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The current review aimed to explore the association between urban greenspaces and health indicators. In particular, our aims were to analyze the association between publicly accessible urban greenspaces exposure and two selected health outcomes (objectively measured physical activity (PA) and mental health outcomes (MH)). Two electronic databases—PubMed/Medline and Excerpta Medica dataBASE (EMBASE)—were searched from 1 January 2000 to 30 September 2020. Only articles in English were considered. Out of 356 retrieved articles, a total of 34 papers were included in our review. Of those, 15 assessed the association between urban greenspace and PA and 19 dealt with MH. Almost all the included studies found a positive association between urban greenspace and both PA and MH, while a few demonstrated a non-effect or a negative effect on MH outcomes. However, only guaranteeing access is not enough. Indeed, important elements are maintenance, renovation, closeness to residential areas, planning of interactive activities, and perceived security aspects. Overall, despite some methodological limitations of the included studies, the results have shown almost univocally that urban greenspaces harbour potentially beneficial effects on physical and mental health and well-being.
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Int. J. Environ. Res. Public Health 2021, 18, 5137.
Association between Urban Greenspace and Health:
A Systematic Review of Literature
Vincenza Gianfredi
, Maddalena Buffoli
, Andrea Rebecchi
*, Roberto Croci
, Aurea Oradini-Alacreu
Giuseppe Stirparo
, Alessio Marino
, Anna Odone
, Stefano Capolongo
and Carlo Signorelli
School of Medicine, University Vita-Salute San Raffaele, 20132 Milan, Italy; (V.G.); (R.C.); (A.O.-A.); (G.S.); (A.M.); (C.S.)
Architecture, Built Environment and Construction Engineering Department, Politecnico di Milano,
20133 Milan, Italy; (M.B.); (S.C.)
Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 20158 Milan, Italy;
* Correspondence:
Abstract: The current review aimed to explore the association between urban greenspaces and
health indicators. In particular, our aims were to analyze the association between publicly accessible
urban greenspaces exposure and two selected health outcomes (objectively measured physical
activity (PA) and mental health outcomes (MH)). Two electronic databases—PubMed/Medline and
Excerpta Medica dataBASE (EMBASE)—were searched from 1 January 2000 to 30 September 2020.
Only articles in English were considered. Out of 356 retrieved articles, a total of 34 papers were
included in our review. Of those, 15 assessed the association between urban greenspace and PA and
19 dealt with MH. Almost all the included studies found a positive association between urban
greenspace and both PA and MH, while a few demonstrated a non-effect or a negative effect on MH
outcomes. However, only guaranteeing access is not enough. Indeed, important elements are
maintenance, renovation, closeness to residential areas, planning of interactive activities, and
perceived security aspects. Overall, despite some methodological limitations of the included
studies, the results have shown almost univocally that urban greenspaces harbour potentially
beneficial effects on physical and mental health and well-being.
Keywords: physical activity; mental health; depression; anxiety; stress; green areas; green
infrastructures; urban greenery; urban health; non-communicable diseases
1. Introduction
Nowadays, humans live in a predominantly urban world. Between 1990 and 2000,
the number of people living in urban areas rose by 25% [1]. Worldwide forecasts estimate
that 6 out of 10 people will live in cities by 2030, a figure that will reach 8 out of 10 by 2050
[2]. This progressive increase has led the scientific community to explore and assess the
urban environment’s salutogenic effects [3]. On the one hand, urbanization has improved
populations’ health status, thanks to better career and education opportunities, and
increased access to essential healthcare services [4,5]. On the other hand, rapidly growing
cities pose new public health threats. Among those is the increase in social inequalities
and lifestyle-related risk factors, such as lack of physical activity and unbalanced dietary
habits [6,7], pollution and traffic, and the environmental degradation of natural areas [8];
which, in turn, increase the incidence of a vast spectrum of diseases and conditions [9,10].
Overcrowding exacerbates the risks of communicable diseases (CD), as shown by the
COVID-19 pandemic [11–13]. Urbanicity might also represent a risk factor for chronic
non-communicable diseases (NCD) and other leading causes of death and disability, such
Citation: Gianfredi, V.; Buffoli, M.;
Rebecchi, A.; Croci, R.;
Oradini-Alacreu, A.; Stirparo, G.;
Marino, A.; Odone, A.; Capolongo,
S.; Signorelli, C. Association between
Urban Greenspace and Health: A
Systematic Review of Literature. Int.
J. Environ. Res. Public Health
2021, 18,
Academic Editor: Paul B.
Received: 24 March 2021
Accepted: 8 May 2021
Published: 12 May 2021
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Licensee MDPI, Basel, Switzerland.
This article is an open access article
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Int. J. Environ. Res. Public Health 2021, 18, 5137 2 of 24
as, for instance, road traffic injuries and violent crimes. As cities exploit a large share of
the world’s natural resources, they account for a considerable contribution to climate
change-related health issues [14,15]. Urbanization’s overall health impact also depends on
specific populations’ elements of vulnerability and resilience, their ability to adapt to
environmental changes, on health services organization and urban planning. In this
perspective, the idea that urban green areas might exert health benefits dates back to the
early 1800s. Healthcare organizations such as the Commons Prevention Society and the
National Health Society started advocating for the creation of publicly accessible urban
green spaces, describing them as “the lungs of the city” [16].
In more recent times, the World Health Organization (WHO) Regional Office for
Europe has launched a “WHO European Healthy Cities Network”, which embodies a
“Healthy Cities” vision. Moreover, referring to the “Urban Health Rome Declaration” at
European meeting “G7 Health”, which defines the strategic aspects and actions to
improve Public Health into the cities, and referring to the Agenda 2030, in which the 11th
Sustainable Development Goal (SDG) argues about “Sustainable Cities and Communities.
Make cities and human settlements inclusive, safe, resilient and sustainable”, one of the
most expressive syntheses of the challenging relationship between urban planning and
Public Health is stated by World Health Organization (WHO, 2016): “Health is the
precondition of urban sustainable development and the first priority for urban planners”.
According to the project’s programmatic framework, “cities’ healthiness level is indicated
“by a process, not an outcome”. The Network defines “a healthy city” as “one that
continually creates and improves its physical and social environments and expands the
community resources that enable people to mutually support each other in performing all
the functions of life and developing to their maximum potential” [17]. Several studies
have shown that green areas can improve general well-being [18], self-perceived health
status [19,20], increase physical activity (PA) levels [21,22], curb morbidity and rise life
expectancy [23], satisfaction with their housing situation, jobs, and life perspectives [24].
However, the evidence is still somehow ambiguous. Previous research failed to univocally
and conclusively demonstrate the beneficial effect of urban green space on both physical
and mental health [25,26]. This is probably due to high heterogeneity in the population’s
characteristics, study period, sample size and study design, but also due to the green area
and infrastructure features included and analyzed.
In light of the above considerations, the current review’s broader objective was to
explore the association between urban greenspaces and health indicators. The specific aim
was to analyze the direction and strength of the association between urban greenspaces
exposure and two selected health outcomes: objectively measured PA, and mental health
(MH) outcomes in Organization for Economic Co-operation and Development (OECD)
countries. Our ultimate goal was to critically appraise the available evidence so as to offer
material to inform future community-based urban planning strategies and public health
policy initiatives.
2. Materials and Methods
The methods for this systematic review were designed following the Cochrane
Collaboration’s recommended approach [27]. We conducted each phase of the study and
reported its results according to the Preferred Reporting Items for Systematic Reviews and
Meta-Analysis (PRISMA) [28] and the Meta-analysis Of Observational Studies in
Epidemiology (MOOSE) [29] guidelines.
2.1. Search Methods for Study Retrieval
Studies were retrieved by searching two electronic databases, PubMed/Medline and
Excerpta Medica dataBASE (EMBASE). The search strategy was developed in September
2020 by pooling predetermined keywords launched at first on PubMed/Medline and then
adapted for EMBASE. Whenever possible, controlled vocabulary thesauruses—PubMed’s
MeSH (Medical Subject Headings) and EMBASE’s Emtree—were used to explore broader
Int. J. Environ. Res. Public Health 2021, 18, 5137 3 of 24
content. Items were logically combined with the Boolean operators “AND”, “OR” and
“NOT”. The full search strategy is available in Supplementary Table S1. The list of
references was also screened to identify any additional eligible studies. Finally, experts in
the field were consulted. We developed a standardized protocol to identify the research
question, formulate the search strategy, set inclusion and exclusion criteria and select
quality appraisal tools for primary studies. The protocol was shared and discussed within
the research team and fully approved before starting the review.
