among different ethnic groups. Andrusaityte 2016, Lithuania et al. 2016) To investigate the associations between surrounding greenness levels and asthma among children, and to explore a possible change of this association by the distance of the residence to a city park Nested study 4-6 year old children of the KANC newborns cohort study (n = 1,489) Doctor-diagnosed asthma International Study of Asthma and Allergies in Childhood 9ISAAC) questionnaire Residential surrounding greenness, Normalised Difference Vegetation Index, (NDVI) as well as distance to the nearest city park ORs adjusted for mother’s age at childbirth, maternal education, parental asthma, maternal smoking during pregnancy, breastfeeding, antibiotic use during the first year of life, keeping a cat during the past 12 months, living in a flat and yearly mean of ambient PM2.5 and NO2 Asthma ↑ IQR increase in NDVI-100: 1.43 (1.10, 1.85) 2016, Spain et al. 2016) To validate the trail’s design by assessing the physiological response to unsupervised walking trails of 1) different intensities in COPD patients, and 2) same intensity from different public spaces in healthy adults Case control study 10 stable COPD patients (9 men, average age 67 ±9 years) and 10 healthy patients (5 men, average age 31 ±4 years) (n = 20) VO2, VCO2, respiratory exchange ratio (RER), min ventilation (VE), heart rate (HR), energy expenditure volume (MET-min), walking time, walking speed, steps, time for breaks, final dyspnea, final leg fatigue Primary measurement and bespoke questionnaire Park walk vs boulevard walk vs Matching of participants VO2, VCO2, respiratory exchange ratio (RER), min ventilation (VE), heart rate (HR), energy expenditure volume (MET-min), walking time, walking speed, steps, time for breaks, final dyspnea, final leg fatigue ↔ trial
forested, agricultural, residential and industrial areas within a 5000m radius from the residential address Flanders Prospective Twin Survey (EFPTS). Mean maternal age 27.5 years (range 19-40) (n = 211) income) and smoking during pregnancy Bixby 2015, England et al. 2015) To assess whether local associations between greenspace and physiological and psychological health are transferable to a larger scale Ecological study Populations of the 50 largest cities in England (n = not specified) Risk of death from all causes, cardiovascular disease, lung cancer and suicide between 2002 and 2009 Individual-level mortality records, UK Small Area Health Statistics Unit Proportion of city area covered by land, Land Cover Map 2007 Adjusted for age, income deprivation and air pollution All cause mortality ↘ Cardiovascular disease mortality ↘ Lung cancer ↗ Suicide mortality ↗ Bodicoat 2014, UK (Bodicoat et al. 2014) To investigate the relationship between neighbourhood greenspace and type 2 diabetes study 6,200 from general population, 4,276 from high-risk population. Mean age 59 years (range: 20-75 years). 47% female, 21% ethnicity (n = 10,476) Screen-detected type 2 diabetes Primary measurement Percentage neighbourhood greenspace, Land Cover Map 2007 Adjusted for ethnicity, age, sex, area social deprivation and urban/rural status for increasing quartiles of neighbourhood greenspace, as well as BMI, physical activity, fasting glucose, 2h glucose and cholesterol for highest vs lowest quartile Type II diabetes ↓ ORs for screen detected type 2 diabetes were 0.97 (0.80, 1.17), 0.78 (0.62, 0.98) and 0.67 (0.49, 0.93) for increasing quartiles of greenspace compared to the least green quartile after adjusting for confounders. Botticello 2015, USA (Botticello et al. 2015) To assess the association between characteristics of the environment and differences in perceived Secondary analysis of survey data Spinal Cord Injury Model Systems (SCIMS) database participants, mean age 44.5 (±16.5) years, 80.5% male Perceived health Bespoke questionnaire Percentage neighbourhood open space, dataset not specified ORs adjusted for demographic, impairment and community socioeconomic differences Perceived health ↑
health among persons with spinal cord injury (SCI) using objective measures of the local community derived from GIS data (n = 503) Brown 2016, USA (Brown et al. 2016) To examine the association between objective measures of block-level greenness (vegetative presence) and chronic medical conditions, including cardiometabolic conditions cohort study Medicare beneficiaries, 76.33 (±7.5) years, 58.33% female (n = 249,405) Number of chronic conditions (out of 27) U.S. Centres for Medicare and Medicaid Services (CMS)’ Master Beneficiary Summary File Mean Normalised Difference Vegetation Index (NDVI) for all Miami-Dade County Census blocks Not specified Increase in mean NDVI: Total no. of chronic conditions ↓ Diabetes ↓ Hypertension ↓ Hyperlipidaemia ↓ Burkart 2016, Portugal (Burkart et al. 2016) To investigate the influence of urban vegetation and water bodies on excess mortality in the elderly >65 years old in Lisbon Ecological study Inhabitants of civil parishes in the Lisbon Metropolitan Area from 1998 to 2008 (n = not specified) Heat-related excess mortality in the elderly National mortality records Amount and spatial distribution of urban green quantified using Normalised Difference Vegetation Index (NDVI) Models adjusted for time trend, average daily mean PM10 and O3 concentrations, percentage of the parish >65 years, building density, % college graduates and proportion of inhabitants receiving social benefits With increasing NDVI quartiles: Heat-related excess mortality in the elderly ↓ Calogiuri 2016, Norway (Calogiuri et al. 2016) To investigate the impact of a green exercise intervention on psychological and physiological RCT Municipality employees, 49 (±8) years, 50% female (n = 14) Potential for restoration, affective state, blood pressure, cortisol awakening Primary measurement Green/nature area vs indoor exercise setting Not specified Cortisol awakening response (improved) Diastolic BP ↓ BP ↔ Serum cortisol ↔ related
Coutts 2010, USA (Coutts et al. 2010) To examine the relationships neyween the presence and accessibility of greenspace and mortality in the state of Florida ecological study Data on all-cause mortality and mortality from major cardiovascular diseases in 2007 were obtained from the Florida Department of Health’s Community Health Assessment Resource Tool Set (CHARTS). (n = 167,708 deaths from 54,542 deaths from cardiovascular diseases) All-cause and cardiovascular mortality State mortality database Greenness in census tracts, 2009 Public land file Controlled for the proportion of the population in each county that are overweight or obese, the proportion who smoke, the proportion of people who report being moderately physically active, the % of the population 65 and older, and % of the population with a bachelor’s degree or higher. Also controlled for ethnicity mortality ↓ Cardiovascular mortality ↓ Coutts 2015, USA (Coutts and Horner 2015) To determine if green space proximity to one’s residential location at time of death was predictive of premature mortality study Death certificate records obtained from the Florida State Department of Health, Bureau of Epidemiology for the years 2000-2012 (n = 2,216,641) Premature mortality from all causes mortality databases Distance from residential address to nearest greenspace, amount of greenspace within a set of defined distances from each residence; 2009 public land file Four separate models for males and four separate models for females, controlling for education, race, Hispanic ethnicity, and marital status of potential life lost ↓ with decreasing distance to nearest greenspace for both males and females Cusack 2017, USA (Cusack et al. 2017) To examine residential greenness and birth outcomes in Texas with large regional variation in greenness levels cohort study All births in Texas from 2000 to 2009 (n = 3,413,787) Birth weight, odds of preterm birth, odds of being small for gestational age Texas Vital Statistics program Estimates of residential greenspace derived from MODIS satellite NDVI imagery Adjusted for maternal and parental (if available) covariates age, smoking, education, race/ethnicity; pregnancy-related variables included method of delivery, parity, prenatal care, gestational age, baby’s sex, Birth weight, odds of preterm birth, odds of being small for gestational age ↔ Associations became non-significant in fully adjusted models based cause
