Ambient greenness, access to local green spaces, and subsequent mental health: a 10-year longitudinal dynamic panel study of 2·3 million adults in Wales.

BACKGROUND: Living in greener areas, or close to green and blue spaces (GBS; eg, parks, lakes, or beaches), is associated with better mental health, but longitudinal evidence when GBS exposures precede outcomes is less available. We aimed to analyse the effect of living in or moving to areas with more green space or better access to GBS on subsequent adult mental health over time, while explicitly considering health inequalities. METHODS: A cohort of the people in Wales, UK (≥16 years; n=2 341 591) was constructed from electronic health record data sources from Jan 1, 2008 to Oct 31, 2019, comprising 19 141 896 person-years of follow-up. Household ambient greenness (Enhanced Vegetation Index [EVI]), access to GBS (counts, distance to nearest), and common mental health disorders (CMD, based on a validated algorithm combining current diagnoses or symptoms of anxiety or depression [treated or untreated in the preceding 1-year period], or treatment of historical diagnoses from before the current cohort [up to 8 years previously, to 2000], where diagnosis preceded treatment) were record-linked. Cumulative exposure values were created for each adult, censoring for CMD, migration out of Wales, death, or end of cohort. Exposure and CMD associations were evaluated using multivariate logistic regression, stratified by area-level deprivation. FINDINGS: After adjustment, exposure to greater ambient greenness over time (+0·1 increased EVI on a 0-1 scale) was associated with lower odds of subsequent CMD (adjusted odds ratio 0·80, 95% CI 0·80-0·81), where CMD was based on a combination of current diagnoses or symptoms (treated or untreated in the preceding 1-year period), or treatments. Ten percentile points more access to GBS was associated with lower odds of a later CMD (0·93, 0·93-0·93). Every additional 360 m to the nearest GBS was associated with higher odds of CMD (1·05, 1·04-1·05). We found that positive effects of GBS on mental health appeared to be greater in more deprived quintiles. INTERPRETATION: Ambient exposure is associated with the greatest reduced risk of CMD, particularly for those who live in deprived communities. These findings support authorities responsible for GBS, who are attempting to engage planners and policy makers, to ensure GBS meets residents' needs. FUNDING: National Institute for Health and Care Research Public Health Research programme.

Nature contact and general health: Testing multiple serial mediation pathways with data from adults in 18 countries.

The role of neighbourhood nature in promoting good health is increasingly recognised in policy and practice, but consistent evidence for the underlying mechanisms is lacking. Heterogeneity in exposure methods, outcome measures, and population characteristics, little exploration of recreational use or the role of different types of green or blue space, and multiple separate mediation models in previous studies have limited our ability to synthesise findings and draw clear conclusions. We examined multiple pathways linking different types of neighbourhood nature with general health using a harmonised international sample of adults. Using cross-sectional survey data from 18 countries (n = 15,917), we developed a multigroup path model to test theorised pathways, controlling for sociodemographic variables. We tested the possibility that neighbourhood nature (e.g. greenspace, inland bluespace, and coastal bluespace) would be associated with general health through lower air pollution exposure, greater physical activity attainment, more social contact, and higher subjective well-being. However, our central prediction was that associations between different types of neighbourhood nature and general health would largely be serially mediated by recent visit frequency to corresponding environment types, and, subsequently, physical activity, social contact, and subjective well-being associated with these frequencies. Several subsidiary analyses assessed the robustness of the results to alternative model specifications as well as effect modification by sociodemographics. Consistent with this prediction, there was statistical support for eight of nine potential serial mediation pathways via visit frequency which held for a range of alternative model specifications. Effect modification by financial strain, sex, age, and urbanicity altered some associations but did not necessarily support the idea that nature reduced health inequalities. The results demonstrate that across countries, theorised nature-health linkages operate primarily through recreational contact with natural environments. This provides arguments for greater efforts to support use of local green/blue spaces for health promotion and disease prevention.

Visiting nature is associated with lower socioeconomic inequalities in well-being in Wales.