2.2. Inclusion and Exclusion Criteria
Since we focused on the association between urban greenspaces objectively
measured physical activity (PA) and mental health (MH), we only included original
papers measuring PA objectively through accelerometer, pedometer, video recording or
similar devices. For MH outcomes, we assessed a plurality of domains, including, but not
limited to, the most prevalent MH disorders, such as depression, anxiety, and
psychosocial stress. Outcomes could be calculated as continuous or dichotomic,
indifferently. Moreover, we accepted both self-reported measures and data extracted from
clinical databases and repositories or self-assessed by interviews for MH outcomes. As for
publicly accessible of urban greenspace exposure, we referred to the general definition
reported in 2016 by the WHO Regional Office for Europe (EURO): “public green areas
used predominantly for recreation such as gardens, zoos, parks and suburban natural
areas and forests, or green areas bordered by urban areas that are managed or used for
recreational purposes” [30]. However, we also relied on a more detailed definition issued
by a 2017 EURO brief for action [31]. We finally synthesized the theoretical framework
with extensive consultation of experts in the field. Details are provided in Supplementary
Table S2.
Furthermore, to improve the internal validity, we set a geographic limit, including
only studies conducted in the OECD area. We also opted for a language limit, selecting
only articles published in English. Lastly, we adopted a time limit, filtering for studies
after 2000. We used this time limit for several scientific reasons. Firstly, the availability of
techniques to objectively measure PA dates back to the last 10 to 15 years. Therefore, we
judged it implausible to find older studies meeting our pre-fixed criteria. A recent
systematic review indirectly confirms our hypothesis, since the earliest study assessing
the association between objectively measured PA and depression was published in 2004
[32]. Secondly, OECD’s urban areas have known profound changes over the last 20 years.
Besides, the psychiatric nosography itself has evolved, with updates to many diagnostic
criteria. Therefore, we assumed that extending the time frame of our research
indiscriminately could undermine its results, with the concrete risk of collecting
heterogeneous, poorly comparable data for both outcomes.
Finally, we excluded all non-original studies (e.g., reviews, book chapters,
correspondence, brief notes, commentaries, conference proceedings, abstracts).
Supplementary Table S3 shows a detailed description of inclusion and exclusion criteria
for both observational and interventional studies, developed in accordance with the
Population, Intervention/Exposure, Comparison, Outcomes and Study design (PEOS),
adjusted for observational studies, and extended with time and language filters, as
recommended by the Cochrane Collaboration [33].
2.3. Study Selection, Data Extraction and Quality Evaluation
All identified records were analyzed in a two-step process. First, three researchers
(G.S., R.C., A.O.-A.) independently screened titles and abstracts to assess potential
eligibility; then, eligible studies were evaluated in full. A pre-defined, customized
spreadsheet was used to extract and collect useful data (Microsoft Excel
for Windows
Redmond, WA, USA, 2007). As carried out before [34], to reduce methodological
heterogeneity and to standardize data extraction, the spreadsheet was pre-piloted by four
researchers (V.G., G.S., R.C., A.O.-A.) on 10 randomly selected records. Disagreements
Int. J. Environ. Res. Public Health 2021, 18, 5137 4 of 24
were solved by discussion among the three researchers involved in the study selection
(G.S., R.C., A.O.-A.), or by the decision of a fourth (senior) researcher (V.G.).
As carried out in previous systematic reviews [35–37], both qualitative and
quantitative data were extracted from the original studies. Qualitative data recorded
included the following items: name of the first author, year of publication, study period,
country, study design, type of urban greenspace analyzed, city where the study was
conducted, statistical analysis performed, tool used to measure PA or MH, and outcomes
domain (for PA, we differentiated between PA generally performed or performed in the
greenspace analyzed; for mental health, we specified which type of condition was
assessed, e.g., depression, anxiety, stress, etc.). Moreover, when available,
sociodemographic characteristics of the subjects were recorded (e.g., age, gender). The
quantitative data extracted included: sample size, and the most relevant results
quantifying the association between urban greenspace and PA or MH. For studies
displaying incomplete or partial data, the corresponding author was reached via e-mail
for clarifications.
The quality evaluation of the included publications was carried out independently
by three authors (A.M., G.S, and A.O.-A.) using the New-Ottawa Scale (NOS) for
observational studies [38] and the Risk of Bias-2 (RoB-2) of the Cochrane Collaboration
tool for randomized trials [39]; the National Institute of Health quality assessment tool for
pre-post intervention studies [40], as suggested by Ma et al. [41]. However, since the NOS
did not provide a checklist for cross-sectional studies, we used a modified version [42],
adapted to perform a quality assessment of cross-sectional studies. We also used the NOS
to assess the methodological quality of quasi-experimental studies, due to their
observational nature. We used the 15-item checklist proposed by Dufault and colleagues
for ecological studies [43]. Referring to the NOS, the maximum quality score (QS) is 9,
categorized as follow: QS > 7 high quality, 5 < QS ≤ 7 moderate quality, and QS 5 low
quality. For the quality assessment of randomized trials, the evaluation only allows for a
quality judgment without quantitative results ranging between high risk of bias, some
concern and low risk of bias. This is the same also for pre-post intervention, for which the
judgment can be good (if score 75%), fair (score between 75% and 25%), and poor (if
score ≤ 25%). Regarding the QS suggested by Dufault et al. for ecological studies, the
maximum score is 21 points, of which QS ≤ 7 was considered low quality, 7 < QS ≤ 14 was
considered moderate quality and lastly QS >14 was considered high quality.
3. Results
3.1. Literature Search
A total of 356 records were initially retrieved by the literature search. After duplicate
removal, 336 records were left for the title-abstract screening. Based on the title and
abstract, 282 articles were removed, while the remaining 54 were screened by reading the
full-text. In the second screening step, 20 articles were eliminated, and the reasons for
removal listed (Supplementary Table S4) [44–63]. Finally, 34 articles met all the inclusion
criteria and were thus incorporated into the qualitative synthesis [64–97]. Figure 1 shows
the selection process. The quality evaluation of the included studies is reported in
Supplementary Table S5. Most of the observational studies were judged as high quality.
In contrast, the interventional studies show some concerns for risk of bias.
Int. J. Environ. Res. Public Health 2021, 18, 5137 5 of 24
Figure 1. Flow diagram of the selection process.
3.2. Characteristics of Included Studies
Overall, the articles’ study period spanned 19 years, from 2000 [79] to 2019 [85].
Almost all the included studies (31/34, 91%) were based in a single country. Half of those
(19/34, 55%) were set in English-speaking countries (12 United States of America [71–
74,77,82,83,88,92–95], four United Kingdom [48,56,58,64], one Canada [75], one Australia
[66], one New Zealand [81]). European and Asian countries were involved in 29% (10/34)
of the articles (three Lithuania [45,47,67], two Netherlands [96,97], one Denmark [64], one
Norway [79], two Japan [85,91], and one South Korea [80]). South America was the least
represented continent, with only two studies, which both took place in Colombia [69,86]
(Table 1). The remaining three studies were multi-country based. One [70] investigated
the association between circadian variation patterns of moderate-vigorous PA and total
parks number in 10 countries. A second article explored the relationship between PA’s
quantity and urban environment features in fourteen OECD countries’ cities [90]. Finally,
a third study considered mental health indicators measured by the MHI-5 (Mental Health
Inventory-5) scale and urban greenspace characteristics in four European cities [89]. As
for the study design, 26 were observational; of them, almost all (23/34, 67%) were cross-
sectional [65,67–70,74,75,77–80,83,84,86–90,93,94,96,97]; the remaining were one cohort
[66] and two ecological study [81,82]. The other eight studies were experimental, with
Int. J. Environ. Res. Public Health 2021, 18, 5137 6 of 24
differences in nature. Five of them were pre-post intervention [44,56,65,71,75], two were
randomized [73,92] and the last one was quasi-experimental with only assessment post-
intervention [72]. For this reason, the latter was assessed as a cross-sectional study (as
reported in Supplementary Table S5). Approximately half of the included studies (14/34,
41%) assessed the health effect of parks and urban meadows (PUM) selectively [45,47,50–
56,62,64,65,67,72]; the other eleven studies combined PUM with other types of urban
green areas [64,68,69,77,79–81,88,93,94,97] (details in Table 1); three studies assessed the
association between recreational and urban gardening facilities (RUGF) and PA [63,66,70];
three studies assessed the impact of small urban greenspaces (SUG) on health outcomes
[71,75,76]; one study evaluated the health-related effect of neighbourhood green spaces
(NGS) [89], one article assessed the total urban greenspace [66]. One single article did not
specify the type of urban greenspace [78].
Table 1. Descriptive characteristics of the included studies stratified by health outcome (PA and mental health) and listed
in alphabetical order and based on study design.