these relationships Gestational age analysis: Adjusted for neighbourhood SEP, degree of urbanisation, distance of residential place to major roads, maternal age, ethnicity, academic level, occupation, smoking, alcohol consumption, parity, history of preterm birth, history of obs/gynae pathologies, use of assisted reproductive technologies and sex of infant Dadvand 2014, Spain (Dadvand et al. 2014) To evaluate health benefits and associated with different types of greenness in children, in terms of sedentary behaviour (excessive screen time), obesity, current asthma and allergic study Population-based sample of schoolchildren years old) in Spain in 2006 (n = 3,178) Sedentary behaviour, obesity, current asthma and allergic rhinoconjuncitivitis Bespoke questionnaire Residential surrounding greenness, Normalised Difference Vegetation Index, (NDVI) Residential proximity to greenspaces, Atlas map (2007) All analyses adjusted for indicators of individual SES, parental education, parental school (public/private), SES at census tract level. Respiratory and allergic outcomes further adjusted for child’s sex and age, exposure to tobacco smoke at home, having older siblings, parental history of asthma. Analyses of overweight/obesity adjusted for sport activity at school or sport facilities and having siblings. Sedentary behaviour analyses controlled for child’s sex and age and having siblings Asthma ↗ Allergic rhinoconjunctivitis ↗ Dadvand 2015, Spain (Dadvand et al. 2015) To assess the association between exposure to greenspace and measures of cognitive Cohort Conducted as part of the brain development and air pollution ultrafine particles in schoolchildren (BREATHE) Developmental trajectory of working memory, superior working memory, and inattentiveness Primary measurement Residential and school surrounding greenness, Normalised Difference Vegetation Index (NDVI) Model adjusted for age, sex and SES indicators at individual and area levels Cognitive development ↑ Pre-post results for greenspace within and surrounding school grounds show significant improvements in working memory, superior working memory and a significant reduction in inattentiveness
development in primary schoolchildren project. Mean age 8.5 years at baseline, 50% female (n = 2,593) Dadvand 2016, Spain (Dadvand et al. 2016) To assess the association between greenness exposure and subjective general health (SGH), and to evaluate mental health status, social support and physical activity as mediators of this association study Population-based randomised sample of adults residing in Barcelona (n = 3,461) SGH, mental health SGH: bespoke questionnaire Mental health: Residential surrounding greenness as well as objective and subjective (perceived) proximity to greenspace; Normalised Difference Vegetation (NDVI), Parks and Garden Map of Barcelona, bespoke questionnaire Randomised sample Models further adjusted a priori for age, sex and indicators of SES at both individual and area levels SGH ↑ 100m buffer OR 1.17 (95% CI 1.05, 1.31) 250m buffer OR 1.18 (95% CI 1.06, 1.32) 500m buffer OR 1.16 (95% CI 1.05, 1.29) Subjective proximity to greenspace OR 1.36 (95% CI 1.11, 1.67) Dalton 2016, UK (Dalton et al. 2016) To investigate the association between neighbourhood greenspace and the occurrence of incident diabetes over time Prospective cohort study EPIC Norfolk cohort study (n = 23,865) Incident type 2 diabetes Self-report of doctor diagnosed self-report of diabetes-specific medication Percentage neighbourhood greenspace, Land Cover Map 2007 Analysis adjusted for status at both the individual and neighbourhood level Diabetes ↓ HR 0.81 (95% CI 0.65, 0.99) for individuals living in the greenest quartiles economic
de Jong 2012, Sweden (de Jong et al. 2012) To assess how perceived green neighbourhood qualities were associated with three indicators of well-being (neighbourhood satisfaction, physical activity and general health) study Questionnaire sent to 52,142 participants randomly selected from the population registry. 55% female (n = 24,847) Three self-reported indicators of neighbourhood satisfaction, physical activity and general health Public health survey data Bespoke objective measurement of greenspace quality Availability of qualities within 300m of residential address, CORINE land use data Analyses were adjusted for possible confounding by sex, age, highest level of education, difficulties, country of origin and type of residence. Stratified analysis on neighbourhood satisfaction for type of residence Self-reported health ↑ Demoury 2016, Canada (Demoury et al. 2017) To assess whether living in the proximity of greener areas was to prostate cancer risk study Men younger than 76 years in the Montreal area (n = 1933 cases, 1994 controls) Newly diagnosed with primary PCa The Prostate Cancer & Environment Study (PROtEuS) Residential greenspace at 2 time points, Landsat TM5 Normalised Difference Vegetation (NDVI) 1: adjusted for age Model 2: adjusted for age, ancestry, first-degree family history of PCa, education, family income, marital status, smoking, alcohol consumption, dietary habits and a history of diabetes Model 3: Further adjusted for neighbourhood material and social deprivation Prostate cancer ↓ 300m buffer, an IQR increase of 0.11 in recruitment OR 0.82 (95% CI 0.74, 0.92) 10 years previous: OR 0.86 (95% CI 0.74, 1.00) Remained significant for all buffer sizes at recruitment time point de Vries 2003, The Netherlands (De Vries et al. 2003) To investigate the association between neighbourhood greenspace and self-reported health Multilevel analysis Health interview survey among random samples of practice populations of 103 general practices in the Netherlands (n = 10,179) Number of symptoms experienced in the last 14 days, perceived general health, Dutch general health questionnaire (GHQ) The Dutch National Survey of Morbidity and Interventions in General Practice Percentage green and blue space in living environment; National Land Cover Classification, presence of a garden (yes/no) The scores on all variables at the (semi-)interval level had been centred (but not standardised) Self-reported health ↑ control
Donovan 2011, USA (Donovan et al. 2011) To investigate whether tree canopy cover is associated with reduced risk of poor birth outcomes in Portland, Oregon Cohort All singleton live births in Portland, Oregon during 2006-7, where the mothers’ address was a single family home. Mean age 30.3 years (n = 5,696) Preterm birth, gestational age of less than 37 weeks, small for gestational age, birth weight below the 10th percentile for gestational age and gender Birth certificate data, Portland, Oregon Percentage tree canopy in 50, 100, and 200m buffers surrounding residential address; Metro land cover classification 2007 To ensure that all confounders were included, any covariate with significant variation in canopy cover within 50m of a house that was not selected for retention during thr backward selection process was re-introduced to the final model. If any variable caused a 10% or greater change in any coefficients of interest, it was retained in the final model. None of the covariates evaluated met this threshold Small for gestational age births ↓ 10% increase in tree canopy cover within 50m of a house reduced the number of small for gestational age births by 1.42 per 1000 births (95% CI -0.11, -2.72) Droomers 2016, The Netherlands (Droomers et al. 2016) To investigate the impact of real-life changes in the quality and quantity of green space in severely deprived neighbourhood on physical activity and perceived general health study National Health Interview Survey from 2004 to 2011 (n = 48,132) Perceived general health Dutch National Health Interview Survey from 2004 to 2011 Local greenspaces that underwent improvement interventions All analyses adjusted for age, sex, household composition, ethnicity, education and standardised disposable household income; additionally adjusted for overall intensity of District Approach Perceived general health ↔ Dunstan 2013, Wales (Dunstan et al. 2013) To determine the association between general health and an objectively assessed measure of the residential Cohort Caerphilly Prospective Study, taken from individual census records, 47.78% male (n = 31,442) Self-reported general health UK census data Residential environment assessment tool (REAT) Models fitted adding individual-level covariates: age, gender, marital status, housing tenure and employment status Self-reported health ↘ al
