
GS playing time;
proximity to major GS
gender, school level, ethnicity, SES,
parental marital status, nSES
preterm birth, breastfeeding,
environmental tobacco smoke,
gestational maternal smoking,
responding person
Average greenness inversely associated
with TDS, H/I & DSM IV-ADHD score;
green space playing time inversely
associated with TDS, emotional and peer
problems; proximity to major GS not
associated with outcome parameters.
Balseviciene, 2014,
Lithuania [19]
4–6 years NDVI, land
cover map residence average greenness
(300 m); distance to
city park SDQ age, gender, parenting stress, SES
Distance to city park positively associated
with TDS, H/I, peer and conduct problems
in low SES subgroup; no associations with
average greenness.
Bezold et al., 2017,
USA [20]
12–18 years NDVI residence average greenness
(250 m, 1250 m) McKnight Risk
Factor Survey
age, gender, ethnicity, grade level,
SES, maternal history of
depression, nSES, PM2.5
IQR increase in average greenness
associated with 11% lower odds of high
depressive symptoms.
Bezold et al., 2018,
USA [21]
9–25 years NDVI residence cumulative average
greenness (1000 m)
Mc Knight Risk
Factor Survey;
age, gender, ethnicity, SES,
maternal history of depression,
population density, nSES, PM2.5
IQR increase in cumulative residential
greenness associated with 6% lower
incidence of high depressive symptoms;
stronger associations for under-18 year olds
and in more densely populated areas.
Dadvand et al.,
2015, Spain [22]
7–10 years NDVI residence,
average greenness
(250 m residence, 50 m
commuting route, 50 m
n-back, ANT age, gender, SES, nSES, air
Average greenness positively associated
with 12 m development of two-back,
three-back and ANT results.
Dadvand et al.,
2017, Spain [23]
4–7 years NDVI, VCF residence
cumulative average
greenness (100 m,
300 m, 500 m), tree
canopy cover
age, gender, preterm birth,
maternal cognitive performance,
gestational smoking,
environmental tobacco exposure,
Cumulative average greenness inversely
associated with K-CPT omission errors and
HRT-SE at 4–5 years, and with ANT HRT-SE
at 7 years.
Dzhambov et al.,
2018, Bulgaria [24]
15–25 years
questionnaire residence
average greenness
(500 m), tree canopy
GS access/quality/usage
age, gender, ethnicity, SES
orientation of rooms duration of
residence, time spent at home, air
pollution, noise, population
No direct associations; positive association
via serial mediation (restoration, physical
activity, social cohesion).
Feng and
Astell-Burt, 2017,
Australia [25]
4–13 years land cover map,
question-naire residence
amount of GS (SA2), GS
quality SDQ age, gender, ethnicity, SES, nSES,
Amount and quality of GS inversely
associated with TDS, IS and ES, for all age
groups; for older children GS quality more
strongly inversely associatied with IS.
Feng, 2017,
Australia [17]
12–13 years land cover map,
question-naire residence amount of GS (SA2),
GS quality SDQ
age, gender, SES, nSES, geographic
Amount of GS inversely associated with the
parent-reported TDS and IS; GS quality
inversely associated with both parent- and
child-reported TDS, IS and ES; stronger
associations found for
parent-reported scores.
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Table 1. Cont.
Author, Year,
Design N, Age Exposure Data
Exposure Concept
Confounders Adjusted for
in Model Significant Results in Adjusted Model
Flouri et al., 2014,
UK [26]
3–7 years land cover map,
question-naire residence
amount GS (LSOA), use
age, gender, ethnicity, SES, family
structure, use of GS, access to
private garden, life adversity, nSES,
maternal (mental) health, physical
Amount of GS inversely associated with
emotional problems score for age 3–5 years.
Huynh et al., 2013,
Canada [27]
11–16 years land cover map school amount GS (5000 m) Cantrill ladder age, gender, ethnicity, SES, nSES Amount of GS not associated
with well-being.
Kabisch et al., 2016,
Germany [13]ecological 30,427
5–6 years land cover map residence amount GS (LEA)
(/capita) health visit
sub-district level: SES, ethnicity,
measles immunization,
participation in check-up,
kindergarten attendance, tobacco
Amount of GS inversely associated with
deficits in visuo-motoric development.
Kim et al., 2016,
USA [28]
9–11 years
remote sensing
(NDVI-like) residence
amount, number, size,
distance to,
cohesiveness of GS (400
m, 800 m)
PedsQL age, gender, SES, nSES, BMI,
physical activity
Larger and more tree areas positively
associated with children’s health related
quality of life.
Markevych et al.,
2014, Germany [29]
10 years land cover map,
NDVI residence distance to nearest GS SDQ age, gender, SES, maternal age at
birth, parental marital status,
screen/outdoors time
Residence > 500 m away from nearest GS
positively associated with TDS, peer
relationship and H/I problems (after
stratification; only association with H/I for
boys), no associations for residential
average greenness.
Richardson et al.,
2017, Scotland [30]
4–6 years land cover map,
question-naire residence amount GS and public
parks (500 m), access to
private garden SDQ age, gender, SES, parental mental
health, nSES, hours of screen time
Private garden access strongly associated
with TDS and H/I and to lesser extent with
peer and conduct problems, neighborhood
amount of GS associated with prosocial
behavior scores, little evidence of influence
on developmental trajectory.
Saw et al., 2015,
Singapore [31]
18–25 years land cover map,
question-naire residence distance from nearest
GS, number of GS’s
(1200 m), use of GS
LSS, Pos.and
Neg. Affect
Scale, PSS
age, gender, SES, physical activity,
serious health problems,
personality traits
Neither access to or use of GS associated
with well-being.
Ward et al., 2016,
New Zealand [14]
11–14 years geolocation and
timing all locations time spent in GS
CNS-Vital Signs
age, gender, school, physical
Time spent in GS and physical activity
positively associated with greater emotional
wellbeing, no associations with
neurocognitive development measures.
Wu et al., 2017,
USA [12]ecological ~3 ×106
5–12 years land cover map school
amout forest and
grassland (school
district), amount
(near-road) tree canopy.
autism district level: ethnicity, gender,
SES, road density
Amount of GS and tree cover metrics
inversely associated with autism prevalence
in high road density districts.
Int. J. Environ. Res. Public Health 2018,15, 2668 7 of 17
Table 1. Cont.
Author, Year,
Design N, Age Exposure Data
Exposure Concept
Confounders Adjusted for
in Model Significant Results in Adjusted Model
Younan et al., 2016,
USA [32]
9–18 years NDVI residence average greenness
(250 m, 350 m, 500 m,
1000 m)
age, gender, ethnicity, SES, nSES,
ambient temperature, traffic
density and proximity to freeways
and roads, maternal depression,
gestational smoking
IQR increase in average greenness inversely
associated with aggresive behaviour.
Zach et al., 2016,
Germany [16]
6–12 years questionnaire residence availablity of GS SDQ gender, country of birth, SES,
single parenthood, crowding,
traffic load
Non-accessibility of green space associated
with TDS and hyperactivity/
inattention problems.
Note: ADHD, Attention Deficit and Hyperactivity Disorder; ANT, Attention Network Task; CBCL, Child Behavior Checklist; CES-D, Center for Epidemiologic Studies—Depression Scale;
comp. CNS-Vital Signs test, computerized Central Nervous System-Vital Signs test; DSM IV, Diagnostic and Statistical Manual Fourth Edition; ES, Externalizing Scale; GHQ, General
Health Questionnaire; GIS, Geographical Information System; GS, Green Space; H/I, hyperactivity/inattention; HRT-SE, Hit Reaction Time Standard Error; HS, Happiness with life
as whole Scale; IQR, Interquartile Range; IS, Internalizing Scale; LEA, Living Environment Area; LSOA, Lower layer Super Output Area; LSS, Life Satisfaction Scale; K-CPT, Kiddies
Continuous Performance Task; NDVI, Normalized Difference Vegetation Index; nSES, neigborhood Socio-Economic Status; PedsQL, Pediatric Quality of Life scale; PM
, Particulate
Matter > 2.5
m; PRS, Perceived Restorativeness Scale; SA2, Statistical Area 2; SAVI, Soil-Adjusted Vegetation Index; SDQ, Strengths and Difficulties Questionnaire; SES, Socio-Economic
Status (i.e., family income, parental education and/or parental employment); TCI, Tree Cover Index; TDIW, Ten Domain Index of Happiness; TDS, Total Difficulties Scale; VCF, Vegetation
Continuous Fields.