Period Country
Type of
City Sample
Tool Used
Measure PA
Domain Main Results QS/9
Cerin E., 2017
Hong Kong,
North Shore,
Trent, Seattle,
PA regardless of
the setting
MVPA in urban
parks was lower
in the late
(1.2 ± 4.0 min/h)
and higher in the
afternoon (3.0 ±
4.0 min/h) of
weekend days
Cohen D.A.,
2014 [72]
2008 US
PUM Los Angeles
PA in greenspace
Average visitor
number: higher
for pocket parks
(n = 147) than
larger UGS (n =
134). Total PA
performed shows
opposite trend:
324 vs 374 METs)
Cohen D.A.,
2017 [74] 2014 US Cross-
25 US cities
PA in greenspace
Parks with
walking loops
attract 80% (95%
CI: 42–139%) [p <
0.001] more
visitors per hour
and show
increased levels
of MVPA with
90% more MET-
hours (95% CI:
49–145%) [p <
0.001] than
J.L., 2017 [75]
2015 CA Cross-
PUM Lethbridge 1646 T-test SOPARC
PA in greenspace
Only 2.7% of
adult visitors
used fitness
Int. J. Environ. Res. Public Health 2021, 18, 5137 7 of 24
equipments for
Parra D.C.,
2019 [83] 2018 US Cross-
RUGF Wellston 599 Chi
PA in greenspace
Children and
41.1% and 50.3%
of total park
respectively. A
total of 47% of
them practised
and 30% was
Ramírez P.C.,
2017 [86] 2015 CO Cross-
RUGF Bucaramanga
6722 Chi
PA in greenspace
Women more
prone to use
outdoor gyms
than men (51.7%
against 48.3%)
and to practise
intense PA levels
(W = 53.5%;
M =
J.N., 2018 [88]
2014 US Cross-
Grand Forks,
ND and East
Grand Forks,
5486 T-test SOPARC
PA regardless of
the setting
Rural parks
dwellers display
lower MPA
prevalence than
urban parks
(34%, n = 240
against 48%, n =
Sallis J.F.,
2016 [90]
North Shore,
Trent, Seattle,
10,008 SEV MEV
PA regardless of
the setting
between PA and
urban parks
presence within
0.5 Km of the
home in Ghent
(exp[β] = 1.772;
95% CI: 1.177–
2.669; p = 0.006)
and Seattle
(exp[β] = 2.064;
95% CI: 1.399–
3.045; p < 0.001)
Spengler J.O.,
2011 [93] 2005 US Cross-
Chicago 3410
PA in greenspace
Children perform
MVPA most
frequently (56.2%
boys, 55.7% girls,
p-value n.a.) in
parks with
playgrounds than
in all other UGS
Suau L.J.,
2012 [94] 2005 US Cross-
Chicago 9454
PA in greenspace
In Chicago’s
parks, PA was
greater in African
American (F =
5.027; p < 0.01)
and high-
neighborhoods (
= 5.027; p = 0
Int. J. Environ. Res. Public Health 2021, 18, 5137 8 of 24
Author, year
period Country
Type of
City Sample
Tool used to
measure PA
Outcome domain
Main results QS/2
Park S., 2018
2015 US Ecologic
al PUM Los Angeles
5975 VPA
PA in greenspace
The proportion of
park use time
spent in MVPA
(33.1%) was
lower than the
level average
Author, year
period Country
Type of
City Sample
Tool used to
measure PA
Outcome domain
Main results QS
H.B., 2017
2012 pre
and post
PA regardless of
the setting
intervention, 4.5
/day increase
in adolescents’
greenspace PA
(95% CI: 1.8, 7.2;
< 0.001)
Cohen D.A.,
2013 [71]
2011 US
d trial
e, Chapel
PA in greenspace
activities (IRR:
1.79; p < 0.001)
and the number
of activity
facilities (IRR:
1.13; p = 0
.01) are
associated with
higher park use.
activities (β = 19
± 37; p < 0.001)
and number of
activity facilities
(β = 28 ± 27; p =
0.30) are
associated also
with higher
energy expended
in the park too
Cohen D.A.,
2017 [73]
2015 US
PUM Los Angeles
52,310 DID
models SOPARC
PA in greenspace
Free classes arm
attracted more
than twice park
visits than the
frequent user
program. (p-
value n.a.).
(Among free
classes arm it was
show a 10%
increase in total
number of park
users, more than
twice the
percentage in
frequent user
program arm
total number (p-
value n.a.)
Tester J., 2009
2007 US
SUG San Francisco
2041 T-test SOPARC
PA in greenspace
increase in
visitors for PA
among children
(p < 0.05) and
Int. J. Environ. Res. Public Health 2021, 18, 5137 9 of 24
adults of both
genders (p <
.001) following
period Country
Type of
City Sample
Tool used to
measure MH
Outcome domain
Main results QS/9
S., et al., 2020
2009 LT Cross-
PUM Kaunas 1489
e logistic
being/quality of
Each increasing
hour/week of
park visits shows
a non-
association with
difficulties: (aO
= 0.98 (0.96–
[p < 0.05])
Burt T.,
et al., 2019
2015 AU Cohort Total
K10 Psychosocial
A 30% increase in
total greenspace
percentage is
protective against
both prevalent
distress (aOR =
0.69 (0.47–1.02) [
= 0.03]) and
incident K10
distress (aOR =
0.46 (0.29–0.69) [
< 0.001])
B., et al., 2014
2009 LT Cross-
PUM Kaunas 1468 LRM SDQ
being/quality of
Proximity to city
parks associated
with increased
difficulties in the
lower maternal
subgroup (beta
coefficient =
1.293, p < 0
.05, R =
Bixby H., et
al., 2015 [68]
2009 UK Cross-
UFAP and
50 largest
cities in
data: ICD-
codes X60–84
quintiles 1 vs.
5 of
coverage. RR of
death from
suicide was 1.02
(0.86–1.23) in
men and 1.10
(0.77–1.57) in
women [p < 0
for both].
Camargo D.
M., et al.,
2017 [69]
2015 CO Cross-
PUM and
SUG Bucaramanga
1392 Multiple
being/quality of
between quality
of life and: tree
conditions status
-> aPR = 1.20
perceived safety -
> aPR = 1.22
Int. J. Environ. Res. Public Health 2021, 18, 5137 10 of 24
(1.04–1.44) [
0.05 for both]
Feda D. M., et
al., 2015 [77]
2010 US Cross-
and RUGF
New York
and Buffalo 68
PSS Psychosocial
Percentage of
park area
perceived stress
= −62.573, [p <
Guite H. F., et
al., 2006 [78]
n.a. UK Cross-
(London) 2696
being/quality of
with open UGS
associated with
lowest quartile
for well being
and quality of
lifeOR = 1.69
Ihlebæk C., et
al., 2018 [79]
2001 NO Cross-
UFAP, BS Oslo 8638 Logistic
Not validated
General mental
With enhanced
exposure to UGS,
significant drop
in MH disorders
prevalence in
women (−6% p
0.049) but not in
men (−2.5% p =
Lee H. J., et
al., 2019 [80]
2015 KR Cross-
UFAP and
areas in
Not validated
Depression and
between stress
levels, depressive
symptoms and
urban green area
ratio (p < 0.005)
Pope, D., et
al., 2018 [84]
2013 UK Cross-
PUM Sandwell 1680
le logistic
GHQ-12 Psychological
Wider greenspace
associated with
reduced PD [OR
= 0.13 (0.42, 0.94)
R., et al., 2014
2008 LT Cross-
PUM Kaunas 6944
CES-D10 Depressive
Living >300 m
away from UGS
and using them
≥4 h/week
showed higher
odds 1.92 (1.11–
3.3) and 1.68
(0.81–3.48) of
A., et al., 2017
Nervous and
feelings of
depression in the
past month
Only in
Barcelona, NGS
quantity was
associated with
better MH status
(1.437 ± 0.71) p <
Van Dillen
, S.
M., et al.,
2012 [96]
2007 NL Cross-
80 Dutch
MHI-5 General mental
Perceived general
health and green
areas, had a
interaction with
the following
Int. J. Environ. Res. Public Health 2021, 18, 5137 11 of 24
quantity = 0.27
(0.013), quality
0.126 (0.066),
interaction term
0.084 (0.040)
Zhang, Y., et
al., 2015 [97]
2014 NL Cross-
Groningen 223
ANOVA MHI-5 General mental
Differences in
have a positive
and significant
mental health, β
0.15, t(245) = 2.10,
p < 0.05
Author, year
period Country
Type of
Tool used to
measure MH
Outcome domain
Main results
Nutsford, D.,
et al., 2013
2009 NZ Ecologic
of which
Mood state and
general anxiety
Better access UGS
access, and
distance (less
than 3km)
reduced the risk
of anxiety/mood
treatment by 4%
and 3%
respectively (p <
Author, year
period Country
Type of
City Sample
Tool used to
measure MH
Outcome domain
Main results QS
Coventry P.
A., et al., 2019
2017 UK
PUM York 45
for multiple
and well-
being/quality of
life/ stress and
(physical) arousal
mean difference
stress levels
across all
participants at all
locations) of −3
(4.79–2.28) [p <
P.I.,et al.,
2019 [85]
2019 JP
PUM Matsudo 24
Mood state and
general anxiety
POMS scores:
0.71 in spring and
0.896 in summer.