environment. (Using the Residential Environment Assessment Tool, REAT) Fjortoft 2004, Norway (Fjørtoft 2004) To investigate the relationship between children’s development and playing in a natural environment study Experimental and groups selected from voluntary kindergartens with the same original playground opportunities in the same geographic area. Age range 5-7 years old (n = not specified) Motor fitness, balance, Primary measurement Forest playground vs traditional outdoor playground Not stated Motor development ↑ in children Fuertes 2014, Germany (Fuertes et al. 2014) To examine whether residential greenness is associated with childhood doctor diagnosed allergic rhinitis, eyes and nose symptoms Cohort study GINIplus and LISAplus birth cohorts (n = 5,803) Childhood allergic rhinitis, eyes and nose symptoms and aeroallergen sensitisation. Also air pollution data (stratified analysis) Bespoke questionnaire Mean residential greenness in a 500m buffer around the 10 year home address; Normalised Difference Vegetation Index, (NDVI) Models were adjusted for age, sex, parental history of atopy, older siblings, maternal smoking during pregnancy, tobacco smoke exposure in the home years), cohort and parental education Eye and nose symptoms ↓ GINI/LISA South (urban) OR 1.15 (95% CI 1.01, 1.31) GINI/LISA North (rural) OR 0.71 (95% CI 0.56, 0.89) Allergic rhinitis ↓ GINI/LISA North (rural) OR 0.75 (95% CI 0.60, 0.93) al
2015a, Lithuania et al. 2015a) To investigate whether surrounding greenness levels and/or distance to city parks affect birth outcomes Cohort study Kaunas birth cohort, participants recruited between 2007-9 in the early stages of pregnancy. Age range 20 to 45 years old (n = 3,292) Gestational age, preterm birth, birth weight, low birth weight, term low birth weight, and small for gestational age Birth certificate data, Kaunas, Lithuania Residential surrounding greenness, distance to nearest park; Normalised Difference Vegetation Index, (NDVI) Low birth weight models adjusted for maternal marital status, education, smoking, blood pressure, BMI, parity, chronic diseases, previous preterm birth, paternal smoking and infant sex Term low birth weight adjusted for maternal marital status, education, smoking, alcohol consumption, BMI, blood pressure, parity, paternal smoking and infant sex Preterm adjusted for maternal marital status, education, smoking, renal diseases, stress, previous preterm birth, parity and paternal smoking Small for gestational age adjusted for maternal age, marital status, education, social status, smoking, BMI, parity and previous preterm birth Birth weight adjusted for maternal height, smoking, marital status, BMI, diabetes and chronic health diseases, parity Gestational age adjusted for maternal marital status, education, smoking, renal diseases, stress, parity, For subjects with low surrounding greenness and >1000m to the nearest park: Low birth weight↑ OR 2.23(95%CI 1.20,4.15) Term low birth weight ↑ OR 2.97 (95% CI 1.04, 8.45) Preterm birth ↑ OR 1.77 (95% CI 1.10, 2.81) Lower gestational age↑ Beneficial park effect on foetal growth in environment with least surrounding greenness ↗
previous preterm birth and paternal smoking 2016, Lithuania et al. 2016) To examine the effects of restorative walking in a park vs in an urban environment on coronary artery disease (CAD) patients stress parameters and cardiac function RCT Male and female Kaunas city residents with CAD, mean age 62.3 ±12.6 years (n = 20) rate, blood pressure, stress levels, mood Primary measurement, Positive and Negative Effect Schedule (PANAS) mood score evaluation Park vs environment Participants randomly assigned to study arm Salivary cortisol ↓ pressure ↓ 2015, USA et al. 2015) To determine whether exposure to attributes of the natural environment (e.g. greenspace) attenuates the likelihood of reporting insufficient sleep among US adults. study 2020 Behavioural Risk Factor Surveillance System (BRFSS), a yearly, randomised telephone survey of behavioural risk factors among US adults ≥18 years of age. 64.13% female. Average age 56.6 years. (n = 255,171) Self-reported insufficiency 2010 Behavioural Risk Surveillance System (BRFSS) survey greenspace; Normalised Difference Vegetation Index, (NDVI) Adjusted for age, gender, marital status, race, education, employment status, number of children, physical activity, smoking, income level, asthma, general health status, emotional support, disability, BMI category and heavy alcohol use Sleep quality ↑ Individuals reporting 7-13 days or 21-29 days of insufficient sleep. 7-13 days OR 0.995 (95% 0.988, 1.002) 21-29 days OR 0.991 (95% CI 0.986, 0.9996) Lower odds of exposure to natural amenities were observed for individuals reporting 21-29 days of insufficient sleep OR 0.843 (95% CI 0.747, 0.951) trial
2014, Spain et al. 2014) To examine (a) whether distance from home to school is a determinant of active commuting to school (ACS), (b) the relationship between distance from home to heavily used facilities (school, spaces and sports facilities) and the weight status and cardiometabolic risk categories and (c) whether ACS has a positive impact on schoolchildren’s health. study Cross-sectional study of the final measurements taken in a cluster randomized to evaluate the effectiveness of leisure-time physical activity on preventing childhood obesity (the MOVI programme). Schoolchildren aged 10-12 years old. 49.37% male, average age 11 years. (n = 956) BMI and fat mass, blood pressure, fasting plasma lipid profile, insulin, fitness, physical activity and active commuting to school (ACS) Primary measurement Distance from home to greenspace; National Plan for Aerial Orthophotography 2007 Model 1 controlled for age, fat mass percentage, and fitness according to age Model 2 controlled for controlled for age, commuting, fitness according to gender Model 3 adjusted for age and cardiovascular fitness; for the MetS index, adjusted for age, cardiovascular fitness and fat mass; for cardiovascular fitness adjusted for age and fat mass Cardiometabolic risk ↔ Hartig 2003, USA (Hartig et al. 2003) To compare “restoration” in natural and field settings. RCT A group of normotensive students mean age 20.8 years (SD 3.7), 50% female and 97% (n = 112) Systolic and diastolic blood pressure, emotional states Primary measurement, Zuckerman’s Inventory of Personal Reactions (ZIPERS) Green vs urban environment Participants randomly assigned to arm Systolic blood pressure ↘ Diastolic pressure ↓
Hoehner 2013, USA (Hoehner et al. 2013) To examine the associations of environment features around the home and workplace with fitness (CRF) on a treadmill test and BMI. study The Cooper Centre Longitudinal 70.9% male. (n = 8,857) Cardiorespiratory fitness Primary measurement Neighbourhood greenspace in buffers surrounding residential address. Dataset unspecified. Adjusted for age, sex, education, race, marital status, presence of children in the home, cigarette smoking, BMI, and all other built environment variables for the respective location of interest as well as weekly MET-minutes of physical activity Cardiorespiratory fitness ↗ Hu 2008, USA (Hu et al. 2008) To examine if there is association of stroke with air pollution, income and greenness in northwest Florida Ecological study Stroke death count data at the census tract level was obtained (n = not specified) Stroke mortality rates State mortality records (Florida CHARTS) Self-reported frequency of visits to greenspace, residential neighbourhood and work buffer; Landsat 7 Enhanced Thematic Mapper Plus (ETM+) Calculated standardized mortality rates Stroke mortality ↓ 95% Credible set (-0.289, -0.031) Hystad 2014, USA (Hystad et al. 2014) To investigate associations between residential greenness and birth outcomes and evaluate the influence of spatially correlated built environment factors on these associations Cohort study All births between 1999-2002 in the metropolitan area of Vancouver (n = 64,705) Birth weight, preterm deliveries, gestational age National birth registry Residential surrounding greenness; Normalised Difference Vegetation Index (NDVI) Analyses adjusted for month and year of birth, infant sex, first nations status, parity, maternal age, maternal smoking during pregnancy as well as maternal education and income quintiles Birth weight ↑ An interquartile increase in greenness (0.1 in residential NDVI) associated with higher term weight: 20.6g (95% CI 16.5, 24.7) Small for gestational age ↓OR 0.97 (0.94, 1.00) Very preterm birth ↓ OR 0.91 (0.77, 1.07) Moderately preterm birth ↓ OR 0.95 90.91, 0.99) trial