Int. J. Environ. Res. Public Health 2018,15, 2668 8 of 17
3.3. Evaluation of Evidence
3.3.1. Emotional and Behavioral Difficulties
As mentioned earlier, nine studies evaluated emotional and behavioral difficulties in children using
the internationally validated Strengths and Difficulties Questionnaire (SDQ), giving opportunities for
the comparison of respective results. All but one study relied on the parent-rated version, although
a teacher-rated version and a self-rated variant suitable from age eleven, were equally available.
The SDQ consisted of five domains, i.e., emotional symptoms, peer problems, hyperactivity and
inattention symptoms, conduct problems and prosocial behavior. The first four domains could
be summed up resulting in the Total Difficulties Score (TDS), a measure of general mental health.
Additionally, an internalizing (emotional symptoms and peer problems) and externalizing subscale
(hyperactivity and inattention symptoms and conduct problems) could be derived. However, not all
studies reported separately on these different domains or subscales. Studies differed substantially
in design, study population and assessed exposure parameters as presented in Table 1. This group
of studies described pre-school and school-aged children between the ages of 3 and 13. Seven out
of those nine studies reported on the Total Difficulties Score after adjustment for demographic and
socio-economic confounders. All of those seven studies documented a significant confounder-adjusted
association between a measure of green space exposure and the Total Difficulties Score [
Adjusting for the assessed confounders did not systematically shift the results in one direction, i.e.,
it depended on the specific city or country context whether taking into account demographic and
socio-economic confounders would strengthen or weaken the associations. Quantitative comparison of
the size of association was limited because of different exposure mapping and variation in measures of
presentation of the results, as mentioned earlier. However, where sufficient data were available,
intra-study comparison highlighted that confounder-adjusted associations between green space
exposure and the Total Difficulties Score were comparable in effect size to the associations of the
family socio-economic status (SES) with this same outcome measure [16,17,25,30].
Regarding the different domains of the SDQ, the strongest results were found for the hyperactivity
and inattention domain. Five out of six studies documented significant associations with hyperactivity
and inattention problems [
]. Smaller associations were found in four out of five studies
for peer problems [
] and less consistently in two out of five studies for conduct [
and emotional problems [
]. Richardson and colleagues [
] found a modest correlation between
prosocial behavior with the amount of residential public green space as compared to private garden
access, being the only study assessing this domain in the light of a different exposure between public
and private green spaces. Two other studies did not find associations between prosocial behavior and
measures of residential green space [18,19].
Next to the Total Difficulties Score, Feng et al. [
] and Feng and Astell-Burt [
] presented scores,
of 4 to 13 year old children, on the internalizing and externalizing subscale of the SDQ, being the only
two studies to do so. Green space quality and quantity were associated with both of the parent-rated
subscales scores for all age groups. For the oldest group in this population, i.e., age 12 to 13 years,
the associations with the internalizing subscale were tested and confirmed on the self-rated version of
the SDQ. Longitudinal results showed that associations with green space quality grew notably stronger
compared to green space quantity, in this older age group of the study population. Green space quality
was defined subjectively in this study as the parents’ answer on the question to what extent good
parks, playgrounds and spaces to play were available in their neighborhood.
Studies that analyzed different types of green space exposure showed that a shorter distance to
the nearest green space and access to a private garden were stronger associated with the SDQ than the
average amount of green space in the neighborhood [
]. Although beneficial correlations to
the SDQ scores were described for all studied age groups, longitudinal studies are not equivocally
presenting an impact of green space on the trajectory of these scores [25,26,30].
Int. J. Environ. Res. Public Health 2018,15, 2668 9 of 17
In a large, prospective twins birth cohort study, Younan et al. [
], found short—(one to three
months) and long-term (one to three years) exposure to neighborhood green space to be associated
with reduced aggressive behavior in Californian children and adolescents, as reported by parents on
the aggression subscale of the Child Behavior Checklist (CBCL). The authors described a decrease in
the CBCL-Aggression score of 0.4 points for an average of 4.86 (SD 5.03) when increasing surrounding
greenness over an interquartile range, i.e., the difference in exposure between the lowest versus highest
quartile of the population. When compared to the decline in aggressive behavior over time seen during
normal development, the decrease in aggression scores associated with higher levels of exposure to
green space was equivalent to approximately two years of behavioral maturation.
In an American cohort of adolescents, Bezold and colleagues [
] documented an 11% decrease in
depressive symptoms on the self-rated McKnight Risk Factor Survey in relationship to an interquartile
range increase in residential neighborhood greenness. In a following study, partially based on the
same data, the authors found the cumulative greenness exposure during childhood and adolescence to
be associated with a 6% decrease in the incidence of high depressive symptoms in adolescents and
young adults, with even stronger associations in highly urbanized neighborhoods [21].
No direct association between indicators of green space exposure and mental health as measured
on the self-reported 12-item General Health Questionnaire was found by Dzhambov and colleagues [
in their study based on a sample of 399 15- to 25-year olds. However, the authors detected indirect
associations of green space exposure with mental health via serial mediation of physical health,
neighborhood social cohesion and perceived restorative quality, a “measure of psychologically
restorative qualities of environmental experience grounded in attention restoration theory” [24].
3.3.2. Mental Well-Being
In the city of Houston, USA, Kim et al. [
] found that for 9- to 11-year old children, more and
larger urban green spaces in the neighborhood were positively associated with their health-related
quality of life, as reported by themselves and their mothers, on the Pediatric Quality of Life Inventory
(PedsQL). Ward et al. [
] collected objective data on 72 adolescents on time spent in green spaces
and physical activity relying on data from GPS-facilitated sports watches. Both exposure measures
showed robust associations with adolescents’ self-rated life satisfaction, well-being and happiness,
but not with their results on a computerized battery of neurocognitive tests. Time spent in green
spaces and physical activity proved to be partially interdependent but were also both independently
related to increased scores on the emotional well-being scales, with green space exposure having the
strongest relationships. It should be noted however, that this study was the only one that did not
include a measure of SES as a possible confounder in the statistical adjustment model. Huynh and
colleagues [
] did not find any significant associations for the average greenness in a 5000 m buffer
surrounding Canadian adolescents’ schools with self-reported emotional well-being on the Cantrill
ladder. Neither were Saw and colleagues [
] able to show that access or use of green spaces affected
emotional well-being of older adolescents and young adults in the tropical city of Singapore.
3.3.3. Neurocognitive Development
In the city of Berlin, Germany, Kabisch and colleagues [
] analyzed the results of community-organized
medical check-ups of pre-school in children in relation to green space exposure on a subdistrict level.
The authors found an inverse correlation between the percentage of naturally covered land and
deficits in visuo-motor and, to a lesser extent, language development. Dadvand and colleagues [
documented an enhanced twelve-month developmental progress in working memory and superior
working memory, and a reduction in inattentiveness in primary school children that were exposed
to higher levels of surrounding greenness. The authors relied on repeated computerized n-back
tests (respectively two- and three-back) and the Attention Network Task (variability of reaction time).