STAI score 0.896
and 0.933
Song, C., et
al., 2015 [91]
2014 JP
SUG Kashiwa City
STAI Anxiety and
mood state
STAI score was
lower after the
urban park walk
than after the city
area walk (urban
park: 39.0 ± 6.3;
city area: 48.4 ±
7.5; p < 0.01)
South, E. C.,
et al., 2018
2014 US
PUM Philadelphia
using time
General mental
health and
ITT analysis of
the greening
demonstrated a
reduction in
overall self-
reported poor
Int. J. Environ. Res. Public Health 2021, 18, 5137 12 of 24
MH with respect
to non-
−62.8%; 95% CI,
−86.2% to 0.4%; p
= 0.051) but a
reduction in
(−41.5%; 95%CI,
−63.6% to −5
p = 0.03)
AU: Australia; BE: Belgium; BR: Brazil; BS: “Blue” spaces; CA: Canada; CEA: Cost-effectiveness analysis; CES-D10: Center
for the Epidemiological Studies of Depression Short Form 10-items; CI: Confidence Interval; CO: Colombia; CZ: Czech
Republic; DID: Difference-in-differences; DK: Denmark; EQ5D-5L: EuroQol 5 Dimensions-5 Levels; ES: Spain; F: Fisher’s
F-test distribution; GAMM: Generalized Additive Mixed Models; GHQ-12: General Health Questionnaire-12; GIS:
Geographic Information Systems; GPS: Global Positioning Systems; Exp: Expected; HK: Hong Kong; ICD-10: International
Statistical Classification of Diseases and Related Health Problems 10; IRR: Incidence Rate Ratio; ITT: intention-to-treat JP:
Japan; K6: Kessler-6-Psychological Distress Scale; K10: Kessler Psychological Distress Scale; KR: Korea; LRM: Linear
regression model; LT: Lithuania; M: Men; METS: Metabolic Equivalents; MEV: Multiple Environmental Variable; MH:
mental health; MHI-5: The Revised Mental Health Inventory-5; MN: Minnesota; MPA: Moderate-intensity Physical
Activity; MVPA: Moderate/Vigorous Physical Activity; MX: Mexico; N: Number; ND: North Dakota; NL: Netherlands;
NZ: New Zealand; OR: Odds Ratio; PA: Physical Activity; POMS-STAI: Profile of Mood States—State Trait Anxiety
Inventory; PSS: Perceived Stress Scale; PUM: Parks and urban meadows; QS: Quality Score; RR: Relative Risk; RUGF:
Recreational and urban gardening facilities; SDQ: Strengths and Difficulties Questionnaire; SEV: Single Environmental
variable; SF-36v2: SF36 subscales for mental health; SOPARC: System of Observing Play and Recreation in Communities;
SOPLAY: System for Observing Play and Leisure Activity in Youth; STAI: State-Trait Anxiety Inventory; SUG: “small”
urban greenspaces; SWEMWBS: Short Warwick–Edinburgh Mental-Wellbeing Scale; UFAP: Urban forests and
agricultural parks; UGS: urban greenspace; UK: United Kingdom; US: United States; UWIST-MACL: Measured by the
University of Wales Institute of Science and Technology -Mood Adjective Checklist; VPA: Vigorous Physical Activity; W:
Women; aPR: adjusted Prevalence Ratio; aOR: adjusted Odds Ratio; n.a.: not available; β: β coefficient.
3.3. Tools Used to Assess Health Outcomes
PA outcomes were analysed by 15 articles [64,70–75,82,83,86,88,90,93–95] (Figure 2).
The majority of those studies (11/15, 61%), dealt specifically with urban greenspace-based
PA [71–75,82,83,86,93–95]. In contrast, a third of them (4/15, 33%) reported overall data
about the total amount of PA practised, regardless of the setting [44,50,68,70]. To
objectively measure PA, the majority of the studies used some kind of video recording
system. In more detail, nine used the System for Observing Play and Recreation in
Communities (SOPARC) [51–55,63,66,68,75], two used the System for Observing Play and
Leisure Activity in Young (SOPLAY) [93,94], whereas four studies used the accelerometer,
alone [50,62,70] or in combination with GPS and GIS [64].
MH outcomes were considered by 19 records [65–69,76–81,84,85,87,89,91,92,96,97]—
all of which seem to adopt a unified analytic approach. Indeed, they evaluate multiple
MH domains in parallel. Public MH research has clearly demonstrated high prevalence
rates of comorbidity in people living with MH disorders [98]. In community surveys of
the general population, findings of several areas of psychologic dysfunction or self-
perceived discomfort are common [99]. Well-being and quality of life were the most
frequently assessed MH outcomes (5/19 26%) [45,47,49,56,58], followed by depression
(3/19, 16%) [60,67,69], stress (4/19, 23.5%) [46,57,60,64], general mental health (4/19, 23.5%)
[59,72,76,77], anxiety and mood state (3/19, 16%) [61,65,71], and suicide [68]. The total
number of MH outcomes assessed is higher than the total included studies, because most
of them assessed more than one outcome at once. All the MH dimensions were assessed
by specific psychometric scales, often validated by the latest edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-V) [100]. Two studies analysed MH
outcomes by an unvalidated questionnaire [79,80], a record linkage [81], and another one
with purely epidemiologic methods [68]. In the latter, authors used a Poisson linear
Int. J. Environ. Res. Public Health 2021, 18, 5137 13 of 24
regression model to describe the relationship between cause-specific mortality rates for
suicide in the general population and 50 English cities’ greenspace coverage [68].
Figure 2. Number of articles stratified by health outcome (Physical Activity (PA) or Mental Health
3.4. Greenspace and Physical Activity
Across all the included studies, a positive association was found between urban
greenspaces exposure and PA levels. Main predictors of enhanced PA were: presence of
urban greenspaces in a 0.5 to 1 km radius from the subjects’ homes [90], total number of
urban greenspace in the neighborhood, and their accessibility through public transport
[70]. In a study analyzing circadian variations in PA patterns, PA levels peaked in the
afternoon (2 to 5 p.m.) and where much lower in the evening and night [70]. Urban
greenspaces with playgrounds are effective enablers of increased PA intensity in children
[93]. However, this urban greenspace feature displayed poorer results in more deprived
city neighborhoods [93,94]. Globally, rural [88] and low-income neighborhoods had
diminished use rates [82]—even more when disaggregating data by sex, with women
being the less frequent users [72]. Interestingly, the same 2014 study highlighting different
rates of women users also found an inverse relationship between park size, visitors and
PA intensity. On average, pocket parks had higher visitors, but less reported PA intensity
than broader-sized urban greenspaces [72].
One study concluded that exercise facilities and related amenities in urban
greenspaces promote PA across demographics, especially in women [86]. Besides
providing public access to [83] and ensuring regular maintenance [95] of urban
greenspaces, the total number and variety of working equipment [75], and scheduled
plans for sports activities are other aspects that need to be factored in [71].
A randomized study with four arms as follows: arm (1) free PA classes; arm (2) a
prize contest based on the number of park visits; arm (3) interventions of arms 1 and 2,
combined; arm (4) no intervention; showed that the most significant increase in PA was
reached in arms 1 and 2 [73]. Walking loops proved effective in boosting PA levels and
incrementing the total number of urban greenspace visitors [74]. Two studies investigated
the effects of urban greenspace renewals on citizenship perception, engagement and use.
The first article’s setting were low-income neighborhoods in San Francisco (USA) [95]. The
scholars proved that, after renovations were carried out in two urban greenspaces, the
average number of adult users increased between four and nine times. A 2017 Danish
study presented a project of integrated urban rebuilding. Four new UGSs were created in
Int. J. Environ. Res. Public Health 2021, 18, 5137 14 of 24
a low-income area in Copenhagen [64]. The authors report an increase in the average daily
time spent by adolescents in practising PA (+4.5 min/day, p < 0.05) [64].
Int. J. Environ. Res. Public Health 2021, 18, 5137 15 of 24
3.5. Greenspace and Mental Health
Only three out of the 19 included MH-related articles did not find a statistically
significant association between the urban greenspace and mental health. A study
comparing greenspace coverage to the cause-specific mortality rates for suicide in
England (between 2002 and 2009) reported no association between increasing quintiles of
greenspace coverage and age-standardized mortality risk ratios for suicide [68]. Similarly,
no statistically significant association was found between urban greenspace use in all
(four) European cities, except for Barcelona, where living in ‘greener’ spaces was
associated with higher Mental Health Inventory-5 (MHI-5) scale scores [89]. Lastly,
Ihlebaek et al. did not find a statistical association between MH disorders and urban
greenspace exposure in men, but only in women in a border-line inverse association [79].
All the remaining included studies found a positive association between urban
greenspace exposure and MH. Specifically, four studies considered psychosocial stress,
alone [77] or in combination with other mental health outcomes [80], both in adolescents
and adults. The main predictors of lower-level stress were a higher number of urban
greenspaces and easier accessibility, higher tree density, and the possibility of performing
leisure activities (both physical and intellectual). In particular, higher number and easier
accessibility were associated with lower levels of stress in both adolescents (in Buffalo and
New York) [77], and elderly (over 65 years old) [80]. The latter also benefited from a lower
level of depression [80]. A cohort study showed that higher tree density in the
neighbourhood was associated with a lesser degree of psychological distress among
adults (Australia) [66]. Lastly, two studies carried out a separate analysis of different
activities performed in urban greenspace to disentangle their relative contributions to
mental well-being and distress [76,84]. In a first article, people going to urban greenspace
to perform leisurely activities experienced significantly lower psychological distress than
their non- urban greenspace dweller counterparts [84]. In a second study by Coventry and
colleagues, various intellectual and motor activities proved effective in reducing stress
levels in the exposed subgroup [76].
