A Review of the Health Benefits of Greenness

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Curr Epidenriol Rep (20t5) 2:l3l-142 DOI I 0. 1007/s40471-0 ls-0043-7 ENVIRONM ENTAL EP IDEMIOLOGY (G WELLENIUS, SECTION EDITOR) A Review of the Health Benefits of Greenness Peter Jrmesr'2. Rachel F. Banay2. Jaime E. HartzJ'Francine Ladenr'z'3 Publishcd onlinc: 9 April 2015 (Ci Springer Intcmational Publishing AG 2015 Abstract Reseatchers are increasingly exploring lrow neigh- borhood greenness: or vegetation, may aftbct health behaviors and outcotnes. Greenness may iuflueuce health by ptomoting physical activity and social contact; decreasing shess; and mitigating air pollution, noise, and heat exposute, Greenness is generally measut'ed using satellite-basecl vegetation indices or land-use databasqs linked to participants' addresses. In this review, we found fairly strong evidence for a positive associ- ation between greenuess and physical activity ancl a lqss con- sistent negative association between gleenness and body rveight. Research suggests greenness is plotective against ad- vcrsc rnental hcaltb outcomes, cardiovascular discasc, and moltality, though most strrdies were limited by cross- sectional or ecological design. There is consistent evidence that grcenness exposut'e duling preg¡ancy is positively asso- ciated with birth weight, though fìndings for other birth out- cornes are less conclusive. Futul'e research should follow This article is part of the Topical Collecti on on Environntenlal Epitlenúob¿9' Elcctronic srrpplemcntrry matcriâl The otlline version of this article (doi: I 0. I 007/s40471 -0 I 5-0043-7) contaius supplernentary tnaterial, rvhich is available to aulltotize<l ttsets. fld Rnchel F- Banuy rachcl, banay(@mai l.harvard.ccln Departrnent olEpiderniology, H¿uvard T.H' Chan Scfiool of Public Health, 401 PaLk Dq 3nJ Floor West, Boston. MA 02215, USA Departrncnt of Enviroltmcntal Hcalth, llarvard T.H. C]han School of Public Health, 401 Park 3rd Floor West, Boston, 022 I 5' USA Charrning Division of Nctrvork Mcdicinc, Dcparturcnt of Mccticinc' Brigharn and Wot¡en's Ilospital aud FIaward Medicsl School, 401 Park Dr, 3rd Floor West, Boston, MA 02215. USA subjects prospectively, differentiate between greenness quan- tity and quality, and identi$r rnediators and effect modifiers of greennessJrealth associations. Keywords Body weight ' Health benefits ' Greenness Physical activity Introduction Across all cultures in the world, an inherent value is placed on nature. For the Japanese, forest bathing, ot Shinrin-yoku llf, involves taking in the forest atmosphere to reduce stress, Frituftsliv is a Scandinavian philosophy basecl on spiritual connectedness with the landscape [2]. Even in large cities, real estate values are highest in proximity to natttral' green spaces t3-51. A growing body of ernpilical evidence has begun to dernonstrate tinks between exposure to nature, specifically grcen vegetation, and an alray of hcalth otttcomes. In this review, we explore the mechanisms by which srtnoundittg grtÌenncss may affcct hcalth (Fig. l), clctail mcthods to moa- sufe greenness exposure, review and sulilxalize the evidence on exposure to greenness and various health outcomes (Table l), attd suggest necessaly next steps to advance re- search in this field. This review is not meant to be conrptrhen- sive, but results from a stuvey of recent public health litera- ture. The details of each shtdy we reviewed can be found in Supplemental Table Sl. Mechanisms for Nature's Effect on Health A number of mechanisms for the positive effects of green and natural spaces on health have beetr suggested- TIre biologist E.O. Wilson developed the biophilia hypothesis, which ' â springer

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A Review of the Health Benefits of GreennessCurr Epidenriol Rep (20t5) 2:l3l-142 DOI I 0. 1007/s40471-0 ls-0043-7
ENVIRONM ENTAL EP IDEMIOLOGY (G WELLENIUS, SECTION EDITOR)
A Review of the Health Benefits of Greenness
Peter Jrmesr'2. Rachel F. Banay2. Jaime E. HartzJ'Francine Ladenr'z'3
Publishcd onlinc: 9 April 2015 (Ci Springer Intcmational Publishing AG 2015
Abstract Reseatchers are increasingly exploring lrow neigh-
borhood greenness: or vegetation, may aftbct health behaviors
and outcotnes. Greenness may iuflueuce health by ptomoting
physical activity and social contact; decreasing shess; and
mitigating air pollution, noise, and heat exposute, Greenness
is generally measut'ed using satellite-basecl vegetation indices
or land-use databasqs linked to participants' addresses. In this
review, we found fairly strong evidence for a positive associ-
ation between greenuess and physical activity ancl a lqss con-
sistent negative association between gleenness and body
rveight. Research suggests greenness is plotective against ad-
vcrsc rnental hcaltb outcomes, cardiovascular discasc, and
moltality, though most strrdies were limited by cross-
sectional or ecological design. There is consistent evidence
that grcenness exposut'e duling preg¡ancy is positively asso-
ciated with birth weight, though fìndings for other birth out-
cornes are less conclusive. Futul'e research should follow
This article is part of the Topical Collecti on on Environntenlal
Epitlenúob¿9'
Elcctronic srrpplemcntrry matcriâl The otlline version of this article
(doi: I 0. I 007/s40471 -0 I 5-0043-7) contaius supplernentary tnaterial,
rvhich is available to aulltotize<l ttsets.
