Use of the Natural Outdoor Environment in Different Populations in Europe in Relation to Access: Implications for Policy.

This cross-cultural study explores the relationship of natural outdoor environment (NOE) use with NOE access. Most urban planning recommendations suggest optimal accessibility to be 300 m-500 m straight distance to spaces with vegetation of at least 1 hectare. Exploring this recommendation, we used data (n = 3947) from four European cities collected in the framework of the PHENOTYPE study: Barcelona (Spain), Doetinchem (The Netherlands), Kaunas (Lithuania) and Stoke-on-Trent (United Kingdom) to obtain residential access to NOE (straight or network distances, using 300 m and 150 m buffers, to NOE larger than 1 hectare or 0.5 hectare) and use of NOE (i.e., self-reported time spent in NOE). Poisson regression models were used to examine the associations between residential access and use of NOE. The models with the strongest association with time spent in NOE in the combined sample were for those living within 300 m straight line distance to either 0.5 ha or 1 ha NOE. Noting that the only indicator that was consistent across all individual cities was living with 150 m network buffer of NOE (of at least 1 ha), this warrants further exploration in reducing recommendations of 300 m straight-line distance to 150 m network distance to 1 ha of NOE for a general indicator for cities within Europe.

Momentary mood response to natural outdoor environments in four European cities.

Exposure to natural outdoor environments (NOE) has been shown in population-level studies to reduce anxiety and psychological distress. This study investigated how exposure to one's everyday natural outdoor environments over one week influenced mood among residents of four European cities including Barcelona (Spain), Stoke-on-Trent (United Kingdom), Doetinchem (The Netherlands) and Kaunas (Lithuania). Participants (n = 368) wore a smartphone equipped with software applications to track location and mood (using mobile ecological momentary assessment (EMA) software), for seven consecutive days. We estimated random-effects ordered logistic regression models to examine the association between mood (positive and negative affect), and exposure to green space, represented by two binary variables indicating exposure versus no exposure to NOE using GPS tracking and satellite and aerial imagery, 10 and 30 min prior to participants' completing the EMA. Models were adjusted for home city, day of the week, hour of the day, EMA survey type, residential NOE exposure, and sex, age, education level, mental health status and neighbourhood socioeconomic status. In addition, we tested for heterogeneity of effect by city, sex, age, residential NOE exposure and mental health status. Within 10 min of NOE exposure, compared to non-exposure, we found that overall there was a positive relationship with positive affect (OR: 1.39, 95% CI: 1.06, 1.81) of EMA surveys, and non-significant negative association with negative affect (OR: 0.80, 95% CI: 0.58, 1.10). When stratifying, associations were consistently found for Stoke-on-Trent inhabitants and men, while findings by age group were inconsistent. Weaker and less consistent associations were found for exposure 30 min prior to EMA. Our findings support increasing evidence of psychological and mental health benefits of exposure to natural outdoor environments, especially among urban populations such as those included in our study.

Exploring mechanisms underlying the relationship between the natural outdoor environment and health and well-being - Results from the PHENOTYPE project.

BACKGROUND: Despite the large number of studies on beneficial effects of the natural outdoor environment (NOE) on health, the underlying mechanisms are not fully understood. OBJECTIVE: This study explored the relations between amount, quality, use and experience of the NOE; and physical activity, social contacts and mental well-being. METHODS: In this cross-sectional study, data on GIS-derived measures of residential surrounding greenness (NDVI), NOE within 300 m, and audit data on quality of the streetscape were combined with questionnaire data from 3947 adults in four European cities. These included time spent in NOE (use); and perceived greenness, and satisfaction with and importance given to the NOE (experience). Physical activity, social contacts and mental health were selected as key outcome indicators. Descriptive and multilevel analyses were conducted both on pooled data and for individual cities. RESULTS: More minutes spent in the NOE were associated with more minutes of physical activity, a higher frequency of social contacts with neighbors, and better mental well-being. Perceived greenness, satisfaction with and importance of the NOE, were other strong predictors of the outcomes, while GIS measures of NOE and streetscape quality were not. We found clear differences between the four cities. CONCLUSIONS: Use and experience of the natural outdoor environment are important predictors for beneficial effects of the natural outdoor environment and health. Future research should focus more on these aspects to further increase our understanding of these mechanisms, and needs to take the local context into account.

Living Close to Natural Outdoor Environments in Four European Cities: Adults' Contact with the Environments and Physical Activity.

This study investigated whether residential availability of natural outdoor environments (NOE) was associated with contact with NOE, overall physical activity and physical activity in NOE, in four different European cities using objective measures. A nested cross-sectional study was conducted in Barcelona (Spain); Stoke-on-Trent (United Kingdom); Doetinchem (The Netherlands); and Kaunas (Lithuania). Smartphones were used to collect information on the location and physical activity (overall and NOE) of around 100 residents of each city over seven days. We used Geographic Information Systems (GIS) to determine residential NOE availability (presence/absence of NOE within 300 m buffer from residence), contact with NOE (time spent in NOE), overall PA (total physical activity), NOE PA (total physical activity in NOE). Potential effect modifiers were investigated. Participants spent around 40 min in NOE and 80 min doing overall PA daily, of which 11% was in NOE. Having residential NOE availability was consistently linked with higher NOE contact during weekdays, but not to overall PA. Having residential NOE availability was related to NOE PA, especially for our Barcelona participants, people that lived in a city with low NOE availability.