period were obtained (n = minimum required population size of 1,750 person years, exact population not specified) Kabisch 2016, Germany (Kabisch et al. 2016) To analyse the potential relationships between childrens’ health determinants, in particular deficits in development, and outcomes and natural areas in Berlin Ecological study Population of Berlin (n = 3,562,166) Deficits in development in children Berlin’s Senate Department for Health and Social Issues % natural area, per capita natural area, availability of natural area; Local land use data from Berlin’s Senate Department of Urban Development and the Environment Not specified Low % natural areas ↑ deficits in viso-motoric development in children Kardan 2015, Canada (Kardan et al. 2015) To examine the association between tree canopy density beside the streets and in other areas such as parks and domestic gardens with an individual’s health. The health variables focused on are 1) overall health perception, 2) Cohort Subset of the Ontario Health Study. 59% female, mean age 43.8 years (range 18-99) (n = 31,109) Self-reports of general health perception, conditions and mental illnesses Ontario Health Study questionnaire Toronto Street Tree General Data and GIS Forest and Land Cover None specified Self-reported health ↑ Cardiometabolic conditions ↓ metabolic
presence of cardio-metabolic conditions, 3) mental health problems 2013, France et al. 2013) To investigate the relationship between green spaces and the spatial distribution of infant mortality taking account neighbourhood deprivation levels Ecological study Prevalence of infant death in the Lyon metropolitan area over the study period 2000-2009 (n = 1,340,155 population of Lyon metropolitan area) Neonatal mortality Equit’Area project municipality mortality records, National Institute for Statistics and Economic Studies Spatial land datasets for Lyon Metropolitan area Stage 1: Unadjusted Stage 2: Adjusted for greenness level or socioeconomic neighbourhood (deprivation index) Stage 3: Adjusted for greenness level and deprivation index at the neighbourhood level including the interaction between the two variables Neonatal mortality ↓ Kim 2015, South Korea (Kim et al. 2015) To assess the feasibility of forest therapy as an adjuvant to enhance natural cytotoxicity. Feasibility study Volunteer women aged 25-60 years with stage III breast cancer. All subjects exposed to daily forest therapy for 14 days. Mean age 56 years. (n = 11) Natural killer cell population, perforin and granzyme B levels Primary measurement Forest Matching of participants Natural killer cell population ↑ MD 125.3 (95% CI 43.1, 207.4) Level of perforin ↗ MD 128.1 (-28.4, 284.5) of granzyme B ↗ MD 6.7 (-2.8, 16.3) Kim 2016, Korea (Kim et al. 2016) To investigate the association between parks and green areas and hyperlipidaemia in adults study Adults participating in the 2009 Korean Community Health Survey (KCHS) (n = 212,584) Hyperlipidaemia Bespoke questionnaire Parks and green areas per capita in 2009 using data from the Korean Statistical Information Service Models adjusted for age, sex, marital status, education, monthly income, jobs, smoking status, alcohol drinking, a history of diabetes mellitus, BMI, stress and moderate physical activity Hyperlipidaemia ↓ Lowest greenspace quartile - diagnosed hyperlipidaemia: OR 1.23 (95% CI 1.17, 1.29) Lowest greenspace quartile - treatment of hyperlipidaemia: OR 1.45 (95% CI 1.35, 1.56)
Lee 2011, (Lee et al. 2011) To provide scientific evidence supporting the efficacy of forest bathing as a natural therapy by investigating its physiological benefits biological indicators in outdoor settings RCT Young male Japanese adults recruited from local universities. Mean age 21.2 years (n = 12) Heart rate variability, LF/HF ratio in R-R interval variability (parasympathetic and sympathetic nervous system activity), cortisol levels, pulse rate, systolic blood pressure, diastolic blood pressure Primary measurement Self-reported psychological measures Forest Matching of participants Parasympathetic activity ↑ Sympathetic activity ↓ Heart rate↓ Salivary cortisol ↓ Lee 2014a, South Korea (Lee et al. 2014a) Investigating the health benefits of forest walking on cardiovascular reactivity RCT Young Japanese adult males. Mean age 21.2 years (n = 48) Blood pressure, heart rate, heart rate variability Primary measurement Forest vs urban Matching of participants Parasympathetic activity ↑ Sympathetic activity ↓ Heart rate ↓ Lee 2014b, South Korea (Lee and Lee 2014b) To investigate the effects of forest walking on arterial stiffness and pulmonary function in Korean elderly women RCT Recruited by advertisement at a senior welfare centre. Participants were all female. Average age of city walking group (n=19) 71.1 years, average age for forest walking group (n=43) 70.2 years (n = 62) Blood pressure, arterial stiffness (CAV1), pulmonary function (FEV1, FEV) Primary measurement Forest/city walking intervention Matching of participants Blood pressure ↓ CAVI ↓ FEV1 ↑ FEV6 ↑
Li 2008a, Japan (Li et al. 2008a) To investigate the effect of a forest bathing trip on human NK activity in female subjects study Healthy nurses aged 25-43 years, selected with informed consent (n = 13) Blood and urine sampled for: Nk activity, numbers of NK and T cells, granulysin, perforin, granzymes lymphotcytes, estradiol and progesterone concentration in serum, Adrenaline and noradrenaline concentration in urine. Phytoncides were also measured in the forest Primary measurement Forest Matching of participants Natural killer cell population and activity ↑ Perforin ↑ Granulysin ↑ Granzymes A/B expressing lymphotcytes ↑ Li 2008b, Japan (Li et al. 2008b) To investigate the effect of forest bathing on NK activity compared with a trip to a city, and to measure how long the effect on NK activity lasts study Twelve healthy male subjects aged 35-56 (n = 12) Blood and urine sampled for: Natural killer cell (NK) activity, numbers of NK and T cells, granulysin, perforin, granzymes lymphotcytes, adrenaline concentration in urine. Phytoncides were also measured in the forest Primary measurement Forest Matching of participants Natural killer cell population and activity ↑ Level of perforin ↑ Granulysin ↑ Granzymes A/B expressing lymphotcytes ↑ Adrenaline concentration in ↓
Maas 2006, The Netherlands (Maas et al. 2006) To investigate the strength of the relationship between the amount of green space in people’s living environment and their perceived general health study Representative of the Dutch population in terms of age, gender and health insurance type (n = 250,782) Perceived general health The second national survey of general practice (DNSGP-2) % neighbourhood greenspace; National Land Cover Database (LGN4) Controlled for urbanity, sociodemographic and socioeconomic characteristics Self-reported health ↑ Maas 2008, The Netherlands (Maas et al. 2008) To investigate whether physical activity mediates the relationship between neighbourhood greenspace and self-perceived health Multilevel analysis, study A subset of the second Dutch national survey of general practice (DNSGP-2). Representative of the Dutch population in terms of age, gender and health insurance type, 54.4% female (n = 4,899) Perceived general health The second Dutch national survey of general practice (DNSGP-2) % neighbourhood greenspace; National Land Cover Database (LGN4) Controlled for urbanity, sociodemographic and socioeconomic characteristics Self-reported health ↑ Maas 2009a, The Netherlands (Maas et al. 2009a) To explore whether social contacts are an underlying mechanism behind the relationship between green space and health Multi-level analysis, cross study The second Dutch national survey of general practice (DNSGP-2). Representative of the Dutch population in terms of age, gender and health insurance type, 54.9% female (n = 10,089) Self-reported health indicators: perceived general health, number of health complaints, propensity to psychiatric morbidity The second national survey of general practice (DNSGP-2) % neighbourhood greenspace; National Land Cover Database (LGN4) Controlled for age, gender, household size, of education, income and urbanicity Self-reported health ↑
Maas 2009b, The Netherlands (Maas et al. 2009b) To investigate whether morbidity is also related to green space in people’s living environment study The second Dutch national survey of general practice (DNSGP-2). Representative of the Dutch population in terms of age, gender and health insurance type (n = 345,143) Morbidity data on physical and mental health National mortality records % neighbourhood greenspace; National Land Database (LGN4) Controlled for urbanity, demographic and socioeconomic characteristics Morbidity ↓ Annual prevalence of 24 disease clusters for people who have 10% more green space than average, for 1km radius: High BP ↓ OR 0.99 (95% CI 0.98, 1.00) Cardiac disease ↓ OR 0.98 (95% CI 0.97, 0.99) CHD ↓ OR 0.97 (95% CI 0.95, 0.99) p<0.01 Stroke, brain haemorrhage ↓ OR 0.98 (95% CI 0.95, 1.00) Neck and back complaints ↓ OR 0.98 (95% CI 0.97, 0.99) p<0.01 Severe back complaints ↓ OR 0.98 (95% CI 0.97, 0.99) p<0.01 Severe neck and shoulder complaints ↓ OR 0.98 (95% CI 0.97, 0.99) p<0.01 Severe elbow, wrist and hand complaints ↓ OR 0.97 (95% CI 0.96, 0.98) p<0.01 respiratory tract infection ↓ OR 0.97 (95% CI 0.96, 0.98) p<0.01 Bronchitis/pneumonia ↓ OR 0.97 (95% CI 0.97, 1.00) Asthma, COPD ↓ OR 0.97 (95% CI 0.96, 0.98) p<0.01 Migraine/severe headache ↓ OR 0.98 (95% CI 0.97, 0.99) p<0.01 Vertigo ↓ OR 0.97 (95% CI 0.95, 0.99) p<0.01 Severe intestinal complaints ↓ OR 0.98 (95% CI 0.96, 1.00)