One study was specifically focused on depressive symptoms [87], while the other
assessed both general mental health and depression. The first one was a Lithuanian study
that indicated an inverse relationship between individual-level depressive symptoms and
residential distance from urban greenspaces, which was more marked in women [87]. The
second, was a USA article exploring the effect of a social gardening program performed
in vacant urban greenspaces located in neighbourhoods with average income levels below
the poverty threshold. There were significantly lower depressive symptoms after
exposure [92], but failed to demonstrate a significant improvement of the general mental
health. On the contrary, the other two studies assessing the impact of urban greenspace
on general mental health found a positive association between higher number and easier
accessibility of urban greenspace among adults, in the Netherlands [96,97].
Four studies dealt with mental well-being/quality of life in adults and children. The
two analysing the paediatric population showed how lower urban greenspace attendance
rates were associated with increased risk of MH issues [65], where lower maternal
education level represents an additional risk factor [67]. A third study based in England
was conducted in a sample of adults. The authors showed that a lack of urban greenspace
access was significantly associated with worse mental well-being [78]. One study
conducted in Colombia considered the effect of urban greenspace on quality of life metrics
[69]. Urban greenspace accessibility, maintenance status, and perceived security were
associated with higher quality of life metrics and lower anxiety and depression levels.
Three studies explored urban greenspace’ effect on anxiety. Song and co-authors [91]
measured anxiety-related symptoms in two groups of citizens after 15 min of walking in
urban greenspaces, as opposed to urban built environments. In the second study, anxiety
levels dropped after the subjects were exposed to natural landscapes [85]. In an ecological
study, anxiety decreased for reduced urban greenspace distance [81].
Int. J. Environ. Res. Public Health 2021, 18, 5137 16 of 24
4. Discussion
The current systematic review has identified a total of 34 studies. Of those, 15
investigated the effect of urban greenspace exposure on PA and 19 on MH. Specifically,
only a small fraction of these demonstrated a non-effect or a negative impact on MH
outcomes. On the contrary, the majority reported a beneficial effect on different MH
aspects, such as levels of self-perceived stress, depressive symptoms and perceived
mental well-being. The same results were reached for PA. All the studies showed that
exposure to urban greenspaces increased PA. However, what emerged is that both health
outcomes improved substantially with the exposure to well-kept urban greenspaces.
Maintenance has also proven to be a therapeutic activity for people with MH issues. In
this perspective, the study by South et al. [92] highlighted how users’ involvement in
abandoned urban greenspaces’ renewal and maintenance, particularly in economically
deprived settings, can act as a surrogate mood-stabilizing therapy for people with
depressive disorders. Many recent pieces of evidence are coherent with our results,
identifying green space as an important factor impacting on both physical and mental
health [101
103]. In particular, Wendelboe-Nelson et al. stressed the importance of
incorporating green space during city planning and in public health policies, especially
considering the world’s growing urban population [101].
Emotional well-being is an essential aspect of overall health. Among young people,
emotional well-being helps develop intrapersonal and interpersonal relationships, with a
long-term influence on health trajectories, both in adulthood and later life stages [104]. Its
absence causes physical and MH problems. Due to the growing burden of mental
disorders in children and adults, the WHO has called on increasing knowledge levels of
emotional well-being determinants [105–107]. The complex and articulated relationship
linking urban greenspaces, emotional well-being, and health benefits involve individual
characteristics and social and physical environments’ features [108,109]. Actually, even
the paucity of the literature, Wendelboe-Nelson et al. in their work found that green
spaces may affect health in different ways and with different benefits based on
population’s characteristics (e.g., socio-economic status, age, and sex) [101]. However, as
confirmed by Lee et al., evidence is limited, especially in understanding the amount of
urban green space exposure and the related beneficial effects [102]. Moreover,
heterogeneous results have been found on how users’ characteristics might impact on
urban green space usability and consequently on the health benefits.
Many theories have been proposed to explain the association between greenspace
exposure and health gains. The first hypothesis is that greenspace exposure may represent
an opportunity for PA. PA is widely recognized as one of the most important protective
factors of many NCDs [110], including cardiovascular diseases [111], hypertension [112],
diabetes [113], obesity [114], mental disorders [32], and cancers [115,116]. However,
according to some studies, higher health gains could be reached with outdoors, rather
than indoors, PA. Outdoor PA allows for enhanced sunlight exposure, thereby facilitating
vitamin D synthesis. Vitamin D is a lipid-soluble molecule acting as a hormone [16].
Among its many biological functions, vitamin D helps regulate calcium metabolism and
exerts an immune-modulating and anti-inflammatory effect. Vitamin D deficiency has
been associated with a wide range of immune-mediated diseases, such as diabetes,
ischemic heart disease, Alzheimer’s, asthma and multiple sclerosis. Another hypothesis
postulates that greenspace attendance increases social interactions and improves
subjective well-being [117]. The fourth is the renowned “old friends hypothesis” [118].
The higher prevalence rates of allergies and immune-mediated disorders might be traced
back to reduced stimuli by antigens and microbes, caused by reduced contact with the
biodiversity-rich natural environments. This would imply that, on the contrary, increased
exposure to natural habitats, and consequently to microbial biodiversity, determines a
protective effect against infections and immune disorders.
Greenspaces can also influence social capital by providing a meeting place for users
to develop and maintain neighbourhood social bonds [23,119]. Social interactions improve
Int. J. Environ. Res. Public Health 2021, 18, 5137 17 of 24
communication skills [120,121], thereby strengthening neighbourhoods’ social bonds,
which dramatically affects perceived safety [120]. Policymaking efforts should be directed
at tackling inequities in urban greenspaces access [122]. In addition to decreasing
inequalities in terms of accessibility to green areas, it is necessary to incentivize the
increase and improvement of characteristics such as the capillarity (through urban
regeneration and greening of the available flat roofs) and the continuity of the green
infrastructures, as well as the promotion of public–private collaboration in the
maintenance of green areas in order to better involve the population and citizenship, with
positive indirect mental health outcomes. Previous studies have shown how the main
predictors of urban greenspaces use are quality and maintenance [44,72,75,102,103]. Low-
income neighbourhoods are often underprivileged in terms of natural resources; even
though urban greenspace might be present, they are often deteriorated and poorly
maintained, with vandalized or dangerous areas [82]. In the early 2000s, scholars coined
the term “environmental justice” [123] to illustrate spatial models where socioeconomic
and environmental deprivation coexisted. Further research has shown how a lack of
contact with restorative natural resources (such as urban greenspaces) is a social
determinant of health inequities, especially in vulnerable, economically disadvantages
subgroups [124]. Alongside the need for basic access to healthcare services, access to green
environments is crucial for social justice. In this perspective, public greenspaces should
be considered essential public health resources [101,106,107].
Our review underscores that mere urban greenspace presence is not enough to secure
the desired health outcomes. On the contrary, important elements that need to be
considered and reinvigorated are maintenance, access, and perceived security aspects. A
pervasive determinant of both MH and PA-related health gains was the degree to which
concrete, interactive activities were planned and disseminated to the general population.
From this perspective, our results are significant for public health experts and
policymakers involved in urban planning, community health promotion, and
improvement of health and social equity [125]. Lastly, our results are consistent with
previous and recent reviews [101–103], despite the fact that the review methodology and
inclusion/exclusion criteria were different. For instance, a scoping review approach was
used, in contrast with our systematic search. Moreover, we only included scientific
literature, whereas another study also included grey literature [103]. Another difference
is the geographical filter adopted. Indeed, in our study, we included general population
living in the OECD area; on the contrary, Callaghan et al. [103] conducted a European-
based review, while Lee et al. [102] and Wendelboe-Nelson et al. [101] did not apply
geographical restrictions. Moreover, previous reviews generically referred to green space
exposure, without focusing on urban green space, as in the current systematic review.
Another different criterion used was the time filter. In particular, we restricted our search
to articles published after 2000, whilst Callaghan [103] included studies until 2019.
Whereas, since Wendelboe et al. [101] published their study in 2011, they could not
include the last decade, and Lee et al. [102] which considers studies from 1990. Moreover,
all the previous researches only focused on mental health/well-being; on the contrary, we
included both physical activity and mental health (using several potential outcomes, such
as, for instance, well-being, anxiety, stress, and etc.). Lastly, even if previous reviews
searched in many electronic databases, the final number of included studies did not
dramatically change, and more importantly, no differences in data interpretation have
been detected.