Results on these tests differed by +5%, +6% and
1%, respectively per interquartile range change
in total, i.e., school-based and residential, greenness exposure. Concentrations of elemental carbon,
Int. J. Environ. Res. Public Health 2018,15, 2668 10 of 17
a traffic-related air pollutant were assessed and explained 20–65% of the variances in neurocognitive
outcome. No association was found when only residential greenness was considered in contrast to the
school-based or the combined exposure. In a following study, comprising a younger population of age
four to seven, Dadvand et al. [
] found an association between specifically greater lifelong residential
green space exposure and enhanced development of sustained attention, derived from the results of
the computerized Attention Network Task and Continuous Performance Task.
Within the pool of identified articles, only one study looked at a possible relationship betwen
green space exposure and the prevalence of autism. Wu et al. [
] conducted an ecological study in
the state of California, United States, finding negative correlations between different types of green
spaces on elementary school district-level, i.e., forests, grasslands and (near road) tree canopy, and
autism prevalence, derived from an existing prevalence database. In stratified analyses based on the
road density of the school districts, these correlations remained intact in the quartile of districts with
the highest road density, but they did not in other quartiles. In these districts with the highest road
density, the authors described for every 10% increase in forest, grassland, average tree canopy and
near-road tree canopy, a decrease in autism prevalence of respectively 10%, 10%, 11% and 19%.
4. Discussion
4.1. Evidence for an Association between Green Space Exposure and Mental Health
The aim of this review was to provide an overview of observational studies assessing the
association between green space exposure and a variety of mental health outcomes in children and
adolescents. The seven studies reviewed regarding emotional and behavioral difficulties, present
credible evidence for an association between green space exposure and the Total Difficulties Score
of the Strengths and Difficulties Questionnaire, a measure of general mental health in children.
Regarding the subdomains that compose this general score, there is considerable evidence for a
consistent and significant correlation between green space exposure and hyperactivity and inattention
problems, suggested by four out of five studies assessing this subdomain. This finding is supported
by two longitudinal studies demonstrating the association between green space exposure and the
neuropsychological development of attention and working memory, relying on computer-based
tests. Furthermore, both studies that investigated the parent- and self-rated emotional well-being
and quality of life of children in the light of green space exposure did find a beneficial correlation.
Less research is available for emotional and behavioral difficulties in adolescents. However, two
studies that assessed self-rated depressive symptoms in this age group, did find an inverse correlation
with green space exposure. One study that investigated aggressive behavior in adolescents in a
longitudinal design, also found a significant inverse relationship. Emotional well-being in adolescents
was assessed in one study without finding a beneficial association. The authors of this early study,
published in 2013, assessed the effects of green spaces in a rather large exposure, i.e., 5000 m around
the adolescent’s schools [
]. This may possibly explain the absence of finding a clear association.
Later studies systematically assessed smaller exposure ranges. Two studies in this review assessed
mental well-being in young adults, however, both did not find a beneficial association with green
space exposure. A small sample size [
] and a tropical climatological setting [
] could explain these
findings. It was noted that young adults were hardly defined as a separate population, explaining
why a small number of studies focusing on 18- to 25-year olds, were identified using the predefined
inclusion criteria.
4.2. Independency of the Association
These described relationships with mental health outcomes are all associations that were adjusted
for demographic (age, gender, ethnicity) and socio-economic confounders (parental education, income,
employment), as those are suggested predictors of mental health. Results on the SDQ and other
outcome parameters after adjustment for these confounders were not systematically shifted towards
Int. J. Environ. Res. Public Health 2018,15, 2668 11 of 17
stronger, weaker or similar associations. This can be understood by the fact that in some cities or
countries green space is spread out equally between the strata of socio-economic status or ethnical
background, such as in the city of Barcelona, Spain [
]. In other settings, inequalities do exist,
e.g., in Scotland the socio-economically most deprived children had lower odds of having private
garden access or a public park in their neighborhood [
]. On the other hand, in the city of Kaunas,
Lithuania, families of higher socio-economic status lived further away from green spaces than their
counterparts of lower socio-economic status [
]. This suggests that depending on the city or country
of interest, these confounding variables work out differently. As mentioned earlier, confounding
by ethnicity, neighborhood socio-economic status and parental mental health were assessed less
systematically. However, it could be noted that associations in studies that adjusted for these concepts
did still find significant associations in line with studies with a more modest adjustment methodology.
Therefore, based on these results, it can be presumed that there is strong evidence for an association
between green space exposure and mental health in children and adolescents, independent of the
aforementioned confounders.
4.3. Direction of the Association
Although our main hypothesis was that green space exposure causes better mental health, it could
be hypothesized that the described association between green spaces and mental health works out in
the opposite direction of what is generally presumed. This alternative, inverse hypothesis would imply
a mechanism that makes parents of a child with more mental health problems, more likely to reside in a
less green neighborhood. Longitudinal studies such as those by Dadvand et al. showed that from birth
to age 7, about 25 % of the children changed addresses, a significant percentage [
]. A clear rationale
to explain a theoretical mechanism is lacking, but since none of the included longitudinal studies
presented data on a possible association between children’s mental health problems and their odds of
moving towards less green neighborhoods, this possibility cannot yet be dismissed. Another theoretical
explanation for this alternative hypothesis could imply a gene-environment interaction making parents
with hyperactivity and attention deficits more likely to choose more stimulating neighborhoods and
thus possibly less green environments to live in. If true, this would mean that finding a greater share
of children with hyperactivity and inattention problems in less green neighborhoods is explained by a
genetic rather than an environmental risk factor. However, based on the presented evidence, parental
mental health does not seem to attenuate the documented associations fully, making this hypothesis
less plausible. Other contra-arguments regarding this alternative hypothesis can be found, as we
discuss below, in the evidence for mediating mechanisms that explain an association in the direction
from more green space exposure towards better mental health. Nonetheless, it would be valuable for
future research to assess the alternative hypothesis in depth by adjusting more profoundly for parental
mental health and specifically for relevant domains such as hyperactivity and inattention problems.
Additionally, in longitudinal research, data could be collected on children’s mental health problems
and their odds of moving towards less green environments.
4.4. Mediation of the Association
In previous work, a multitude of mediators of the association between green space and mental
health were suggested [
]. The included studies in this review, provide some evidence for the roles
of air pollution, physical activity and social interaction, adding plausibility to the causal role of
green space exposure. Firstly, the protective role of green spaces against air pollution was especially
examined for neurocognitive development outcome parameters such as (superior) working memory,
inattentiveness and autism prevalence [
]. Although this evidence is limited, it adds consistency
to the growing evidence for the concerning, detrimental role of air pollutants on children’s brain
development, increasing the odds of having an impaired attentional function and autism spectrum
disorder [
]. Research in adult populations also suspects that exposure to poor air quality increases
the odds of depression [
]. Bezold et al. found no such role for fine particulate matter as a mediator
Int. J. Environ. Res. Public Health 2018,15, 2668 12 of 17
in the association between green space exposure and depressive symptoms in adolescents [
]. In this
study, however, average levels of this subgroup of air pollutants hardly differed between the strata of
green space exposure, possibly explaining the negative findings. Buffering of noise annoyance, which
often correlates with traffic load and indirectly with air pollution, was not assessed separately as a
mediating mechanism in the included studies. However, this factor is known to be associated with
behavioral problems in children [
] and thus could be another plausible mediator that future research
could investigate.
Secondly, Ward et al. provided objective data on time spent in green spaces and physical activity
relying on data by GPS-facilitated sports watches. Spending time in green spaces was related to higher
levels of physical activity and to better mental health. Associations of green space exposure with
children’s well-being were in part attenuated by separately adjusting for their physical activity in
those green spaces, suggesting a partial mediating role for physical activity [
]. Lastly, some evidence
is available for the role of social interaction as another plausible mediator of the association. Green
space playing time, in contrast to the mere availability of green spaces [
], was strongly associated to
less peer problems, and access to public instead of private green space was modestly associated with
increased prosocial behavior [30].