McCracken 2016, UK (McCracken et al. 2016) To examine the health-related quality of life of children in relation to quality and use of greenspace study Children at participating schools aged 8-11, mean age 9.7 ±9 years, 55.6% female (n = 276) Health-related quality of life, Kid-KINDL questionnaire Residential greenspace: Central Scotland Green Network Use of urban greenspace: bespoke questionnaire Additional demographic information collected included: page, gender, number of siblings, type of home, and presence of a garden Health related quality of life ↑ Mitchell 2007, England (Mitchell and Popham 2007) To determine the association between the percentage of greenspace in an area and the standardised rate of “not good” health, and to explore whether this association holds for areas exhibiting different combinations of urbanity and income deprivation. ecological study Respondents to the 2001 census who were asked whether their health was “good”, “fairly good” or “not good”. (All residents in England as at the 2001 census, number not stated) “Not good" health status England 2001 census Generalized Land Use Data 2005 dataset (GLUD) Each controlled for urban higher income, urban lower income, suburban higher income, suburban lower income, rural higher income and rural lower income (unless model was stratifying by characteristic) Self-reported health ↗ Mitchell 2008, England (Mitchell and Popham 2008) To investigate whether the magnitude of income-related health inequality varies by exposure to green space ecological study Anonymised individual mortality records. Populations older than retirement age were excluded as inequalities in mortality tend to be at a maximum mortality, specific mortality (circulatory disease, lung cancer, and intentional Individual-level mortality records Generalized Land Use Data 2005 dataset (GLUD) All models adjusted for age group, sex, deprivation in education, skills and training, deprivation in living environment, population density and urban or rural classification All-cause mortality ↓ Incidence rate ratio for all-cause mortality for the most income deprived quartile compared with the least deprived was 1.93 (95% CI 1.86, 2.01) in the least green areas, whereas it was 1.43 (95% CI 1.34, 1.53) in the most green areas Cardiovascular mortality ↓ IRR 2.19 (95% CI 2.04, 2.34) least green
in the working age population (n = 40,813,236, with 366,348 deaths) IRR 1.54 (95% CI 1.38, 1.73) most green Intentional self harm ↔ Mitchell 2010, UK (Mitchell et al. 2011) To investigate whether associations between greenspace exposure and health vary according to the origins of the green space indicator and, by proxy, the type of green spaces captured by the indicator Ecological study 286 areas in four British cities (York, Exeter, Edinburgh and Glasgow). Each “small area” was a Census Area Statistic (CAS) ward (n = 1,625,495) Mortality and morbidity Mortality records and census data Coordination of information on the Environment (CORINE), British Ordnance Survey’s master map (OSMM), Generalized Land Use Data 2005 dataset (GLUD) All models controlled for age and sex of the exposed populations Self-reported health ↑ Mortality ↓ Morita 2011, Japan (Morita et al. 2011) To study the non-temporary effects of successive walks in forested areas (shinrin-yoku) on hypertension prevalence and blood pressure levels Cohort study Results from the baseline survey of the Japan Collaborative Cohort (J-MICC) study, mean age 52.1 years, 68% male (n = 4,666) pressure, hypertension Primary measurement, bespoke questionnaire Self-reported frequency of forest walking Adjusted for age, BMI, smoking status, alcohol consumption and habitual exercise Blood pressure ↔
Nakau 2013, Japan (Nakau et al. 2013) To examine the effect of spiritual care of cancer patients by integrated medicine in a environment study – pre-post Cancer patients, mean age 58.1 years, 18 females (mean age 56.6 years) and 4 males (mean age 65.3 years) with breast or lung cancer (n = 22) QOL questionnaire, spirituality, fatigue (cancer fatigue psychological state and Natural Killer (NK) cell activity Primary measurement, bespoke questionnaire Forest Matching of participants Natural killer cell activity ↑ Cancer-associated fatigue ↓ Self-reported health ↑ Ngom 2016, Canada (Ngom et al. 2016) To determine the role of proximity to specific types of greenspaces as well as their spatial location in the relationship with the most morbid cardiovascular diseases (CVD) and diabetes study Sample of data from the Quebec Integrated Chronic Disease Surveillance System (QICDSS) (n = 3,920,000) Diabetes, ischaemic heart disease, cerebrovascular diseases, heart failure Quebec Integrated Chronic Disease Surveillance System (QICDSS) Nearest distance to several types of greenspace and the presence of vegetation in open areas using CanMap Controlled for several social and environmental factors Cerebrovascular prevalence ↓ Highest distance to greenspace with sports facilities: PRR 1.11 (95% CI 1.01, 1.22) Diabetes ↓ Highest distance to greenspace with sports facilities: PRR 1.09 (95% CI 1.03, 1.13) Heart failure ↔ Ischaemic heart disease ↔ Ochiai 2015, Japan (Ochiai et al. 2015) To assess the physiological and psychological effects of forest therapy on middle aged males with blood pressure. Pre-post study Japanese males (mean age 56 years, range years) with high-normal blood pressure (n = 9) Blood pressure, urinary adrenaline and serum cortisol (not salivary) Primary measurement Forest Matching of participants Blood pressure ↓ Urinary adrenaline ↓ Serum cortisol ↓ normal
Ohtsuka 1998, Japan (Ohtsuka et al. 1998) To investigate the effect of shinrin-yoku on blood glucose in diabetic patients Pre-post study 58 female and 29 male non-insulin dependent diabetic patients volunteered for the study, mean age years (n = 87) glucose and HbA1c Primary measurement Forest Not specified Non-fasting glucose ↔ HbA1c ↔ Padilla 2016, France (Padilla et al. 2016) To identify and describe how socioeconomic, health accessibility and exposure factors accumulate and interact in areas in a French urban context, to assess environmental health inequalities related to infant and neonatal mortality Ecological Population of Nice metropolitan area, France (n = approximately 537,769) Infant and neonatal mortality rate Death certificate records Proportion of geographic area occupied by greenspaces, Coordination of Information on the Environment (CORINE) Not specified Infant and neonatal mortality ↔ Paquet 2014, Australia (Paquet et al. 2014) To investigate whether residential environment characteristics related to food, walkability and public open spaces were associated with incidence of four cardio-metabolic risk factors in a Cohort study North West Adelaide Health Study (NWAHS), a longitudinal biomedical cohort. 52.4% female, mean age 51.5 years (n = 3,145) hypertension, dislipidaemia, abdominal obesity Primary measurement Road network distance to public open space (POS); defined by Normalised Difference Vegetation Index (NDVI) Analyses accounted for spatial clustering, gender, age, household income, education, duration of follow up and area-level deprivation Diabetes ↔ Prediabetes ↔ Hypertension ↔ Dyslipidaemia ↔
biomedical cohort Park 2007, Japan (Park et al. 2007) To examine the physiological effects of shinrin yoku RCT Healthy male students, mean age 22.8 years (n = 12) Salivary cortisol and cerebral activity, sensory evaluation Primary measurement, bespoke self-reported sensory evaluation Forest Matching of participants Cerebral activity ↓ Salivary cortisol ↓ Park 2009, Japan (Park et al. 2009) To examine the physiological effects of forest recreation on autonomic nervous activity. RCT Male university students, mean age 21.8 (n = 12) BP, HR, HRV Primary measurement Forest Matching of participants Blood pressure ↓ Heart rate ↓ Heart rate variability ↓ Park 2010, (Park et al. 2010) To review previous research on Shinrin yoku and present new results to clarify physiological effects. study 12 healthy male university students in 24 areas between 2005-6, 280 students in total. Mean age 21.7 years. (n = 280) Salivary cortisol, BP, HR, HRV Primary measurement Forest Matching of participants Blood pressure ↓ Heart rate ↓ Heart rate variability ↓ Salivary cortisol↓ Sympathetic nervous activity ↓ Parasympathetic nervous activity ↑ Pasanen 2014, Finland (Pasanen et al. 2014) To investigate the relationship between perceived health and physical activity indoors, outdoors in built environments and outdoors in nature survey National survey data from Finland. 55.6% female, mean age 45.2 years (range years) (n = 2,070) Perceived general health, emotional well-being and sleep quality Bespoke questionnaire Outdoor Recreation Demand Inventory Finnish Forest Research Institute Adjusted for covariates Self-reported health ↑ Sleep quality ↗