fld Rnchel F- Banuy rachcl, banay(@mai l.harvard.ccln
Departrnent olEpiderniology, H¿uvard T.H' Chan Scfiool of Public
Health, 401 PaLk Dq 3nJ Floor West, Boston. MA 02215, USA
Departrncnt of Enviroltmcntal Hcalth, llarvard T.H. C]han School of Public Health, 401 Park D¡ 3rd Floor West, Boston, MÀ 022 I 5' USA
Charrning Division of Nctrvork Mcdicinc, Dcparturcnt of Mccticinc'
Brigharn and Wot¡en's Ilospital aud FIaward Medicsl School, 401
Park Dr, 3rd Floor West, Boston, MA 02215. USA
subjects prospectively, differentiate between greenness quan-
tity and quality, and identi$r rnediators and effect modifiers of greennessJrealth associations.
Keywords Body weight ' Health benefits ' Greenness
Physical activity
Introduction
Across all cultures in the world, an inherent value is placed on
nature. For the Japanese, forest bathing, ot Shinrin-yoku llf, involves taking in the forest atmosphere to reduce stress,
Frituftsliv is a Scandinavian philosophy basecl on spiritual
connectedness with the landscape [2]. Even in large cities, real
estate values are highest in proximity to natttral' green spaces
t3-51. A growing body of ernpilical evidence has begun to
dernonstrate tinks between exposure to nature, specifically
grcen vegetation, and an alray of hcalth otttcomes. In this
review, we explore the mechanisms by which srtnoundittg
grtÌenncss may affcct hcalth (Fig. l), clctail mcthods to moa-
sufe greenness exposure, review and sulilxalize the evidence
on exposure to greenness and various health outcomes
(Table l), attd suggest necessaly next steps to advance re-
search in this field. This review is not meant to be conrptrhen-
sive, but results from a stuvey of recent public health litera-
ture. The details of each shtdy we reviewed can be found in
Supplemental Table Sl.
Mechanisms for Nature's Effect on Health
A number of mechanisms for the positive effects of green and
natural spaces on health have beetr suggested- TIre biologist
E.O. Wilson developed the biophilia hypothesis, which '
â springer
AllOutcomes May Be lnterrelatedStresc reducllon,
cognitlvg reslorât¡on
depre68ion and anriely
Rêduccd ca¡drovosçular disease
Heat ônd hqmidrly tegulålion
Fig. I Pathways thxrugh which gr€enness rnay afièct health
suggests that human beings have evolved to have an affrnity for naturg plaffs, and living thirrgs [6, 7], Building on this,
Ulrich's psychoevolutionary theory posits that eKposure to naturc may have a dilect restorative effect on cognition and
may decrease stress [8, 9]. Access to green spaces may also
provide opportunities f'ol social interactions and increase so-
cial cohesion. Higher levels ofsociaI cohesion, ot the presence
of strong social bonds, have been linked to multiple health
outcornes [0]. Natural cnvironments provide locations for both routine and recreational physical activity I l]. Vegetation
may buflèr exposule to ail pollution, renoving ozone, partic-
ulate rnatter, NO2, SO2, and cal'bon monoxide from the air
[2]. Vegetation may also recluce exposure to hannful noise
I l3], as well as alleviate thennal discomfofi durùrg heat stress
u4l.