Since evidence is available for the beneficial effects of green spaces on adults’ mental health [
parental mental health is a tentative mediating factor as well. Some studies adjusted for possible
confounding effects of parental mental health, however in the included studies, mediation analysis of
this factor was lacking.
4.5. Variability by Age Group
Green space exposure seems to be correlated with children’s and adolescents’ mental health in
different ways depending on their developmental level. In children, especially, the availability of
a private garden and a shorter distance from their residential address to a green space seems to be
beneficial [
]. This observation may reflect the smaller environmental circle that is accessible
at this age. For older children and adolescents, associations with mental health are found more
consistently with average greenness in the surrounding neighborhood and with the quality of green
spaces, suggesting that this age group benefits not merely from the closest green space, but rather from
green spaces of their choice, reflecting their growing autonomy [25].
4.6. Relevance of the Association
In general, concluding a causal pathway between green space exposure and children’s and
adolescents’ mental health might be preliminary. However, the presented associations are resistant
to adjustment for the most important demographic and socio-economic confounders and there is
considerable evidence for plausible mediators between exposure and outcome. Therefore, these results
warrant, from a precautionary principle, attention from policy makers, urban planners and health care
providers. The importance of green space exposure for public mental health is indicated by Younan
et al. and Dadvand et al. Based on their data, they suggest that if surrounding greenness would be
increased over an interquartile range, then respectively 12% and almost 9% percent of children in a
clinical range of aggressive behavior and superior working memory impairment, would move out of
this category [
]. This represents the fact that although individual effects can be rather small and
do not explain the majority of variance in mental health problems, the effects are apparent across the
full dimension of urban-dwelling youth and not only in the clinical range. Therefore, the effects of
green spaces are of societal importance.
4.7. Strengths and Limitations
The strengths of this systematic review lie in the number of identified articles providing
opportunities to compare results of similarly designed studies. Additionally, this review could
include some longitudinal studies, studies on adolescent populations and studies relying on objective
Int. J. Environ. Res. Public Health 2018,15, 2668 13 of 17
neuropsychological tests, which is a fairly recent evolution in this field. In contrast to the recent
systematic review of McCormick [
], this review differed in search terms and inclusion criteria,
focusing on observational studies and more prominently on reliable mental health and developmental
outcome parameters. In comparison to the earlier systematic review on the topic by Gascon et al. [
published in 2015, this review relied on a largely similar methodology, but could include 17 new
studies examining the impact of green spaces on children’s and adolescents’ mental health, proving
the emerging interest in this field of research. In addition to previous work, this review looked
at green space exposure beyond a residential environment, including the school environment and
focused in particular on the available evidence for different outcome domains. It can be noted as
a strength that beneficial associations of green space exposure with mental health are presented,
independent of the measurement instrument, i.e., multiple behavioral and quality of life questionnaires
and neuropsychological tests, and independent of the information source, i.e., parents and children.
Limitations can be identified at the study-level, noting that the assessment of green space
exposure differed largely between studies, although this difference also provided opportunities
to assess which green space exposure concepts might be beneficial in particular. Additionally, the
comparison of outcome results for high and low exposure groups were generally conducted within a
given geographical region, making it difficult to define an optimal, absolute amount of green space
exposure. Furthermore, it can be noted that mental health problems in adolescents such as addiction,
that are not easily detected by general questionnaires as the SDQ or CBCL, fell out of the scope of
this review.
At review-level, despite the thorough exploration of relevant keywords prior to the final search, an
incomplete retrieval of results relying on the selected search terms and databases cannot be excluded.
However, no additional studies were detected via the references of the search results and all studies
matching the inclusion criteria mentioned in earlier systematic reviews were identified, suggesting
that the conducted search was fairly adequate. Grey literature, i.e., publications by organizations or
governments published outside of the traditional academic journals, was not systematically searched.
Although urbanization occurs most quickly in terms of geography—in Africa and Asia—, and —in
terms of economics—, in low- and middle-income countries [
], none but one study collected data in
these settings.
4.8. Future Research Suggestions
Based on our discussion and the aforementioned limitations, it would be valuable if future
research would assess differential effects of varying green space exposure concepts (i.e., time spent
in, proximity and quality of green spaces etc.) and different exposure ranges simultaneously,
taking into account non-residential exposure such as exposure in school and leisure environments.
This future research could be particularly valuable in guiding policy-making and urban planning
more concretely. Analogously, future reviewers of literature might benefit from using a broader
set of keywords concerning non-residential green spaces. Keywords such as ‘natural environment’,
‘natural playground’, ‘green schoolyard’ etc., were up to now used to a rather limited extent within
the field. However, these keywords might gain traction in the coming years as can be suspected
from publications that appeared after the final search for this review had been conducted [
For reasons of comparability, use of the same outcome measures as in earlier research, such as the
SDQ, is recommended. This instrument can be used for adolescent populations as well, since the
questionnaire is validated for individuals up to 17 years old. The parent-based CBCL or the Youth
Self Report are other valuable alternatives, since they provide broader and more clinical information.
To overcome biases introduced by single informant questionnaires, the use of multi-informant variants
are recommended. Research that addresses mental health problems outside the scope of the frequently
used questionnaires would be welcomed. Gaming and internet addiction could be such a topic
of interest since it can be hypothesized that screen time and green space exposure are inversely
correlated [
] and since horticultural therapy has been mentioned as a relevant intervention in the
Int. J. Environ. Res. Public Health 2018,15, 2668 14 of 17
context of addiction [
]. Studying the role of green spaces seems particularly valuable in rapidly
urbanizing and highly urbanized countries in Northeast Asia where internet addiction is reported to
be highly prevalent [42].
Additionally, it could be valuable for this line of research to add biological correlates of mental
health to the outcome parameters for comparison with questionnaires and neurocognitive tests.
Recently, hair cortisol analysis in children [
] and neuro-immunological measures [
] and mobile
neuro-imaging [45] in adults were introduced in this field.
Furthermore, to shed light on other confounding and/or mediating variables of the established
associations, future studies could try to build models assessing the separate roles of air and noise
pollution, physical activity, social interaction and parental mental health. Longitudinal studies with
broad screening tools adapted to different age groups are welcomed to investigate the impact on the
developmental process and to raise the probability of causality. Attention should be paid to change of
address during follow-up as mentioned earlier.
Finally, studies in rapidly urbanizing African and Asian countries seem to be very relevant for
policy guidance.
5. Conclusions
In children and adolescents, there is significant evidence for an inverse relationship between green
space exposure and emotional and behavioral problems. These beneficial associations are resistant to
the adjustment for demographic and socio-economic factors and thus may represent an independent
link. The presented evidence suggests potential partial mediation via physical activity, buffering of
air pollution and social interaction. Future research is needed to shed more light on confounders,
mediators, varying impacts during development and causality. The presented findings warrant the
attention of policy makers, urban planners and health care workers in order to protect the mental health
of children and adolescents in an urbanizing world, by providing sufficient exposure to green spaces.
Author Contributions:
Conceptualization, G.-J.V.; methodology, G.-J.V.; analysis, G.-J.V.; Writing—original draft
preparation, G.-J.V.; Writing—review and editing, M.D.; supervision, M.D.
Funding: This research received no external funding.
Conflicts of Interest: The authors declare no conflicts of interest
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... Exposure to green space has been shown to have beneficial effects on mental health (e.g. Gascon et al., 2015;Hartig et al., 2014;Houlden et al., 2018;Meredith et al., 2020;Tillmann, Tobin, et al., 2018;Van den Berg et al., 2015;Vanaken & Danckaerts, 2018). However, in parallel with the increase in mental health problems, urbanisation is growing. ...
... not looking at a specific green space type) have pointed at better mental health (Van den Berg et al., 2015) and better emotional and behavioural functioning for children (Vanaken & Danckaerts, 2018) with an increase in the quantity of surrounding greenness. Therefore, studies looking at availability of or proximity to a specific type of green space may benefit from adding other green space types as covariates. ...