Strengths and Limitations
However, some limitations to our results generalization and external validity need
to be acknowledged. Firstly, this was a systematic review, which was limited to only two
databases. Nevertheless, the assessment of two databases is in line with the minimum
requirements set by the PRISMA guidelines for systematic reviews. Secondly, we limited
our search to articles published in English. However, since only one article was removed
Int. J. Environ. Res. Public Health 2021, 18, 5137 18 of 24
because of this language limitation, that in any case was not relevant to our topic, we are
confident that our results are not affected by selection bias. Thirdly, in most of the cases,
the authors used a cross-sectional or a before-after design, limiting the interpretability of
the results. Moreover, the use of a cross-sectional design did not exclude reverse causality.
Fourthly, the methodological quality of the included studies was below the cut-off for
high quality. It was particularly true for interventional studies. Lastly, high heterogeneity
was detected in both study design, outcome identification and outcome measures. MH
outcomes were often grouped into macro-domains, such as depressive symptoms, anxiety
levels, psychosocial stress, and even elusive categories, such as “perceived well-being”.
The same degree of heterogeneity permeated the chosen psychometric scales. As for PA,
although the results were often operationalized as METS (metabolic equivalents), there
was heterogeneity in the tools used to derive such measures (accelerometers, SOPARC
and others). However, our study also has important strengths. It is a systematic review
that assessed more than 300 papers retrieved in two databases. Furthermore, our search
was not restricted to only one outcome. Indeed, we reviewed articles establishing
associations between several mental and physical health domains. Lastly, despite the
weaknesses of the included studies, the results were coherent in retrieving the beneficial
effects of urban green spaces and health (both physical activity and mental health).
5. Conclusions
Despite the above-mentioned limitations inherent to the current systematic review,
we can state that the different studies identified have shown an almost univocal potential
beneficial effect of urban greenspaces. Such an impact is to be ascribed, at least partially,
to a complex relationship mediated by different personal and environmental factors.
Nevertheless, such results need to be tailored to specific contexts, population
characteristics, and the level of maintenance, accessibility and perceived security of
individual urban greenspaces. Future research should help reduce the high
methodological heterogeneity, and the use of validated tools should be encouraged.
Importantly, urban greenspaces exposure should be measured more accurately by future
research. According to what is suggested and encouraged by the World Health
Organization (WHO) regarding the “urban green spaces and health” issues, both green
areas and the exposure to it should be deeply analyzed, through specific indicators. Those
indicators, for instance, could be related to: (i) indicators of green space availability (i.e.,
density and diversity of trees or percentage of green space by area, using also GIS-based
data); (ii) indicators of green space accessibility (proximity to an urban park or proportion
of green space from residence, using also GIS-based data); (iii) indicators of green space
usage (community-based survey about both frequency of attendance, and time and
methods of the green areas’ use and accessibility, different for types of users, or using
global positioning system technology, or digital gate count).
Indeed, almost all the included studies took indirect indexes, such as residential
closeness, as a proxy indicator of urban greenspaces exposure. All these elements can
improve comparability and reduce uncertainty. In this respect, joining research efforts
into consortia or multicentric studies is a plausible solution.
Supplementary Materials: The following are available online at
4601/18/10/5137/s1, Table S1: Detailed search strategy, Table S2: Definitions of urban greenspaces
used, Supplementary Table S3: Detailed description of inclusion/exclusion criteria according to a
Population, Exposure, Outcomes and Study design (PEOS), Supplementary Table S4: Articles
assessed in full and excluded with reasons, Supplementary Table S5: Quality assessment of the
included studies, in alphabetical order and stratified by study design.
Author Contributions: A.R. and R.C., conceptualized and designed the study, R.C., A.O.-A., G.S.
and V.G. analyzed and interpreted data, and wrote the manuscript. A.O.-A., G.S., R.C. and A.M.
contributed to the data collection, and managed the database. All the Authors provided important
Int. J. Environ. Res. Public Health 2021, 18, 5137 19 of 24
intellectual supports in various steps of the study. All authors have read and agreed to the published
version of the manuscript.
Funding: This research was funded by Fondazione Banco di Monte Lombardia in Italy, within the
project Green Areas & Infrastructures and Public Health Outcomes.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: All data are presented in the current manuscript (text, tables, and
supplementary material).
Conflicts of Interest: The authors declare no conflict of interest. The financier did not intervene in
data collection, selection or interpretation.
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... As an exemplary thematic field for the comprehensive integration of sex/gender into environmental health, we chose exposure to green spaces in the residential environment. Within environmental health research, green spaces and green infrastructure have been proven to be an important environmental resource of health [23][24][25][26]. Green spaces act as places for socialising, exercise and recreation [23,27,28] and can have a positive impact on physical activity as well as social and psychological well-being [29]. ...
... Within environmental health research, green spaces and green infrastructure have been proven to be an important environmental resource of health [23][24][25][26]. Green spaces act as places for socialising, exercise and recreation [23,27,28] and can have a positive impact on physical activity as well as social and psychological well-being [29]. Green spaces also reduce exposure to noise, air pollutants and intense heat and improve air quality [25,27,29]. ...
... Results from the CIT analysis for the continuous exposure variable greenness within a 300 m buffer indicated a tree with six splits leading to seven final subgroups (see Supplementary Materials S1, pp. [23][24]. The primary split was based on the degree of urbanization (SGRelationsUrbanisation) sending participants living in a city to one branch and the rest of the population to the other one. ...
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Recently, attention has been drawn to the need to integrate sex/gender more comprehensively into environmental health research. Considering theoretical approaches, we define sex/gender as a multidimensional concept based on intersectionality. However, operationalizing sex/gender through multiple covariates requires the usage of statistical methods that are suitable for handling such complex data. We therefore applied two different decision tree approaches: classification and regression trees (CART) and conditional inference trees (CIT). We explored the relevance of multiple sex/gender covariates for the exposure to green spaces, measured both subjectively and objectively. Data from 3742 participants from the Cooperative Health Research in the Region of Augsburg (KORA) study were analyzed within the INGER (Integrating gender into environmental health research) project. We observed that the participants’ financial situation and discrimination experience was relevant for their access to high quality public green spaces, while the urban/rural context was most relevant for the general greenness in the residential environment. None of the covariates operationalizing the individual sex/gender self-concept were relevant for differences in exposure to green spaces. Results were largely consistent for both CART and CIT. Most importantly we showed that decision tree analyses are useful for exploring the relevance of multiple sex/gender dimensions and their interactions for environmental exposures. Further investigations in larger urban areas with less access to public green spaces and with a study population more heterogeneous with respect to age and social disparities may add more information about the relevance of multiple sex/gender dimensions for the exposure to green spaces.
... Indeed, cities with a high density of bicycle and pedestrian paths can induce more active lifestyles [75]. At the same time, urban green space is also associated with more PA performed, which in turn is associated with physical and mental health [76]. Moreover, a recent systematic review revealed that urban green space is associated with a higher level of recreational activities performed during the day and, consequently, a lower level of distress and depressive symptoms [76]. ...
... At the same time, urban green space is also associated with more PA performed, which in turn is associated with physical and mental health [76]. Moreover, a recent systematic review revealed that urban green space is associated with a higher level of recreational activities performed during the day and, consequently, a lower level of distress and depressive symptoms [76]. Although data on leisure activities and working hours are not reported in the included primary studies, it can be assumed that most people work on weekdays and through the afternoon. ...
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Recent research suggested that daily pattern of physical activity (PA) may have an important association with depression, but findings are limited and contradictory. Our aim was to conduct a systematic review of the literature to summarize the literature evidence on the association between timing of PA and depression. A comprehensive search of PubMed/Medline and Scopus databases has been performed, and a total of five manuscripts have been thoroughly reviewed. The performed descriptive analysis shows lower levels of PA among individuals with depression or depressive symptoms, although evidence on the 24 h pattern of PA and depression is limited. An interesting finding is the association between lower PA during the morning, higher PA late in the evening (night), and depression or depressive symptoms. However, definitive conclusions could not be drawn due to the observational nature of the studies, their limited number, the high hetero-geneity in the sample populations, and the studies' differing outcome definitions and exposure assessments. Future studies considering not only the level of PA but also its daily variability might be important to further explore this novel area of research.
... Similar to the built environment, the natural environment is a multifaceted construct. Traditionally, the natural environment has been interpreted in terms of toxicity, focusing on how air pollution [9], climate change [9], natural disasters [10], and agricultural chemicals [11] negatively impact health; in terms of beneficence, focusing on the healthful benefits of exposure to nature and, more recently, urban greenspace [12]; and in terms of the "biophilia hypothesis", where humans possess an innate tendency to connect with nature [13,14]. Fewer studies focus on the nonmodifiable domains of the natural environment in which individuals reside, such as topography and climate. ...
