Resident participation in neighbourhood audit tools - a scoping review.

Background: Healthy urban environments require careful planning and a testing of environmental quality that goes beyond statutory requirements. Moreover, it requires the inclusion of resident views, perceptions and experiences that help deepen the understanding of local (public health) problems. To facilitate this, neighbourhoods should be mapped in a way that is relevant to them. One way to do this is participative neighbourhood auditing. This paper provides an insight into availability and characteristics of participatory neighbourhood audit instruments. Methods: A scoping review in scientific and grey literature, consisting of the following steps: literature search, identification and selection of relevant audit instruments, data extraction and data charting (including a work meeting to discuss outputs), reporting. Results: In total, 13 participatory instruments were identified. The role of residents in most instruments was as 'data collectors'; only few instruments included residents in other audit activities like problem definition or analysis of data. The instruments identified focus mainly on physical, not social, neighbourhood characteristics. Paper forms containing closed-ended questions or scales were the most often applied registration method. Conclusions: The results show that neighbourhood auditing could be improved by including social aspects in the audit tools. They also show that the role of residents in neighbourhood auditing is limited; however, little is known about how their engagement takes place in practice. Developers of new instruments need to balance not only social and physical aspects, but also resident engagement and scientific robustness. Technologies like mobile applications pose new opportunities for participative approaches in neighbourhood auditing.

Characterisation of the natural environment: quantitative indicators across Europe.

BACKGROUND: The World Health Organization recognises the importance of natural environments for human health. Evidence for natural environment-health associations comes largely from single countries or regions, with varied approaches to measuring natural environment exposure. We present a standardised approach to measuring neighbourhood natural environment exposure in cities in different regions of Europe. METHODS: The Positive Health Effects of the Natural Outdoor environment in TYPical populations of different regions in Europe (PHENOTYPE) study aimed to explore the mechanisms linking natural environment exposure and health in four European cities (Barcelona, Spain; Doetinchem, the Netherlands; Kaunas, Lithuania; and Stoke-on-Trent, UK). Common GIS protocols were used to develop a hierarchy of natural environment measures, from simple measures (e.g., NDVI, Urban Atlas) using Europe-wide data sources, to detailed measures derived from local data that were specific to mechanisms thought to underpin natural environment-health associations (physical activity, social interaction, stress reduction/restoration). Indicators were created around residential addresses for a range of straight line and network buffers (100 m-1 km). RESULTS: For simple indicators derived from Europe-wide data, we observed differences between cities, which varied with different indicators (e.g., Kaunas and Doetinchem had equal highest mean NDVI within 100 m buffer, but mean distance to nearest natural environment in Kaunas was more twice that in Doetinchem). Mean distance to nearest natural environment for all cities suggested that most participants lived close to some kind of natural environments (64 ± 58-363 ± 281 m; mean 180 ± 204 m). The detailed classification highlighted marked between-city differences in terms of prominent types of natural environment. Indicators specific to mechanisms derived from this classification also captured more variation than the simple indicators. Distance to nearest and count indicators showed clear differences between cities, and those specific to the mechanisms showed within-city differences for Barcelona and Doetinchem. CONCLUSIONS: This paper demonstrates the feasibility and challenges of creating comparable GIS-derived natural environment exposure indicators across diverse European cities. Mechanism-specific indicators showed within- and between-city variability that supports their utility for ecological studies, which could inform more specific policy recommendations than the traditional proxies for natural environment access.

Characterizing urban areas with good sound quality: development of a research protocol.

Due to rapid urbanization, the spatial variation between wanted and unwanted sounds will decrease or even disappear. Consequently, the characteristics of (urban) areas where people can temporarily withdraw themselves from urban stressors such as noise may change or become increasingly scarce. Hardly any research has been carried out into the positive health effects of spending time in areas with a good sound quality. One of the problems is that an overview of what aspects determines good sound quality in urban areas and how these are interrelated is lacking. This paper reviews the literature pertaining to the sound quality of urban areas. Aim is to summarize what is known about the influence of social, spatial, and physical aspects other than sounds, on peoples' perception of urban sound qualities. Literature from both conventional sound research and from the so-called soundscape field, published between 2000 and the beginning of 2013 in English or Dutch, was evaluated. Although a general set of validated indicators that can be directly applied, is not available yet, a set of indicators was derived from the literature. These form the basis of a study protocol that will be applied in "Towards a Sustainable acoustic Environment", a project that aims to describe sound qualities at a low-scale level. Key-elements of this study protocol, including a questionnaire and the systematic audit of neighborhoods, were presented in this paper.

