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Living near, recreating in, and feeling psychologically connected to, the natural world are all associated with better mental health, but many exposure-related questions remain. Using data from an 18-country survey (n = 16,307) we explored associations between multiple measures of mental health (positive well-being, mental distress, depression/anxiety medication use) and: (a) exposures (residential/recreational visits) to different natural settings (green/inland-blue/coastal-blue spaces); and (b) nature connectedness, across season and country. People who lived in greener/coastal neighbourhoods reported higher positive well-being, but this association largely disappeared when recreational visits were controlled for. Frequency of recreational visits to green, inland-blue, and coastal-blue spaces in the last 4 weeks were all positively associated with positive well-being and negatively associated with mental distress. Associations with green space visits were relatively consistent across seasons and countries but associations with blue space visits showed greater heterogeneity. Nature connectedness was also positively associated with positive well-being and negatively associated with mental distress and was, along with green space visits, associated with a lower likelihood of using medication for depression. By contrast inland-blue space visits were associated with a greater likelihood of using anxiety medication. Results highlight the benefits of multi-exposure, multi-response, multi-country studies in exploring complexity in nature-health associations. This project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 666773 (BlueHealth). Data collection in California was supported by the Center for Conservation Biology, Stanford University. Data collection in Canada was supported by the Faculty of Forestry, University of British Columbia. Data collection in Finland was supported by the Natural Resources Institute Finland (Luke). Data collection in Australia was supported by Griffith University and the University of the Sunshine Coast. Data collection in Portugal was supported by ISCTE—University Institute of Lisbon. Data collection in Ireland was supported by the Environmental Protection Agency, Ireland. Data collection in Hong Kong was supported by an internal University of Exeter—Chinese University of Hong Kong international collaboration fund. The funders had no role in the conceptualisation, design, analysis, decision to publish or preparation of the manuscript.

The urban forest is a green infrastructure system that delivers multiple environmental, economic, social and health services, and functions in cities. Environmental benefits of urban trees are well understood, but no review to date has examined how urban trees affect human health. This review provides a comprehensive summary of existing literature on the health impacts of urban trees that can inform future research, policy, and nature-based public health interventions. A systematic search used keywords representing human health, environmental health, and urban forestry. Following screening and appraisal of several thousand articles, 201 studies were conceptually sorted into a three-part framework. Reducing Harm, representing 41% of studies, includes topics such as air pollution, ultraviolet radiation, heat exposure, and pollen. Restoring Capacities, at 31%, includes attention restoration, mental health, stress reduction, and clinical outcomes. Building Capacities, at 28%, includes topics such as birth outcomes, active living, and weight status. The studies that were reviewed show substantial heterogeneity in purpose and method yet indicate important health outcomes associated with people’s exposure to trees. This review will help inform future research and practice, and demonstrates why urban forest planning and management should strategically promote trees as a social determinant of public health.

Field studies have shown that dense tree canopies and regular tree arrangements reduce noise from a point source. In urban areas, noise sources are multiple and tree arrangements are rarely dense. There is a lack of data on the association between the urban tree canopy characteristics and noise in complex urban settings. Our aim was to investigate the spatial variation of urban tree canopy characteristics, indices of vegetation abundance, and environmental noise levels. Using Light Detection and Ranging point cloud data for 2015, we extracted the characteristics of 1,272,069 public and private trees across the island of Montreal, Canada. We distinguished needle-leaf from broadleaf trees, and calculated the percentage of broadleaf trees, the total area of the crown footprint, the mean crown centroid height, and the mean volume of crowns of trees that were located within 100m, 250m, 500m, and 1000m buffers around 87 in situ noise measurement sites. A random forest model incorporating tree characteristics, the normalized difference vegetation index (NDVI) values, and the distances to major urban noise sources (highways, railways and roads) was employed to estimate variation in noise among measurement locations. We found decreasing trends in noise levels with increases in total area of the crown footprint and mean crown centroid height. The percentages of increased mean squared error of the regression models indicated that in 500m buffers the total area of the crown footprint (29.2%) and the mean crown centroid height (12.6%) had a stronger influence than NDVI (3.2%) in modeling noise levels; similar patterns of influence were observed using other buffers. Our findings suggest that municipal initiatives designed to reduce urban noise should account for tree features, and not just the number of trees or the overall amount of vegetation.