Natural outdoor environments and mental health: Stress as a possible mechanism.

INTRODUCTION: Better mental health has been associated with exposure to natural outdoor environments (NOE). However, comprehensive studies including several indicators of exposure and outcomes, potential effect modifiers and mediators are scarce. OBJECTIVES: We used novel, objective measures to explore the relationships between exposure to NOE (i.e. residential availability and contact) and different indicators of mental health, and possible modifiers and mediators. METHODS: A nested cross-sectional study was conducted in: Barcelona, Spain; Stoke-on-Trent, United Kingdom; Doetinchem, Netherlands; Kaunas, Lithuania. Participants' exposure to NOE (including both surrounding greenness and green and/or blue spaces) was measured in terms of (a) amount in their residential environment (using Geographical Information Systems) and (b) their contact with NOE (using smartphone data collected over seven days). Self-reported information was collected for mental health (psychological wellbeing, sleep quality, vitality, and somatisation), and potential effect modifiers (gender, age, education level, and city) and mediators (perceived stress and social contacts), with additional objective NOE physical activity (potential mediator) derived from smartphone accelerometers. RESULTS: Analysis of data from 406 participants showed no statistically significant associations linking mental health and residential NOE exposure. However, NOE contact, especially surrounding greenness, was statistically significantly tied to better mental health. There were indications that these relationships were stronger for males, younger people, low-medium educated, and Doetinchem residents. Perceived stress was a mediator of most associations, and physical activity and social contacts were not. CONCLUSIONS: Our findings indicate that contact with NOE benefits mental health. Our results also suggest that having contact with NOE that can facilitate stress reduction could be particularly beneficial.

Does the Health Impact of Exposure to Neighbourhood Green Space Differ between Population Groups? An Explorative Study in Four European Cities.

It has been suggested that certain residents, such as those with a low socioeconomic status, the elderly, and women, may benefit more from the presence of neighbourhood green space than others. We tested this hypothesis for age, gender, educational level, and employment status in four European cities. Data were collected in Barcelona (Spain; n = 1002), Kaunas (Lithuania; n = 989), Doetinchem (The Netherlands; n = 847), and Stoke-on-Trent (UK; n = 933) as part of the EU-funded PHENOTYPE project. Surveys were used to measure mental and general health, individual characteristics, and perceived neighbourhood green space. Additionally, we used audit data about neighbourhood green space. In Barcelona, there were positive associations between neighbourhood green space and general health among low-educated residents. In the other cities and for the other population groups, there was little evidence that the association between health and neighbourhood green space differed between population groups. Overall, our study does not support the assumption that the elderly, women, and residents who are not employed full-time benefit more from neighbourhood green space than others. Only in the highly urbanised city of Barcelona did the low-educated group benefit from neighbourhood green spaces. Perhaps neighbourhood green spaces are more important for the health of low-educated residents in particularly highly urbanised areas.

The relationship between natural outdoor environments and cognitive functioning and its mediators.

BACKGROUND: Urban residents may experience cognitive fatigue and little opportunity for mental restoration due to a lack of access to nature. Natural outdoor environments (NOE) are thought to be beneficial for cognitive functioning, but underlying mechanisms are not clear. OBJECTIVES: To investigate the long-term association between NOE and cognitive function, and its potential mediators. METHODS: This cross-sectional study was based on adult participants of the Positive Health Effects of the Natural Outdoor Environment in Typical Populations in Different Regions in Europe (PHENOTYPE) project. Data were collected in Barcelona, Spain; Doetinchem, the Netherlands; and Stoke-on-Trent, United Kingdom. We assessed residential distance to NOE, residential surrounding greenness, perceived amount of neighborhood NOE, and engagement with NOE. Cognitive function was assessed with the Color Trails Test (CTT). Mediation analysis was undertaken following Baron and Kenny. RESULTS: Each 100m increase in residential distance to NOE was associated with a longer CTT completion time of 1.50% (95% CI 0.13, 2.89). No associations were found for other NOE indicators and cognitive function. Neighborhood social cohesion was (marginally) significantly associated with both residential distance to NOE and CTT completion time, but no evidence for mediation was found. Nor were there indications for mediation by physical activity, social interaction with neighbors, loneliness, mental health, air pollution worries, or noise annoyance. CONCLUSIONS: Our findings provide some indication that proximity to nature may benefit cognitive function. We could not establish which mechanisms may explain this relationship.

The effect of randomised exposure to different types of natural outdoor environments compared to exposure to an urban environment on people with indications of psychological distress in Catalonia.

