"My Family Was Also Happy": Couples' Qualitative Reports of a Combined Behavioral Economics and Cognitive Behavioral Therapy Intervention to Reduce Alcohol Use and Intimate Partner Violence.

Improving intimate partner violence interventions requires understanding pathways to change among couples participating in these interventions. This article presents qualitative data from 18 males and 16 females who participated in a combined behavioral economics (contingency management) and cognitive behavioral therapy alcohol and violence reduction intervention trial in Bengaluru, India. Results confirmed several theorized pathways of change, as well as identified further mechanisms through which the intervention supported the change. These included the emotional impacts of incentives, perceived and actual accountability via breathalyzers and family involvement, and enhanced support gained through counseling skills. Findings reveal critical insights into intervention design for future implementation.

Greenness and Depression Incidence among Older Women.

BACKGROUND: Recent evidence suggests that higher levels of residential greenness may contribute to better mental health. Despite this, few studies have considered its impact on depression, and most are cross-sectional. OBJECTIVE: The objective of this study was to examine surrounding residential greenness and depression risk prospectively in the Nurses' Health Study. METHODS: A total of 38,947 women (mean age throughout follow-up 70 y [range 54­91 y]) without depression in 2000 were followed to 2010. Residential greenness was measured using the satellite-based Normalized Difference Vegetation Index (NDVI) and defined as the mean greenness value within [Formula: see text] and [Formula: see text] radii of the women's residences in July of each year. Incidence of depression was defined according to the first self-report of either physician-diagnosed depression or regular antidepressant use. We used Cox proportional hazards models to examine the relationship between greenness and depression incidence and assessed physical activity as a potential effect modifier and mediator. RESULTS: Over 315,548 person-years, 3,612 incident depression cases occurred. In multivariable-adjusted models, living in the highest quintile of residential greenness within [Formula: see text] was associated with a 13% reduction in depression risk ([Formula: see text] [95% confidence interval (CI): 0.78, 0.98]) compared with the lowest quintile. The association between greenness and depression did not appear to be mediated by physical activity, nor was there evidence of effect modification by physical activity. CONCLUSIONS: In this population of mostly white women, we estimated an inverse association between the highest level of surrounding summer greenness and the risk of self-reported depression. https://doi.org/10.1289/EHP1229.

Designing a Pilot Study Protocol to Test a Male Alcohol Use and Intimate Partner Violence Reduction Intervention in India: Beautiful Home.

Introduction: Evidence suggests alcohol consumption is correlated with intimate partner violence (IPV) making alcohol reduction interventions a promising method for reducing IPV. While both financial incentive and cognitive behavioral therapy (CBT) interventions in high-income countries, respectively, have effectively reduced alcohol consumption and IPV perpetration among men, little evidence exists demonstrating that these approaches can work in a low-resource setting. Methods: The objective of this study is to design and pilot test a low-cost, scalable intervention for reducing alcohol consumption and IPV in Bengaluru, India, where alcohol has been shown to be a key driver of high rates of IPV. A pilot randomized controlled trial (RCT) design will be used to examine the feasibility of testing a combined incentive and CBT based intervention among couples to stimulate immediate behavior change and to sustain positive behaviors pertaining to alcohol use and IPV. Sixty couples will be screened and enrolled into one of three study arms: an incentive-only, incentive plus counseling, or a control arm. Extensive procedures have been included to ensure participant safety, including staff training on global safety procedures for violence intervention research, careful messaging of study aims, screening procedures to exclude those at high risk of alcohol withdrawal or severe violence due to the study, and a referral and case management system. Male and female participants will complete surveys at baseline and immediately and 3-months post-intervention. Breathalyzers will be used to capture male participants' blood alcohol content daily for intervention arm participants and three times a week for control participants. A sub-sample of male and female members of couples will participate in qualitative in-depth interviews to further explore pathways to change. The results from this preliminary study will inform the development of a larger RCT study of male alcohol and IPV reduction.

The relationship between surrounding greenness in childhood and adolescence and depressive symptoms in adolescence and early adulthood.

PURPOSE: Exposure to nature, particularly vegetation (greenness), may be beneficial for mental health. We investigated whether higher surrounding greenness in early life was associated with subsequent reduced risk of depressive symptoms and whether this association was modified by age, sex, or population density. METHODS: Participants from the Growing Up Today Study were included if they reported on depressive symptoms between 1999 and 2013. Greenness exposure was characterized as the cumulative average normalized difference vegetation index value (1000 m resolution) from 1989 until 2 years before outcome assessment or age 18 based on geocoded addresses. We defined high depressive symptoms as the top 10% of scores on the McKnight Risk Factor Survey or the Center for Epidemiologic Studies of Depression scale, depending on the questionnaire. Data were analyzed using Cox proportional hazards model adjusted for socioeconomic status and other confounders. RESULTS: There was a 6% lower incidence of high depressive symptoms associated with an interquartile range increase in greenness (95% confidence interval, 11%-0%). This relationship was stronger in higher population density areas (>1000 people/mi2, 8% lower incidence, 95% confidence interval 15%-1%). CONCLUSIONS: Living in an area with greater surrounding greenness during childhood may be beneficial for mental health, particularly in more urban areas.

The Association Between Natural Environments and Depressive Symptoms in Adolescents Living in the United States.

PURPOSE: Exposure to nature and natural environments may be beneficial for mental health; however, most population-based studies have been conducted among adults whereas few have focused on adolescents. We aimed to investigate the relationship between both greenness (vegetation) and blue space (water), and depressive symptoms among teenagers in the United States. METHODS: The study population included 9,385 participants ages 12-18 in the 1999 wave of the Growing Up Today Study. We characterized greenness exposure using the Normalized Difference Vegetation Index at a 250-m and 1,250-m radius around a subject's residence using data from the moderate-resolution imaging spectroradiometer onboard the National Aeronautics and Space Administration's Terra satellite. Exposure to blue space was defined as the presence of blue space within a 250-m and 1,250-m radius and distance to the nearest blue space. We used logistic regression models to examine associations with high depressive symptoms, measured using self-reported responses to the McKnight Risk Factor Survey. RESULTS: An interquartile range higher peak greenness in the 1,250-m buffer was associated with 11% lower odds of high depressive symptoms (95% confidence interval .79-.99). Although not statistically significant, this association was stronger in middle school students than in high school students. No such association was seen for blue spaces. CONCLUSIONS: Surrounding greenness, but not blue space, was associated with lower odds of high depressive symptoms in this population of more than 9,000 U.S. adolescents. This association was stronger in middle school students than in high school students. Incorporating vegetation into residential areas may be beneficial for mental health.

Interrelationships Between Walkability, Air Pollution, Greenness, and Body Mass Index.

BACKGROUND: Recent studies have linked urban environmental factors and body mass index (BMI); however, such factors are often examined in isolation, ignoring correlations across exposures. METHODS: Using data on Nurses' Health Study participants living in the Northeastern United States in 2006, we estimated associations between neighborhood walkability (a composite of population density, street connectivity, and business access), greenness (from satellite imagery), and ambient air pollution (from satellite-based spatiotemporally resolved PM2.5 predictions and weighted monthly average concentrations of NO2 from up to five nearest monitors) and self-reported BMI using generalized additive models, allowing for deviations from linearity using penalized splines. RESULTS: Among 23,435 women aged 60-87 years, we observed nonlinear associations between walkability and BMI and between PM2.5 and BMI in single-exposure models adjusted for age, race, and individual- and area-level socioeconomic status. When modeling all exposures simultaneously, only the association between walkability and BMI remained nonlinear and nonmonotonic. Increasing walkability was associated with increasing BMI at lower levels of walkability (walkability index <1.8), while increasing walkability was linked to lower BMI in areas of higher walkability (walkability index >1.8). A 10 percentile increase in walkability, right above 1.8 was associated with a 0.84% decrease in log BMI. The relationship between walkability and BMI existed only among younger participants (<71 years old). CONCLUSIONS: Neighborhood walkability was nonlinearly linked to lower BMI independent of air pollution and greenness. Our findings highlight the importance of accounting for nonlinear confounding by interrelated urban environmental factors when investigating associations between the environment and BMI.

Residential greenness: current perspectives on its impact on maternal health and pregnancy outcomes.

Recent research in environmental epidemiology has attempted to estimate the effects of exposure to nature, often operationalized as vegetation, on health. Although many analyses have focused on vegetation or greenness with regard to physical activity and weight status, an incipient area of interest concerns maternal health and birth outcomes. This paper reviews 14 studies that examined the association between greenness and maternal or infant health. Most studies were cross-sectional and conducted in birth cohorts. Several studies found evidence for positive associations between greenness and birth weight and maternal peripartum depression. Few studies found evidence for an association between greenness and gestational age or other birth outcomes, or between greenness and preeclampsia or gestational diabetes. Several assessed effect modification by individual or area-level socioeconomic status and found that effects were stronger among those of lower socioeconomic status. Few studies conducted mediation analyses of any kind. Future research should include more diverse birth outcomes and focus on maternal health (especially mental health) and capitalize on richer exposure information during pregnancy rather than cross-sectional assessment at birth.

Built Environment and Depression in Low-Income African Americans and Whites.

INTRODUCTION: Urban environments are associated with a higher risk of adverse mental health outcomes; however, it is unclear which specific components of the urban environment drive these associations. METHODS: Using data collected in 2002-2009 from 73,225 low-income, racially diverse individuals across the Southeastern U.S., analyses evaluated the cross-sectional relationship between a walkability index and depression. Walkability was calculated from population density, street connectivity, and destination count in the 1,200-meter area around participants' homes, and depression was measured using the Center for Epidemiologic Studies Depression Scale for depression symptomatology and questionnaire responses regarding doctor-diagnosed depression and antidepressant use. Data were analyzed in 2015. RESULTS: Participants living in neighborhoods with the highest walkability index had 6% higher odds of moderate or greater depression symptoms (score ≥15, 95% CI=0.99, 1.14), 28% higher odds of doctor-diagnosed depression (95% CI=1.20, 1.36), and 16% higher odds of current antidepressant use (95% CI=1.08, 1.25), compared with those in the lowest walkability index. Higher walkability was associated with higher odds of depression symptoms in the most deprived neighborhoods only, whereas walkability was associated with lower odds of depression symptoms in the least deprived neighborhoods. CONCLUSIONS: Living in a more walkable neighborhood was associated with modestly higher levels of doctor-diagnosed depression and antidepressant use, and walkability was associated with greater depression symptoms in neighborhoods with higher deprivation. Although dense urban environments may provide opportunities for physical activity, they may also increase exposure to noise, air pollution, and social stressors that could increase levels of depression.

Exposure to Greenness and Mortality in a Nationwide Prospective Cohort Study of Women.

BACKGROUND: Green, natural environments may ameliorate adverse environmental exposures (e.g., air pollution, noise, and extreme heat), increase physical activity and social engagement, and lower stress. OBJECTIVES: We aimed to examine the prospective association between residential greenness and mortality. METHODS: Using data from the U.S.-based Nurses' Health Study prospective cohort, we defined cumulative average time-varying seasonal greenness surrounding each participant's address using satellite imagery [Normalized Difference Vegetation Index (NDVI)]. We followed 108,630 women and observed 8,604 deaths between 2000 and 2008. RESULTS: In models adjusted for mortality risk factors (age, race/ethnicity, smoking, and individual- and area-level socioeconomic status), women living in the highest quintile of cumulative average greenness (accounting for changes in residence during follow-up) in the 250-m area around their home had a 12% lower rate of all-cause nonaccidental mortality [95% confidence interval (CI); 0.82, 0.94] than those in the lowest quintile. The results were consistent for the 1,250-m area, although the relationship was slightly attenuated. These associations were strongest for respiratory and cancer mortality. The findings from a mediation analysis suggested that the association between greenness and mortality may be at least partly mediated by physical activity, particulate matter < 2.5 µm, social engagement, and depression. CONCLUSIONS: Higher levels of green vegetation were associated with decreased mortality. Policies to increase vegetation may provide opportunities for physical activity, reduce harmful exposures, increase social engagement, and improve mental health. Planting vegetation may mitigate the effects of climate change; in addition, evidence of an association between vegetation and lower mortality rates suggests it also might be used to improve health. CITATION: James P, Hart JE, Banay RF, Laden F. 2016. Exposure to greenness and mortality in a nationwide prospective cohort study of women. Environ Health Perspect 124:1344-1352; http://dx.doi.org/10.1289/ehp.1510363.

A Review of the Health Benefits of Greenness.

Researchers are increasingly exploring how neighborhood greenness, or vegetation, may affect health behaviors and outcomes. Greenness may influence health by promoting physical activity and social contact; decreasing stress; and mitigating air pollution, noise, and heat exposure. Greenness is generally measured using satellite-based vegetation indices or land-use databases linked to participants' addresses. In this review, we found fairly strong evidence for a positive association between greenness and physical activity, and a less consistent negative association between greenness and body weight. Research suggests greenness is protective against adverse mental health outcomes, cardiovascular disease, and mortality, though most studies were limited by cross-sectional or ecological design. There is consistent evidence that greenness exposure during pregnancy is positively associated with birth weight, though findings for other birth outcomes are less conclusive. Future research should follow subjects prospectively, differentiate between greenness quantity and quality, and identify mediators and effect modifiers of greenness-health associations.

A health impact assessment of a proposed bill to decrease speed limits on local roads in Massachusetts (U.S.A.).

Decreasing traffic speeds increases the amount of time drivers have to react to road hazards, potentially averting collisions, and makes crashes that do happen less severe. Boston's regional planning agency, the Metropolitan Area Planning Council (MAPC), in partnership with the Massachusetts Department of Public Health (MDPH), conducted a Health Impact Assessment (HIA) that examined the potential health impacts of a proposed bill in the state legislature to lower the default speed limits on local roads from 30 miles per hour (mph) to 25 mph. The aim was to reduce vehicle speeds on local roads to a limit that is safer for pedestrians, cyclists, and children. The passage of this proposed legislation could have had far-reaching and potentially important public health impacts. Lower default speed limits may prevent around 18 fatalities and 1200 serious injuries to motorists, cyclists and pedestrians each year, as well as promote active transportation by making local roads feel more hospitable to cyclists and pedestrians. While a lower speed limit would increase congestion and slightly worsen air quality, the benefits outweigh the costs from both a health and economic perspective and would save the state approximately $62 million annually from prevented fatalities and injuries.