The burden of disease related to indoor air in the Netherlands: do different methods lead to different results?

BACKGROUND: Dutch policy makers needed a knowledge base for prioritising control of different indoor air pollutants. Several burden of disease (BoD) estimates were available, but it was not known if they could be applied to The Netherlands. OBJECTIVES: To quantify the BoD related to indoor air in The Netherlands, and to compare the outcomes with a previous study (EnVIE), which used a different BoD methodology. RESULTS: The largest BoD was attributable to environmental tobacco smoke. The next most important indoor air pollutants were radon and thoron from soils and building materials, followed by dampness and carbon monoxide (CO). Formaldehyde exposure did not contribute to the total BoD, according to our estimates. The EnVIE estimate was three times higher, and the most important indoor air pollutants by BoD were combustion products from outdoor sources, bioaerosols due to dampness and by outdoor sources, volatile organic compounds, radon from soils, pathogens and CO. The differences in estimates were primarily caused by the different selection or definition of substances in indoor air, rather than the differing BoD methodology. CONCLUSIONS: Indoor air exposure is associated with a considerable BoD in The Netherlands; approximately 1500 healthy life years per 1 million inhabitants are lost due to 1 year of exposure. The results from the different BoD studies examined here are difficult to compare--even the relative order of most important pollutants depends on choices and assumptions in the assessment. A careful evaluation of BoD estimates is required before they can be used in policy making.

Does traffic-related air pollution explain associations of aircraft and road traffic noise exposure on children's health and cognition? A secondary analysis of the United Kingdom sample from the RANCH project.

The authors examined whether air pollution at school (nitrogen dioxide) is associated with poorer child cognition and health and whether adjustment for air pollution explains or moderates previously observed associations between aircraft and road traffic noise at school and children's cognition in the 2001-2003 Road Traffic and Aircraft Noise Exposure and Children's Cognition and Health (RANCH) project. This secondary analysis of a subsample of the United Kingdom RANCH sample examined 719 children who were 9-10 years of age from 22 schools around London's Heathrow airport for whom air pollution data were available. Data were analyzed using multilevel modeling. Air pollution exposure levels at school were moderate, were not associated with a range of cognitive and health outcomes, and did not account for or moderate associations between noise exposure and cognition. Aircraft noise exposure at school was significantly associated with poorer recognition memory and conceptual recall memory after adjustment for nitrogen dioxide levels. Aircraft noise exposure was also associated with poorer reading comprehension and information recall memory after adjustment for nitrogen dioxide levels. Road traffic noise was not associated with cognition or health before or after adjustment for air pollution. Moderate levels of air pollution do not appear to confound associations of noise on cognition and health, but further studies of higher air pollution levels are needed.

Neurobehavioral effects of exposure to traffic-related air pollution and transportation noise in primary schoolchildren.

BACKGROUND: Children living close to roads are exposed to both traffic noise and traffic-related air pollution. There are indications that both exposures affect cognitive functioning. So far, the effects of both exposures have only been investigated separately. OBJECTIVES: To investigate the relationship between air pollution and transportation noise on the cognitive performance of primary schoolchildren in both the home and school setting. METHODS: Data acquired within RANCH from 553 children (aged 9-11 years) from 24 primary schools were analysed using multilevel modelling with adjustment for a range of socio-economic and life-style factors. RESULTS: Exposure to NO(2) (which is in urban areas an indicator for traffic-related air pollution) at school was statistically significantly associated with a decrease in the memory span length measured during DMST (χ(2)=6.8, df=1, p=0.01). This remained after additional adjustment for transportation noise. Statistically significant associations were observed between road and air traffic noise exposure at school and the number of errors made during the 'arrow' (χ(2)=7.5, df=1, p=0.006) and 'switch' (χ(2)=4.8, df=1, p=0.028) conditions of the SAT. This remained after adjustment for NO(2). No effects of air pollution exposure or transportation noise exposure at home were observed. Combined exposure of air pollution and road traffic noise had a significant effect on the reaction times measured during the SRTT and the 'block' and the 'arrow' conditions of the SAT. CONCLUSIONS: Our results provide some support that prolonged exposure to traffic-related air pollution as well as to noise adversely affects cognitive functioning.