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Background: The aim of this study was to explore the nonlinear relationships between natural amenities and health at the intersection of sociodemographic characteristics among primary care patients with chronic conditions. Methods: We used survey data from 3409 adults across 119 US counties. PROMIS-29 mental and physical health summary scores were the primary outcomes. The natural environment (measured using the County USDA Natural Amenities Scale (NAS)) was the primary predictor. Piecewise spline regression models were used to explore the relationships between NAS and health at the intersection of sociodemographic factors. Results: We identified a nonlinear relationship between NAS and health. Low-income individuals had a negative association with health with each increase in NAS in high-amenity areas only. However, White individuals had a stronger association with health with each increase in NAS in low-amenity areas. Conclusions: In areas with low natural amenities, more amenities are associated with better physical and mental health, but only for advantaged populations. Meanwhile, for disadvantaged populations, an increase in amenities in high-amenity areas is associated with decreases in mental and physical health. Understanding how traditionally advantaged populations utilize the natural environment could provide insight into the mechanisms driving these disparities.
... Our exposure of interest was the number of neighborhood parks near participants' residences. Although park access is inconsistently defined in the literature, the number of parks in a given area has often served as a proxy for this measure (Bancroft et al., 2015;Cohen et al., 2016;de Keijzer et al., 2020;Gianfredi et al., 2021;Zhang et al., 2019). We used self-reported zip codes as proxies for residential neighborhoods, as these were the smallest geographic unit collected from participants. ...
The role of parks and nature to support well-being during the COVID-19 pandemic is uncertain. To examine this topic, we used mixed-methods data collected in April–May 2020 from US adults aged ≥55 in the COVID-19 Coping Study. We quantitatively evaluated the associations between number of neighborhood parks and depression, anxiety, and loneliness; and conducted qualitative thematic analysis of participants’ outdoor experiences. Among urban residents, depression and anxiety were inversely associated with the number of neighborhood parks. Thematic analysis identified diverse engagement in greenspaces that boosted physical, mental, and social well-being. The therapeutic potential of outdoor and greenspaces should be considered for interventions during future epidemics. FREE ACCESS till July 13, 2022:
... Parks provide ample spaces for physical activity [19], contribute to restoration and stress relief [20], promote life satisfaction [21], and enable recovery from hazard-related, stressful life events [22]. Previous studies have shown that the health benefits of parks can be explained and achieved through a variety of pathways, including promoting physical activity [23][24][25][26][27], social coherence [28][29][30][31][32], and psychological well-being [33][34][35]. The contribution of parks to health varies based on park characteristics. ...
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The COVID-19 pandemic has limited people’s visitation to public places because of social distancing and shelter-in-place orders. According to Google’s community mobility reports, some countries showed a decrease in park visitation during the pandemic, while others showed an increase. Although government responses played a significant role in this variation, little is known about park visitation changes and the park attributes that are associated with these changes. Therefore, we aimed to examine the associations between park characteristics and percent changes in park visitation in Harris County, TX, for three time periods: before, during, and after the shelter-in-place order of Harris County. We utilized SafeGraph’s point-of-interest data to extract weekly park visitation counts for the Harris County area. This dataset included the size of each park and its weekly number of visits from 2 March to 31 May 2020. In addition, we measured park characteristics, including greenness density, using the normalized difference vegetation index; park type (mini, neighborhood, community, regional/metropolitan); presence of sidewalks and bikeways; sidewalk and bikeway quantity; and bikeway quality. Results showed that park visitation decreased after issuing the shelter-in-place order and increased after this order was lifted. Results from linear regression models indicated that the higher the greenness density of the park, the smaller the decrease in park visitation during the shelter-in-place period compared to before the shelter-in-place order. This relationship also appeared after the shelter-in-place order. The presence of more sidewalks was related to less visitation increase after the shelter-in-place order. These findings can guide planners and designers to implement parks that promote public visitation during pandemics and potentially benefit people’s physical and mental health.
Background The association between short-term exposure to air pollution and cognitive and mental health has not been thoroughly investigated so far. Objectives We conducted a panel study co-designed with citizens to assess whether air pollution can affect attention, perceived stress, mood and sleep quality. Methods From September 2020 to March 2021, we followed 288 adults (mean age = 37.9 years; standard deviation = 12.1 years) for 14 days in Barcelona, Spain. Two tasks were self-administered daily through a mobile application: the Stroop color-word test to assess attention performance and a set of 0-to-10 rating scale questions to evaluate perceived stress, well-being, energy and sleep quality. From the Stroop test, three outcomes related to selective attention were calculated and z-score-transformed: response time, cognitive throughput and inhibitory control. Air pollution was assessed using the mean nitrogen dioxide (NO2) concentrations (mean of all Barcelona monitoring stations or using location data) 12 and 24 hours before the tasks were completed. We applied linear regression with random effects by participant to estimate intra-individual associations, controlling for day of the week and time-varying factors such as alcohol consumption and physical activity. Results Based on 2,457 repeated attention test performances, an increase of 30 μg/m³ exposure to NO2 12h was associated with lower cognitive throughput (beta = −0.08, 95% CI: −0.15, −0.01) and higher response time (beta = 0.07, 95% CI: 0.01, 0.14) (increase inattentiveness). Moreover, an increase of 30 μg/m³ exposure to NO2 12h was associated with higher self-perceived stress (beta = 0.44, 95% CI: 0.13, 0.77). We did not find statistically significant associations with inhibitory control and subjective well-being. Conclusions Our findings suggest that short-term exposure to air pollution could have adverse effects on attention performance and perceived stress in adults.
Urban sustainability and health are two wings of the same bird. Both are complementary to each other and aim at incorporating different disciplines with a strong focus on the built environment. Urban sustainability works as a vision providing a long-term outlook of urban development, while urban health provides a context for individuals to live comfortably and communities to thrive. Both concepts have an enormous impact on all aspects of life, not in the least quality of life. This chapter provides a brief history to prove the challenge of health and well-being in the built environment. It provides a strong integration of sustainability and health with intelligence as this is needed in the years ahead. The combination of urban intelligence and digital twins as a planning tool to optimize the performance of cities and communities coveys the message that urbanization requires artificial intelligence by using smart technologies and data-driven planning solutions to enhance human and nature intelligence, not to replace them. This approach requires a holistic partnership that promotes human-centric design and intelligence into the built environment to address infrastructure challenges in cities and facilitate sustainability, health, pandemic response, adaptability, therapy, and knowledge.
Urban green spaces and the biodiversity therein have been associated with human health and well-being benefits, but the contribution of domestic gardens to those benefits is insufficiently known. Using data from a cross-sectional sample (n = 587) of domestic garden owners in Flanders and Brussels (northern Belgium), associations between residential green space quality in and around domestic gardens, green space related activities and socioeconomic background variables of the gardeners, and self-reported health (stress and depression) were investigated with structural equation models. Socioeconomic security was associated with lower stress and depression. Nature relatedness and green space in the neighbourhood of the house were associated with higher exposure to green space, which was in turn negatively associated with stress and depression. Garden quality, indicated by biodiversity values and size, and nature relatedness were associated with being active in the garden, which was in turn associated with lower values of depression, but not stress. Nature relatedness seems to play a key role in the pathway linking gardens to improved health. Improving biodiversity and ecosystems services in gardens may increase exposure to green space and help to restore and enhance nature relatedness. This, in turn, could potentially improve human health and well-being, and contribute to the conservation of biodiversity in urban environments.
In an urbanizing world, with 55% of the population living in cities, it is essential to design friendly and healthy ones. An emerging body of evidence has associated greenspace exposure with improved cognitive development, including attentional function; however, the longitudinal studies looking at the association with attentional function are still scarce. Therefore, the objective of this study was to analyze the association of the exposure to greenspace and attention in school children. This study was based on 751 participants at 8 years and 598 at 11–13 years of two sub-cohorts of the INMA cohort study in Gipuzkoa and Asturias, Spain. Greenspace exposure at home was characterized using four indicators: (i) average of Normalized Difference Vegetation Index (NDVI) and (ii) Vegetation Continuous Field (VCF) in buffers of 100 m, 300 m, and 500 m around the residential address, (ii) availability of a green space within 300 m from the residential address, and (iv) residential distance to green spaces. Participants’ attention was characterized twice at ages of 8 and 11 years, using the computerized Attentional Network Test (ANT). General linear models were used for the cross-sectional analyses and linear mixed effects model for the longitudinal analyses. Our cross-sectional analyses showed a statistical significant protective association between average NDVI at 300 m and inattentiveness (−7.20, CI 95%: 13.74; −0.67). In our longitudinal analyses, although we generally observed beneficial associations between greenspace exposure and attention, none attained statistical significance. No statistically significant indirect effect were seen for NO2. Our findings add to the emerging body of evidence on the role of green spaces in neurodevelopment, which can provide the evidence base for implementing intervention aimed at promoting neurodevelopment in urban children.
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The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement, published in 2009, was designed to help systematic reviewers transparently report why the review was done, what the authors did, and what they found. Over the past decade, advances in systematic review methodology and terminology have necessitated an update to the guideline. The PRISMA 2020 statement replaces the 2009 statement and includes new reporting guidance that reflects advances in methods to identify, select, appraise, and synthesise studies. The structure and presentation of the items have been modified to facilitate implementation. In this article, we present the PRISMA 2020 27-item checklist, an expanded checklist that details reporting recommendations for each item, the PRISMA 2020 abstract checklist, and the revised flow diagrams for original and updated reviews.