... Even though research shows clear benefits of generic green space on mental health (e.g. Gascon et al., 2015;Hartig et al., 2014;Houlden et al., 2018;Meredith et al., 2020;Tillmann, Tobin, et al., 2018;Van den Berg et al., 2015;Vanaken & Danckaerts, 2018), our scoping review highlights a need for scholars to think beyond green space as a uniform landscape type. Future research should be interdisciplinary-integrating the natural, social and health sciences with the involvement of urban designers and planners-to measuring specific green space types and characteristics and assess their effects on mental health. ...
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Green space matters for mental health but is under constant pressure in an increasingly urbanising world. Often there is little space available in cities for green areas, so it is vital to optimise the design and usage of these available green spaces. To achieve this, experts in planning, design and nature conservation need to know which types and characteristics of green spaces are most beneficial for residents' mental health. A scoping review of studies that compare different green space types and characteristics on mental health was conducted. A total of 215 (experimental, observational and qualitative) papers were included in the scoping review. This review highlights a high level of heterogeneity in study design, geographical locations, mental health outcomes and green space measures. Few of the included studies were specifically designed to enable direct comparisons between green space types and characteristics (e.g. between parks and forests). The included studies have predominantly experimental research designs looking at the effects of short‐term exposure to green space on short‐term mental health outcomes (e.g. affect and physiological stress). More studies enabled only indirect comparisons, either within the same study or between different studies. Analysis of the direction of the mental health outcomes (positive, neutral, negative) from exposure to various types and characteristics of green space found positive (i.e. beneficial) effects across all green space types. However, green space characteristics did appear to render more diverse effects on mental health, which is especially the case for vegetation characteristics (e.g. higher vegetation density can be negative for mental health). The scoping review reveals gaps in the present evidence base, with a specific need for more studies directly comparing green space types and characteristics within the same study. Proposed future research directions include the use of longitudinal research designs focusing on green space characteristics, considering actual exposure and systematically addressing heterogeneity in factors influencing the relation between green spaces and mental health (e.g. type of interaction, user experience). Read the free Plain Language Summary for this article on the Journal blog.
... Though evidence suggests clearly that contact with nature has considerable benefits for wellbeing [8][9][10], the number of children in the UK who regularly play outdoors has assume for our purposes a generally sociological approach to understanding these topics; that is, we adhere to theories of wellbeing which bridge objective life circumstances (e.g., physical health and socio-economic status) with subjective evaluations of those circumstances (e.g., judgements and emotions) [32,33]. When a person exhibits good wellbeing, they are sometimes referred to as 'flourishing', language which reflects an eudaimonic (pursuit of what is meaningful), as opposed to hedonic (pursuit of pleasurable experiences), viewpoint on happiness and living well [34]. ...
... This was also supported from children who said that: The importance of placing nature within the purview of wellbeing has been identified in a wealth of evidence. For example, current systematic reviews have found strong associations between nature connection and children's mental health and wellbeing [8][9][10] and their overall quality of life [81]. The most recent meta-analysis also found associations between one's personal connection to nature and reductions in depressive mood, anxiety, and negative affects [82]. ...
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Estimates of mental health disorders and poor wellbeing among children and young people in England are escalating. While maintaining a positive relationship with nature is thought to promote personal and collective wellbeing, children and young people are spending less time outdoors, exhibiting a lack of appreciation for the environment and degrees of ‘plant blindness’. As such, there is a pressing need on behalf of schools to address these issues, and to adapt to students’ needs for a deeper and more purposeful connection with nature. This study aimed to explore the potential of one avenue to achieving this: arts-in-nature practice. This involved utilising arts-based research methods, through which 97 children aged 7–10 drew their ‘happy place’, alongside participatory observations, and interviews and focus groups with artists and teachers, as part of the wider Eco-Capabilities project. Findings suggest that following the arts-in-nature sessions there was a significant increase in the number of children’s drawings which featured nature as a main focus. This was achieved in three ways: by drawing newfound attention to nature; by attributing increased value to nature; and by explicitly placing nature within the purview of wellbeing. As such, we argue that creative pedagogies outdoors likely enhance what we term ‘nature visibilisation’ in children, an outcome necessary for their personal wellbeing and sustainability of the environment. This has significant implications for school practice in relation to how to support children’s mental health and wellbeing, alongside boosting interest in environmental sustainability and pro-environmental behaviour.
... Neighborhood crime is also associated with poor sleep duration and quality (Mayne et al., 2021a), teenage pregnancy (Decker et al., 2018), and anxiety, depression, oppositional defiant disorder, conduct disorder, and internalizing problems (Baranyi et al., 2021). Other salient built environment attributes include noise levels and tree canopy, which affect adolescent sleep outcomes (Mayne et al., 2021b), and access to green space, which is associated with lower rates of hyperactivity and inattentive disorders (Vanaken & Danckaerts, 2018). ...
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This study examines how community-level cumulative environmental stress affects child and adolescent emotional distress and chronic health conditions both directly and indirectly through stressors at the household, family, and individual levels. Data comes from the Women and their Children’s Health (WaTCH) Study, which sought to understand the health implications of exposure to the 2010 Deepwater Horizon oil spill (DHOS) among a cohort of 596 mothers with children ages 10 to 17 in southeastern Louisiana. Community-level environmental stress was measured using a newly developed geospatial index. Household-level stressors included previous hurricane impacts, impacts of DHOS, degree of financial difficulty, and degree of housing physical decay. Family stressors included maternal depression, self-rated physical health, and degree of parenting stress. Child stress was based on perceived stress; child mental health was based on serious emotional disturbance; and child physical health was based on diagnosis of chronic illness. Structural equation modeling used weighted least squares means and variance and theta parameterization. Results showed a significant negative direct path between community-level cumulative environmental stress and child/adolescent serious emotional disturbance and chronic illness. However, the indirect relationship through household, family, and individual-level stressors was significant and positive for both child/adolescent serious emotional disturbance and chronic illness. These findings point to the centrality of the household and family in determining child and adolescent physical and mental health outcomes in communities exposed to frequent disasters and ongoing environmental stressors.
... Because we only found associations with all vegetation greenspace density but not high vegetation greenspace density this implies that the association with PE is specific to functional greenspace. Greenspace has been hypothesized to cause stress reduction (Fett et al., 2019) and several studies have found less mental health symptoms in children and adolescents (Vanaken and Danckaerts, 2018), adults (Tillmann et al., 2018), and also in patients with mental illness (Tran et al., 2022) who live in green areas. Areas with low greenspace could be targeted to improve mental health (Markevych et al., 2017; WHO Regional Office for Europe, 2016). ...
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Objective: In 2050 two-thirds of the world's population is predicted to live in cities, which asks for a better understanding of how the urban environment affects mental health. Urbanicity has repeatedly been found to be a risk factor, in particular for psychosis. Here, we explored what factors of the urban exposome underlie the association between urban characteristics and psychotic experiences (PE) in adolescents. Methods: Participants were 815 adolescents (mean age 14.84 years, SD 0.78) from an at-risk cohort (greater Rotterdam area, the Netherlands) oversampled on their self-reported emotional and behavioral problems. We used linear regression analysis to examine the association with detailed geodata on urbanicity (surrounding address density), green space density (high and low vegetation), and mixed noise levels (road, rail, air, industry, and wind power) with PE in adolescents. Analyses were adjusted for multiple socio-economic and parental confounders. Furthermore, we explored sex-interaction effects. Results: Higher surrounding address density and low greenspace density were each independently associated with more PE (B = 0.18, 95 % CI 0.02; 0.34 and B = 0.17, 95 % CI 0.01; 0.32, respectively). High mixed noise levels were only associated with more PE in boys (B = 0.23, 95 % CI 0.01; 0.46). A sex-interaction effect was found for high urbanicity (B = -0.46, 95 % CI -0.77; -0.14) and low greenspace density (B = -0.49, 95 % CI -0.73; -0.11), illustrating that these associations with PE were specific for boys. Conclusion: Multiple characteristics of living in an urban area are associated with more PE in adolescent boys. Our observations provide leads for prevention of mental health problems via urban designing.