Trends in aircraft noise annoyance: the role of study and sample characteristics.

Recently, it has been suggested that the annoyance of residents at a given aircraft noise exposure level increases over the years. The objective of the present study was to verify the hypothesized trend and to identify its possible causes. To this end, the large database used to establish earlier exposure-response relationships on aircraft noise was updated with original data from several recent surveys, yielding a database with data from 34 separate airports. Multilevel grouped regression was used to determine the annoyance response per airport, after which meta-regression was used to investigate whether study characteristics could explain the heterogeneity in annoyance response between airports. A significant increase over the years was observed in annoyance at a given level of aircraft noise exposure. Furthermore, the type of annoyance scale, the type of contact, and the response percentage were found to be sources of heterogeneity. Of these, only the scale factor could statistically account for the trend, although other findings rule it out as a satisfactory explanation. No evidence was found for increased self-reported noise sensitivity. The results are of importance to the applicability of current exposure-annoyance relationships for aircraft noise and provide a basis for decisions on whether these need to be updated.

Neurobehavioral effects of transportation noise in primary schoolchildren: a cross-sectional study.

BACKGROUND: Due to shortcomings in the design, no source-specific exposure-effect relations are as yet available describing the effects of noise on children's cognitive performance. This paper reports on a study investigating the effects of aircraft and road traffic noise exposure on the cognitive performance of primary schoolchildren in both the home and the school setting. METHODS: Participants were 553 children (age 9-11 years) attending 24 primary schools around Schiphol Amsterdam Airport. Cognitive performance was measured by the Neurobehavioral Evaluation System (NES), and a set of paper-and-pencil tests. Multilevel regression analyses were applied to estimate the association between noise exposure and cognitive performance, accounting for demographic and school related confounders. RESULTS: Effects of school noise exposure were observed in the more difficult parts of the Switching Attention Test (SAT): children attending schools with higher road or aircraft noise levels made significantly more errors. The correlational pattern and factor structure of the data indicate that the coherence between the neurobehavioral tests and paper-and-pencil tests is high. CONCLUSIONS: Based on this study and previous scientific literature it can be concluded that performance on simple tasks is less susceptible to the effects of noise than performance on more complex tasks.

The role of annoyance in the relation between transportation noise and children's health and cognition.

On the basis of this study it cannot be ruled out that the appraisal of the noise affects the association between air and road traffic noise exposure and children's health and cognition. However, the conclusion is limited due to the relatively small group of annoyed children, which may have influenced our group comparisons. Furthermore, the observed relation between annoyance and perceived health is possibly biased due to the fact that both were measured within the same questionnaire. These are the main conclusions of a cross-sectional multi-center study carried out among 2,844 schoolchildren (age 9-11 years) attending 89 primary schools around three European airports. The aim was to investigate how annoyance affects the relation between air and road traffic noise exposure and children's health and cognition. Different, sometimes competing, working mechanisms of how noise affects children's health are suggested. Some effects are supposed to be precipitated through (chronic) stress, while others may arise directly. There is still no theory that can adequately account for the circumstances in which noise will affect cognitive performance.

The effects of road traffic and aircraft noise exposure on children's episodic memory: the RANCH project.