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Our aim was to assess the association between a priori defined dietary patterns and incident depressive symptoms. We used data from The Maastricht Study, a population-based cohort study (n = 2646, mean (SD) age 59.9 (8.0) years, 49.5% women; 15,188 person-years of follow-up). Level of adherence to the Dutch Healthy Diet (DHD), Mediterranean Diet, and Dietary Approaches To Stop Hypertension (DASH) were derived from a validated Food Frequency Questionnaire. Depressive symptoms were assessed at baseline and annually over seven-year-follow-up (using the 9-item Patient Health Questionnaire). We used Cox proportional hazards regression analyses to assess the association between dietary patterns and depressive symptoms. One standard deviation (SD) higher adherence in the DHD and DASH was associated with a lower hazard ratio (HR) of depressive symptoms with HRs (95%CI) of 0.78 (0.69–0.89) and 0.87 (0.77–0.98), respectively, after adjustment for sociodemographic and cardiovascular risk factors. After further adjustment for lifestyle factors, the HR per one SD higher DHD was 0.83 (0.73–0.96), whereas adherence to Mediterranean and DASH diets was not associated with incident depressive symptoms. Higher adherence to the DHD lowered risk of incident depressive symptoms. Adherence to healthy diet could be an effective non-pharmacological preventive measure to reduce the incidence of depression.
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(1) Background: The purpose of this meta-analysis was to investigate associations between physical activity (PA) and risks and mortality of liver cancer (LC) to suggest a minimum physical activity threshold to reduce LC risks and morality. (2) Methods: A database search was performed to identify relevant studies on the associations between PA and risks and mortality of LC before August 2020. The PA amounts were divided into three groups (high: ≥3 h/week, moderate: 2–3 h/week, and low: <2 h/week). The pooled relative risks of LC were calculated. (3) Results: A total of 10 prospective cohort studies were included. LC risks and mortality were 26% and 25% lower with high amounts of PA and 23% and 19% lower in moderate amounts of PA, respectively, compared to low amounts of PA. At the vigorous intensity PA level, high and moderate amounts of PA reduced the LC risk by 54% and 45%, respectively. (4) Conclusions: PA helps to reduce LC risks and mortality in a dose-dependent manner. At a minimum, two hours/week PA are mandatory to reduce LC mortality.
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Depression is one of the leading causes of disability worldwide, with more than 264 million people affected. On average, depression first appears during the late teens to mid-20s as result of a complex interaction of social, psychological and biological factors. The aim of this systematic review with meta-analysis is to assess the association between red and processed meat intake and depression (both incident and prevalent). This systematic review was conducted according to the methods recommended by the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Relevant papers published through March 2020 were identified by searching the electronic databases MEDLINE, Embase and Scopus. All analyses were conducted using ProMeta3 software. A critical appraisal was conducted. Finally, 17 studies met the inclusion criteria. The overall effect size (ES) of depression for red and processed meat intake was 1.08 [(95% CI = 1.04; 1.12), p-value < 0.001], based on 241,738 participants. The results from our meta-analysis showed a significant association between red and processed meat intake and risk of depression. The presented synthesis will be useful for health professionals and policy makers to better consider the effect of diet on mental health status.
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Aims Regular exercise is considered a cornerstone in the management of type 2 diabetes mellitus (T2DM). It improves glucose control and cardiovascular risk factors, contributes to weight loss, and also improves general well-being, likely playing a role in the prevention of chronic complications of diabetes. However, compliance to exercise recommendations is generally inadequate in subjects with T2DM. Walking is the most ancestral form of physical activity in humans, easily applicable in daily life. It may represent, in many patients, a first simple step towards lifestyle changes. Nevertheless, while most diabetic patients do not engage in any weekly walking, exercise guidelines do not generally detail how to improve its use. The aims of this document are to conduct a systematic review of available literature on walking as a therapeutic tool for people with T2DM, and to provide practical, evidence-based clinical recommendations regarding its utilization in these subjects. Data Synthesis Analysis of available RCTs proved that regular walking training, especially when supervised, improves glucose control in subjects with T2DM, with favorable effects also on cardiorespiratory fitness, body weight and blood pressure. Moreover, some recent studies have shown that even short bouts of walking, used for breaking prolonged sitting, can ameliorate glucose profiles in diabetic patients with sedentary behavior. Conclusions There is sufficient evidence to recognize that walking is a useful therapeutic tool for people with T2DM. This document discusses theoretical and practical issues for improving its use.
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(1) Background: The aim of this study is to establish which specific elements of the built environment can contribute to improving the physical activity of self-sufficient, noninstitutionalized and living in the city adults > 65 years. (2) Methods: An extensive literature search was conducted in several database. Umbrella review methodology was used to include the reviews that presented a sufficient methodological quality. (3) Results: Eleven reviews were included. The elements positively associated with physical activity in older adults were: walkability; residential density/urbanization; street connectivity; land-use mix-destination diversity; overall access to facilities, destinations and services; pedestrian-friendly infrastructures; greenery and aesthetically pleasing scenery; high environmental quality; street lighting; crime-related safety; traffic-related safety. The elements that were negatively associated with physical activity were: poor pedestrian access to shopping centers; poor pedestrian-friendly infrastructure and footpath quality; barriers to walking/cycling; lack of aesthetically pleasing scenery; crime-related unsafety; unattended dogs; inadequate street lighting and upkeep; traffic; littering, vandalism, decay; pollution; noise. (4) Conclusions: Evidence shows that specific elements of the built environment can contribute to promoting older people’s physical activity. The city restructuring plans should take into consideration these factors.
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Since the World Health Organization (WHO) declared the coronavirus infectious disease 2019 (COVID-19) outbreak a pandemic on 11 March, severe lockdown measures have been adopted by the Italian Government. For over two months of stay-at-home orders, houses became the only place where people slept, ate, worked, practiced sports, and socialized. As consolidated evidence exists on housing as a determinant of health, it is of great interest to explore the impact that COVID-19 response-related lockdown measures have had on mental health and well-being. We conducted a large web-based survey on 8177 students from a university institute in Milan, Northern Italy, one of the regions most heavily hit by the pandemic in Europe. As emerged from our analysis, poor housing is associated with increased risk of depressive symptoms during lockdown. In particular, living in apartments <60 m2 with poor views and scarce indoor quality is associated with, respectively, 1.31 (95% CI: 1046–1637), 1.368 (95% CI: 1166–1605), and 2.253 (95% CI: 1918–2647) times the risk of moderate–severe and severe depressive symptoms. Subjects reporting worsened working performance from home were over four times more likely to also report depression (OR = 4.28, 95% CI: 3713–4924). Housing design strategies should focus on larger and more livable living spaces facing green areas. We argue that a strengthened multi-interdisciplinary approach, involving urban planning, public mental health, environmental health, epidemiology, and sociology, is needed to investigate the effects of the built environment on mental health, so as to inform welfare and housing policies centered on population well-being.
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Purpose of review: The aim of this systematic review and meta-analysis was to investigate the effect of resistance training on arterial stiffness (AS) in healthy subjects. Two electronic databases (PubMed and Scielo) were searched for randomized controlled trials comparing the effect of dynamic and/or isometric resistance training stand-alone versus non-exercise control group on AS assessed by pulse wave velocity (PWV) in healthy subjects. Random-effects modeling was employed to compare delta changes (post-pre-intervention) in AS between the resistance training and control group. Data were reported as weighted mean difference (MD) and its 95% confidence intervals (CI). Statistical significance was set at 5%. Recent findings: A total of 10 studies involving 310 participants (46.5% female; resistance training groups, n = 194; control groups, n = 116) were included in the meta-analysis. Comparing changes from pre- to post-resistance training groups versus control groups, no differences were observed in PWV (MD - 1.33 cm/s (95% CI - 34.58 to 31.91), p = 0.94, I2 = 91%). Resistance training stand-alone does not elicit changes (i.e., improvement or impairment) on AS in healthy subjects, but the high heterogeneity suggests influence of training protocol and/or personal characteristics that should be investigated in the future.
The cardiac benefits of exercise have been recognized for centuries. Studies have undisputedly shown that regular exercise is beneficial for the cardiovascular system in young, old, healthy and diseased populations. For these reasons, physical activity has been recommended worldwide for cardiovascular disease prevention and treatment. Although the benefits of exercise are clear, understanding of the molecular triggers that orchestrate these effects remains incomplete and has been a topic of intense research in recent years. Here, we provide a comprehensive review of the cardiac effects of physical activity, beginning with a brief history of exercise in cardiovascular medicine and then discussing seminal work on the physiological effects of exercise in healthy, diseased and aged hearts. Later, we revisit pioneering work on the molecular mechanisms underlying the cardiac benefits of exercise, and we conclude with our view on the translational potential of this knowledge as a powerful platform for cardiovascular disease drug discovery. Moreira et al. discuss the physiological and molecular effects of exercise in healthy, diseased and aged hearts.