activity and health 15-74, 55.4% female (n = 3,108) Putrik 2015, The Netherlands (Putrik et al. 2015) To explore associations between certain features of neighbourhood environment and self-rated health and depressive symptoms in Maastrict study Survey data. Mean age 55 years, 52% female (n = 9,879) Self-rated health and presence of depressive symptoms Bespoke survey Neighbourhood environment characteristics; bespoke survey Models adjusted for individual age, gender, education and income group Self-reported health ↗ Qin 2013, China (Qin et al. 2013) To investigate the influence of urban greenspaces on physiological status study Visitors to the Shanghai Botanical Garden (n = 64) Heart rate variability; (EEG), electrocardiogram (ECG) Primary measurement of park visitors Shanghai botanical gardens None specified Heart rate variability ↓ Reklaitiene 2014, Lithuania (Reklaitiene et al. 2014) To assess the relationship between greenspace proximity, use of green space and depressive symptoms and perceived general health amongst a random sample study Population-based sample in Kaunas, Lithuania. Age range 45-72, 54.7% female (n = 6,944) Health behaviours, depressive symptoms and poor and very poor perceived general health Bespoke questionnaire, depressive systems assessed using scale Distance to city park and park use; unspecified dataset Analyses adjusted for age, marital status, education, smoking, use of alcohol and BMI Self-reported health ↑ Women only, non-significant for men
Requia 2016, Brazil (Requia et al. 2016) To quantify the diseases risk related to 28 neighbourhood aspects in the Federal District, Brazil study Hospital admissions for cardiorespiratory disease in Brazil (n = not specified) Cardiorespiratory diseases risk Brazilian National Health Database Natural environment land use, Sedhab (2012) database Not specified Cardiorespiratory diseases risk ↓ 1km2 increase in green areas intra urban was associated with reduced risk of hospital admission Richardson 2010a, New Zealand (Richardson et al. 2010a) To investigate whether there is a socioeconomic gradient in green space exposure and whether green space exposure is associated with cause-specific mortality (CVD and lung cancer) Ecological study Anonymised individual-level mortality data for every registered death between 1996 and 2005 from the New Zealand Ministry of Health. Limited to adults under 65 (n = 1,546,405) Risk of mortality from cardiovascular disease and from lung cancer Individual-level mortality records, New Zealand Ministry of Health 2001 Census area unit greenspace coverage; Department of Conservation (DOC) Conservation Boundaries data set (2003), Land Information New Zealand’s (LINZ) Core Records System (2004), Ministry for the Environment Land Cover Database 2 (LCDB2 2001) Controlled for census level data on income, employment, communication, support, transport, qualifications, living space, home ownership, smoking, air pollution, and population density as a measure of urbanity Cardiovascular mortality and respiratory mortality ↗ Richardson 2010b, UK (Richardson and Mitchell 2010b) To examine the relationship between urban greenspace and health and to investigate gender differences in this relationship Ecological study Individual-level mortality records were obtained and matched to CAS wards with an estimate of green space coverage (n = 28,600,000) Cardiovascular disease mortality, respiratory disease mortality, limiting long-term illness Individual-level mortality records, Office of National Statistics (England and Wales), General Register Office for Scotland, Northern Ireland Statistics and Research Agency (NISRA) Generalised Land Use Database (GLUD) and Coordination of Information on the Environment (CORINE) All models adjusted for income deprivation quartile, air pollution and country Cardiovascular mortality ↓ men only IRR 0.95 (95% CI 0.91, 0.98) greenest wards Respiratory mortality ↓ men only IRR 0.89 (95% CI 0.83, 0.96) greenest wards
deprived neighbourhoods Manchester: Rochdale and Oldham) (n = 523) Ruokolainen 2015, Estonia and Finland (Ruokolainen et al. 2015) To test the diversity hypothesis by analysing the relationship between land use around the home and atopic sensitisation in children Cohort study Four cohorts of children and adolescents years (n = 1,044) Serum IgE specific to inhallant allergens, proteobacteria on the skin of healthy individuals. Prevalence of atopic sensitisation in children and adolescents aged 0.5-20 years Primary measurement, DIABIMMUNE, LUKAS, KARA datasets Percentage neighbourhood greenspace; Coordination of Information on the Environment (CORINE) Adjusted for potential confounding factors Atopic sensitisation ↓ children Sbihi 2015, Canada (Sbihi et al. 2015) To investigate the effect of early-life exposure to surrounding residential greenness on asthma incidence Cohort study All 1999-2002 single births in the metropolitan area of Vancouver, British Columbia (n = <65,000 children) Asthma diagnosis Physician billing and hospital discharge records Residential surrounding greenness; Normalised Difference Vegetation Index (NDVI) Sex and age matched to 5 randomly chosen controls; models adjusted for covariates including month/year of birth, sex, first nation status, as well as maternal parity, age, smoking during pregnancy and initiation of breastfeeding and assigned socioeconomic indicators Asthma ↓ Skarkova 2015, Czech Republic (Skarková et al. 2015) To assess the impact of the environment on asthma prevalence study Representative sample of children aged 5, 9, 13 and 17 from the Czech Republic (n = 13,456) Asthma prevalence National Institute of Public Health (NIPH) questionnaire survey Land cover data; Fundamental Base of Geographic Data (ZABAGED) administered by the Czech Office for Surveying, Mapping and Cadastre Adjusted regression coefficients calculated Asthma prevalence: ↓ with presence of natural forests ↑ with agricultural land use
Song 2013, Japan (Song et al. 2013) To investigate the physiological and psychological effects of walking in urban parks in winter on young males Controlled Japanese male university students, mean age 22.5 years (n = 13) rate, Heart rate variability (HRV), mood states Primary measurement, Profile of Mood State (POMS) questionnaire, Anxiety Inventory (STAI) Walking intervention; urban park/city area Matching of participants Heart rate ↓ Heart rate variability ↓ Song 2015a, Japan (Song et al. 2015a) To investigate the effect of forest walking on autonomic nervous system activity in middle aged hypertensive individuals Japanese men, mean age 58.0 years (n = 20) Heart rate, Heart rate variability (HRV), relaxation questionnaire Primary measurement, Profile of Mood State (POMS) questionnaire, modified semantic differential method (SD) Walking intervention; forest/urban setting Matching of participants Heart rate ↓ Heart rate variability ↓ Song 2015b, Japan (Song et al. 2015b) To clarify the physiological and psychological effects of walking in urban green areas study Japanese males, mean age 22.3 ±1.2 years (n = 23) Heart rate, heart rate variability, Profile of Mood States (POMS), State-Trait Anxiety Inventory Primary measurement, POMS questionnaire, Anxiety Inventory Urban park vs city area Matching of participants rate ↓ Sympathetic nervous activity ↓ Parasympathetic nervous activity ↑ Stigsdotter 2010, Denmark (Stigsdotter et al. 2010) To investigate the associations between greenspace and health, quality of life and stress study 2005 Danish Health Interview Survey, age range 16-64 years (n = 21,832) Health-related quality of life and stress Danish Institute of Public Health 2005 health interview survey, Short form health survey (SF-36) Self-reported proximity to a greenspace; Danish Institute of Public Health 2005 health interview survey Analyses adjusted for gender, age, cohabitation status, combined school and vocational education, accommodation type, size of municipality and ethnic background Self-reported health ↑ >1km from a greenspace/natural area OR 1.42 (95% CI 1.17, 1.73)