... 45,46 Moreover, a systematic review reported that adolescents may feel more socially connected and be exposed to more green space when they are more physically active than usual, which may promote positive perceptions of satisfaction with their life. 47 As the level of PA has positive effects and the level of ST has negative effects on life satisfaction, targeting both the behaviors has the potential to increase life satisfaction of young people. This is particularly important given that only one in 5 adolescents in Bangladesh are meeting the current PA (20%) or ST (21%) guidelines. ...
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Background: The aim of this study was to evaluate the effectiveness of a school-based multicomponent physical activity intervention on mental health of adolescents. Methods: A clustered, randomized, controlled trial was employed in 8 high schools in Dhaka, Bangladesh, which were randomly assigned to either an intervention or control group; 40 students in grades 8 and 9 from each school took part in the trial (n = 160/group). Students in the intervention schools participated in a 12-week physical activity intervention with multiple components (eg, supervised circuits, lunchtime sports, health education, infographics), while control schools received no intervention. Participants completed baseline and postintervention surveys measuring depressive symptoms (Center for Epidemiologic Studies Depression Scale) and life satisfaction (Cantril Ladder), along with other sociodemographic and behavioral characteristics. Linear mixed-effects modeling was used to evaluate the intervention effects. Results: Depressive symptoms in the intervention group decreased at postintervention, but remained stable in the control group. There was an increase in life satisfaction in the intervention group and a decrease in the control group. Multivariable modeling showed that students in the intervention group had a significantly lower level of depressive symptoms (β = -4.60; 95% confidence interval, -5.76 to -3.46) and higher level of life satisfaction (β = 1.43; 95% confidence interval, 0.77 to 2.10) compared with their counterparts in the control group. Sensitivity analyses supported the positive effects of the intervention. Conclusions: Our school-based, multicomponent physical activity intervention is effective in improving mental health indicators in adolescents. Future trials should be ramped up to include schools in rural and regional settings, using robust measures of mental well-being.
... Protected areas such as parks, playgrounds, or ballfields facilitate and promote regular physical exercise, social cohesion, and a sense of community, which can positively impact mental and physical health [22]. The majority of physical health benefits result from multiple and frequent visitation, and proximity to parks is shown to increase visitation [7,18]. Amenities such as public restrooms, designated sports fields, or walking paths can improve the visitor experience and encourage long-term participation; alternately, PPAs such as forests or wilderness areas provide exposure to nature and act as barriers to noise and other environmental pollution, which can have a calming and restorative effect on the mind [6,20,21]. ...
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An increasingly vast segment of the literature examines the relationship between greenspace and pediatric health. However, the bulk of this research continues to use proximate relative greenness as a measure for exposure to the ecosystem services provisioned by natural areas, despite increasing recognition that relative greenness fails to capture the public accessibility, recreation potential, or desirability of natural areas. Thus, this present research demonstrates the use of emerging data sources that can be used in conjunction with traditional greenspace measures to improve modeling as it relates to nature’s impacts on pediatric health. Using spatial park and protected area data in concert with mobile phone location data, we demonstrate exploratory analysis on how park and protected area attributes may influence pediatric health in northwest Montana, USA. Suggestive findings concerning how the attributes of park and protected areas (i.e., conservation status, access, recreation demand) influence pediatric health (i.e., attention-deficit/hyperactivity disorder, asthma, and anxiety/mood disorders) lead us to introduce directions for future research beyond greenspace. Importantly, this research does not intend to provide definitive or generalizable findings concerning how parks and protected areas influence pediatric health. Instead, we aim to provide an initial exploration toward a larger, future body of the literature, evaluating parks and protected areas’ influence on pediatric health.
... Even short-term visits to natural spaces can have a positive impact on reducing people's stress compared to urban environments (Tyrväinen et al., 2014). There is an inverse relationship between green space exposure and emotional and behavioral problems in children (Vanaken and Danckaerts, 2018). As an important part of urban green space, park open spaces allow children to burn off excess energy, improve their motor skills, and enhance their interaction with other children. ...
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This study used meteorological monitoring, subjective thermal perception surveys, and activity records to explore the factors that affect children’s outdoor thermal comfort in China’s severely cold regions. The Universal Thermal Climate Index (UTCI) was used to determine children’s thermal benchmarks and calendar, based on which a strategy to improve thermal comfort was proposed. Results showed (1) significant differences in solar radiation and wind speed, but not in air temperature and relative humidity between different areas. (2) Different Microclimate parameters affected children’s thermal perception in different seasons: solar radiation (G) in winter, air temperature (Ta) in summer. (3) Children tolerate the UTCI changes in winter than in summer. (4) Children’s neutral UTCI in winter and summer were 9.7 °C and 17.6 °C, respectively, and its ranges were 2.3–17.1 °C and 13.6–21.7 °C, respectively. The thermal acceptability range by 80% of the interviewed children was 2.1–16.3 °C. (5) Based on these results, a thermal comfort improvement on two dimensions—children and the environment—was implemented. This study enriches basic research on children’s outdoor thermal comfort and provides a reference for the construction of urban child-friendly spaces.
... Effects on stress reduction have been evidenced, including significant reductions in cortisol, an indicator of stress [3]. Systematic reviews have demonstrated the effects on attention restoration of exposure to green space, including the alleviation of hyperactivity and inattention problems in children [27], and some evidence of attention restoration for adults [28]. In addition, Kaplan theorised similar restorative effects of environments such as museums [29], which are also provided by local authorities through the CEP funding stream. ...
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Background Over the past decade, there have been significant and unequal cuts to local authority (LA) budgets, across England. Cultural, environmental and planning (CEP) budgets have been cut by 17% between 2011 and 2019. This funding supports services such as parks, leisure centres, community development and libraries, all of which have potential to influence population mental health. We therefore investigated whether cuts to CEP services have affected mental health outcomes and the extent to which they have contributed to mental health inequalities between areas. Methods Using fixed effects regression applied to longitudinal LA-level panel data in England, we assessed whether trends in CEP spend were associated with trends in mental health outcomes, between 2011 and 2019. The exposure was CEP spend and the primary outcome was the LA-average Small Area Mental Health Index (SAMHI). Additionally, we considered subcategories of CEP spend as secondary exposures, and antidepressant prescription rate and self-reported anxiety levels as secondary outcomes, both aggregated to LA-level. We adjusted all models for confounders and conducted subgroup analysis to examine differential mental health effects of spending cuts based on the level of area deprivation. Results The average decrease in CEP spend of 15% over the period was associated with a 0.036 (95% CI: 0.005, 0.067) increase in SAMHI score, indicating worsening mental health. Amongst subcategories of CEP spending, cuts to planning and development services impacted mental health trends the most, with a 15% reduction in spend associated with a 0.018 (95% CI: 0.005, 0.031) increase in the SAMHI score. The association between cuts in CEP and deteriorating mental health was greater in more affluent areas. Conclusion Cuts to spending on cultural, environmental, planning and development services were associated with worsening population mental health in England. Impacts were driven by cuts to planning and development services in particular. Reinvesting in these services may contribute to improved public mental health.
... Greenspace (Vanaken and Danckaerts, 2018;Ye et al., 2022) Space for play, physical activity, social connection (Gemmell et al., 2022) Active travel environment ( Rothman et al., 2021( Rothman et al., , 2022 Noise (Stansfeld and Clark, 2015) Air quality (Holm et al., 2021) Traffic environment (Quistberg et al., 2022;Rothman et al., 2022) Housing (Qiu and Zhu, 2017;Nasim, 2022) Water, Sanitation (Fink et al., 2011;Ngure et al., 2014) Natural space (Lee et al., 2012) Evidence Natural spaces, biodiversity ( Salmón, 2000) Evidence for how urban environments influence child rights to culture, religion and language. Evidence for how urban environments influence children's access to play. ...