Previous studies have found that chronic exposure to aircraft noise has a negative effect on children's performance on tests of episodic memory. The present study extended the design of earlier studies in three ways: firstly, by examining the effects of two noise sources, aircraft and road traffic, secondly, by examining exposure-effect relationships, and thirdly, by carrying out parallel field studies in three European countries, allowing cross-country comparisons to be made. A total of 2844 children aged between 8 years 10 months and 12 years 10 months (mean age 10 years 6 months) completed classroom-based tests of cued recall, recognition memory and prospective memory. Questionnaires were also completed by the children and their parents in order to provide information about socioeconomic context. Multilevel modeling analysis revealed aircraft noise to be associated with an impairment of recognition memory in a linear exposure-effect relationship. The analysis also found road traffic noise to be associated with improved performance on cued recall in a linear exposure-effect relationship. No significant association was found between exposure to aircraft noise and cued recall or prospective memory. Likewise, no significant association was found between road traffic noise and recognition or prospective memory. Taken together, these findings indicate that exposure to aircraft noise and road traffic noise can impact on certain aspects of children's episodic memory.

Evidence Relating to Environmental Noise Exposure and Annoyance, Sleep Disturbance, Cardio-Vascular and Metabolic Health Outcomes in the Context of IGCB (N): A Scoping Review of New Evidence.

WHO published the Environmental Noise Guidelines for the European Region in 2018, based on seven systematic reviews including studies published between 2000 and 2014. Since then, new studies were published. At the request of the UK Department for Environment, Food and Rural Affairs (DEFRA), a review on annoyance, sleep disturbance, cardiovascular and metabolic effects in relation to environmental noise was prepared. The aim was to advise the Interdepartmental Group on Costs and Benefits Noise Subject Group (IGCB(N)) whether this new evidence warrants an update of their recommendations. Four databases for observational studies were screened and data were extracted on design, type and measurements of exposures and outcomes and confounders and their associations. The quality of the studies was indirectly assessed for cardiovascular and metabolic effects by only including studies with a case control or cohort design. For studies on annoyance and sleep disturbance, the risk of bias was expressed in exposure misclassification, selective participation and confounding. The update yielded 87 papers, pertaining to 108 new studies of which 40 new studies were on annoyance, 42 on sleep disturbance and 26 concerning cardiovascular and metabolic effects. The number, size and quality of the new studies suggest new meta-analyses could be undertaken over the sources and effects included in the WHO reviews.

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

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

Children's annoyance reactions to aircraft and road traffic noise.

Since annoyance reactions of children to environmental noise have rarely been investigated, no source specific exposure-response relations are available. The aim of this paper is to investigate children's reactions to aircraft and road traffic noise and to derive exposure-response relations. To this end, children's annoyance reactions to aircraft and road traffic noise in both the home and the school setting were investigated using the data gathered in a cross-sectional multicenter study, carried out among 2844 children (age 9-11 years) attending 89 primary schools around three European airports. An exposure-response relation was demonstrated between exposure to aircraft noise at school (L(Aeq,7-23 h)) and severe annoyance in children: after adjustment for confounders, the percentage severely annoyed children was predicted to increase from about 5.1% at 50 dB to about 12.1% at 60 dB. The findings were consistent across the three samples. Aircraft noise at home (L(Aeq,7-23 h)) demonstrated a similar relation with severe annoyance. Children attending schools with higher road traffic noise (L(Aeq,7-23 h)) were more annoyed. Although children were less annoyed at levels above 55 dB, the shapes of the exposure-response relations found among children were comparable to those found in their parents.

Annoyance in Response to Vibrations from Railways.

Rail transport is a key stepping stone in the EU's transport policy and is pinpointed for investment and growth over the coming decades. This expanding infrastructure implies increased exposure to environmental stressors, such as noise and ground-borne vibrations. Little is known about the health impacts of exposure to these vibrations. The aim of this paper is to examine the association between annoyance from rail vibrations and the distance of residential dwelling from the railway. It reports the first results of a large epidemiological study, EpiVib, which was designed to investigate the long-term health effects of exposure to rail vibrations. The first part of this study examines a self-reported questionnaire. In total, 6894 individuals aged between 18 and 80 living within 1 km of a railway in west Sweden participated. Results presented here examine the association between distance to the railway and annoyance from vibrations and are stratified by train type. A positive association between closer distance and increased annoyance is seen. After adjustment for important modifiers, results showed that vibrations from freight trains and maintenance operations are reported to be moderately and highly annoying at distances of up to 400 m from the railway and diesel up to 300 m. Vibration from passenger and fast trains are significantly annoying up to 200 m from the track. Vibration from freight trains and maintenance operations were considered highly annoying up to 300 m from the track, diesel up to 400 m. Vibration from passenger and fast trains are not reported to be highly annoying after adjustment. Heavier, slower moving locomotives, in the form of diesel and freight trains, appear to be the source of annoyance at distances further from the railway compared to passenger and fast trains. This has implications in terms of property, transport, and infrastructure planning.