Urban green and blue spaces promote health by offering areas for physical activity, stress relief, and social interaction, which may be considered as cultural ecosystem services. They also provide a number of regulating ecosystem services that can be regarded as nature-based solutions to mitigate impacts from urbanization-induced challenges. Urban trees and other vegetation provide cooling through shade and evapotranspiration, which reduce the impact of the urban heat island on hot summer days. Urban vegetation may improve air quality by removing air pollutants. Open areas in cities, such as parks, gardens, playgrounds and cemeteries, are unsealed spaces that also improve infiltration during extreme precipitation events providing water regulating functions. All these services have the potential to improve the health of urban residents, particularly of specific vulnerable groups such as children and the elderly. The aim of this paper is to provide an overview of the current state of evidence on the relationship between the health of children and the elderly and urban green and blue spaces that can account as nature-based solutions to urbanization-induced challenges. We discuss potential confounding factors and refer to the different green space metrics used to identify associations to health. From the results, we cannot conclude on a universal protective health effect of urban green and blue spaces for children and the elderly. While the association trend is positive, the results remain inconclusive, context dependent and are partly overridden by socioeconomic confounders. However, the research area is consistently increasing, and we advance important prospects for future research on urban green and blue spaces in the face of global challenges such as urbanization.

In this study, we assess how the Scania Green Score (SGS5), and the five distinct perceived neighbourhood green dimensions within this area-aggregated index (1 km2 squares), is associated with self-reported physical activity and general health, and if perceived safety and social coherence has a moderating effect. Two independent surveys, both conducted in Scania, Sweden, was used for data on SGS5 and health outcomes (N=28 198 and N=23 693), respectively. SGS5 was more clearly associated with physical activity (OR 1.06; 95% CI 1.02–1.10) than with general health (OR 1.02; 95% CI 1.00–1.04). This association was moderated by safety (p for interaction

Highlights - Urban natural spaces benefit health by cultural and regulating ecosystem services. - The evidence on health impact is insufficiently implemented in urban planning. - Transdisciplinary actions are required to bridge the science policy gap. - Human dependence on healthy urban ecosystems must be brought to the agenda. - Details on disservices and specific features must not overshadow the general good.

inVIVO Planetary Health (inVIVO) is a progressive scientific movement providing evidence, advocacy, and inspiration to align the interests and vitality of people, place, and planet. Our goal is to transform personal and planetary health through awareness, attitudes, and actions, and a deeper understanding of how all systems are interconnected and interdependent. Here, we present the abstracts and proceedings of our 8th annual conference, held in Detroit, Michigan in May 2019, themed “From Challenges, to Opportunities”. Our far-ranging discussions addressed the complex interdependent ecological challenges of advancing global urbanization, including the biopsychosocial interactions in our living environment on physical, mental, and spiritual wellbeing, together with the wider community and societal factors that govern these. We had a strong solutions focus, with diverse strategies spanning from urban-greening and renewal, nature-relatedness, nutritional ecology, planetary diets, and microbiome rewilding, through to initiatives for promoting resilience, positive emotional assets, traditional cultural narratives, creativity, art projects for personal and community health, and exploring ways of positively shifting mindsets and value systems. Our cross-sectoral agenda underscored the importance and global impact of local initiatives everywhere by contributing to new normative values as part of a global interconnected grass-roots movement for planetary health.