Exposure Assessment
Greenness and green space access have been quantified in epiclcrniologic studics predominmtly using a vcgetation index
(typically the Norrnalized Difference Vegetation lndex (NDVD) or land-use databases. Vegetation indices, derived
fiom satellite imagery nÌeasLlre light reflected from the earth's
surface during photosynthetic activit¡ from which vegetative
clensity can be estimated fl5], GLeenness is often defined as
the rnean NDVI value within a spatial area (e,g., census tract
or: radius around a participant's home). Studies that have
employed land-r.tse databases [6-18], which classiff land
units accorcling to their prcdominant use, typically calculnted
the percent ofa spatial area cor¡ered by parks, public gardens,
sports fields, tbrests, or other gleen space types. A thfurl, Iess
common nretric involved measuring the clistance frorn a par-
ticipant's residence to the nearest par*, rnajor green space? or public open space [19-21]. For an example of these metrics, please see F-ig. 2. Finally, a slnal[ nu¡nberof studies conducted
environmental asscsstncnts [22.] or queried participants about
the perceived greenness of their neighborhood [23]. Exposure rnetrics vary according to their spatial and tem-
poral characteristics, Vegetation indices are available at a
range of spatial and temporal resolutions. The comrnonlyused NDVI can be downloaded at resolutions fiorn 30 rn-8 lan fbr periods of 7 days to half a month [24]. Land-use datasets
classif, land uses at various resolntions. Depending on the
soulce, spatial resolution can be fine (e,g., 30 m [25]) and
land-use datasets are usually updated over years rather than
rnonths. For instance, the National Land Cover Dataset is
updated every 5 years.
Outcome Study de-signs
Physical activity
Setting Findings
4 studies in the USA, 6 in the UK, 2 in France, I Consistent evidence of positive association between
each in A¡stralia, Netherlands, New Zealand, and Spain greenness and physical activity. Few prospective studies.

G
o
G
t9
\, a
I
u9.43.4649, sr-541 I prospective srudy [50]
I I cross-sectional studies
2 cross-sectional studies
and hyperactivity Í21 ,32. 431.
2 experimental shrdies [83. 84] 3 ecological studies [6, 73, 79]
3 cross-sectional studies [62, 80, 8l] I prospcctivc cohort strrdy [82.1 3 prospectivc sn:ctics [82', 85, 87]
5 ecological studies
ll 6, 78, 79, 86. 881
3 studies in the USA, 2 in lhe UK, 2 in Canada, I
cach in Australia, Denmark, Egypt, and Spain
4 studies in the UK 2 in Netherlands, 2 in the USA, I each in Australia, Canada, Denrnark, Nert-
Zealand, Spain. and Sweden
2 studics in Spain,2 studics in Gcnnany I each in Cana<la, Francc, Isracl, and the UK
4 studies i¡r the UK. I each in the USA, Netherlands,
Germany, .{ustrali4 and Canada
3 studics in thc UK 2 studics in tlrc USA, I sach in Japan, New Zezlañ, and Canada
Sorne evidence ofnegative association between II grecnncss ov'crrvcight/obesity. though fu dings (especially among children) were mixed. Possible
efect modification by gender. Few prospective studies.
Suggestive protective effect ofgreenness on self- II reported lnerrtal healtlr. More prospective studies needed,
Consistc¡rt cvidcnce of a positir.e relationship bctwcen
rcsidcntial grcenncss cxposure and bitth rvcight.
Possible effect modification by SES. Findings for other birth and developmental outcornes require
further widence. Consistent evidence ofhigher greenness and lorver
ca¡diovascular disease; horvever, most studies are
ecological and cross-sectional. One prospective
study could not account for individual-levclsnoking. Fairly consistcnt cvidcncc ofhigber grccnncss and lotvcr
rnortality; however, majority of studies are ecological-
Two prospective studies were in specific zubpopulations (elderly and stoke survivors). One prospective shrdy could not account for individual-level smoking.
Shength ofevidence
Strength of evidence definitions:
I : High: evidence is consistent plausible, and precisely quantified and there is lou'probability ofbias
Il = Intermediate: evidence exists, but not entirely consistent, is not quantified precisely, or may be vulnerable to bias
III : Lotv: evidence is inconsistent, implausible, and/or may be vulnerable to bias severely limiting the value ofthe efect being described
II
tegend
value;li;,
Legend
ffifff,'.r-'. c It rf
and drawbacks. Land-usedatasets may provide more itlfonna-
tion about specifrc types ofgreen spaces, potentially giving an
indication of their quality or usability. Howevc¡ speci{ic des-
ignations may mischaracterize "green" land uses, for example
parks that do not contain vegetation. Additionally, land-use
files may be too coaße to capture small'scale vegetation' such
as gardeus and sû'eet trees. Conversely, vegetation indices do
not provide qualitative infonnation about the type of land use
but may offer sufficient information ifvegetative density itself
is the instrumental exposure. Since land-use datasets are pro-
duced less frequently, analyses focused on these datasets rnay
encounter problems with temporal mismatch of exposure and
outcome data. This temporal mismatch is less comrnon with
vegetation indices because they are available at finer temporal
interyals. Finally, land-use datasets may vary both between
and within countries due to differentunderlying data availabil-
ity and diverse land classification methodologies across dif:
ferent municipalities. Because vegetation indices cover the
entirc planet and are collected trsing uniform methocìologies,
they confer consistency and cotnparability across analyses.