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Urban environments influence child behaviours, exposures and experiences and may affect health, development, achievement and realization of fundamental human rights. We examined the status of eleven UN Convention on the Rights of the Child articles, in a multi-case study across four global cities. Within all study cities, children experienced unequal exposure to urban environmental risks and amenities. Many violations of child rights are related to car-based transportation systems and further challenged by pressures on urban systems from rapid population increases in the context of climate change. A child rights framework provides principles for a collective, multi-sectoral re-imagination of urban environments that support the human rights of all citizens.
This paper presents an analysis of the distribution of urban spaces, parks, and other green areas in the City of Copenhagen in relation to demographic indicators, notably concerning population density and the spatial concentration of different age groups. The broad health benefits provided by urban greenery to urban dwellers are well documented in urban studies. The aim of this paper is to further contribute to this scholarship through the analysis of accessibility to green spaces by different age groups and in this way to shed light on their opportunities for health enhancing physical activity in the urban environment. The analysis is part of an ongoing study of urban density mapping based on a collaboration with the City of Copenhagen. The analysis of distribution of green spaces is based on several datasets, including location of major green spaces and parks, location, and radius of individual trees and NDVI index. The Copenhagen Municipal Plan 2019 proposes to increase social equity through physical and mental health-promoting urban planning and through provision of good quality green public spaces. The analysis shows that vulnerable groups such as the older population (≥ 65-year-olds) are not particularly challenged in terms of accessibility to green spaces. Based on this analysis, the authors formulate urban policy recommendations for meeting the targets for healthy living set by the City of Copenhagen.
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Background: The effects of residential landscape, i.e., land use and traffic, on psychosocial stress in children are unknown, even though childhood stress might negatively affect normal development. In a longitudinal study, we investigate whether the residential landscape predicts childhood psychosocial stress and whether associations are independent of noise and air pollution. Methods: Belgian children aged 6.7-12.2 (N = 172, 50.9% boys) were followed for three years (2012-2015). Information on stress was obtained using standardized behavioral and emotional questionnaires and by a measure of hair cortisol. Residential landscape, including natural, agricultural, industrial, residential areas, and traffic, in a 100-m to 5-km radius around each child's home was characterized. Cross-sectional and longitudinal associations between psychosocial stress and the residential landscape were studied using linear regression and mixed models, while adjusting for age, sex, and parental socioeconomic status. Results: Natural landscapes were positively associated with better emotional status (increased happiness and lower sadness, anxiousness, and total negative emotions, β = 0.14-0.17, 95% CI = 0.01-0.30). Similarly, we observed an inverse association between residential and traffic density with hyperactivity problems (β = 0.13-0.18, 95% CI = 0.01-0.34). In longitudinal analyses, industrial area was a predictor of increases in negative emotions, while a natural landscape was for increases in happiness. Only the effect of natural landscape was partly explained by residential noise. Conclusion: Residential greenness in proximity to a child's residence might result in a better childhood emotional status, whereas poorer emotional status and behavioral problems (hyperactivity problems) were seen with residential and industrial areas and increased traffic density in proximity to a child's home.
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The effect of horticultural therapy (HT) on immune and endocrine biomarkers remains largely unknown. We designed a waitlist-control randomized controlled trial to investigate the effectiveness of HT in improving mental well-being and modulating biomarker levels. A total of 59 older adults was recruited, with 29 randomly assigned to the HT intervention and 30 to the waitlist control group. The participants attended weekly intervention sessions for the first 3 months and monthly sessions for the subsequent 3 months. Biological and psychosocial data were collected. Biomarkers included IL-1β, IL-6, sgp-130, CXCL12/SDF-1α, CCL-5/RANTES, BDNF (brain-derived neurotrophic factor), hs-CRP, cortisol and DHEA (dehydroepiandrosterone). Psychosocial measures examined cognitive functions, depression, anxiety, psychological well-being, social connectedness and satisfaction with life. A significant reduction in plasma IL-6 level (p = 0.02) was observed in the HT intervention group. For the waitlist control group, significant reductions in plasma CXCL12 (SDF-1α) (p = 0.003), CXCL5 (RANTES) (p = 0.05) and BDNF (p = 0.003) were observed. A significant improvement in social connectedness was also observed in the HT group (p = 0.01). Conclusion: HT, in reducing plasma IL-6, may prevent inflammatory disorders and through maintaining plasma CXCL12 (SDF-1α), may maintain hematopoietic support to the brain. HT may be applied in communal gardening to enhance the well-being of older adults.
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Background: Natural environments, including green spaces, may have beneficial impacts on brain development. However, longitudinal evidence of an association between long-term exposure to green spaces and cognitive development (including attention) in children is limited. Objectives: We evaluated the association between lifelong residential exposure to green space and attention during preschool and early primary school years. Methods: This longitudinal study was based on data from two well-established population-based birth cohorts in Spain. We assessed lifelong exposure to residential surrounding greenness and tree cover as the average of satellite-based normalized difference vegetation index and vegetation continuous fields, respectively, surrounding the child's residential addresses at birth, 4-5 y, and 7 y. Attention was characterized using two computer-based tests: Conners' Kiddie Continuous Performance Test (K-CPT) at 4-5 y (n=888) and Attentional Network Task (ANT) at 7 y (n=987). We used adjusted mixed effects models with cohort random effects to estimate associations between exposure to greenness and attention at ages 4-5 and 7 y. Results: Higher lifelong residential surrounding greenness was associated with fewer K-CPT omission errors and lower K-CPT hit reaction time-standard error (HRT-SE) at 4-5 y and lower ANT HRT-SE at 7 y, consistent with better attention. This exposure was not associated with K-CPT commission errors or with ANT omission or commission errors. Associations with residential surrounding tree cover also were close to the null, or were negative (for ANT HRT-SE) but not statistically significant. Conclusion: Exposure to residential surrounding greenness was associated with better scores on tests of attention at 4-5 y and 7 y of age in our longitudinal cohort.
Greening schoolyards is an initiative to reconnect children with nature and afford meaningful experiences that foster children’s well-being. To strengthen the empirical basis for greening schoolyards, we conducted a longitudinal prospective intervention study with a two-year follow-up, to investigate the impact of greening schoolyards on schoolchildren’s (age 7–11) appreciation of the schoolyard, and their physical, cognitive, and social-emotional well-being. Data were collected amongst nine elementary schools in moderate-to-high-urbanized areas in The Netherlands with approximately 700 children at each measurement. At baseline, all nine schoolyards were paved. Five schools greened their schoolyard between baseline and first-follow-up. Objective measurements included accelero-based measurements of physical activity during recess, attentional tests (Digit Letter Substitution Test, Natu & Argwal, 1995; Sky Search Task, Manly et al., 2001) and a social orientation test (Social Orientation Choice Card, Knight, 1981). Self-report questionnaires included children’s appreciation of the schoolyard (naturalness, likability, attractiveness and perceived restoration), and their social- and emotional well-being (Strength and Difficulties Questionnaire, van Widenfelt, Goedhart, Treffers & Goodman, 2003; Social Support, RIVM, 2005; Pediatric Quality of Life Inventory, Varni, Seid & Kurtin, 2001). Multilevel data analyses support our expectation that greening has a positive impact on children’s appreciation of the schoolyard, their attentional restoration after recess and social well-being. Furthermore, our results indicate that greening stimulates physical activity of girls. We found no impact on emotional well-being. These findings provide some support for the relevance of greening schoolyards and may guide further development of schoolyards that facilitate the well-being of schoolchildren.