Background Several studies have assessed the relationship between exposure to natural environments (NEs) and childhood mental health and development. In most cases, a positive association has been found, but results are inconsistent, and the strength of association is unclear. This inconsistency may reflect the heterogeneity in measurements used to assess NE. Objectives This systematic review aims to identify the most common NE metrics used in childhood mental health and development research. Our second aim is to identify the metrics that are most consistently associated with health and assess the relative strength of association depending on type of NE exposure measurement, in terms of metric used (i.e., measurement technique, such as remote sensing), but also rate (i.e., spatial and temporal exposure). Methods We used the PRISMA protocol to identify eligible studies, following a set of pre-defined inclusion criteria based on the PECOS strategy. A number of keywords were used for retrieving relevant articles from Medline, Embase, PsychINFO, and Web of Science databases between January 2000–November 2020. From these, we extracted data on type of NE measurement and relative association to a number of indicators of childhood mental health and development. We conducted a systematic assessment of quality and risk of bias in the included articles to evaluate the level of evidence. Case studies and qualitative studies were excluded. Results After screening of title (283 studies included), abstract, and full article, 45 studies were included in our review. A majority of which were conducted in North America and Europe (n = 36; 80%). The majority of studies used land use or land covers (LULC, n = 24; 35%) to determine exposures to NEs. Other metrics included the normalized difference vegetation index (NDVI), expert measures (e.g., surveys of data collection done by experts), surveys (e.g., self-reported assessments), and use of NE (e.g., measures of a participant's use of NE such as through GPS tracts or parent reports). Rate was most commonly determined by buffer zones around residential addresses or postal codes. The most consistent association to health outcomes was found for buffers of 100 m, 250 m, 500 m, and within polygons boundaries (e.g., census tracts). Six health categories, academic achievement, prevalence of doctor diagnosed disorders, emotional and behavioral functioning, well-being, social functioning, and cognitive skills, were created post hoc. We found sufficient evidence between NDVI (Landsat) and emotional and behavioral well-being. Additionally, we found limited evidence between LULC datasets and academic achievement; use of NE, parent/guardian reported greenness, and expert measures of greenness and emotional and behavioral functioning; and use of NE and social functioning. Discussion This review demonstrates that several NE measurements must be evaluated further before sufficient evidence for a potential association between distinct NE exposure metrics and childhood mental health and development can be established. Further, we suggest increased coordination between research efforts, for example, by replication of studies and comparing different NE measurements systematically, so that effect sizes can be confirmed for various health outcomes. Finally, we recommend implementing research designs that assess underlying pathways of nature-health relations and utilize measurement techniques that adequately assess exposure, access, use, and perception of NEs in order to contribute to a better understanding of health impacts of surrounding natural environments.

Research suggests that certain forest environments can contribute to lower stress levels in humans. This might be increasingly important to consider given the rising prevalence of stress-related diseases and illness absence. To make it feasible to plan for forest management strategies that take such restorative effects into account, it would seem to be important to identify the precise physical properties that contribute to the restorative qualities of forest stands. It would also be useful if forest stand data typically already collected by forest owners could be used for this purpose. In the present study, forest stands in northern, central, and southern Sweden were visited and assessed regarding their restorative potential. These assessments were analysed together with available forest stand data for each region using statistical models. Our results indicate that of the available forest stand data parameters, the most important individual indicators of forest stands’ restorative qualities were tree age, tree sparsity, and tree height. Models based on these parameters explained 30–40 % of the variation in restorative qualities among the evaluated stands, indicating that they can be useful in planning and modelling scenarios where restorative properties of forest stands are considered.

Background Growing evidence suggests health benefits of natural environments. Yet, the effects of different types of natural environments (vegetation and water features) and forms of human-nature contact (access versus exposure) remain relatively unexplored. Methods A cross-sectional observational survey was used to analyse the relationship between both access and exposure to different types of urban natural environments and health outcomes in Metro Vancouver, Canada. Data for health outcomes (self-reported general health, mental health, and common mental disorders) and key confounders were obtained from the 2013–2014 Canadian Community Health Survey. Natural environments were quantified using local land use and land cover data, and linked to survey respondents by six-digit postal code. Access was defined as living within 300 m of a public greenspace (≥ 1 hectare) and exposure as the percentage of different land cover types within multiple buffer distances of postal code centroids. Separate logistic regression models were used to estimate the associations of the access and exposure metrics with the three health outcomes. Results Exposure to water within 1,000 m buffers was associated with a reduced odds of reporting poor general health (OR = 0.982, 95% CI = 0.965, 0.999). A similar association was found for exposure to shrub and grass-herb vegetation types for reported mental health and common mental disorder, respectively (OR = 0.741, 95% CI = 0.576, 0.953 for shrubs in 250 m; OR = 0.737, 95% CI = 0.577, 0.942 for shrubs in 500 m; OR = 0.731, 95% CI = 0.570, 0.938 for shrubs in 1,000 m; OR = 0.980, 95% CI = 0.965, 0.995 for grass-herbs in 250 m). Neither access to public greenspace nor aggregated greenspace exposure were associated with self-reported health. Results from stratified analyses suggest that observed associations between human-nature contact and self-reported health differ according to gender. Conclusions Results suggest that type of natural environment should be considered in future research studying the health-promoting aspects of natural environments, and that positive health effects may be more consistent for daily life exposure than for access to public greenspace.