While these are standard measures in the literaturg there is
sornc cluestion as to the accttracy with which they characterize
a person's gteenness exposure. For example, residential
greenness may not fully capture exPosure among people
who wotk or tecreate away from home. Furthennol'e, vely
few studies address gteen space use' even in the physical
activiÇ liteiatutr, wherc the prirnary hypothesis is that higher
srrrror.rndìng greenness pronrotes physical activity through
rccreation in green spaces. Notable exceptions inclucle studies
in which participants wore global positioning systerns (GPS)
devices and accelerometers [26', 27-29]- Though objective
lu'leasurts of grcenness cannot accoutrt f'ol the qualities that
rnight make it usable or pleasant, NDVI has been found to
be highly corclated with environmental psychologists' eval-
uations ofgreen sPaces [30]' Because greenness is correlated with other spatial and
contextual factors, researchers have attempted to account
for these associations in theit studies to isolate the specifìc
rolc that grcenness might play in influencing health. For
instance, Hystad et al. showed that in a birth cohort acloss
Vaucouver, the avetage NDVI levels within 100 ln of each
residence were correlated with predicted NO (-0-43)' NO2
(-0.42), PM2.s (-0.36), and black carbon (-0-31), as well
as modeled tratÏc noise (-0.05), all noise (0.20), and
neighborhood rvalkability (-0' 5 8) [3 I'], The investigatol's
found that their associations were robust to adjustment for
these nroderately correlated factors. Other studies, such as
Fuertes et al. [32], lrave stratifìed by population densily
and founcl similar eft'ects of grccnness among cliffcrent
strata of population density. Still, further atfention is re-
quired to isolate the specifìc effects of greeuness on healtll
by accouuting for these correlated factot's.
Physical ActivitY
Greenness may encouftrge physical activity by providing both
a walking or cycling destination and a venue for play and
exercise I I I ]. A uumber of studies have assessed t]re associa-
tion between green sp¿Ìco and physical activity, typically in
cross-sectional analyses where neighborhood greenness is de-
rived lìicrn land-use files and physical activity is a"scertained
by survey. In general, this evidence supports a moderately
positive association between green space and physical activity
in adults (e.g., walking time, walking tnaintenance, meeting
physical activity recornmendations) [33-38], Some analyses
did not obsele an association [39, 40], and Maas et al' found
a negative association between green space atrd leisure-titne
physical activity [41]. h children, greenness has been associ-
ated with increased pla¡ime outdoors 1421, and in a str'rdy by
Ãlmartza et al, that used wearable GPS units and accelerom-
eters, with higher o<ftls of contenrporaneous physical activþ when in greener areas [26']' Similar studies ernploying GPS
units and accelerometers in children lbund that about half of weekend moderate-vigorous physical activity took place in
grcen space 127), and that epochs of moderate-vigorous pltys-
ical activity were significantþ mole likely to occur in green
space (vercus ouldoors not in gÍeen space) for boys, but the
relationship wns not signilìcant for girls [28]. Relatedly,
greenness and f:orest proximity were associated with lower
prevalence of excessive screen tinre (more so for children
whose pu'euts had more education) t43]- Of studies that in-
cluded measures of perceived gltenness' one found that both
subjective and objective green space were associated with
walking rnaintenance [44], while the other fuund that only
perceivecl greenness was related to walking trips [45]. While individual cross-sectioual analyses may liurit causal
inference, the strong consistency across shrdies after adjust-
ment for a range of individual and atea-level potential con-
founders (age, gender, individual socioeconomic status (SES),
alea-level SES, and population density) suggests that green-
ness may promote physical activity.
Overweight/ObesitY
of obesity because of its poterrtial association with physical
activity, Prirnarily, studiss of grcenness and obesity were
cross-sectional in design and measured BMI based on sur-
veys, although sor¡e studies queried electrotric medical re-
cords. [n general, greater ncighborlrood greonross (and in
one case, variation in greenness) was associated with lower
likelih<rotl of ovcrweight or obesity, Mowafi et al. [46], how-
ever, found no association after adjus[nent for neighborhood
SES, and Cummins and Fagg [47] found that greeu space was
associated with increased odds of overweight and obesity'
â springer
Sours cffcct modificationby gcnderhas been observed, In one
study, green space was associated wilh a reduced liketihood of overweight and obesity alnong worren but not men [48]; in anothe¡ it lvas absociated with a reduced likelihood of phys-
ical activity and increased overweighlobesity in men but de-
creascd overwc'ight/obesity in lvomen [49]. Findings among children have been mixed, The only pro-
spective study found greenness to be associated with lower BMI z scores and lower odds of increasing BMI z scores
between fw'o follow-up times [50]. Another study found that greonness and forest proximity wei'e associated with lower prevalence of overweight and obesity [a3], Liu et al, fbund that greenness was associated with decreased risk for over-
weight, but only a¡tÌong those in areas with greater population density [5 l]. One shrdy found that street tree density lrut not park arca was associated with lower obesity prevalence [52], and another study found that green space access'was not as-
sociated with children's weight [53]. Despite the presunrptive mechanisrn of physical activity,
only a fèw studies analyzed it as a potential mediator. These
results vaded; in one, those further frorn gt'een spaçe were less
likety to partake in physical activity and had higher odds of obesity thau those living closer [54]. Another shrdy fbund the
op¡rosite: hìgher levels of green space were associated with lcss physical activity (and increasecl overweight/obesity in rnen, but decreased overweight/obesity in wornen [49]), One
s¡¡dy found that living close to a park was positively associ- ated with physical activity, but not associated with overweight/obesity [9]. Finally, another shrdy found that,
even controlling for physical activity, the negative association
between green space arrd weight (in wornen but not men)
rcmained [48]. Scveral mcthodological shortcorniugs are cornmon to thcsc
papers, which are al¡nost all cross-sectional, and in which survey non-response coukl limit genelalizability, Most analy- ses, however, controlled for a range ofpotential confounclers (e,g., age sex, race, ethnicity, SES, and area-level SES and
urbanicity). The general consistency of lesr-rlts suggosts that there may be au inverse association between greenness and
ovcrwcigh/obesiry; howcver, tirthcr study (and prospective
analyses) is needed to establish temporality, explorc mediation (e,g., by physical activity), and plobe potential effect rnodifi- cation by gender.
Mental Health
ical activity, fostering soçial cohesion, or providing a direct psychological beneftt [7, 55]. Most studios of greenness and
mental health were cross-sectional, snwey-based, and use<l
self:adrninistered clinical scales to assess rnental health st¿tus,
thouglr Some exhacted rnedical recolds 120, 561. In geuelal,
greater neighborhood grcenncss or acccss to grcen space was
associated with reduced risk of shess, propensity to psychiat-
ric morbidit¡r, psychological distress, depressive symptonx, clinical anxiety and deprcssion prevalence, and mood disorder treahnent in adults I I 8, 20, 22., 5ç62]. Though most studies
consiclerc d objcctive greenness measures, Sugiyama et al, [23] found that those who perceived theil neighborhood as highly green had higher odds of better mental health than those who perceived theil neighborhood as least green. One study did not fìnd any assosiation between greenness and psychological
distress [ó3], while an analysis of green space and emotional well-being in children found weak and inconsistent results,
with modest prctective eilbcts in small cities [64]. A nurnber of studies focused on rnental health explored
rnediation. Three analyses found that the protective associ-
ation betwecn perceived or objective greenness and mental health remaìned even when controlling for physical activity and sooial cohesion f22., 23,58]. Arnong those who used
woods or forest for physical activit¡ odds of poor mental health were reduced compared to non-users [65]. Fan et al,
[60] explored mediation in different green space types, finding that parks rnitigated stress through social support, while neighborhood vcgetation mitigated stress directly but negatively affected social support. Finally, Maas et al. [56] tbund that loneliness partially ¡nediatsd and peroeivcd shortage of social suppotr fully mediated the association between lower levels of green space and propensity to psy-
chiatric rnorbidity. The majority of sírclies of greenness and niental health are
cross-sectional, though thrrce studies witl longer follow-up periods showed beneficial effects of green space on rnenlal
health, White et al. [57] used panel data from a longitudinal suvey in the UK and fou¡rd that greatel urban grcen space was
associated with lower risk of psychological distress. Annerstcdt et al. [66] found a reduced risk of poor mental
health arnong wornen who were physically active and had
access to grcen space with specific qualities (serenity and
space). Finally, without accounting fol age, Astell-Burt et al.
[67] found that green space was associated wilh better rnental
hcalth among mcn. but flot women. Flowcvcr; ¿rmong lnen
lhere was a stronger protective effect ofgreen space on psy-
chiatric morbidiy in early to mid-adulthood. For older wom- en, those with moderate grcen space had bettel mental health
compared to those with low grcen space access.
Other limitations inoluded possible selection bias due to
survey non-response [23, 59, 60, 66], instances of temporal misalignment between greenness and health tneasures [61], and coarse grccn space mcasures that did not capture smallcr elenrents like gardens and trees [56].
Despitc thcse t'laws, consistency among a largc and diverse
group ofstudies that etnployed sensitive psychological scales
and adjusted for several individual- aud area-level potential
confonnders suggests an association between green space
â Springer
and mcntal hcalth. Further study, especially in ptospectivc
analyses, is wamanted,
mental outcomes are suggestive but require further evidence'
Birth and Developmental Outcomes
enhancing social contacts amoirg rnothers, r'educing tnatemal
noise and air pollution exposure, and moderating ambient
temperatures [68]. The effect ofgreenness on pregnancy and
birth outcomes hæ been studied extensively in analyses across
multiple countries. Studies generally involved birth registries
where the mother's address at bifih was linked to a measurc of greer,ness, most commonly NDVI, and birth otttcomes were
assçssed fiom medical recotds that presented few opportuni-
ties for systematic bias, Positive associations between green-
ness and birth weight were reported consistently across the
nrajority of studies l3l',69-721' Other studies fouud that
higher greenneris exposure was linked to lower oclds of a child
being small for gesational age or preterm [3]'], larger heacl
circumferences [68], and lower infant mortality risk [73], al-
though these tìndings were not rcplicatcd actoss studies.
The rnajority of analyses adjusted for race, natemal age,
season of conceptiolt, arca-level SES, and child's sex, rnini-
mizing concems for confounding. While some birth registry
studies were not able to account for alcohol or tobacco use
[69] or maternal incolne or educatio¡r [3 l']' most analyses
were able to adjust for these factors' Some studies were able
to adclitionally model complex exposures, including air pollu-
tion [31., 68], neighborhood walkability, and noise [3 ]']. As-
sociations between greenness and birth outcolnes were robust
to adjustment for these impottant covat'iates. Stronger associ-
atiorrs between greelrness and birth outcolres were observed
arnong those whoss parents had lower education and lower
SES [68,69,71], as well as for mothers of white race as
compared to immigrants [72]' A few studies cousidered greenness in relation to develop-
mental otttcomes and allergies in children, positing that bene-
tìcial eflbcts may be mecliated by physical activity; social en-
gagemen[ reduced süess; and noise, heat, and ail pollution
rcductions [74]. Distance to the nearest gleen space from a
child's rcsideltce was positively associated with odds of hy-
peractivity and inattention [2 I ]. Dadvand et al- [43] found that
grccnness and forcst proximity was not associated with asth-
ma or allergic rhinoconjunctivitis, btlt pl'oxirnity to palks was
associated with higher astlma prevalence. In another shrdy,
greonness was positively associated with allergic rhinitis and
eye and nose symptolÌls in urban areas, but negatively associ-
atcd with thcse symptoms in rural areas [32]' While sorne studies were tirnited by incomplete control for
important potential confounders, the body of literattue ou
greenness and birth otttcotnes indicates that there is strong
Cardiovascular Outcomes
Greenness exposure nray affect levels of pþsical activity,
stress, social engagetnent, noise, and air pollution exposure'
whicli may drÌve cardiovascular disease risk [75-77]' Thrce
ecological studies analyzed mortality records and found that
area.s with lower greenne*s had lrigher levels of stroke mortal-
ity [78] and cardiovascular disease mortality [16' 79]. Maas
et al. [62] reviewed cross-sectional morbidity data fiom Dutch
general pructitioners and tbuncl that higher residential green-
ness r¡i'as assocìated with lower odds of coronary hearl disease.
Markevych et al. [80] observed lower systolic and diastolic
blood prcssure amollg chìldren fronr a Gennan birth cohort
who had higher residential greenness, after accounting fbr
tempemtur€, air pollution, noise, and ut'banization. A cross-
sectional suvey irr Australia demonstrated lower odds of hos-
pitalization for heart disease or stroke for adults with highcr
variability in greenness around their homes, although no as'
sociations were seen for absolute Sreenness [81]. Finally'
Villeneuve conducted a prospective survival analysis based
in Ontario, Canada [82'], After adjustrnent for air pollution
exposure, higher levels of greenness were associated with
lower risk of CVD, ischemic heart disease, and stroke mortal-
ity. While numerous cova¡iates were included in ana$ical
models, the autltols did not have individual-level data on
srnoking. A UK-wide analysis by Mitchell et al. fìrund tliat higher'
lèvels of green space decreased inequities in circulalory mor-
tality by area-lcvel SES [6], while a Dutch shrdy found that
groups with lower levels of education had a greater health
benefit from green space exposure compared to those with
higher levels of education [62]. Two studies applied experimental approaches to examine
the association bctween short-term exposure to simulatcd
gl'een spaces and blood pl€sstll'e after short bouts of physical
activity tS3, S4l and found that subjecls viewing videos of green, natual spaces had small reductions in blood prcssure
compared to those viewing r¡rban scenes-
A small botìy of literatrre supports an association betwecn
$eenness and a rauge ofcardiovascular outcotnes; howeve¡
the majority of these studies was cl'oss-sectional and
ernployed ecological study designs. One high-quality pro-
spective analysis reinforced the links between greenness and
cardiovascular mortality, but this analysis did not includc
individual-level information on important potential con-
fbunders. More prospective analyses with individuallevel in-
fonnation on exposure and outcotle are required to establish a
â springer
causal relationship between glccnness and cardiovasoular outcomes,
rec¡rired to cxplain the mcchanism ttuough which greenness
affects mortality,
ultirnately affect mofiality. The filst mortality analysis took place in Japan, where researchers asked elderly particþants about characteristics oftheir residential srurormdings at base-
line [E5], l.-ive-year survival rates were highest among those reporting treelined streets near their rcsidence. Si-nce this ini- tial study, several ecological analyses have exarnined larger-
scale data, including a natiouwide analysis using a land-use
dataset from the UK [16]. Thc authors found a 6 % lowcl mortality rate compadng administrative arcas in the highest quintile of greenness to the lowest. A similar study across the
UK found that male cardiovascular and rcspiratory urortality r¿tes decrcased with increasing green space, but no associa-
tions were found for women [79], An ecological analysis of census tracts in Florida found that areas witl low greenness
had the highest ratcs of shoke deaths [78], while a census-
based analysis in New Zealand observed no associations be- tween usable or total gl€en space and rnortality [86]. Vlle- reuve et al. [82.] examined mortality in Ontario, Canada and
evaluated exposure to greenness based on the area alound each participant's residcnce. They fbund that aftel adjustrnent
flor air pollut'ion exposrü'e? an increase in greenness was asso-
ciated with reducecl overall non-accidental mortality, driven by the cardiovascnlar outcomÞs described above. Using data
on stroke survivors, Wilker et al. [87] found that higber green-
lless was associated with a lowcr morlality rate. Lachowycz and.lones tested whether selÊreported walking would mediate
thc assooiation between access to green space and rnortality in an ecological study of residents of England [88], While an
association between greenness and walking wa.s observed in all areas, the association between greenness and reduced mor- tality was only apparent in the most depfived areas. The au.
thors also found no evidence that recroational walking cx- plained the associations between greenness and mortality,
The small set of studies examining greenness and mortality is generally consistent and shows tlrat increased greenness is
associated wilh lower mortality. The majority of these studies,
however; was based on ecological datathat limit statcments on
causality, Three prospeclive cohor[ analyses have been con- ducted, although two studies have lirnited generalizability due to special popnlations (elderly and stroke survivom), whilc thc
third study was not able to completely account for smoking. Morc prospective cohort analyscs are necessary to replicate
these findings, In adrlition, while one study found that the
association between greeïìness and mortality could not be ex- plained by recreational physical activity, more tesearch is
Inequalities
Creenness and access to green spaces is not equally distribut- ed across space, and certain populations may have lower ex-
posure and decreased access to these resoulces. Researchers
have attempted to quantifli inequalities in greenness exposure
an<l green space access. Studies have demonstrated that neigh- borhoods with higher percentages of rninorities in the USA
[89] and lower SES in Australia [90] have lower levels of $een space access, although one study in Melboume, Austra- lia found that there was no link between neighborhood SES
and access to lecreational open spaces [91]. An examination ofnationwide US Census block goup clata showed that racial
rninolities were more likely to live in areas with lower tree
cauopy cover and lrigherimpervious surfaces [7]. Researchers have also highlighted differential efIècts of
greenness on health, with consistent evidence ofstronger as-
sociations between greenness and health among low SES in- dividuals. Multiple studies of greenness and bir{r outcomes
found stronger associations atrong rnothers who were of low- erSES [68-70] and one snrdy indicated differential efrècts by etlmicity [70]. Higher greenness appeaß to decrease the effect of income deprivatiorr on all-cause and cardiovascularrnortal- ity [6], and particþants with the lowest levels of education had the largest benefit fìom grren space exposure iu terms of clrronic obstructive pulmonary disease 1621. In addition, the
association between gleenness and reduced mortality is stron- gest in the most deprived areas [88]. Greater green space has
also been shown to be proteotive against psychological dis- tress among more physically active subjects, but not among thc least active [18]. Dillbrential associations by sex are in- ronsistent, One study showed that women with higher levels of greenness in tbeir census warcl had lower levels of salivary cortisol, although similar results were not found in rncn [92]. In one sfudy, green space was associated with a lower likeli- hood of overweight and obesity in women but not men [48]; in
another, greenlless \ivas associated with a reduced likelihood of physical activity and i¡rcreasecl overweight/obesity in merr
but decreased overweighUobcsity in womcn [49]. Conversely,
arrother study found that male cardiovascular disease and re-
spiratory disease mortality rates decrcased with increasing gleen space, but no associations were found for women [79], In children, greenness wæ found to be positively associated
witlr allergic lhinitis, and eye and nose symptoms in urban
areas, but with reductions in risk in rural areas [32]. Addition- ally, proximity to a forcst was associated with lowcr odds of excess scl'een time among children in Spain [43]. This associ-
ation was strongest among children with parents of higher
education cornpared to those with lower education.
Q springer
Conclusions
to be stronger for certain outcomes than others. Cross-
sectional studies ofphysical activity have exhibited consistcnt
results across a wide valiety of study populations, suggestillg
a robust positive associatiou with greenness. This connectiott
is underscored by studies in which participants wore GPS
devices and accelerometers, in which greenness was associat-
ed with gleater odcls of physical activity. Despite suggestions
of a link between greenlless and physical activity, the results
ofstr¡dies on gteenness and weight stah¡s have been less con-
clusive, though sonre evidence points to an inverse association
of greenness against overweight and obesity. Many pt'ocess-
es-genetic, behavioral, and environmental-contributc to
weight status, and further work is required to understand the
relative conh'ibution of greenness. A number of studies on
mental health have found increased greenness to be associated
with lower likelihood ofpsychological distress and other men-
tal heatth outcomes and have begun identifying potential me-
diators such as physical activity, stress, ancl social cohesiott,
prirnalily in cross-sectional studies. Arnong children, there is
consistent evidence fi'om birlh cohort studies that higher
greenness during plegnancy is positively associated with birth
weight, though studies of other birth outcomes are less con-
clusive. The mixed fìndings among the few studies on devel-
opmental health underscote tlre need for funher work in this
area. Studies examinìng the effects ofgreenness on cardiovas-
cular disease and mortality rely mostly on ecological and
cross-sectional analyses (excepting two high-quality pt'ospec-
tive studies [82., 87]) but suggest that greater gleenness may
ìrc associated with lowcr catdiovascular diseasc prevalencc
and lower mortality.
establistred interesting potentia[ relationships between green-
ness exposure and health. The vast majority of studies, how-
eve¡ ate cross-sectional, limiting the extetlt to which the often
protective effect of gleentless can be construed as causal.
Studies will be subject to the possibitity of self-sclcction
(lvherein healthier subjects or those with mot'e healtlt-
prornoting behaviors move to greener areas) until prospective
analyses can be conducted.
Exposure characterization can be improved by enrphasiz-
ing grecn space quality and subjects' use of gtcen spacc in
future sítdies, for exatnple by gatlrering both objective and
subjective measures and by replicating work done with wear-
able GPS devices and accelelometers. Otttcome asscssment
can be inrproved through medical records extraction and other
obj ective asccrtainment.
space access and its health benefits dift'er according to incli-
vidual and neighborhood-level characteristics deselves fttrther
exploration. Agc, gender; and especially SES may modifu the
association between greenness and health behaviors and out-
cornes. In particular, the fìnding that lower SES groups have
less grcen space access but perhaps benefit tnole from grcen-
ness exposure deserves further sildy. If bome out, that dynam-
ic may suggest one shategy to mitigate socioeconomic health
disparities. In sutnmary the body of literature assessing the eftècts of
gl'eenness on health provides sotne evidence that greenness
rnay be beneficial for physical activity, obesity, mental health,
birth outcomes, cardiovascular outcomes, ancl mortality.
White futther work is needed to finnly establish cattsal rela-
tionships, greenness shows prornise as a modifiable and
health-promoting exposure.
Acknowledgmcnts Theresearch
supported by the Harvald NHLBI C Gr:rnt Tl2 HL 09lJ04ll and Environ
T32 ES 07069. Thc sponsor of this study neither played a role in study
dcsign; coltection, analysis, or intorpretfltion oFdata; in the writing ofthe
report; nor in thc dccision to submit lor publication.
Compliancc rvith Ethics Guidclincs
Conflict of Intcrcst P. Jarnes, R.F. Bana¡ J.E. Hârt, and F Laden all
declarc no conflicts ofintetest.
Human and Animal Rights anrl Informcd Conscnt This article does
not contain any snrdics with human or anirnal subjects perfonncd by any
of thc authors.
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