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

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

Neighbourhood green space, social environment and mental health: an examination in four European cities.

OBJECTIVES: This study examines the relationship between neighbourhood green space, the neighbourhood social environment (social cohesion, neighbourhood attachment, social contacts), and mental health in four European cities. METHODS: The PHENOTYPE study was carried out in 2013 in Barcelona (Spain), Stoke-on-Trent (United Kingdom), Doetinchem (The Netherlands), and Kaunas (Lithuania). 3771 adults living in 124 neighbourhoods answered questions on mental health, neighbourhood social environment, and amount and quality of green space. Additionally, audit data on neighbourhood green space were collected. Multilevel regression analyses examined the relation between neighbourhood green space and individual mental health and the influence of neighbourhood social environment. RESULTS: Mental health was only related to green (audit) in Barcelona. The amount and quality of neighbourhood green space (audit and perceived) were related to social cohesion in Doetinchem and Stoke-on-Trent and to neighbourhood attachment in Doetinchem. In all four cities, mental health was associated with social contacts. CONCLUSIONS: Neighbourhood green was related to mental health only in Barcelona. Though neighbourhood green was related to social cohesion and attachment, the neighbourhood social environment seems not the underlying mechanism for this relationship.

Transport choice when travelling to a sports facility: the role of perceived route features - Results from a cross-sectional study in the Netherlands.

BACKGROUND: Physical activity and sedentary behaviour are independently associated with health outcomes, where physical activity (PA) is associated with health benefits and sedentary behaviour is associated with health risks. One possible strategy to counteract sedentary behaviour is to stimulate active transport use. As monitoring studies in the Netherlands have shown that among sedentary people the proportion of adults who engage in sports (hereafter: sports practitioners) is 62.3%, sports practitioners seem a feasible target group for this strategy. Previous studies have generally reported associations between neighbourhood characteristics and active transport use. However, the neighbourhood covers only part of the route to a certain destination. Therefore, we examined the association between perceived route features and transport choice when travelling up to 7.5 kilometres to a sports facility among sports practitioners. METHODS: For 1118 Dutch sports practitioners - who indicated that they practice a sport and travel to a sports facility - age 18 and older, data on transport choice and perceived features of the route to a sports facility were gathered. Participants were classified into one of three transport groups based on their transport choice: car users, cyclists and walkers. Participants were asked whether perceived route features influenced their transport choice. Logistic regression was used to model the odds of cycling versus car use and walking versus car use in the association with perceived route features, adjusted for potential confounders. RESULTS: Perceived traffic safety was associated with lower odds of cycling (OR: 0.36, 95% CI: 0.15-0.86). Perceived route duration was associated with lower odds of both cycling (OR: 0.54, 95%CI: 0.39-0.75) and walking (OR: 0.60, 95%CI: 0.36-1.00). Perceived distance to a sports facility and having to make a detour when using other transport modes than the chosen transport mode were associated with higher odds of both cycling and walking (ORrange: 1.82-5.21). What and who people encountered during their trip (i.e. visual aspects) was associated with higher odds of both cycling and walking (ORrange: 2.40-3.69). CONCLUSIONS: Perceived traffic safety, duration, distance, detour, and visual aspects, when travelling to a sports facility were associated with transport choice. Therefore, the perception of route features should be considered when stimulating active transport use among sports practitioners.

Traffic-related air pollution and noise and children's blood pressure: results from the PIAMA birth cohort study.