Sugaya 2011, Japan (Sugaya et al. 2011) To compare oxidative damage levels after urban walking and forest walking study Female patients with rheumatoid arthritis aged years old (n = 12) hydroperoxide, MMP-3, uringary and salivary IgA Primary measurement Forest vs environment Matching of participants Urine 8-0 HdG levels, MMP-3, salivary IgA ↑ Serum hydroperoxide ↓ Sugiyama 2008, Australia (Sugiyama et al. 2008) To examine associations of perceived neighbourhood greenness with perceived physical and mental health, and to investigate whether walking and social factors account for these relationships study Observational epidemiological study, 63% female, mean age 45 years (n = 1,895) Physical and mental health scores Short-form health survey (SF-12), physical component scores (PCS), mental component scores (MCS) Perceived neighbourhood greenness; Neighbourhood Environment Walkability adjusted for age, education, work status, household income, marital status, and a further model also adjusted for walking for recreation, social coherence score and local social interaction Self-reported health ↗ Sugiyama 2009, UK (Sugiyama et al. 2009) To examine what aspects of neighbourhood open space are associated with walking for recreation and for transport by older people study 60.8% female, mean age 75.0 years, 10% (n = 284) Self-reported quality of life (QOL) and "health status" Behavioural Risk Factor Surveillance Scheme (BRFSS), Satisfaction With Life Scale (SWLS) Bespoke scale measuring quality of neighbourhood open space (NOS) All models adjusted for participants’ age, functional capability and their level of educational attainment Self-reported health ↗ Sulander 2016, Finland (Sulander et al. 2016) To investigate the relationship between urban greenspace visits and mortality among adults study 939 women; mean age 82 years, 456 men; mean age 81 years Mortality National Population Information System survey Frequency of visiting urban green areas, bespoke questionnaire Model 1: Adjusted for sociodemographics and education Mortality ↓ Visit a green area few times a year or less: HR 2.2 (95% CI 1.2, 4.1) Model 3, but significant for all models
(n = 1,395) Model 2: Adjusted for sociodemographics and diseases 3: Adjusted for sociodemographics, diseases and functional capacity Sung 2012, Japan (Sung et al. 2012) To investigate the effects of forest therapy on blood pressure, salivary cortisol and quality of life in patients with hypertension Controlled Enrolled for the after referral from local health centres (n = 56) Blood pressure, salivary cortisol and quality of life Primary measurement, bespoke questionnaire Forest and control setting Not specified Quality of life ↑ Salivary cortisol ↓ Takano 2002, Japan (Takano et al. 2002) To investigate the association between greenery filled public in close proximity to residences and the longevity of senior citizens in a densely populated, developed megacity Cohort study Representative sample of residents born in 1903, 1908, 1913 and 1918 (n = 3,144) Longevity Official 5 year survival rates Self-reported neighbourhood greenspace and frequency of use; bespoke questionnaire Controlled for age, sex, marital status and socioeconomic status Longevity ↑ OR 1.13 (95% CI 1.03, 1.24)
Tamosiunas 2014, Lithuania (Tamosiunas et al. 2014) To explore the associations of the distance and use of urban greenspaces with the prevalence of cardiovascular diseases and its risk factors. To evaluate the impact of accessibility and use of greenspaces on the incidence of CVD Cohort study Kaunas cohort study. Mean age 60.4 years, 57% female (n = 5,112) Blood pressure, cognitive function, serum lipids, fasting glucose, health, symptoms of depression, coronary heart disease measured by a history of myocardial infarction or ischaemic changes in ECG. Angina, diabetes and stroke diagnosis recall Primary measurement, Centre for Epidemiologic Studies Depression Scale 10), medical records, bespoke questionnaire Distance to nearest greenspace; unspecified special land cover dataset for Kaunas city Adjusted for age CVD ↓ men only 3rd tertile compares to 1st: HR 1.36 (95% CI 1.03, 1.80) CVD ↓ women only 2nd and 3rd tertile compared to 1st: HR 2.78 (95% CI 1.16, 6.70) Toda 2013, Japan (Toda et al. 2013) To investigate the effect of walking through woodland on salivary endocrinological stress makers, cortisol and chromogranin A Pre post Healthy mean age 67.6 years (n = 20) Salivary cortisol and chromogranin A, visual analogue scales of perceived stress Primary measurement, stress visual analogue scale Forest vs office Matching of participants Systolic blood pressure ↓ Salivary cortisol ↓ Heart rate ↑ 2015, Spain et al. 2015) To investigate the association between natural outdoor environments (separately blue and green spaces) and health (general and mental) and its possible study Catalonia Health Survey. 50.06% female, mean age 48 years (n = 8,793) Self-perceived general health Short form health survey (SF-36), General health questionnaire questions from ESCA questionnaire Access to natural outdoor environments and surrounding greenness; Normalised Difference Vegetation Index (NDVI) Adjusted for gender, age, education completed, birth place, type of health insurance, marital status and indicators of household and neighbourhood socioeconomic status Self-reported health ↑ Surrounding greenness within 300m, OR for less than good self-perceived general health: OR 0.90 (95% CI 0.83, 0.98)
mediators and modifiers Tsunetsugu 2007, Japan (Tsunetsugu et al. 2007) To investigate the physiological effects of shinrin-yoku on blood pressure, pulse rate, HRV, salivary cortisol and immunoglobin A RCT Male university students, mean age 22 years (range 21-23) (n = 12) Blood pressure, heart rate, heart rate variability (LF&HF), salivary cortisol and mental health Primary measurement, bespoke 13-point scale Forest vs city Matching of participants pressure ↓ rate ↓ Heart rate variability ↓ Salivary cortisol ↓ Tsunetsugu 2013, Japan (Tsunetsugu et al. 2013) To investigate the physiological and psychological effects of viewing urban forest landscapes on 48 young male urban residents Controlled 12 university students who participated in each of the four experimental areas. Mean age 21.1 years (n = 12) pressure, heart rate, heart rate variability Primary measurement Forest vs urban site Matching of participants Diastolic blood pressure ↓ Heart rate ↓ Heart rate variability ↓ Tyrvainen 2014, Finland (Tyrväinen et al. 2014) To investigate the psychological and physiological effects of visits to urban nature environments RCT Healthy adults, mean age 47.64 years (range years), 87.17% female (n = 77) Salivary cortisol concentration as well as psychological symptoms Primary measurement, Focus of Attention Scale (TFOAS), Restoration Outcome Scale (ROS), Perceived Restorativeness Scale (PRS), Positive and Negative Affect Scale (PANAS), Creativity Scale, Subjective Vitality Scale Forest vs park vs city centre Matching of participants Salivary cortisol ↔
Ulmer 2016, USA et al. 2016) To enhance the understanding of the potential of trees in an urbanised region of the US study California Health Interview Survey (CHIS); 58% female, mean age 46 years (n = 7,910) Diabetes, blood pressure, asthma, general health status California Health Interview Survey (CHIS) LiDAR tree canopy cover data All demographic, and built environment variables were included in every model as covariates, and all models included adjustment for the DAC-provided raked sample weights Poor general health ↓ OR 0.871 (0.799, 0.949) Blood pressure, asthma, diabetes ↘ Ulrich 1984, USA (Ulrich 1984) To investigate the influence of a hospital window view on patients’ emotional and recovery cohort study Cholecystectomy patients assigned to rooms on the second and third floors of a hospital between 1972 and 1981, during months when the trees had foliage. Age range 20-69. 65% female (n = 46) Number of days hospitalisation, number and strength of analgesics each day, number and strength of for anxiety, including tranquilisers and barbiturates, each day, minor complications such as persistent headache and nausea requiring which are considered to result frequently from conversion reactions, and all Hospital records on stay duration and medication type/frequency, nurses' notes View from hospital window Participants matched for age, sex, smoking status, obesity, history of hospitalisation, year of surgery and floor level Post-operative recovery time ↓ promoting