Mental health and well-being are consistently influenced—directly or indirectly—by multiple environmental exposures. In this review, we have attempted to address some of the most common exposures of the biophysical environment, with a goal of demonstrating how those factors interact with central structures and functions of the brain and thus influence the neurobiology of depression. We emphasize biochemical mechanisms, observational evidence, and areas for future research. Finally, we include aspects of contextual environments—city living, nature, natural disasters, and climate change—and call for improved integration of environmental issues in public health science, policies, and activities. This integration is necessary for reducing the global pandemic of depression.

We provide consensus on the benefits of nature experience for mental health, and a model for integrating them into urban design., A growing body of empirical evidence is revealing the value of nature experience for mental health. With rapid urbanization and declines in human contact with nature globally, crucial decisions must be made about how to preserve and enhance opportunities for nature experience. Here, we first provide points of consensus across the natural, social, and health sciences on the impacts of nature experience on cognitive functioning, emotional well-being, and other dimensions of mental health. We then show how ecosystem service assessments can be expanded to include mental health, and provide a heuristic, conceptual model for doing so.

IntroductionDeficiencies in childhood development is a major global issue and inequalities are large. The influence of environmental exposures on childhood development is currently insufficiently explored. This project will analyse the impact of various modifiable early life environmental exposures on different dimensions of childhood development.MethodsBorn to be Wise will study a Canadian cohort of approximately 34 000 children who have completed an early development test at the age of 5. Land use regression models of air pollution and spatially defined noise models will be linked to geocoded data on early development to analyse any harmful effects of these exposures. The potentially beneficial effect on early development of early life exposure to natural environments, as measured by fine-grained remote sensing data and various land use indexes, will also be explored. The project will use data linkages and analyse overall and age-specific impact, including variability depending on cumulative exposure by assigning time-weighted exposure estimates and by studying subsamples who have changed residence and exposure. Potentially moderating effects of natural environments on air pollution or noise exposures will be studied by mediation analyses. A matched case–control design will be applied to study moderating effects of natural environments on the association between low socioeconomic status and early development. The main statistical approach will be mixed effects models, applying a specific software to deal with multilevel random effects of nested data. Extensive confounding control will be achieved by including data on a range of detailed health and sociodemographic variables.Ethics and disseminationThe study protocol has been ethically approved by the Behavioural Research Ethics Board at the University of British Columbia. The findings will be published in peer-reviewed journals and presented at scholarly conferences. Through stakeholder engagement, the results will also reach policy and a broader audience.

Background: Increasing evidence suggests that residential exposures to natural environments, such as green spaces, are associated with many health benefits. Only a single study has examined the potential link between living near water and mortality. Objective: We sought to examine whether residential proximity to large, natural water features (e.g., lakes, rivers, coasts, “blue space”) was associated with cause-specific mortality. Methods: Our study is based on a population-based cohort of nonimmigrant adults living in the 30 largest Canadian cities [i.e., the 2001 Canadian Census Health and Environment Cohort) (CanCHEC)]. Subjects were drawn from the mandatory 2001 Statistics Canada long-form census, who were linked to the Canadian mortality database and to annual income-tax filings, through 2011. We estimated associations between living within 250m of blue space and deaths from several common causes of death. We adjusted models for many personal and contextual covariates, as well as for exposures to residential greenness and ambient air pollution. Results: Our cohort included approximately 1.3 million subjects at baseline, 106,180 of whom died from nonaccidental causes during follow-up. We found significant, reduced risks of mortality in the range of 12–17% associated with living within 250m of water in comparison with living farther away, among all causes of death examined, except with external/accidental causes. Protective effects were found to be higher among women and all older adults than among other subjects, and protective effects were found to be highest against deaths from stroke and respiratory-related causes. Conclusions: Our findings suggest that living near blue spaces in urban areas has important benefits to health, but further work is needed to better understand the drivers of this association. https://doi.org/10.1289/EHP3397