INTRODUCTION: Experimental studies have reported associations between short-term exposure to natural outdoor environments (NOE) and health benefits. However, they lack insight into mechanisms, often have low external and ecological validity, and have rarely focused on people with some psycho-physiological affection. The aim of this study was to use a randomized, case-crossover design to investigate: (i) the effects of unconstrained exposure to real natural and urban environments on psycho-physiological indicators of people with indications of psychological distress, (ii) the possible differential effects of 30 and 30+180 minutes exposures, and (iii) the possible mechanisms explaining these effects. MATERIAL AND METHODS: People (n = 26) with indications of psychological distress were exposed to green (Collserola Natural Park), blue (Castelldefels beach) and urban (Eixample neighbourhood) environments in Catalonia. They were exposed to all environments in groups for a period of 30+180 minutes between October 2013 and January 2014. During the exposure period, participants were instructed to do what they would usually do in that environment. Before, during (at 30 and 30+180 minutes) and after each exposure, several psycho-physiological measures were taken: mood (measured as Total Mood Disturbance, TMD), attention capacity (measured as backwards digit-span task), stress levels (measures as salivary cortisol), systolic and diastolic blood pressure, heart rate, autonomous nervous system (assessed as heart rate variability and the indicators: low frequency power (LF), high frequency power (HF), ratio between LF and HF (LF:HF), and coefficients of component variance of LF, HF, and LF:HF). We also measured several potential mediators: air pollution, noise, physical activity, social interactions, and self-perceived restoration experience. RESULTS: When compared with responses to urban environment, we found statistically significantly lower TMD [-4.78 (-7.77, -1.79) points difference], and salivary cortisol [-0.21 (-0.34, -0.08) log nmol/L] in the green exposure environment, and statistically significantly lower TMD [-4.53 (-7.57, -1.49) points difference], and statistically significant favourable changes in heart rate variability indicators (specifically LF:HF and CCV-LF:HF with around -0.20 points of difference of the indicators) in the blue exposure environment. Physical activity and self-perceived restoration experience partially mediated the associations between NOE and TMD. Physical activity and air pollution partially mediated the associations between NOE and heart rate variability. DISCUSSION AND CONCLUSIONS: This study extends the existing evidence on the benefits of NOE for people's health. It also suggests NOE potential as a preventive medicine, specifically focusing on people with indications of psychological distress. TRIAL REGISTRATION: Clinicaltrials.gov NCT02624921.

Visiting green space is associated with mental health and vitality: A cross-sectional study in four european cities.

Many epidemiological studies have found that people living in environments with more green space report better physical and mental health than those with less green space. However, the association between visits to green space and mental health has seldom been studied. The current study explored the associations between time spent in green spaces by purposeful visits and perceived mental health and vitality in four different European cities, and to what extent gender, age, level of education, attitude towards nature and childhood nature experience moderate these associations. Data was gathered using a questionnaire administered in four European cities (total n=3748). Multilevel analyses showed significant positive associations between time spent visiting green spaces and mental health and vitality in the pooled data, as well as across the four cities. Significant effect modification was found for level of education and childhood nature experience. The findings confirm the hypothesis that more time spent in green space is associated with higher scores on mental health and vitality scales, independent of cultural and climatic contexts.

The impact and process of a community-led intervention on reducing environmental inequalities related to physical activity and healthy eating - a pilot study.

BACKGROUND: There is growing recognition that a sedentary lifestyle is being driven, at least in part, by environmental factors that affect individuals' physical activity choices and health behaviours. In other words, the environments in which we live, and with which we interact, have become ones that encourage lifestyle choices that decrease physical activity and encourage over-consumption of foods. However, evidence from community-led interventions to change local neighbourhood environments to support physical activity and healthy eating is lacking. This article summarises the research protocol developed to evaluate a community-led intervention "My Health Matters" aimed at reducing health inequalities relating to increasing physical activity and healthy eating as defined by community members themselves. METHODS/DESIGN: This study includes three of the most deprived electoral wards in Stoke-on-Trent. In each of these areas, environmental factors including proximity of physical activity spaces, greenspace and leisure facilities, neighbourhood connectivity and walkability, land-use-mix and population density, traffic, safety and crime, and food outlets will be mapped using Geographical Information Systems (GIS). A community postal survey of randomly selected addresses assessing environmental characteristics relating to physical activity, perceived health status, social capital, fruit and vegetable consumption and levels of physical activity will be undertaken (baseline and at 2 year follow-up). Based on baseline findings an intervention will be designed and implemented over a 2 year period that includes the following; use of community participatory research to build effective community partnerships; use of partnership consensus to identify, prioritise and design intervention(s) related to specific health disparities; recruitment of local residents to help with the delivery and sustainability of target intervention(s); and the development of local systems for ongoing monitoring and evaluation of the intervention(s). DISCUSSION: A community-led and multidisciplinary approach to modifying environmental factors that support and reinforce healthful behaviours may be more successful than focusing on individual behaviour change as this approach does not exclusively rely upon individual will and capacity.Study findings will be collated in 2012 and, if successful in improving levels of physical activity and healthy eating, will help to inform the design of a larger area-based, cluster randomized controlled trial to determine effectiveness.