nurses' notes relating to a patients condition or course of recovery van Dillen 2012, The Netherlands (van Dillen et al. 2012) To investigate the link between the objectively assessed quantity and quality of (1) green areas and (2) streetscape greenery on the one hand and three health indicators on the other study Questionnaires sent to a random sample of 100 households in each neighbourhood, non-western ethnic minorities heavily (n = 1,641) Health questionnaire: general health, acute health complaints, general mental health status Bespoke questionnaire Objectively measured quantity of green area; Pikora et and Hillsdon et tools Adjusted for gender, age, education level and income Self-reported health ↑ Van Herzele 2012, Belgium To investigate the relationship between local greenness and health and wellbeing of study Two neighbourhoods, Dierentuin (More green, n=97, 53.6% female, mean age 43.2 Self-reported general health, bodily functioning and general wellbeing Bespoke questionnaire Van Herzele and Wiedemann green space monitoring tool Adjusted for gender, age, education, income, smoking, alcohol consumption and having a pessimistic personality Self-reported health ↗
(Van Herzele and de Vries 2012) inhabitants by looking at possible mediators :PA, stress, ability to concentrate, social cohesion and neighbourhood satisfaction years) and (Less green, n=93, 54.8% female, mean age 43.6 years) (n = 190) Villeneuve 2012, Canada (Villeneuve et al. 2012) To investigate the relationship between urban greenspace and mortality in Ontario, Canada Cohort study Randomly selected from 10 urban areas in Ontario, >35 years, 50.8% male (n = 574,840) Canadian mortality database Canadian mortality database, 2001 Canadian Community Health Survey % neighbourhood greenspace; Normalised Difference Vegetation Index (NDVI) Adjusted for smoking, physical activity and BMI category Non-accidental mortality ↓ A 1IQR increase in greenspace in a 500m buffer associated with reduced non-accidental mortality: RR 0.95 (95% CI 0.94, 0.96) Respiratory disease mortality ↓ RR 0.91 (95% CI 0.89, 0.93) Vogt 2015, Germany (Vogt et al. 2015) To examine the associations between proximity to two features of the residential environment and three aspects of health aging study KORA (Cooperative Health Research in the Region of Augsburg)-Age study participants aged 65 or over (n = 1,711) Health-related quality of life KORA-Age study survey Distance to public green space, Augsburg city records Model 2 controlled for age, sex and per capita income Model 3 also controlled for regional deprivation Health-related quality of life ↔ Wang 2016, China (Wang et al. 2016) To examine the impact of both indoor and outdoor spatial factors on lung cancer study 62% female (n = 472) Lung cancer morbidity Bespoke questionnaire Distance to parks, internal greenspace, dataset not specified Participants matched for age and gender Adjusted for other demographic and lifestyle factors Lung cancer morbidity ↓ with internal greenspace ↑ with distance to parks
Ward 2016, New Zealand (Ward et al. 2016) To investigate the relationship between children’s time spent in greenspace with various physiological and psychological variables study 59% female, mean age 12.66 (n = 108) Cognitive development: visual memory, verbal memory, processing speed, psychomotor speed, reaction time, cognitive flexibility and executive function Computerised neurocognitive testing conducted using CNS Vital Signs Locational data from GPS, greenspace exposure calculated using Personal Activity Location Measurement System (PALMS) All models included sex, age and school as covariates Cognitive development ↔ Ward Thompson 2012, Scotland (Thompson et al. 2012) To investigate the relationship between greenspace in urban deprived areas and stress (salivary cortisol and self-report) and general wellbeing Exploratory study People were recruited through community centres and training opportunity centres in Dundee. Mean age 43.4 years (age range 33-57 years), 52% female (n = 25) Salivary cortisol, self-reported measures of stress and Primary measurement Percentage neighbourhood greenspace in Census Area Statistics Ward; data from Centre for Research on Environment Society and Health (CRESH) Not specified Salivary cortisol ↓ Ward Thompson 2016, Scotland (Ward Thompson et al. 2016) To investigate the nature of access to greenspace necessary before any health benefit is found survey 54.7% female, mean age 44 ±17.1 years (n = 406) General health Bespoke single-item assessment Self-reported access to greenspace and objective measure Ordnance Survey MasterMap Not specified General health ↑ Weimann 2015, Sweden To investigate the effects of changing exposure to neighbourhood survey Prognostic group for good general health at baseline: Self-reported general health Bespoke questionnaire Perceived neighbourhood greenness, public health survey Adjusted for covariates associated with general or mental health Self-reported health ↑ Evidence of beneficial effect of increased greenness indicated among subjects with lowest prognostic of good general health:
(Weimann et al. 2015) greenness on general and mental health 48% male. Age range 18-80 (n = 8,891) OR 1.24 (95% CI 1.01, 1.52) Weltin 2012, USA (Weltin and Lavin 2012) To investigate whether a community garden could provide improved diabetes control A parallel designed study Members of a Midwest community of immigrants from the Marshall Islands. Mean age 51 (range years), 52.9% male (n = 17) levels Primary measurement Community garden Matching of participants ↓ Wheeler 2012, UK (Wheeler et al. 2012) To investigate whether rates of good health improve with proximity to the coast and percentage green space ecological study 2001 census data for England (n = 48,200,000) Self-reported "good" health 2001 census data for England % land area classified as greenspace in Lower-layer Super Output Areas (LSOA), Generalised Land Use Database Not specified Self-reported health ↑ Quintile 3: Rural: 0.31 (95% CI 0.04, 0.57) Quintile 4: 0.23 (95% CI 0.13, 0.33) Town/fringe: 0.49 (95% CI 0.19, 0.79) Quintile 5: Rural 0.36 (95% CI 0.26, 0.47) Town/fringe: 0.69 (95% CI 0.39, 0.99) Rural: 0.59 (95% CI 0.30, 0.88) Wheeler 2015, UK (Wheeler et al. 2015) To investigate the relationship between different and qualities of natural environments on health and Ecological study 2011 UK census data (n = 63,260,000) Age/sex standardised prevalence of both good and bad health 2011 census data for Great Britain Greenspace per Super Output Areas (LSOA) for England and Wales, and Data Zones (DZs) for Scotland; UK Land Cover Map 2007 Regression analyses adjusted for income, education and employment scores and models also adjusted for urban/rural classification Self-reported health ↑ Significant positive associations observed between good health prevalence and the density of several greenspace types: ‘broadleaf woodland’, ‘arable and horticulture’ and ‘improved grassland’ as well as ‘saltwater’ and ‘coastal’ after adjusting for confounders.
Wu 2015, England (Wu et al. 2015) To investigate the impact of the community environment on cognition in later life study The MRC Cognitive Function and Ageing Study (CFAS). 60.7% female, mean age 81.7 years (n = 2,424) Cognitive impairment and dementia Bespoke questionnaire including self-reported past medical history Land use per Lower-layer Super Output Areas (LSOA); Generalised Land Use Dataset (GLUD) 2001 Adjusted for age, gender, education, social class and number of chronic illnesses with a further adjustment for area deprivation Dementia ↑ Quartile 4 (Highest % natural environment) OR 2.23 (95% CI 1.17, 4.24) Cognitive impairment ↑ Quartile 4 OR (95% CI 1.00, 1.98) Yamaguchi 2006, Japan (Yamaguchi et al. 2006) To investigate the effects of exercise in forest and urban environments on sympathetic nervous activity of normal young adults Healthy male university students, mean age 22.2 years (n = 15) Salivary amylase activity, sympathetic nervous activity (heart rate variability) Primary measurement Forest vs urban environment Matching of participants rate variability ↓ Young 2016, USA et al. 2016) To determine the risk of gestational diabetes (GDM) and preeclampsia associated with various community response Ecological study Los Angeles and Orange Counties birth records (n = 6,567,580 women, 362,525 pregnancies) Gestational diabetes and preeclampsia California Birth Certificate database Ratio and km of park area in each zipcode; land use data from Southern California Association of Government Adjusted model accounted for maternal age, prepregnancy BMI, race, ethnicity and median household income Gestational diabetes and preeclampsia ↔ ↑= significant increase; ↓= significant decrease; ↗= non-significant increase; ↘= non-significant decrease; ↔= non-significant, direction not reported. Significant increase in a measurement may or may not be an improvement References: