Curr Epidenriol Rep (20t5) 2:l3l-142DOI 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- Banuyrachcl, 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 ofPublic 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 ofgreennessJrealth 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 '

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132 Curr Epiderniol Rep (2015) 2:131-142

AllOutcomes MayBe lnterrelatedStresc reducllon,

cognitlvg reslorât¡on

REduced p¡ychrÉflcmorb¡drly. includlng

depre68ion and anriely

lncreasBd phy3icslacl¡vity

RoducÁd ovoùo¡9ht ândobss¡ly

lncree6ed soclal¡nlelâcl¡on årtd cohêsion

Rêduccd ca¡drovosçulardisease

Greenness Exposure

Noise m¡tigaùon

R€duced alhcåusemorlal¡ly

Heat ônd hqmidrlytegulålion

lmproYed biÍlh outoomes

A¡r pollulion fllration

Fig. I Pathways thxrugh which gr€enness rnay afièct health

suggests that human beings have evolved to have an affrnityfor naturg plaffs, and living thirrgs [6, 7], Building on this,

Ulrich's psychoevolutionary theory posits that eKposure tonaturc 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 forboth 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 inepiclcrniologic 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? orpublic 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 comrnonlyusedNDVI can be downloaded at resolutions fiorn 30 rn-8 lan fbrperiods 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.

@ Springet

Table I Strength ofevidence for greenness and health outcomes

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.

E¡

G

o

G

t9

\,a

I

ÞN

Ovenveighuobcsity

Menfa'l he¿lth

Birth and

dcvcloprncntalorìtcomes

Cardiovascularoutconles

I 5 cross-sectional shrdies

Í26.,27,28, 3343, 451

I prospective study [44]I 0 c¡oss-sectional studies

u9.43.4649, sr-541I prospective srudy [50]

I I cross-sectional studies

120,22-,23,56,s851. 63-6sl

3 prospective studies

lJ7. 66, 671

6 bifh coho¡t sûrdics

[3r., 68. 69, 7 ]-731

2 cross-sectional studies

of alleryies and asthma

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 [82.13 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 inCana<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 inJapan, New Zezlañ, and Canada

Sorne evidence ofnegative association between IIgrecnncss 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- IIreported 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 forother 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 shrdycould not account for individual-level smoking.

Shength ofevidence

lÏ

fl/I1I

ìl

MoÍality

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

t9Ø

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134 Curr Epidemiol Rep (2015) 2:l3l-142

tegend

MODIS NDVI Dåta July 2014

value;li;,

Legend

Natlonal Lend Cover Dalaset Pefcent Tree Canopy Cover

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@ Springer

l3sCun Epidemiol Rep (2015) 2:l3l-142

Differcnt exposuro metrics present diffbrent advantages

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 activþwhen in greener areas [26']' Similar studies ernploying GPS

units and accelerometers in children lbund that about half ofweekend 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

Grcenness has been explorcd as an cnvirontncntal detcnninant

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'

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136 Curr Epi<lemiol Rep (2015) 2:l3l-142

Sours cffcct modificationby gcnderhas been observed, In one

study, green space was associated wilh a reduced liketihood ofoverweight and obesity alnong worren but not men [48]; inanothe¡ 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 lowerBMI z scores and lower odds of increasing BMI z scores

between fw'o follow-up times [50]. Another study found thatgreonness and forest proximity wei'e associated with lowerprevalence of overweight and obesity [a3], Liu et al, fbundthat greenness was associated with decreased risk for over-

weight, but only a¡tÌong those in areas with greater populationdensity [5 l]. One shrdy found that street tree density lrut notpark 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 ofobesity thau those living closer [54]. Another shrdy fbund the

op¡rosite: hìgher levels of green space were associated withlcss physical activity (and increasecl overweight/obesity inrnen, 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 withoverweight/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 whichsurvey 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 thatthere 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

Grccnncss tnay pronote mental health by encouraging phys-

ical activity, fostering soçial cohesion, or providing a directpsychological 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 disordertreahnent 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 highlygreen had higher odds of better mental health than those whoperceived theil neighborhood as least green. One study did notfìnd any assosiation between greenness and psychological

distress [ó3], while an analysis of green space and emotionalwell-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 mentalhealth remaìned even when controlling for physical activityand sooial cohesion f22., 23,58]. Arnong those who used

woods or forest for physical activit¡ odds of poor mentalhealth 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 butnegatively affected social support. Finally, Maas et al. [56]tbund that loneliness partially ¡nediatsd and peroeivcdshortage of social suppotr fully mediated the associationbetween 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-upperiods showed beneficial effects of green space on rnenlal

health, White et al. [57] used panel data from a longitudinalsuvey 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 temporalmisalignment between greenness and health tneasures [61],and coarse grccn space mcasures that did not capture smallcrelenrents 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

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137Cun Epidenriol Rep (2015) 2:l3l'-142

and mcntal hcalth. Further study, especially in ptospectivc

analyses, is wamanted,

cvidence for an associ¿rtion betwcen residential greenness cx-

posule and birth weight, Þ'indings fot'other birth and develop-

mental outcomes are suggestive but require further evidence'

Birth and Developmental Outcomes

Greenness exposure may affect birth outcomes by altering

rnatemal levels of physical activity, reducing tttaternal stress,

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 ofgreer,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 ofgreen, 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

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138 Clun Epidentiol Rep (20 I 5) 2:l3l-142

causal relationship between glccnness and cardiovasoularoutcomes,

rec¡rired to cxplain the mcchanism ttuough which greenness

affects mortality,

Mortality

The mechanisms through lvhich greenness affects health rnay

ultirnately affect mofiality. The filst mortality analysis tookplace in Japan, where researchers asked elderly particþantsabout characteristics oftheir residential srurormdings at base-

line [E5], l.-ive-year survival rates were highest among thosereporting 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 % lowclmortality rate compadng administrative arcas in the highestquintile of greenness to the lowest. A similar study across the

UK found that male cardiovascular and rcspiratory urortalityr¿tes decrcased with increasing green space, but no associa-

tions were found for women [79], An ecological analysis ofcensus 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 aloundeach 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, drivenby 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. Lachowyczand.lones tested whether selÊreported walking would mediate

thc assooiation between access to green space and rnortality inan ecological study of residents of England [88], While an

association between greenness and walking wa.s observed inall 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 mortalityis 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 dueto 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 examinationofnationwide 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 byetlmicity [70]. Higher greenness appeaß to decrease the effectof income deprivatiorr on all-cause and cardiovascularrnortal-ity [6], and particþants with the lowest levels of educationhad the largest benefit fìom grren space exposure iu terms ofclrronic 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 amongthc least active [18]. Dillbrential associations by sex are in-ronsistent, One study showed that women with higher levelsof greenness in tbeir census warcl had lower levels of salivarycortisol, 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 likelihoodof 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 increasinggleen 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 ofexcess 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.

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139Cun Epidemiol Rep (2015) 2J3I-142

Conclusions

Evidence linking greenness to various health behaviors and

physical wellbeing continues to groq and associatirjns appear

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.

In gcneral, this relativcly nelv lins of inquiry has

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.

Finally, the snggestion in some analyses that both green

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 CGr: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.

References

Papers ofparticttlttr interest, published recentl¡ have been

highlighted as:

. Of impoftance

l, Tsunetsugtt Y, Park BJ, Miyazaki Y. Trends in research related to

"shinlin-yoku" (taking in the fbrest atmosphere or fbrest bathing)

in Japarr, Environ Heahh Prcv Med, 2010;15(1):27-37.

2. Celter H. Frilufìstiv: the Scandinavian philosophy of outdoor life'

Can J Enviton Educ.2000;5(l):77.

3. Conway D, Li CQ, Wolch J, Kahle C, Jenett M, A spatial autocor-

relation approach for exarninilrg the eflects ofurban grcenspace on

residential property vatlres. J Real Estate Finauc Econ 20 1 0;4 1 (2):

150 69.

4. Potyakov M, Pannell DJ, Pandit R, Tapsuwtn S, Park G'

Capìtalized anrenity value ofnative vegetation in a multifunctional

nrral lantlscape. Arn J Agric Econ. 2015;97(l):299114'

5. Wu J, Wang M, Li W, Peng J, Huaug L, Impact of uttan gtcett

space on rcsidctttial housing prices: casc snrdy in Shenzhen' Joumal

ofUrban Planning and Developrnent. 2014.

6. Wilson EO, Biophilia, Conrbridge: Harvard University Press; 1984'

7. Grin<lc ll, Patil GG. I3iophilia: does visu¿l contact with uaturc im-

pact on heallh and wcll-being? Int J EnviLon Res Publ I'lealth'

2009;6(9):233243.

fl Spring"r

140 Curr Epidemiol Rep (2015) 2:l3l-142

fl, tJlrich RS. Vierv thlough a windorv tnay infìuence recovety lÌontsnrgery. Science. 1 984;224(6A):420-L

9, Ulrich RS, Sirnons RF, Losito BD, Fiorito E, Miles MA, Zelson M.Stress recovery during exposure to natural ancl urban environments.J Environ Psychol. l99l;I I:201-30.

10. Berknrarr LF, Kawachi l. Social epidemiology. USA: Oxford(Jniversity Press; 2fi)0.

I l. Bedimo-Rung AL. Mowen AJ, Cohen DA. The signifìctnce ofparks to physical activity and public lrealth: a csnceptual tnodel.

Arn J Prev Med. 2005;2tl(2 Suppl 2):159-{13.

12. Nowak DJ, Crane DE, Stevens JC. Air polluticnr rernoval by ulbantlees and shrubs in the United States. Urban For Urban Grecn.2006:4:ll5-23.

13. GidlöÊGunnarsson A. Ohrstörrr E. Noise and rvell-being in urban

lcsidenti¿l envir<lnments: the potantial lole of perceived avaìlabilityto ncarby green ¿ueas. Landsc Ulban Plan.2007;83:ll5-2ó.

14. L¿rfortezza R, Carus G, Sanesi G, Davies C. Benefits and rvell-being perceived by people visiting green spâces ir.r periods ofheatstre,ss. Urban For Urban Olcen. 2009;8(2):97-108,

15. l,Veier J, Hening D. Measuring vegetation (NDVI & EVI).Creenbelt: NASA 2011.

1 6. Mitchell R, Pophâm F. Elfect ofexposure to naturål envilomnent onhealth inequalities: an observational population study. Lancet.2008:37 2(9650): I 655-{0.

17. Jesdale BM, MorelloJrosch R, Cushing L. Thc racial/eth¡ic distri-bution ofheat risl<-relatecl land cover in relation to residential seg-

r egation. Envi¡on Health Perspect. 20 I 3;l 2 I (7):8 I I -7 .

18. Astell-Burt T, l'eng X, Kolt GS. Mental health benefits ofncighbourhood glccn sp¿lcc arc stronger among physically activc

adults in niddle-to-oldcr âgo: cvidcnce fron 260,061 Australians.Prcv Mcd. 201 3;57(5):60 l{j.

19. Coombcs E, Jones AR I'litlsdon M. Thc relationship of pltysical

activity and ovcru,cight to objcctivcly mcasurcd grccn spûcc acoes-

sibility anctusc. Soc Sci Med. 2010;70(6):816-22.20. Nutsford D, Pcarson AL, Kinghaur S. An ccological study investi-

gating the association betweeu access to urban green space and

mental hcalth. Pub[ Health. 2013;127(l l):1005-l l.2l. Markevych l, Tiesler CM. Fuctes E, Rornanos M, Dadvand R

Nicuwenhuijscn MJ, et al. Access to urban green spaccs and behav-

ioural problenrs in chiidLen: results from the CINIplus and

LISAplus studies. Envilon ht. 20l4;7|:29-35.22.. de Vries S, van Dillen SM, Groenewegen PP, Spreeirwenbetg lì

Streetscape greeneiy and health: stress, social cohesion and physical

activity as rnediators. Soc Sci Med, 2013;94:2613, The authorsassessed both quantity and quulity ofstreetscape greenery, fìnd-ing thåt greenery quality was significantly associated with bet-ter mentÐl health (ovcr nnd tbove qunntity). Medirtion rnaly-scs lbund that social cohesion and stress each mediated fully thegreenne!ùs-mental hcalth relntionship (for qurtntity but not qual-ity) and green activity partially mediated the quality ofgrccnncss-mcntûl hcaltb rclationship,

23. Sugiyama T, Leslie E, Giles-Corti B, Owen N. Associatious ofneighboulltood greenness with physical a¡rd ruental health: do

walking, social coherence and local social irrteraction explain the

relationships? J Epidemiol Clo¡m¡unity Health. 200tt;62(5):e9.

24. USGS. NDVI for AVHRR 2015 (2015). Available lìtrrr: http://phenology.cr. usgs.gov/ndvi_a vhn php.

25. Multi-Resolutior Larul Use Char¿ctelistics Cousortium. NationalLand Cover D¿tabase 20ll 2015 (2015). Available frorn: http://wrvw.mrlc.gov/nlcd20 I I .php.

26.. Alnat:øa E, Jenett M, Drurton C, Seto E, Penlz MA. A study ofcomururity design, gleenness, and physical activity in children

using satellitc, GPS and 0ccelerometer data. Flealth Placc.20 I 2; I 8(l ):46-54. The authors dcmonstrâtcd through rvcarablcGPS units tnd accelerometers that higher greenness increascdodds of childrcnts contcmpornneous physical activity.

27 . Lachow¡rç7 l(, ¡enes AP, Page AS, Wreele¡ BW, Cooper AR. What

can global positioning systetns tell us about the contribution ofdifferent types ofurban gteen$pace to children's physical activity?Health Place. 20 I 2; I ll(3):5t|6-'94.

28. Wheeler BW, Cooper: AR, Page AS, Jago R, Greerrspace and chil-dren's physical aotivity: a GPS/GIS analysis of the PEACH projeot.

P¡ev Med. 2010;5 I (2): 14tl-52.29. Quigg R, Cray A, Reeder AI, Holt A, rùy'aters DL. Using acceler'-

ometers and GPS unils to identifr the pruportiotr of daily physical

âctivity located in par*s widr playgnrulds in New Zealand children.

Prev Med. 20 I 0;50(5-l):235-40.30. Rhew IC, Vander Stoep A, Keamey A, Smith NL, Dunbar MD.

Validation of the nomralizeti difference vegetâtion index as a mea-

sure of neighborltood greenness. Ann Epiderniol. 20 I I ;2 I( I 2):946-52.

31.. Ilystad P, Davies FIW Frank L, Van Loon J, Gehring U, Tambtrric

L, et al. Residential grcenness ¿nd birth outcomes: evalunting the

influe¡ce of spatially correlated built-environment factors, Environl{ca[th Perspect.20l4;122(10):1095-102. In a birth cohort studythat adjusted for arealevel exposures such as air pollution andnolse, neþhborhood walkability, and park proximity' indepen-dent effects of greenness on four birth outcomes was found.

32. Fuertcs Ë, Markcvych l, von Iìcrg A, Bauer CP, Bcrdel D, KolctzkoS, ot 41. Grccnness and allergies: evidoncs ofdiffcrential associa-

tions in two areas in Germany. J Epidemiol Cornmunity Flealth.

20 I 4;68(8):787-90.33. Chaix B, Simon C, Chareire H, Thornas F, Kestens Y, Karusisi N,

ct al, The environnrclltal conclates ofl ovcrall and ncighborhoodbased recreational lvalking (a cross-sectional analysis of the

RECORD Study), Int J Betrav Nutr Phys Àct. 2014;11(l):20,34. Karusisi N, Bezur K, Oppert JM, Pannier B, Chaix B. Multiple

dirnensions oflcsidential environments, neighborhood experiences,

and jogging behavior in the RECORD Study. Prev Med'201 2;55(l ):50-5,

35. Richardson EA, Pearce J, Mitchell R, Kingham S, Role of physical

activity in the relationship between nrban green space arrd health.Publ Health. 201 3 ;l 27 (4):3 I 8-24.

36, Mynon OT, Townsend N, Rùtter H, Foster C, Green space andphysical activity: an obsetvational shrdy using Health Survey fbrEngland data. Henlth Plnce, 201 2; I 8(5): I 034-4 l.

3'1. Li F, Hanner PA, Cardinnl BJ, Bos'rvorfh M, Acock A, Johnson-

Shelton D, et al. Bnilt environnrent, adiposity, and physical activityin ¿rdults aged 50-75. Am J Prev Med. 2008;35(l):38-46.

38. Gong Y, Gallacher J, Palmer S, Fòne D, Neighbourhood green

space, physical litnction and participation in physical act¡vities

urong elderly rrren: the Caerphilly Prospective Study. Int J Behav

Nuh Phys Act. 2014:l I (l):40.39. Ord K, Mitchell R, Pearce J. Is level of neighbourfiood green space

associated with physical activity in green space? lnt J Behav NttnPhys Act. 2013;10:127.

40. Hillsdon M, P¿urtel J, Foster C, Jones A. The relationship belween

access and quality of urban gteen $p¿ce with population physical

acrivþ. Publ Healr}. 2006; l2r)(12):l 12712.41. Maas J, Verheij RA, Spreeuwenberg P, Ctoenewegen PP. Physical

âctivity as n possible meclìanism behind the relationship betweengrcen space ¿nd health: ¿r lnultilevel anaþsis. BMC Public Health.

200tt;tt:206.42. Crigsby-Toussaint DS, Chi SH, Fiese BH, Croup SKPW. Where

they live, how they play: neighborhood greeunuss and outdoorphysical activity anrong preschoolers. Int J Health Ceogr.201 l;10:6ó.

43. Dadvand P, Villnnuevd CM, FonçRibera L, Marlinez D, Basagana

X, Belnlonte J, et à1, Risks and benefrts ofgrecn spnces for children:

a cross-sectiorral study of associations with sedenøry behavior,

obesity, asthma. and allergy. Envirou l'lealtlt Perspect.20 I 4;122(12): | 329-1 5.

Q springer

t4lCun Epidemiol Rep (2015) 2:l3l-142

14, Sugiyanra T, Ciles-Corti B, Sunrtners J, du Toit L, Leslie E, Owen

N. lnitiuting and maintaining recrcalional rvalking: a longitudinal

s$dy on the intluence ofneighborhoocl green space, Prev Med'

2013;57(3): l Ttl-|12.

45. Tilt JH, Unläed TM' Rooa B, IJsing objective and subjective nreu-

sutes of neighborùood grcenne$s and accessible destinations tìtr

untlentauding walking trips urrd BMI in Selttle, Washington' Am

J Henlth Prumot 2007;21(4 Suppl):371-9.4(t. Morvafi M, Khatlr Z, Bennett G, Hill A, Karvachi I, Subramanian

SV. ls acr;ess to ueighbolhood green spitce associ¿tecl with BMI

anrong Egyptians? A rnultilevel study of Cairo neighborhoods'

tleahh Place. 20I2; I 8(2):385-90.47. Cummins S, Fagg J. Does greenet mean thinuer? Associations be-

tween neighbourhood greenspace and weight stattrs atnong adults

in England. lnt J Obes. 2012;36(8): I 108-l 3.

48. Astell-Burt T. Feng X, Kolt GS. Greeuer neighboilroods, slimmer

people? Evidence frorn 246,920 Australi¿ns- Irrt J Obes'

2014:38(l ):156_9.4(). Prince SA, Kristjansson EA, Russell K, BilletteJM' Suwada M' Ali

A, et al. A nlultilevel analysis ofneighbourhood built and social

cnvironments and adult sclf-rcportcd physical actìvity and body

mass indcx in Ottawa, Canada. Int J Environ Rcs Publ l-lealtlt.

201 l;8(l 0):39s3-78.50. Bcll JÞ', Wilson JS, Liu CC, Ncighborhoocl grccnncss arld z-yctr

changcs in body mass indcx ofchildrcn and youth. Am J Pruv Mcd'

2008;35(6):547-53.5 I . Liu GC, Wilson JS, Qi R, Ying J. Grccn ncighborhoods, food rctail

and chitdhood overwcight: difncrcnccs by population dcnsity. Am J

Ilealth Promot. 2007 ;21 (4 Suppl):3 1 7-25.

52. Lovasi GS, SchwaLtz-Soicher O, Qlrinn JW, Bcrger DK'Neckerman KM, Jaslow R, et al. Neighborhood safery and green

spacc as preclictoLs of obesity amottg pttschool childrcn flotn low-

incoure families in New York City. Prcv Med. 2013;57(3):189-93'

53. Potcstio ML, Patel AB, Powcll CD, McNeil DA, Jacobson RD,

Mclaren L. Is there an association betrveen spatial access to

pa*s/green space and childhood ovenveighVobesity in Calgary'

Canada? lnt J Behav Nutr Phys Act. 2009:6:77 '

54. Toftager M, Ekholrr O, Schipperün J, Stigsdotter U, Bentsen R

Gronbaek M, et al. Distance to green space atttl physical activity:

a Danish nationnl replçsentative survey. .l Phys Act Health,

201 l;8(6):741-9.55. Lee AC, Maheswaran R. Thç health benefìts of urtalì green spaces:

n revierv of the eviclence. J Publ Health (Oxfbrd). 2011;33(2):212-

22.

56. Mnas J, van Dillen SM, Velheij RA. Gtoenewegen PP. Social con-

tâcls as â possible ¡:reclranistn behind the relation betrveen green

space and health. He¡rlth Place' 2009; l5(2):586_95.

57. WÍite MR Alcock I, Wheeler BW, Deptedge MH. Would you be

happier living in a grcener rrtban at'ea? A fìxed-ellècts analysis ofol Sci. 201 3;24(6):920-tl.

58. D¿rdv¿nd P, Cirach M, Matlinez D, Meclina A,

l. Natural outdoof environtneuts and nreut¿rl and

relationships and mech¿rnisms. Environ Int'2015l.77C:3541.

59. Stigsdotter UK, Ekhohn 0, Schipperijn J' Toflager M, Kamper-

Joryensen F, Randrup TB. Health ptomoting outdoor envirou-

rnents-associations betlveen green spâce' and health' health-

rclated quality of life and stless based olr a Danish national repre-

sentnrive sruvey. Scand J Publ llealth. 2010138(4):41 l-7'60. Fan ! Das KV, Chen Q. Neighborhood green, social support,phys-

lcal activity. and stress: assessing the cttrnulittive impact. l'lealth

Place. 20t I ; l7(6):1202-l l.61. l3eycr KM, Kaltenbach A. Szabo A, Bogar S, Nlcto FJ, Malecki

KM. Exposttrc to neighborlrood grcelr spûcc and mental lrcalth:

svi(lencc from thc srtrvey of the health of Wiscon5in. Int J

Envirorr Rcs PLrbl ic I lcal th. 2O I 4;l | (3\:3 453 -7 2.