Features of the natural environment such as tree canopy and green space have been found to promote health and well‐being; however, minimal research has investigated potential benefits of nature near schools for early childhood development. This study examined differences in teacher ratings of preschoolers’ socio‐emotional and behavioral functioning in relation to the presence of natural elements (e.g., trees, parks) near children's homes and schools. Students’ development of emotional and behavioral regulatory skills was the greatest when there were high levels of tree canopy either at home or school. Additionally, students developed greater independence and social skills when their schools were in neighborhoods with limited impervious surface (e.g., concrete); this trend was the most pronounced for students from neighborhoods low in impervious surface. Further, results suggested that associations with tree canopy may fluctuate seasonally (i.e., stronger relationships in the spring) and that the potential impact of school nature may depend on levels of home nature exposure. Although not yielding causal evidence regarding the impact of nature exposure or the effectiveness of greening interventions, findings suggest that school administrators and city planners could collaborate to maximize potential benefits of greening efforts near schools or within their catchment zones. Natural features near schools are associated with early childhood development. Preschoolers near more trees and fewer built features improved most in socio‐emotional competencies. Associations may fluctuate by season and depend on the level of exposure near children's homes.
Purpose: Exposure to nature, particularly vegetation (greenness), may be beneficial for mental health. We investigated whether higher surrounding greenness in early life was associated with subsequent reduced risk of depressive symptoms and whether this association was modified by age, sex, or population density. Methods: Participants from the Growing Up Today Study were included if they reported on depressive symptoms between 1999 and 2013. Greenness exposure was characterized as the cumulative average normalized difference vegetation index value (1000 m resolution) from 1989 until 2 years before outcome assessment or age 18 based on geocoded addresses. We defined high depressive symptoms as the top 10% of scores on the McKnight Risk Factor Survey or the Center for Epidemiologic Studies of Depression scale, depending on the questionnaire. Data were analyzed using Cox proportional hazards model adjusted for socioeconomic status and other confounders. Results: There was a 6% lower incidence of high depressive symptoms associated with an interquartile range increase in greenness (95% confidence interval, 11%-0%). This relationship was stronger in higher population density areas (>1000 people/mi2, 8% lower incidence, 95% confidence interval 15%-1%). Conclusions: Living in an area with greater surrounding greenness during childhood may be beneficial for mental health, particularly in more urban areas.
The aim of this paper was to review studies analyzing the associations between air pollution and neurodevelopment in children as well as the effect on adult population. Effect of prenatal exposure to polycyclic aromatic hydrocarbons (PAHs, benzo[a]pyrene, B[a]P) were already studied on cohorts from New York, Poland, China, and Spain. All results indicate changes of child behavior and neurodevelopment at the age of 3-9 years, decrease of IQ, increase of Attention Deficit Hyperactivity Disorder (ADHD), decrease of brain-derived neurotrophic factor (BDNF), reduction of left hemisphere white matter. Effect of traffic-related air pollution (TRAP) to neurobehavioral development in children, measured as PM2.5 (particulate matter <2.5 µm), PM10, elemental carbon (EC), black smoke (BC), NO2, NOx, were studied in USA, Spain, Italy, and South Korea. Increased concentrations of TRAP were associated with the increase of ADHD, autism, affected cognitive development; PM2.5 decreased the expression of BDNF in placenta. Increased concentrations of PM2.5 affected adults cognition (episodic memory), increased major depressive disorders. Increased concentrations of NO2 were associated with dementia, NOx with Parkinson's disease. Increased concentrations of PAHs, PM2.5 and NO2 in polluted air significantly affect central nervous system in children and adults and represent a significant risk factor for human health.
Purpose: Exposure to nature and natural environments may be beneficial for mental health; however, most population-based studies have been conducted among adults whereas few have focused on adolescents. We aimed to investigate the relationship between both greenness (vegetation) and blue space (water), and depressive symptoms among teenagers in the United States. Methods: The study population included 9,385 participants ages 12-18 in the 1999 wave of the Growing Up Today Study. We characterized greenness exposure using the Normalized Difference Vegetation Index at a 250-m and 1,250-m radius around a subject's residence using data from the moderate-resolution imaging spectroradiometer onboard the National Aeronautics and Space Administration's Terra satellite. Exposure to blue space was defined as the presence of blue space within a 250-m and 1,250-m radius and distance to the nearest blue space. We used logistic regression models to examine associations with high depressive symptoms, measured using self-reported responses to the McKnight Risk Factor Survey. Results: An interquartile range higher peak greenness in the 1,250-m buffer was associated with 11% lower odds of high depressive symptoms (95% confidence interval .79-.99). Although not statistically significant, this association was stronger in middle school students than in high school students. No such association was seen for blue spaces. Conclusions: Surrounding greenness, but not blue space, was associated with lower odds of high depressive symptoms in this population of more than 9,000 U.S. adolescents. This association was stronger in middle school students than in high school students. Incorporating vegetation into residential areas may be beneficial for mental health.
Conference Paper
Recent studies have shown that pleasant and unpleasant emotions could be detected through functional Near-Infrared Spectroscopy (fNIRS). This study investigates the prefrontal cortical activation in human subjects while they were viewing urban and garden scenes. A multi-channel continuous wave fNIRS system was used to record the prefrontal cortical activations from seven subjects. During the data collection, the subjects viewed 40 trials of video clips. In each trial, the subjects viewed a video of randomized urban or garden scenes for 30s followed by 30s of idle scene which showed a dark blue progress bar on black background on the screen. NIRS-SPM is employed to work out the changes of hemoglobin response and the prefrontal cortical activations were generated using group analysis based on the contrasts of urban versus idle, garden versus idle and urban versus garden. The activation for the contrast of urban versus garden showed an increase of oxy-hemoglobin on the right area of the prefrontal cortex with p <; 0.05. This preliminary result showed that the garden scene might provide a pleasant and less stressful experience as compared to the urban scene for subjects. This suggests the possibility of using a NIRS-based Brain-Computer Interface to detect subject preferences of different scenes.
Background: Urban greenspace can benefit mental health through multiple mechanisms. They may work together, but previous studies have treated them as independent. Objectives: We aimed to compare single and parallel mediation models, which estimate the independent contributions of different paths, to several models that posit serial mediation components in the pathway from greenspace to mental health. Methods: We collected cross-sectional survey data from 399 participants (15 – 25 years of age) in the city of Plovdiv, Bulgaria. Objective “exposure” to urban residential greenspace was defined by the Normalized Difference Vegetation Index (NDVI), Soil Adjusted Vegetation Index, Tree cover density within the 500-m buffer, and Euclidean distance to the nearest urban greenspace. Self-reported measures of availability, access, quality, and usage of greenspace were also used. Mental health was measured with the General Health Questionnaire. The following potential mediators were considered in single and parallel mediation models: restorative quality of the neighborhood, neighborhood social cohesion, commuting and leisure time physical activity, road traffic noise annoyance, and perceived air pollution. Four models were tested with the following serial mediation components: (1) restorative quality  social cohesion; (2) restorative quality  physical activity; (3) perceived traffic pollution  restorative quality; (4) and noise annoyance  physical activity. Results: There was no direct association between objectively-measured greenspace and mental health. For the 500-m buffer, the tests of the single mediator models suggested that restorative quality mediated the relationship between NDVI and mental health. Tests of parallel mediation models did not find any significant indirect effects. In line with theory, tests of the serial mediation models showed that higher restorative quality was associated with more physical activity and more social cohesion, and in turn with better mental health. As for self-reported greenspace measures, single mediation through restorative quality was significant only for time in greenspace, and there was no mediation though restorative quality in the parallel mediation models; however, serial mediation through restorative quality and social cohesion/physical activity was indicated for all self-reported measures except for greenspace quality. Conclusions: Statistical models should adequately address the theoretically indicated interdependencies between mechanisms underlying association between greenspace and mental health. If such causal relationships hold, testing mediators alone or in parallel may lead to incorrect inferences about the relative contribution of specific paths, and thus to inappropriate intervention strategies.