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B.A. Revich
Health Risk Analysis. 2023. no. 2
168
ANALYTICAL REVIEWS
UDC 613, 314.48, 57.045
DOI: 10.21668/health.risk/2023.2.17.eng Read
online
Review
ТHE SIGNIFICANCE OF GREEN SPACES FOR PROTECTING HEALTH
OF URBAN POPULATION
B.A. Revich
Institute of Economic Forecasting of the Russian Academy of Sciences, 47 Nakhimovskii Ave., Moscow, 117418,
Russian Federation
Green spaces (green infrastructure, green areas) are important components of urban environment. They are able to
mitigate health outcomes of climatic risks, exposure to urbanization and adverse environmental factors. Bigger areas cov-
ered with plants should increase their accessibility for people living in cities. Analysis of the results reported in foreign stud-
ies that addressed influence of green spaces on public health proves that they promote physical activity by urban citizens,
sports included, development of interpersonal communication and social interactions, improve mental health, and reduce
prevalence of diabetes mellitus and other diseases.
In some cases massive construction of residential housing and public buildings in Russian megacities and large cities
led to reduction in green areas. The existing construction standards in Russia do not consider the recommendation of the
WHO/Europe that requires accessibility of green spaces within a 15–20 minute walking distance and provision of 9 m2 of
green spaces per person. Utility of green spaces for public health depends on evenness of their distribution. In case their
distribution is mosaic, their benefits for public health and protection capacities are reduced.
The present review shows the importance, needs and advantages of developing green infrastructure with continuous
canopy that create potent green shading.
Keywords: public health, mental health, obesity, health risks, diabetes, physical activity, green spaces, green infra-
structure, city planning, urban studies, megacities.
Creation of large green spaces in cities is
one of few ways to protect health of people
who are exposed to the aggressive urban envi-
ronment. The issue has come into the limelight
recently due to dynamic urbanization; this
process causes a lot of concern that people in
large cities are going to have reduced contact
with natural greenness. Also, effective meth-
ods of remote sensing are available now; they
allow better quantification of green spaces re-
lying on values of the Normalized Difference
Vegetation Index (NDVI) and this provides
another incentive to investigate this issue.
Green spaces protect health since they can
function as places for recovery; places for so-
cial interaction and physical activity; they are
also able to mitigate risks of harmful exposure
to ambient air pollution, noise, and abnormally
high temperatures.
The UN Sustainable Development Goals
declare that by 2030 it is necessary to ‘provide
universal access to safe, inclusive and acces-
sible, green and public spaces, in particular
for women and children, older persons and
persons with disabilities’1. Although there is
common understanding that green spaces are
_
_
________________________
Revich B.A., 2023
Boris A. Revich – Doctor of Medical Sciences, Professor, Chief Researcher and Head of the Laboratory for Environment
Quality Prediction and Population Health (e-mail: brevich@yandex.ru; tel.: +7 (499) 129-36-33; ORCID: https://orcid.org/0000-
0002-7528-6643).
1 News UN in Russia. United Nations in the Russian Federation. Available at: http://www.unrussia.ru/en/un-in-
russia/news (January 15, 2023).
Тhe significance of green spaces for protecting health of urban population
ISSN (Print) 2308-1155 ISSN (Online) 2308-1163 ISSN (Eng-online) 2542-2308 169
necessary for protecting and improving public
health, only one review has been published in
Russian [1], which provides a general idea of
basic trends in foreign research on the issue as
well as some information about the signifi-
cance of green spaces for public health pub-
lished in 2022 [2]. However, this work does
not provide any quantitative health risk indica-
tors in a situation when necessary open green
spaces or green infrastructure are either absent
or barely accessible or when green spaces are
located too far from residential areas. There-
fore, we have set a task to provide healthcare
workers, ecologists, constructors, urbanists,
and experts in urban planning with necessary
knowledge about the actual utility of green in-
frastructure, both existing and under develop-
ment, and about reduction in public health
risks evidenced by findings reported in out-
standing epidemiological studies.
The concept of green infrastructure as an
integral component of the ecological frame in
any city has been described in detail in publi-
cations by Klimanova and others [3]. Instead
of the traditional Russian term ‘greenness,
green plants’, the authors of these works sug-
gest using the term ‘green infrastructure’,
which means ‘integrity, connection, and hier-
archy of green elements that provide stability
of the environment thereby accomplishing the
major function of green spaces’. This concept
is in line with foreign publications where the
term ‘green infrastructure’ as something more
than just a green space is being used more and
more often. The definition of green infrastruc-
ture which is widely cited now is as follows:
‘green infrastructure is an interconnected
network of green space that conserves natural
ecosystem values and functions and provides
associated benefits to human populations’ [4].
Parks, boulevards, forests, city gardens and
many other forms of public and private com-
ponents of the natural landscape (greenness)
taken together in one complex can also be con-
sidered green infrastructure.
However, architects point out that work
with green infrastructure requires, first of all,
knowledge of biology and ecology as its inte-
gral part and not of urban planning or consid-
ering the concept of ‘green corridors’ deve-
loped within this subject [5]. For example,
L. Lunts2, an architect, mentioned the neces-
sity to consider a type of vegetation depending
on climatic conditions in his manual on urban
green development issued as far back as 50
years ago. This is especially vital at present
due to climate change and occurrence of so
called ‘heat islands’ in cities where public
health risks are elevated.
Benign effects of greenness are associ-
ated, among other things, with overall im-
provement of urban residents’ health including
declining incidence of chronic diseases (for
example, diabetes mellitus and cardiovascular
diseases), development of cognitive functions
in adults, mental health protection, and more
favorable pregnancy outcomes (for example,
normal birth weight) and a decline in prema-
ture deaths [6–13].