Background Multiple external environmental exposures related to residential location and urban form including, air pollutants, noise, greenness, and walkability have been linked to health impacts or benefits. The Canadian Urban Environmental Health Research Consortium (CANUE) was established to facilitate the linkage of extensive geospatial exposure data to existing Canadian cohorts and administrative health data holdings. We hypothesize that this linkage will enable investigators to test a variety of their own hypotheses related to the interdependent associations of built environment features with diverse health outcomes encompassed by the cohorts and administrative data. Methods We developed a protocol for compiling measures of built environment features that quantify exposure; vary spatially on the urban and suburban scale; and can be modified through changes in policy or individual behaviour to benefit health. These measures fall into six domains: air quality, noise, greenness, weather/climate, and transportation and neighbourhood factors; and will be indexed to six-digit postal codes to facilitate merging with health databases. Initial efforts focus on existing data and include estimates of air pollutants, greenness, temperature extremes, and neighbourhood walkability and socioeconomic characteristics. Key gaps will be addressed for noise exposure, with a new national model being developed, and for transportation-related exposures, with detailed estimates of truck volumes and diesel emissions now underway in selected cities. Improvements to existing exposure estimates are planned, primarily by increasing temporal and/or spatial resolution given new satellite-based sensors and more detailed national air quality modelling. Novel metrics are also planned for walkability and food environments, green space access and function and life-long climate-related exposures based on local climate zones. Critical challenges exist, for example, the quantity and quality of input data to many of the models and metrics has changed over time, making it difficult to develop and validate historical exposures. Discussion CANUE represents a unique effort to coordinate and leverage substantial research investments and will enable a more focused effort on filling gaps in exposure information, improving the range of exposures quantified, their precision and mechanistic relevance to health. Epidemiological studies may be better able to explore the common theme of urban form and health in an integrated manner, ultimately contributing new knowledge informing policies that enhance healthy urban living.

An emerging body of evidence has associated natural environments with improved brain development in children; however, these studies have mainly focused on cognition and available evidence for motor development is still scarce. This study aimed to evaluate the protective association of neighbourhood greenspace with motor development deficits in children. We obtained data on motor development deficits (separately for fine and gross motor developments) at sub-district level from routine medical check-up of children prior to enrolment into primary schools in the city of Berlin (2015-2016). Neighbourhood natural environments across the sub-districts were measured with three different metrics: the average of satellite-based normalized difference vegetation index (NDVI), the share of public green spaces, and the share of both public blue and green spaces (composite nature) across the sub-district. We applied negative binominal models to estimate the association between neighbourhood natural environments and fine and gross motor development deficits (one at a time), controlled for relevant sociodemographic indicators. Higher neighbourhood public green space and composite nature were significantly associated with lower risk of motor development deficits; however, the association were not statistically significant when using NDVI. Our findings, if confirmed by future studies, could provide evidence for implementing targeted interventions to enhance motor development in urban children.

Urbanisation and climate change affect people’s health and well-being in various ways. Nature-based solutions implemented as natural, sustainable solutions in cities can attenuate negative health impacts of these processes. In this chapter, urban green spaces are considered as one type of nature-based solutions that use urban ecosystem services to provide mitigation and adaptation actions and solutions to climate change and urbanisation related challenges. An overview over the relationships to urban health is presented. The city of Berlin is used as a case, to show how an unequal distribution of urban green area may be linked to an insufficient provision of ecosystem services and the related positive health outcome effect. This is discussed through the presentation of the distribution of different vulnerable population groups such as children and elderly people throughout the city area. The link to environmental justice is made and discussed in this context.