62, Maas J, Verfieij RA, de M'ies S, Spreetlwenberg B Schellevis FG'

Gtoenewegen PP. Morbidity is related to a gr€en living environ-

nrent, .l Epideniol Conrmunity Health. 2009;63(12):967-73.

63. Salkar C, Gallacher J, \ilebstel C. Urban built envimnment config-

uration and psychological disness in older nren: t'esults lionr the

Cìaerph c Health.2013;13:695.

64, Huynh Pickett W. Exposure to public nâturdl

spacs ¿r r clnotional well-being illnong yourg

people in Canada. BMC Public Health. 2013;13:407'

65. -tiZ¡t.lt.tt

R. Is physical activity in nahr¿l envi¡onments better for

menurl he¿ltb than physicul uctìvity iu other environtnents? Soc Sci

' Med.20l3;9t:13G4.66. Anne¡stedt M, Ostergren PO, Bjork J' Grahn P, Skarback E'

Wahrborg P. Green qualities iIr the neighbourhood and mental

health-iesults from a longitudinal cohort study in Southem

Swedetr. BMC Public Health. 2012;12:337.

67. Astell-Burt ! Mitchell R, Hart ig T- The association between green

space and mental health var:ies across the lilbcoulse. A longitudinal

siudy. J Epidcmiot Community I-lcalth. 2014;68(6):578-83'

68. Dadvantl P, Sunyer'J, Basagana X, Ballester F, Lertxtrndi A'F'cmandcz-Somoano A, ct al. Surrounding grcenncss and prcgnan-

cy outcomss in four Spanish birth cohorts. Environ l{ealth

Pcrspect. 20 l2;l 20(10): 148 l-7.69. egay-Shay K, Peled A, Crespo AV, Peretz C, Amiuai T Linn S'

ctìÍ. Grccn spaccs and adverse pregnancy outcomes' Occup

Envi¡on Mcd, 2014;.7 1(8):562-9.

10. Dadvand P, dc Nazcllc A, F'igueras F, Basagono X, Su J, Amoly E'

ct al. Grcen spacc, hcalth lnequality and pregnancy' Enviton Int'

2012;40:l l0-5'7 l. Markevych I, Fuertcs E, Ticsler CM, Bfu'k M' Batrcr CP, Kolctzko

S, et al. Sunounding greenness and biÉh rveight: results from the

GlNlphrs and LISAplus bitth cohorts in Munich. Hoalth Placc'

2014:,26:3946.72. Dadvand B Wriglrt J, Martinez D, Basagana X, McEachan RR'

Cirach M, et al. Inequality, green spaces' and plegnant lvomen:

roles ofethnioiry and individual and neighbourhood socioeconomic

status. Environ lnt. 2014;71 :l0l-8.73. Kihal-Talantikite W Padilla CM, Lalloue B, Gelomriui M, Zmilott-

Navier D, Deguen S. Gt'een space, social inequalities and neonatal

rnortality in France. BMC Pregnancy Childbirth, 201 3; 13 ; I 9 1'

74. Dadvancl B Osho B, Figueras F, Foraster M, Basagana X, Valentin

A, et al, Rcsidential proxirnity to nrajor roads and telm low bitth

weight: the roles of air pollution, heat. noise, and road-adjacent

trees. Epidemiol ogy, 2014;25(4):5 I 8-25.

75. Blair SN Motris JN. Healthy hearts-ancl the univerual benefits ofbeing physically active: physical ¿otivity and health' Anu

Epidemiol. 2009 ; 19 (41:253-4.

7 6. Albus C. Psych<llogicat and social f¿ctom in coronary heart disease'

Ann Med. 20 I 0 ;42(7 ):487 -9 4'

77. Cold DR, Mittlenran MA. Neu, insights into pollutiou aml the cat'-

cliovasculal system: 2010 to 2¡J12. Circulation. 2013;127(ltt):I 903-l 3.

?8. Hu Z, Liebens J, Rao KR. Linking shoke mortality with air: pollrr-

tion, income, aud greenness in northwest Floritla: an ecological

geographical shrcly. Int J Health Ceogr' 2008;7:20.

7g. ni"hot'.ltun EA, Mitchell R' Gende¡ <lifferences in relationships

between urbatr green space and health in the United Kingdom'

Soc Sci Med. 2010;71(3):568-75.

et a[. The association belweeu neighborhood greenness and ca¡dio-

vascular diseasel an obset'vational study. ßMC Public llealth'

2012:12:466.

fl Springer

142 Curr Epiderniol Rep (2015) 2:l3l-142

82.. Mllcneuve PJ, Jenett M, Su JC, Bunrett RT, Chen H, Wheelel AJ,et al. A cohort stucly relating urùan green space with mortality inOnturìo, Canada, Environ Res, 2012;l l 5:51-8. In a lalge prospec-live survival analysis, highcr levels of greenncss ìvcrc rssociritedwith lower riskof CVD, ischcmic hcårtd¡scåsc, ånd strokc rnor-tality aftcr ùdjustmont for åmbicnt air pollution.

¡13. Pretty J, Peacocrk.l, Sellens M, Gúllin M. The mental and physicalhealth outcomes of greert exercise. lnt J Environ Health Res.200s; I s(s):3 19-37.

84. Duncan MJ, Clalke ND, Birch SL, Tallis J, Hankey J, Bryant E,et a[. The effec[ ofgreen cxercisc on blood prcssurc, heart mtc and

rnood state in prinrary school childt'en. Int J Environ Res Publllcalth. 2014; I t (4):367E-88.

85. Takano T, Nakamura K, Watanabc M. Urban residential cnvirou-rncnts and seuior citizens' longevity in megacity areas: the impor-tancc of walkable grcen spaces. J Epidenriol Community Health.2002;56(l 2):913-8.

86. I{ichardson E, Pealce J, Mitchell R, Day R Kingham S. The asso-ciation between green space and cause-specific mortality in urbanNew Zealand; an ecological analysis of grcen space utility, BMCPublic Health. 201 0; 10:240.

87. Wilker EH, Wu CD, McNeely E, Mostofsky E, Spenglet'.I,Wellenius GA, et al. Grren space and mortality f'ollowing ischernic

snoke. Environ Res. 20141 I 33:42-8,8¡3. Lachowycz K, Jones AP. Does walking explain associations be-

tween âccess to gì?enspaoe ancl lower mortali!? Soc Sci Med.2014;107:9-17.

89. Duncan DT, Kuwa<¡hi I, White K, Williuns DR. The geography ofI'ecreâtioual open spÍrc€: iulluence of neighbolhood raciâl compo-sition and neighborhood poverty. J Urban Health.20l3;90(4):618-31.

90. Astell-Burt I Feng X, Mavoa S, Badland HM, Giles-CoÍi B. Dolow-income neighbourhoods havc the lcast grccn space? A cross-

scctional study of Australia's most populous citics. BMC Publicl-Iealth. 20 I 4:I 4 t292.

91. Timpcrio A, Ball K, Salmon J, Roberts R, Crawfonl D. Is availabil-ity of public opon spacc equitable across areas? Health Place.

2007;l3Q):33s40.92. l{oe JJ, Thornpson CW Aspinall PA, Brewcr MJ, DuffEl, Miller D,

et al. Green space and stress: evidence fìom cortisol measu¡es in

deprived utban communities, Int J Environ Res Publ Healtlt,201 3; I 0(9):4086-l 03.

fl springer