Nature contact and children's health: A systematic review

ABSTRACT

Background: Daily outdoor play for children has been encouraged by the American Academy of Pediatrics,which has long recognized the importance of play for promoting children's health and social-emotionaldevelopment. The COVID-19 related school closures and activity restrictions have highlighted potentialinequities in opportunities for children to play outdoors. There is increasing evidence, of varying quality, thatoutdoor environments containing elements of nature may offer benets for children's health that comespecically from the nature contact experienced. However, one barrier to increasing support for naturecontact from the health care community has been the lack of systematically and rigorously reviewedaccessible evidence on this topic. Objective: Our goal was to conduct a systematic review to evaluate andaggregate the evidence regarding the impacts of nature contact on children's health and well-being. Methods:We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines forsystematic reviews. The database search was conducted using PubMed, CINAHL, PsychInfo, ERIC, Scopus, andWeb of Science in June 2018. In all searches, the rst element included nature terms (exposure occurring birth to 18 years) and the second element included child health outcome terms (physical, mental, andcognitive/learning outcomes). Studies that focused only on outdoor time or play, without nature elements,were excluded. Two reviewers evaluated each study and reached consensus for 1) review inclusion;2)determination of nature exposure category;and 3) quality assessment using the Mixed Methods AppraisalTool (MMAT). The MMAT is a reliable and valid quality assessment metric;a summary score ≥ 80% wasconsidered high quality. Results: Of the 8756 studies initially identied, 163 were included in the review. Moststudies included were observational (n=159) and examined the presence of natural environments (greenspace) around residential or school locations (n=89). Our quality assessment suggested that several high-quality studies were present within each nature exposure category. We categorized studies into one of thefollowing types of nature exposure green space/park proximity to home (n=74, 83% high quality), green spaceactivity (n=27, 37% high quality), green space/park proximity to school (n=14, 93% high quality), wildernessexposure (n=11, 9% high quality), gardening (n=6;25% high quality), greening intervention (n=5, 40% highquality), outdoor classroom (n=5, 0% high quality), and nature walks (n=2, 0% high quality), and other (n=19,27% high quality). Studies focused on a range of outcomes including physical health (n=111, 68%), mentalhealth (n=36;22%), and cognitive/learning outcomes (n=16, 10%). Conclusions: Our systematic reviewsummarizes literature available regarding the impact of nature exposure on health outcomes in children, withan emphasis on high quality studies. Ultimately, we seek to make this evidence accessible to pediatricians tobase clinical recommendations, develop health-promoting programs and policies, and guide future research.