AIMS: Elevation of a child's blood pressure may cause possible health risks in later life. There is evidence for adverse effects of exposure to air pollution and noise on blood pressure in adults. Little is known about these associations in children. We investigated the associations of air pollution and noise exposure with blood pressure in 12-year-olds. METHODS: Blood pressure was measured at age 12 years in 1432 participants of the PIAMA birth cohort study. Annual average exposure to traffic-related air pollution [NO2, mass concentrations of particulate matter with diameters of less than 2.5 µm (PM2.5) and less than 10 µm (PM10), and PM2.5 absorbance] at the participants' home and school addresses at the time of blood pressure measurements was estimated by land-use regression models. Air pollution exposure on the days preceding blood pressure measurements was estimated from routine air monitoring data. Long-term noise exposure was assessed by linking addresses to modelled equivalent road traffic noise levels. Associations of exposures with blood pressure were analysed by linear regression. Effects are presented for an interquartile range increase in exposure. RESULTS: Long-term exposure to NO2 and PM2.5 absorbance were associated with increased diastolic blood pressure, in children who lived at the same address since birth [adjusted mean difference (95% confidence interval) [mmHg] 0.83 (0.06 to 1.61) and 0.75 (-0.08 to 1.58), respectively], but not with systolic blood pressure. We found no association of blood pressure with short-term air pollution or noise exposure. CONCLUSIONS: Long-term exposure to traffic-related air pollution may increase diastolic blood pressure in children.

The association between noise exposure and blood pressure and ischemic heart disease: a meta-analysis.

It has been suggested that noise exposure is associated with blood pressure changes and ischemic heart disease risk, but epidemiologic evidence is still limited. Furthermore, most reviews investigating these relations were not carried out in a systematic way, which makes them more prone to bias. We conducted a meta-analysis of 43 epidemiologic studies published between 1970 and 1999 that investigate the relation between noise exposure (both occupational and community) and blood pressure and/or ischemic heart disease (International Classification of Diseases, Ninth Revision, codes 410-414). We studied a wide range of effects, from blood pressure changes to a myocardial infarction. With respect to the association between noise exposure and blood pressure, small blood pressure differences were evident. Our meta-analysis showed a significant association for both occupational noise exposure and air traffic noise exposure and hypertension: We estimated relative risks per 5 dB(A) noise increase of 1.14 (1.01-1.29) and 1.26 (1.14-1.39), respectively. Air traffic noise exposure was positively associated with the consultation of a general practitioner or specialist, the use of cardiovascular medicines, and angina pectoris. In cross-sectional studies, road traffic noise exposure increases the risk of myocardial infarction and total ischemic heart disease. Although we can conclude that noise exposure can contribute to the prevalence of cardiovascular disease, the evidence for a relation between noise exposure and ischemic heart disease is still inconclusive because of the limitations in exposure characterization, adjustment for important confounders, and the occurrence of publication bias.

Positive health effects of the natural outdoor environment in typical populations in different regions in Europe (PHENOTYPE): a study programme protocol.

INTRODUCTION: Growing evidence suggests that close contact with nature brings benefits to human health and well-being, but the proposed mechanisms are still not well understood and the associations with health remain uncertain. The Positive Health Effects of the Natural Outdoor environment in Typical Populations in different regions in Europe (PHENOTYPE) project investigates the interconnections between natural outdoor environments and better human health and well-being. AIMS AND METHODS: The PHENOTYPE project explores the proposed underlying mechanisms at work (stress reduction/restorative function, physical activity, social interaction, exposure to environmental hazards) and examines the associations with health outcomes for different population groups. It implements conventional and new innovative high-tech methods to characterise the natural environment in terms of quality and quantity. Preventive as well as therapeutic effects of contact with the natural environment are being covered. PHENOTYPE further addresses implications for land-use planning and green space management. The main innovative part of the study is the evaluation of possible short-term and long-term associations of green space and health and the possible underlying mechanisms in four different countries (each with quite a different type of green space and a different use), using the same methodology, in one research programme. This type of holistic approach has not been undertaken before. Furthermore there are technological innovations such as the use of remote sensing and smartphones in the assessment of green space. CONCLUSIONS: The project will produce a more robust evidence base on links between exposure to natural outdoor environment and human health and well-being, in addition to a better integration of human health needs into land-use planning and green space management in rural as well as urban areas.