Most epidemiological studies with their
aim to assess influence of green spaces on pub-
lic health have relied on using cross-sectional or
descriptive methods. Cohort studies, including
prospective ones, are used significantly rarer;
they can provide the best evidence but they are
also the most complicated3.
1. Basic characteristics of green spaces
in cities. The system of indicators to assess
green spaces in cities was first developed by
the state authorities within the Development of
Comfortable Urban Environment Federal pro-
ject of the Housing and Urban Environment
National project. Within the project, the basic
target is to raise the index of urban environ-
ment quality by 30 points. Such indexes are
based on 38 indicators that are distributed into
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_________________________
2 Lunts L.B. Gorodskoe zelenoe stroitel'stvo [Urban green development]: the manual for higher education institutions.
Moscow, Stroiizdat, 1974, 275 p. (in Russian).
3 Revich B.А., Avaliani S.L., Tikhonova G.I. Ekologicheskaya epidemiologiya [Environmental epidemiology]: the man-
ual for higher educational institutions. In: B.А. Revich ed. Moscow, Akademiya, 2004, 384 p. (in Russian); Vlasov V.V. Epi-
demiologiya [Epidemiology]: the manual, 3rd ed., revised and supplemented. Moscow, GEOTAR-Media, 2021, 496 p. (in
Russian); Briko N.I., Pokrovskii V.I. Epidemiologiya [Epidemiology]: the manual for higher educational institutions. Moscow,
GEOTAR-Media, 2017, 368 p. (in Russian).
B.A. Revich
Health Risk Analysis. 2023. no. 2
170
six groups describing six types of urban
spaces. ‘Green spaces” is one of them; it, in its
turn, consists of six indicators. The most sig-
nificant indicators describe reduction in health
risks caused by exposure to ambient air pollu-
tion and noise and growth in urban residents’
mobility and levels of their physical activity.
Such indicators include ‘the share of public
green spaces in the whole area of green
spaces’; ‘level of greenness’, that is, the share
of the city area covered with greenness in the
whole city area; ‘effectiveness of manage-
ment’, that is, the share of urban residents who
have access to public green spaces.
In 2020, the indexes of urban environ-
ment quality were estimated for 1116 cities in
Russia, including 15 cities with population ex-
ceeding one million people. Among these
megacities, the lowest values as per the ‘green
spaces’ indicator were established in Omsk,
Yekaterinburg and Volgograd; the highest
ones, in Moscow, Saint Petersburg, Ufa, Perm,
Kazan, and Nizhniy Novgorod [14]. In our
opinion, the values established in Moscow and
Saint Petersburg require some clarification
since green spaces are very heterogeneous in
these two cities.
Unfortunately, the ‘green spaces’ charac-
teristic within the aforementioned Federal pro-
ject does not include the most informative in-
dicator of greenness levels in cities, the Nor-
malized Difference Vegetation Index (NDVI)4.
Still, the index was applied in the fundamental
study conducted by experts from the Geo-
graphical Department of M.V. Lomonosov
Moscow State University [3, 15]. The term
‘open green spaces’ is used in urban planning
documents and multiple medical articles and it
seems much more suitable when considering
designs for new urban areas.
Green infrastructure is becoming more
and more significant these days when micro-
climate in cities gets warmer and more and
more soils and grounds are ‘closed’ in centers
of Russian cities, that is, it is very hard to find
land spots with open soils not covered with
asphalt. Most studies describe green spaces
and their areas relying on remote sensing and
the Normalized Difference Vegetation Index
(NDVI)4. Some publications provided much
more detailed descriptions of green spaces
with such data as exact numbers of trees,
squares of greenness, and squares of canopy
cover. The descriptions were provided specifi-
cally for forests, trees, shrubs, grass, arborous
marsh plants, agricultural lands and gardens
[16]. Green spaces are described with different
values such as the ratio of the area covered by
tree vegetation to the whole city area; provi-
sion with greenness in square meters per one
resident; peculiar configuration of an ecologi-
cal frame with greenness (mosaic, along a
river, peripheral, and some others) [3].
These teams of geographical experts as-
sessed green infrastructure in 15 largest cities
in Russia using the share of territories covered
by tree vegetation and provision with canopy
cover. As a result, they divided these 15 cities
into several groups. Two of them, Volgograd
and Omsk, have small shares of areas covered
with trees, 16 and 18 % accordingly; Yekater-
inburg and Perm have the biggest areas cov-
ered with forests, 59 and 61 % accordingly.
The medium values were established in Vo-
ronezh, Kazan, Krasnoyarsk, Rostov-on-Don,
and other cities. The other indicator was the
square of the whole tree vegetation per one
resident; its minimal values were established
in four cities (Chelyabinsk, Perm, Rostov-on-
Don, and Volgograd); the maximum ones, in
Yekaterinburg and Novosibirsk [3]. It is obvi-
ous from the analysis of this work and the
study by Dyachkova [14], that green spaces
and their quantity can be assessed quite differ-
ently depending on indicators used in this as-
sessment.
At present, there is no standard in urban
planning that specifies the mandatory green-
ness on a territory; but some construction
standards and rules that had been valid until
2016 stipulated that the share of greenness
should be equal to 40 %. When it comes down
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_________________________
4 This index is calculated as per a specialized formula and shows the ratio of sunlight reflection coefficients in infrared
and red spectral zones.
Тhe significance of green spaces for protecting health of urban population
ISSN (Print) 2308-1155 ISSN (Online) 2308-1163 ISSN (Eng-online) 2542-2308 171
to how useful green spaces are for urban resi-
dents’ health, we should remember that green-
ness should have an even structure and not a
mosaic one since the latter weakens its protec-
tive properties. Another important indicator
that describes utility of green spaces is their
location within walking distance, which, ac-
cording to the recommendation of the
WHO/Europe, should not exceed 15–20 min-
utes and provision should equal 9 m2 of green
spaces per person [17]. This large-scale review
by the WHO/Europe covers different systems
of indicators that support urban planning in
order to provide sustainable health and pro-
vides some of them that describe the environ-
ment in cities. These indicators are used in
such UN programs as UN-Habitat, ISO (the
International Organization for Standardization)
and some others. They are applied within risk-
based urban planning, which should consider
levels of ambient air pollution based on aver-
age annual concentrations of fine-dispersed
particles (РМ2.5 and РМ10) as well as excessive
mortality caused by ambient air pollution, in-
sufficient provision with green spaces per one
person etc.
The role of different greenness including
vertical one (‘green parking lots’, gardens on
roofs, and other objects) has been described in
many Russian publications, for example, in the
review by Weber, Kucherov and Lylov [18];
but these studies did not consider influence
exerted by greenness on public health using
methods of evidence-based medicine. There
has been a drastic growth in the number of
foreign publications in the sphere starting from
2000. Our search in the Library of the US Na-
tional Institute of Health (PubMed) has re-
vealed more than 405 articles following the
search request ‘green place and health’ pub-
lished by January 01, 2023 including more
than 10 reviews published between 2017 and
2022 [6–13].
Most studies rely on various indicators to
estimate influence of green spaces on health;
predominantly, they use the Normalized Dif-
ference Vegetation Index (NDVI) but it cannot
be applied to estimate heterogeneity of green-
ness. For example, green spaces differ as per
their objectively measured benign properties
(such as tree canopy, pedestrian walkways,
and sitting places) and other, more subjective
ones (emotional or spiritual bond between an
object and a person). At the same time, prox-
imity to motorways with intensive traffic or
absence of easy access can make visit to green
spaces more difficult.
2. Green spaces and mental health.
Availability of many evidence-based epidemi-
ological studies prompted the WHO to initiate
a review [19] to sum up their findings includ-
ing those addressing effects produced by green
spaces on children’s mental health. Some re-
views have also focused on studies that inves-
tigated influence of green spaces on children’s
physical health [20, 21]. This new knowledge
on children’s mental state (as regards any is-
sues with peers, hyperactivity or inattention
symptoms, behavioral or other issues) has
been obtained by using computerized neuro-
psychological tests aimed at estimating chil-
dren’s cognitive development. All the studies
mentioned at least one indicator that described
a socioeconomic status, that is, a family in-
come, parents’ education and / or employment,
access to green spaces for walks, and housing
costs. The evidence provided in 21 studies
consistently suggested a beneficial association
between green space exposure and children's
and adolescents’ emotional and behavioral dif-
ficulties [22].
Low levels of physical activity raise a lot
of concern regarding children’s mental health;
this is also typical for Russia. For example,
according to the study conducted in Kaunas
(Lithuania), every additional hour of time
spent in parks was associated with decreased
sedentary behavior and a lower risk of poor
health; shorter park usage was associated with
the risk of poor health and the general risk of
mental difficulties in 4–6-year-old children
[23]. The medical expert society in Russia ac-
knowledges the problem; in 2020, the National
Medical Center for Children’s Health together
with the Russian Society for the School
Healthcare Development published the article
with evidence that ‘informatization of the so-
cial processes with use of electronic teaching
B.A. Revich
Health Risk Analysis. 2023. no. 2
172
aids that has been growing steadily over the
last years has already deteriorated children’s
health’5 [24].
A major issue in assessing influence of
green spaces on a child’s mental health is the
necessity to isolate effects produced by this
very factor after adjusting (considering) those
produced by many other ones. Great attention
has always been paid to the role played by so-
cioeconomic factors since a place where a
child’ family lives depends exactly on them.
Patients who lived in the greenest areas had
many physical or mental disorders much less
frequently (after the adjustment for most prob-
able socioeconomic and demographic factors)
than their peers who lived in areas where
greenness was minimal. It is remarkable that
the most significant deviations in mental de-
velopment were identified in children with
mental disorders who lived in areas with
scarce greenness.
In 2009, the findings of a remarkable
study were published; it established associa-
tions between green spaces near housing and
medical diagnoses put by healthcare organiza-
tions for primary medical and sanitary aid for
approximately 345 thousand Dutch patients
from various age groups. Patients, who lived
in the greenest areas, after considering socio-
economic and demographic factors, were
much less frequently diagnosed with certain
physical or mental disorders in comparison
with patients who lived in areas with the poor-
est greenness [25]. Since then, more and more
studies have been estimating associations be-
tween greenness and children’s and adoles-
cents’ mental health. The authors of the study
that involved meta-analysis of 21 publications
highlight these associations between green
spaces and adolescents’ mental health [22].
According to them, children who live near
green spaces have fewer problems with their
peers and are rarer diagnosed with ‘hyperac-
tivity’ [26].
Positive effects produced by green spaces
on mental health have also been evidenced for
other age groups; for example, urban citizens
were more likely to have depression [27] or
suicidal indicators in case they lived in areas
with the smallest number of parks and green
zones [28]. There is evidence of an association
between frequent visits to parks and a person’s
emotional state and their satisfaction with life
[29]. Peculiarities of the design and upkeep of
parks are also significant [30].
There is increasing attention and evidence
for a positive relation between the amount of
green space in the living environment and
people's health and well-being, especially for
low-income and poor urban residents [25].
Proximity to parks was associated with more
frequent physical activity and weight loss (for
example, [31]), lower incidence of ischemic
heart disease (for example, [25]). Some studies
also report the association between influence
of green spaces and benefits for mental health
occurring regardless of physical activity due to
such effects as perceived availability of green
spaces for rest and recovery (for example,
[32]). These benefits include better spirits and
higher self-esteem, lower levels of stress and
cognitive fatigue, greater attention focusing
and promotion of emotional recovery [33].
Greenness provides a safe space for social in-
teractions and this can lead to lower social iso-
lation, creation of social capital, a rise in social
solidarity, sense of belonging and more solid
trust between residents living in the same area.
Therefore, urban green spaces are directly as-
sociated with life quality of urban residents.
When discussing better mental health of
urban residents who live near parks, we should
mention the role that belongs to sports; parks
with sport grounds create favorable conditions
for such activities [27] (the minimal time that
should be spent on physical exercises is
20 minutes; the optimal time, 90 minutes). On
the other hand, criminal risks, crime rates, and
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_________________________
5 Kuchma V.R., Selova А.S., Stepanova M.I., Barsukova N.K., Aleksandrova I.E., Aizyatova М.V., Grigor’ev О.А., Ko-
marov D.B. [et al.]. Gigienicheskie normativy i spetsial'nye trebovaniya k ustroistvu, soderzhaniyu i rezhimam raboty v uslovi-
yakh tsifrovoi obrazovatel'noi sredy v sfere obshchego obrazovaniya [Hygienic standards and specific requirements to the or-
ganization, maintenance and modes of work in the digital educational environment in general education]: guide. Moscow, Na-
tional Medical Research Center for Children’s Health of the RF Ministry of Health, 2020, 20 p. (in Russian).
Тhe significance of green spaces for protecting health of urban population
ISSN (Print) 2308-1155 ISSN (Online) 2308-1163 ISSN (Eng-online) 2542-2308 173
anti-social behavior are likely to grow on
blighted green areas [34].
The systemic review of publications
aimed at identifying and generalizing findings
about how effective green spaces were for im-
provement of adults’ mental and physical
health revealed that mental health indicators
were much more likely to improve than physi-
cal health ones. The analysis of findings re-
ported in 16 studies confirmed the hypothesis
that greenspace exposure promoted lower in-
cidence of depression in urban citizens [21].
A study on the analyzed subject with a
highly unusual design was conducted in Den-
mark. In this small country, experts investi-
gated associations between mental health and
living near greenness in childhood for more
than 940 thousand people. The control group
was made of people born between 1985 and
2003. Green space presence was assessed at
the individual level using high-resolution sat-
ellite data to calculate the Normalized Diffe-
rence Vegetation Index within a 210 × 210 m
square around each person’s place of residence
from birth to the age of 10. Risk for subse-
quent mental illness, such as depression, anxi-
ety, and use of psychoactive substances, was
up to 55 % higher for those who lived with the
lowest level of green space during childhood
compared with those who lived with the high-
est level of green space. The association be-
tween mental disorders and greenspace expo-
sure remained authentic even after adjusting
for socioeconomic factors, parental history of
mental illness, and parental age [35, 36]. In
addition, proximity of public parks to places of
residence (400–8000 meters) contributed to
better mental health of women and reduced
prevalence of depression among them (espe-
cially in young women and homemakers) [37].
The issue of green spaces and health of
megacity residents, which we are considering
in this review, is also extremely vital in the
South-East Asia. Several studies have been
conducted in China to assess influence of
green spaces on mental health of megacity
residents, one of them in Shenzhen (17 million
people). It is noteworthy that this study relied
not only on the aforementioned Normalized
Difference Vegetation Index (NDVI), but also
Quick Bird – 2 high-resolution remote sensing
image data; mental health was assessed using
specifically designed questionnaires. The
study findings are authentic and indicate the
significance of creating larger green spaces in
megacities [38].
Having compared the results of studies that
address effects produced by greenness on peo-
ple’s mental health in such countries as South
Korea and Iran (with drastic differences in their
socioeconomic conditions), we observed quite a
similar situation. In Korea (169 thousand exam-
ined participants), depression and suicidal idea-
tion was 16–27 % higher in areas with minimal
greenness after adjustment for all the potential
variables. People without moderate physical
activity had higher odds for self-reported de-
pression and suicidal ideation than those with
moderate physical activity [28]. In Iran, fre-
quent visits to parks also made for better emo-
tional state of a person [29].
Studies with their focus on estimating in-
fluence of green spaces on mental health are
gradually switching from using questionnaires
or psychological tests to instrumental exami-
nations, MRI included [39]. Nevertheless, a
few studies do not give evidence of positive
effects produced by greenness on health; on
the contrary, they concentrate on probable de-
terioration of a criminal situation in green
spaces [34, 40]. It is also reported in some
studies that additional green spaces in some
city areas can result in higher housing costs
and property values; this, in its turn, leads to
displacement of people with a lower socioeco-
nomic status into other areas with less green-
ness in them [41].
Loneliness can be another reason for men-
tal ill-being. Psychological problems associ-
ated with loneliness in a city, a megacity in
particular, are an extremely important chal-
lenge for contemporary healthcare, sociology,
urban studies, and other disciplines that inves-
tigate the issue of ‘a person in a city’. Loneli-
ness is widespread in the contemporary society
and this raises a lot of concern in healthcare
workers, sociologists, psychologists and ex-
perts in other areas. Persistent loneliness trou-
B.A. Revich
Health Risk Analysis. 2023. no. 2
174
bles people across the life span, with its preva-
lence being as high as 61 % in some groups of
elderly people [42].
Loneliness as a social phenomenon has
been examined in detail within the famous
study entitled the Russian Monitoring of Eco-
nomic Status and Public Health performed by
the Higher School of Economics National Re-
search University and Demoskop LLC with
the participation of the Carolina Population
Center at the North Carolina University [43].
The study findings indicate that 3 % of Rus-
sians feel lonely all the time and 40 % feel
lonely periodically. According to sociologists,
women more often feel lonely and they suffer
more from this state than men. This is also re-
lated to the fact that women remain single
more frequently than men and loneliness can
be observed in various age groups, including
young people. In elderly people, loneliness can
lead to poor health and exacerbation of chronic
diseases.
Green spaces in residential areas or in
proximity to them promote better physical and
mental health of lonely people; 22 studies have
provided evidence of it over the last years and
11 out of them have been cross-sectional. Ac-
cording to the review of these studies, of 132
associations, 88 (66.6 %) indicated potential
protection from green space against loneliness,
with 44 (33.3 %) reaching statistical signifi-
cance (p < 0.05). Most of the studies in this
review were conducted in high-income coun-
tries [42]. Over the last five years, a new state
policy has been developed in the USA, Spain,
Singapore, Australia and some other countries;
its specific aim is to create more green spaces
in cities as a part of the strategy to reduce
loneliness.
3. Green spaces and obesity, diabetes.
Over the last forty years, the number of obese
people worldwide has almost tripled. The issue
has become so serious for public healthcare
that experts in prevention medicine consider it
a world epidemic [44]. Obesity is a recognized
factor of early deaths and declining life expec-
tancy at birth. The number of obese people
older than 18 years has reached almost 2 bil-
lion all over the world and prevalence of the
disease is expected to grow; according to the
WHO estimates, by 2025 the shares of obese
people can reach 18 % among men and 21 %
among women [45]. Up to 3.5 million deaths
worldwide are associated with obesity, which
often involves poorer life quality and shorter
life expectancy. Obesity is a serious health is-
sue not only in developed countries: preva-
lence of overweight and obesity grew from 5
to 13 % in developing countries as well over
the period between 1980 and 2013 [46]. In the
USA, total public healthcare spending associ-
ated with overweight and obesity is expected
to double each decade and reach 16–18 % of
the total public healthcare expenses.
Overweight is becoming a more and
more vital issue in Russia as well; our country
is among those where prevalence of obesity is
the highest. The literature review that ad-
dresses prevalence of obesity and elevated
body mass index (BMI) among adults in Rus-
sia provides the results of several projects
(WHO MONICA Project, 1985–1995;
HAPIEE 2003–2005 and some others) [47].
Thus, obesity was diagnosed in 10.7 million
men and 18.7 million women in 2014 [48] or,
according to the WHO data, in 18.1 % men
and 26.9 % women6. A growth in the number
of people with elevated BMI is also evidenced
by findings of the epidemiological study con-
ducted in Moscow (random samples in several
districts in 1975–2014); this growth is close
the world trends but is still not so significant
[49]. According to the WHO study, obesity is
growing not only among adults but among
adolescents as well [50].
Obesity is a basic risk factor able to cause
many non-communicable diseases including
cardiovascular and oncological ones, strokes,
diabetes, cancer and asthma as well as mental
disorders. Obesity turned out to be a risk factor
_
_________________________
6 Prevalence of obesity among adults, BMI >= 30 (age-standardized estimate) (%), 1975–2016, Both sexes. WHO. Avail-
able at: https://www.who.int/data/gho/data/indicators/indicator-details/GHO/prevalence-of-obesity-among-adults-bmi-=-30-
(age-standardized-estimate)-(-) (February 13, 2023).
Тhe significance of green spaces for protecting health of urban population
ISSN (Print) 2308-1155 ISSN (Online) 2308-1163 ISSN (Eng-online) 2542-2308 175
of COVID-19 mortality. Prevalence of obesity
is a huge financial burden for a government,
public healthcare system, and people. To pre-
vent obesity is a serious challenge for practi-
tioners and researchers dealing with healthcare
issues.
More and more studies accept the fact that
prevalence of obesity is caused by social and
environmental factors. Urban design peculiari-
ties can promote obesity by limiting opportuni-
ties for people to have any physical activity
[51]. Green spaces in cities are considered a
crucial factor for health improvement includ-
ing maintenance of healthy weight.
Many studies report a negative relation
between access to green spaces and obesity,
time spent on watching TV, BMI and chil-
dren’s weight. A distance to the closest green
space measured by using a GIS in 10 studies
was often used to estimate access to the closest
green space. In addition, indicators of green-
ness levels included the average NDVI value
at different distances from a place of resi-
dence, the number of green spaces, tree den-
sity at a 0.5-km distance from a residential
area, a distance to the closest park or any other
green space and some others [52].
The large-scale study (700 thousand peo-
ple) was conducted in two American cities
with different climate, Phoenix with low
greenness levels and Portland with sea climate
and vast green spaces. In this study, cause-
effect relations between access to green spaces
and urban residents’ weight were estimated.
Greenness along city streets was proven to be
a predictor of healthy weight. Each 10 % of
growth in such greenness within 2 km was as-
sociated with 18 % lower risks of overweight
or obesity (odds ratio (OR) = 0.82, 95 % CI:
0.81–0.84 in Phoenix; 0.82, 95 % CI: 0.81–0.83
in Portland). Prevalence of overweight or obesity
was 18 % lower in greener areas (OR = 0.87
for Portland, 95 % CI: 0.81–0.92) [16]. Similar
relations were established in New York.
A higher density of street trees (at the 75th vs
25th percentile) was associated with 12 %
lower prevalence of obesity [53]. Similarly in
Spain, residential proximity to forests was as-
sociated with 39 % and 25 % lower relative
prevalence of excessive screen time and over-
weight/obesity accordingly [54]. Many studies
reported a positive correlation between healthy
weight and green spaces within 500 m radius
from home [55, 56].
Evidence of a relationship between chil-
dren’s BMI and green spaces is not so appar-
ent. The review that addressed the issue con-
sidered research articles published prior to
January 01, 2019. Sample sizes ranged be-
tween 108 and 44,278 cases. The authors of
the review believe that it still remains difficult
to draw a clear conclusion on the association
between access to green space and BMI and it
is necessary to conduct further prospective
studies on the matter [57]. The necessity of
such studies has also been mentioned by some
other authors [25, 58, 59].
Obesity as a health issue is to a certain ex-
tent related to physical activity and this indica-
tor is mentioned in the documents issued by
the Rosstat7 and The Ministry of Sports of the
Russian Federation. According to these
sources and questionnaires, the share of people
who systematically do sports and/or physical
exercises does not exceed 30 % in Russia.
Therefore, it has become extremely vital to
install more equipment for doing sports or eve-
ryday exercises in green spaces. The role of
green spaces as an important factor able to mo-
tivate people to have physical activity and to
prevent type 2 diabetes has been investigated
in a large-scale study of urban population con-
ducted in the USA. This prospective cohort
study included 5574 people. Its aim was to in-
vestigate a relation between green spaces and
type 2 diabetes. Green spaces were estimated
as per the normalized difference vegetation
index identified from satellite imagery within
1 km radius from participants’ homes; type 2
diabetes was diagnosed by a doctor relying on
_
________________
_
________
7 Dolya grazhdan, sistematicheski zanimayushchikhsya fizicheskoi kul'turoi i sportom [The share of citizens who system-
atically do sports and physical exercises]. EMISS: gosudarstvennaya statistika [state statistics], 2020. Available at:
https://fedstat.ru/indicator/59266 (January 18, 2023) (in Russian).
B.A. Revich
Health Risk Analysis. 2023. no. 2
176
fasting glucose levels, use of insulin, and use
of hypoglycemic medicine. Of the 5574 study
participants with no prevalent diabetes at base-
line, 886 (15.9 %) developed incident diabetes
over the study period. For each IQR increase
in NDVI, the risk of developing diabetes was
21 % less among those with higher neighbor-
hood NDVI compared to lower, controlling for
individual characteristics, neighborhood-level
covariates, and diabetes risk factors (ОR = 0.79;
95 % CI: 0.63–0.99) [60].
4. Green spaces, mortality and inci-
dence among urban residents. Ambitious
projects are being implemented in many cities
worldwide with their aim to create vaster
green spaces with a closed tree canopy cover.
These expensive measures have been substan-
tiated, among other things, by findings of
some longitudinal studies evidencing relation-
ships between access to green spaces and mor-
tality. Thus, some quantitative indicators were
calculated to identify a relationship between
green spaces and mortality risks for 1645 peo-
ple who had a stroke between 1999 and 2008.
It turned out that the hazard was lower for pa-
tients living in locations in the highest quartile
of green space compared to the lowest quartile.
This association remained statistically signifi-
cant after adjustment for residential proximity
to a high traffic road [61]. Lower cardiovascu-
lar mortality was identified for hospitalized
patients with type 2 diabetes and myocardial
infarction [62].
Longitudinal studies with more than 8
million people participated in them involved
using the Normalized Difference Vegetation
Index NDVI calculated from a space image
with spatial resolution 30 × 30 meters. The
findings were estimated using meta-analysis
and as a result it was established that the
NDVI was associated with air temperatures.
The retaliate risk value ОR = 0.96 (95 % CI:
0.94–0.97) indicates that it is trees, and not
grass-plots or lawns, that ensure a decrease in
high air and soil temperatures thereby creating
more comfortable conditions. Trees also pro-
mote a decline in public health risks caused by
exposure to extremely high temperatures; that
is, they help reduce mortality among urban
residents [63], including that caused by circu-
latory diseases [64]. The same has been proven
in other studies [33, 65]. Their authors applied
such an indicator as ‘the square of tree cover
or a share of ground covered by tree canopy’
based on aerospace images made by LIDAR
[66].
For example, municipal authorities in
Philadelphia (1.6 million) have set a strategic
goal to be achieved by 2025. The goal is to
increase the total forest area in the city and to
achieve the 30–40 % tree canopy cover, a level
recommended for all the American cities. The
necessity to implement such a program is
caused by Philadelphia being drastically dif-
ferent from 10 other largest US cities as per
such indicators as population incomes (the
lowest level) and higher mortality (the applied
all-cause mortality rate for the city’s adult
residents in 2015 was 887 deaths per 100,000
people compared with 733 deaths per 100,000
people in the USA overall) [67]. Therefore,
together with some other healthcare programs
aimed at reducing mortality, the greenness
program is also about to begin. It is largely
based on a hypothesis that such high mortality
rates would be prevented in case tree canopy
cover increased by 30 %. The plan was to re-
duce excessive mortality among the city resi-
dents by 2025, first of all, in areas with low
socioeconomic status. In 2015, the overall
number of premature deaths associated with
scarce greenness reached 403 cases in Phila-
delphia (95 % CI: 298–618), of which 244
(95 % CI: 180–373) occurred in districts with
lower socioeconomic indicators. Squares of
green spaces in the city were estimated using
the LIDAR.
The authors used quite an interesting
technique for dividing the city territory into
zones. It was divided into 384 tracts and so-
cioeconomic status of each tract was identified
as well as the existing and necessary squares
of closed tree canopy covers. Of 384 census
tracts in Philadelphia, 80 already meet or ex-
ceed the 30 % tree canopy cover goal, and
103 census tracts could meet the goal by plant-
ing trees in areas currently covered with grass
or shrubs. Average household incomes in the
Тhe significance of green spaces for protecting health of urban population
ISSN (Print) 2308-1155 ISSN (Online) 2308-1163 ISSN (Eng-online) 2542-2308 177
city coincided with the total greenness in the
city districts; as a rule, there were fewer trees
or greenness in districts with lower socioeco-
nomic status than in richer ones. Increases in
tree canopy cover were estimated to provide a
decrease in population mortality and, conse-
quently, considerable health and economic
benefits [11].
In Moscow, a similar method for dividing
the city territory into zones was applied by
N.B. Barbash, Candidate of Geographical Sci-
ences from the Moscow Institute for the Gen-
eral Town Planning Scheme. This was done to
identify micro-districts with elevated popula-
tion density, elevated levels of ambient air pol-
lution, and proximity to green spaces8. Later,
the cross-sectional epidemiological study with
its focus on prevalence of bronchial asthma in
children identified locuses of areas with the
highest values of this indicator [68]. The find-
ings of this study (of course, together with
economic, ecological, and some other reasons)
were used by the Moscow Institute for the
General Town Planning Scheme to substanti-
ate the necessity to relocate some enterprises
and to reinforce the pulmonologic service for
children.
The largest European project aimed at as-
sessing influence of greenness on mortality
was implemented in 2015 in 49 large cities
located in 31 European countries. Square areas
of greenness were estimated as per the Nor-
malized Difference Vegetation Index (NDVI)
and the percentage of green area was estimated
at a fine grid-cell level 250 × 250 meters. The
project established that annual mortality was
by 43 thousand cases lower in cities where
green areas were located within 15–20 minute
access for population. This accounted for
2–3 % (95 % CI: 1.7–3.4) of the total natural-
cause mortality; 245 cases (95 % CI: 184–366)
of lost years of life per 100 people. Among
European capitals, Athens, Brussels, Budapest,
Copenhagen, and Riga showed some of the
highest mortality burdens due to the lack of
green space [69].
Relationships between access to green
spaces and incidence have not been studied as
profoundly as it was with mortality rates. Still,
the issue has been investigated in more than 60
publications in English where green spaces are
described with the Normalized Difference
Vegetation Index (NDVI) and indicators re-
flecting qualitative parameters of tree cover
[70]. For example, higher land-cover diversity
promoted a decline in prevalence of chronic
diseases [71] and bronchial asthma in children
[72]. Higher density of trees in parks was as-
sociated with lower prevalence of cardiovascu-
lar diseases [73, 74] and better life quality
[75, 76]. Health is also influenced by a scale of
‘green spot’, that is, closed tree canopy cover
in a city. Most studies found certain evidence
of a relationship between various health indi-
cators and large green areas, including body
mass index [77, 78], mortality caused by circu-
latory diseases [64], depressions [79], all-
cause mortality including cardiovascular one
[12], obesity, prevalence of type 2 diabetes,
osteoporosis, and other health disorders [33].
Access to green spaces can promote lower cor-
tisol levels, pulse rate and blood pressure [52].
Recently, some studies have provided
evidence of multisensory influence exerted by
park vegetation including visual, hearing and
tactile feelings that ensured a recovery effects
produced by a visit to a park [80]. Higher den-
sity of trees among park vegetation had an as-
sociation with lower prevalence of cardiovas-
cular diseases [73].
Discussion. The issue of green spaces in
cities has been given more and more attention
not only by architects, constructors, or experts
on creation of urban green spaces but health-
care researchers as well. The necessity to cre-
ate green infrastructure with tree ranges is con-
firmed by epidemiological studies conducted
in many countries. The COVID-19 pandemic
and post-pandemic issues have also attracted
additional interest to the subject since people
started to spend more time in green spaces
willing to overcome the consequences of strict
_
_________________________
8 Barbash N.B. Metodika izucheniya territorial'noi differentsiatsii gorodskoi sredy [The methodology for investigating
territorial differentiation of the urban environment]. Moscow, Institut geografii AN SSSR Publ., 1986, 180 p. (in Russian).
B.A. Revich
Health Risk Analysis. 2023. no. 2
178
quarantine and resulting psychological prob-
lems [81–83].
Mechanisms that underlie effects of green
spaces on health have not been studied com-
pletely; still, there is solid evidence that visits
to green spaces contribute to eliminating nega-
tive outcomes of stress and exposure to ambi-
ent air pollution, noise, high temperatures;
they improve cognitive functions; they pro-
mote social interactions and higher levels of
physical activity. The analysis of research re-
sults reported in many countries worldwide
proves that it is necessary to develop urban
green spaces. We have found solid confirma-
tion of hypotheses that when green spaces are
within a walking distance, this leads to greater
mobility of urban residents, lower prevalence
of diabetes and cardiovascular diseases among
them. Green spaces are a vital component of
the urban environment; they play a key role in
mental well-being of urban residents, produce
positive effects on people suffering from de-
pression. Health risks tend to go down in areas
with green spaces with closed tree canopy
cover.
In Russia, some singleton articles have
been published with their focus on influence of
green spaces on health; one of these studies
has been conducted in Ufa where green infra-
structure has 30 scores and the Normalized
Difference Vegetation Index (NDVI) is high as
well; that is, green infrastructure is quite de-
veloped in the city [3]. Individual carcinogenic
risks were assessed in this city based on data
about benz(a)pyrene levels in ambient air pro-
vided by the Bashkortostan Office for Hydro-
meteorology and Environmental Monitoring.
The risks turned out to be within their permis-
sible levels. For comparison, similar study was
conducted in Arkhangelsk where industries
and energy production were not so well devel-
oped and greenness levels were lower than in
Ufa where the Normalized Difference Vegeta-
tion Index (NDVI) identified well-developed
vegetation. The authors of this study believe
that high greenness in a city reduces risks cre-
ated by benz(a)pyrene in ambient air [84];
health risks are predominantly caused by lev-
els of fine-dispersed particles. People living in
another Russian megacity, Chelyabinsk, were
questioned in order to identify any psychologi-
cal problems; the questioning revealed more
apparent effects produced by stress-factors in a
district in the city where green areas were
scarce [85].
Urban green infrastructure is considered
by economists a most significant element of
ecosystem services. Intensive urban develop-
ment has already made urban areas unstable in
some cities [86, 87] and, consequently, created
green space deficiency. It is especially true for
rapidly developing Krasnodar where the wa-
ter-green city frame is absent, trees are not
preserved systematically, and the number of
existing parks and public gardens is not suffi-
cient. The newly developed general town
planning scheme stipulates about 400 green
areas different in their sizes but they are not
combined into unified green infrastructure
[88]. On the other hand, we can mention some
very successful town planning solutions aimed
at creating a large green infrastructure in a dis-
trict in Kazan (20 thousand people). A three-
time growth in the conventional greenness
level, that is, up to 60 % of the total area, will
make the district much more comfortable. Ac-
cording to the nature capital model developed
by the Dutch National Institute for Public
Health and the Environment, in summer, air
temperatures will go down by 2 °С and the ave-
rage wind speed will decrease by 8 m/sec in
this district; the number of people satisfied
with air temperature will grow by 6 % in win-
ter and by 8 % in summer against the tradi-
tional scenario [86].
The state policy as regards comfort pro-
vided by the urban environment has started to
change in our country as well. For example,
the issue is given a lot of attention in the Pro-
gram for Development of Recovery Potential
of Public Green Spaces included in the Green
Spaces section of the Comfortable Urban En-
vironment Federal project. Within this Pro-
gram, green spaces were estimated in Yekater-
inburg using several indicators including
shares of public green spaces in the total
square area of green spaces (%), level of
greenness (%), quality of greenness, attraction
Тhe significance of green spaces for protecting health of urban population
ISSN (Print) 2308-1155 ISSN (Online) 2308-1163 ISSN (Eng-online) 2542-2308 179
of green spaces. Recommendations have been
developed on how to achieve proper quality of
the urban environment in Ekaterinburg; they
include various recovery activities and mea-
sures aimed at making sport grounds more ac-
cessible for people with limited mobility [89].
However, healthcare workers also need to
know what percentages of people from differ-
ent age group have green areas within 15–20
minute walking distance from the total popula-
tion as per separate districts.
The scales of researches aimed at assessing
quality of green spaces and their influence on
health are growing steadily. The results indicat-
ing their utility have been more apparent for
people living in areas with large tree canopy.
There is a demand for additional prospective
studies that include estimating quality of green
spaces and consider factors able to distort
analysis. Investigations that concentrate on as-
sessing quality of green spaces have practical
significance for urban planning.
Cities with high population density tend to
face some challenges in renovation; in particu-
lar, it is often difficult to preserve green areas
and easy access to them for population groups
with different socioeconomic status. Therefore,
it is necessary to search for compromises be-
tween town developers, constructors, municipal
authorities, on the one hand, and healthcare ex-
perts, ecologists, and experts in green infra-
structure, on the other hand. In addition, it
would be advisable to give responsibility over
planning and managing green spaces as well as
control of their quality to town planning au-
thorities, offices for architecture and planning
or any other managerial structures responsible
for creating a comfortable urban environment.
This issue should be supervised by them and
not by housing and communal services or of-
fices responsible for improvement of city areas.
Since space is limited in any city, changes in
quality of existing green areas can help main-
tain and even improve quality of life in urban
societies, especially given the ongoing climate
change.
Protection of urban residents’ health re-
quires development of green spaces as well as
planning of city landscapes considering
health risks and developing new recommen-
dations on optimal population density.
Economists believe that ‘the complex ap-
proach to creating the urban environment
with emphasis on residents’ health and well-
being not only satisfies the demands of a
modern urban resident but is also beneficial
for urban economies and the country economy
as a whole’ [88]. Further development of green
spaces requires closer coordination between
town planning organizations and relevant mu-
nicipal services responsible for territorial im-
provement. Parks, public gardens, boulevards
and other green spaces are too important for
creating a more comfortable urban environ-
ment and protecting urban citizens from harm-
ful environmental exposures. Therefore, it is
advisable to take responsibility over them from
municipal authorities on territorial improve-
ment and assign it to structures responsible
for rational use of natural resources and envi-
ronmental protection.
Funding. The research was not granted any
sponsor support.
Competing interests. The authors declare no
competing interests.
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Received: 17.02.2023
Approved: 21.05.2023
Accepted for publication: 02.06.2023