Research suggests that there is a relationship between the health of urban populations and the availability of green and water spaces in their daily environment. In this paper, we analyze the potential intra-urban relationships between children’s health determinants and outcomes and natural areas in Berlin, Germany. In particular, health indicators such as deficits in viso-motoric development in children are related to environmental indicators such as the natural area cover, natural area per capita and distance to natural areas; however, these indicators are also correlated with social determinants of health. The methodological approach used in this study included bivariate and multivariate analyses to explore the relations between health inequalities and social, socio-economic, and land use parameters. The results on a sub-district level indicated that there was a correlation between natural areas and social health determinants, both of which displayed a certain intra-urban spatial pattern. In particular, a lower percentage of natural area cover was correlated with deficits in viso-motoric development. However, results with percentage of natural area cover and per capita natural area with childhood overweight were not conclusive. No significant correlation was found for percentage of natural area cover and overweight, while significant negative correlation values were found between overweight and per capita natural area. This was identified particularly in the districts that had lower social conditions. On the other hand, the districts with the highest social conditions had the comparatively lowest levels of complete measles immunization. This study may facilitate public health work by identifying the urban areas in which the strengthening of health resources and actions should be prioritized and also calls for the inclusion of natural areas among the social health indicators included in intra-urban health inequality tools.

Background: Frequencies in reported psychosomatic illnesses have increased in Sweden among children, adolescents, and young adults. Little is known about demographic differences in self-reported psychosomatic complaints, such as between urban and rural areas, and whether surveys launched on the Internet could be a useful method in sampling such data. Objectives: This study examines the connection between psychosomatic illnesses and demographics in Swedish children and youth. The feasibility of using the Internet to gather large amounts of data regarding psychosomatic complaints in this group is another major objective of this study. Methods: A cross-sectional study using 7 validated questions about psychosomatic health, were launched in a controlled way onto a recognized Swedish Internet community site, which targeted users 10 to 24 years of age. The subjects were able to answer the items while they were logged in to their personal domain. The results were analyzed cross-geographically within Sweden. Results: In total, we received 100,000 to 130,000 individual answers per question. Subjects of both sexes generally reported significantly higher levels of self-reported psychosomatic complaints in major city areas as compared with minor city/rural areas, even though the differences between the areas were small. For example, 12.00% (4472/37,265) of females in minor regions reported always feeling tense, compared with 13.80% (3156/22,873) of females in major regions (P

Aims: In this study, the aim was to develop and test an urban green space indicator for public health, as proposed by the World Health Organisation (WHO) Regional Office for Europe, in order to support health and environmental policies. Methods: We defined the indicator of green space accessibility as a proportion of an urban population living within a certain distance from a green space boundary. We developed a Geographic Information System (GIS)-based method and tested it in three case studies in Malmö, Sweden; Kaunas, Lithuania; and Utrecht, The Netherlands. Land use data in GIS from the Urban Atlas were combined with population data. Various population data formats, maximum distances to green spaces, minimum sizes of green spaces, and different definitions of green spaces were studied or discussed. Results: Our results demonstrated that with increasing size of green space and decreased distance to green space, the indicator value decreased. As compared to Malmö and Utrecht, a relatively bigger proportion of the Kaunas population had access to large green spaces, at both shorter and longer distances. Our results also showed that applying the method of spatially aggregated population data was an acceptable alternative to using individual data. Conclusions: Based on reviewing the literature and the case studies, a 300 m maximum linear distance to the boundary of urban green spaces of a minimum size of 1 hectare are recommended as the default options for the indicator. The indicator can serve as a proxy measure for assessing public accessibility to urban green spaces, to provide comparable data across Europe and stimulate policy actions that recognise the importance of green spaces for sustainable public health.

Exposure to natural environments is associated with a lower risk of common mental health disorders (CMDs), such as depression and anxiety, but we know little about nature-related motivations, practices and experiences of those already experiencing CMDs. We used data from an 18-country survey to explore these issues (n = 18,838), taking self-reported doctor-prescribed medication for depression and/or anxiety as an indicator of a CMD (n = 2698, 14%). Intrinsic motivation for visiting nature was high for all, though slightly lower for those with CMDs. Most individuals with a CMD reported visiting nature ≥ once a week. Although perceived social pressure to visit nature was associated with higher visit likelihood, it was also associated with lower intrinsic motivation, lower visit happiness and higher visit anxiety. Individuals with CMDs seem to be using nature for self-management, but ‘green prescription’ programmes need to be sensitive, and avoid undermining intrinsic motivation and nature-based experiences.