Natural environments can promote well-being through multiple mechanisms. Many studies have investigated relationships between residential green/blue space (GBS) and well-being, fewer explore relationships with actual use of GBS. We used a nationally representative survey, the National Survey for Wales, anonymously linked with spatial GBS data to investigate associations of well-being with both residential GBS and time in nature (N = 7631). Both residential GBS and time spent in nature were associated with subjective well-being. Higher green-ness was associated with lower well-being, counter to hypotheses (predicting the Warwick and Edinburgh Mental Well-Being Scale (WEMWBS): Enhanced vegetation index ß = - 1.84, 95% confidence interval (CI) - 3.63, - 0.05) but time spent in nature was associated with higher well-being (four hours a week in nature vs. none ß = 3.57, 95% CI 3.02, 4.13). There was no clear association between nearest GBS proximity and well-being. In support of the equigenesis theory, time spent in nature was associated with smaller socioeconomic inequalities in well-being. The difference in WEMWBS (possible range 14-70) between those who did and did not live in material deprivation was 7.7 points for those spending no time in nature, and less at 4.5 points for those spending time in nature up to 1 h per week. Facilitating access and making it easier for people to spend time in nature may be one way to reduce socioeconomic inequalities in well-being.

GroundsWell: Community-engaged and data-informed systems transformation of Urban Green and Blue Space for population health - a new initiative.

Natural environments, such as parks, woodlands and lakes, have positive impacts on health and wellbeing. Urban Green and Blue Spaces (UGBS), and the activities that take place in them, can significantly influence the health outcomes of all communities, and reduce health inequalities. Improving access and quality of UGBS needs understanding of the range of systems (e.g. planning, transport, environment, community) in which UGBS are located. UGBS offers an ideal exemplar for testing systems innovations as it reflects place-based and whole society processes , with potential to reduce non-communicable disease (NCD) risk and associated social inequalities in health. UGBS can impact multiple behavioural and environmental aetiological pathways. However, the systems which desire, design, develop, and deliver UGBS are fragmented and siloed, with ineffective mechanisms for data generation, knowledge exchange and mobilisation. Further, UGBS need to be co-designed with and by those whose health could benefit most from them, so they are appropriate, accessible, valued and used well. This paper describes a major new prevention research programme and partnership, GroundsWell, which aims to transform UGBS-related systems by improving how we plan, design, evaluate and manage UGBS so that it benefits all communities, especially those who are in poorest health. We use a broad definition of health to include physical, mental, social wellbeing and quality of life. Our objectives are to transform systems so that UGBS are planned, developed, implemented, maintained and evaluated with our communities and data systems to enhance health and reduce inequalities. GroundsWell will use interdisciplinary, problem-solving approaches to accelerate and optimise community collaborations among citizens, users, implementers, policymakers and researchers to impact research, policy, practice and active citizenship. GroundsWell will be shaped and developed in three pioneer cities (Belfast, Edinburgh, Liverpool) and their regional contexts, with embedded translational mechanisms to ensure that outputs and impact have UK-wide and international application.

An ecosystem service perspective on urban nature, physical activity, and health.

Nature underpins human well-being in critical ways, especially in health. Nature provides pollination of nutritious crops, purification of drinking water, protection from floods, and climate security, among other well-studied health benefits. A crucial, yet challenging, research frontier is clarifying how nature promotes physical activity for its many mental and physical health benefits, particularly in densely populated cities with scarce and dwindling access to nature. Here we frame this frontier by conceptually developing a spatial decision-support tool that shows where, how, and for whom urban nature promotes physical activity, to inform urban greening efforts and broader health assessments. We synthesize what is known, present a model framework, and detail the model steps and data needs that can yield generalizable spatial models and an effective tool for assessing the urban nature-physical activity relationship. Current knowledge supports an initial model that can distinguish broad trends and enrich urban planning, spatial policy, and public health decisions. New, iterative research and application will reveal the importance of different types of urban nature, the different subpopulations who will benefit from it, and nature's potential contribution to creating more equitable, green, livable cities with active inhabitants.

Neighbourhood greenspace and smoking prevalence: Results from a nationally representative survey in England.

OBJECTIVE: The current study investigated whether people are less likely to be smokers when they live in greener neighbourhoods, and whether such an association is attributable to lower rates of ever-smoking and/or higher rates of smoking cessation. METHOD: Using a representative sample of the adult population of England (N = 8,059), we investigated the relationships between neighbourhood greenspace and three inter-related smoking outcomes (current smoking, ever-smoking and smoking cessation). RESULTS: After controlling for a range of individual and area-level covariates, including socioeconomic status, income and education, living in the highest greenspace quartile was associated with a 20% lower prevalence of current smoking, compared to living in the lowest greenspace quartile (PR = 0.80, CI = 0.67, 0.96, p < .017). Neighbourhood greenspace was not significantly associated with ever-smoking. However, amongst ever-smokers, residing in the two highest quartiles of neighbourhood greenspace quartiles (vs. 1st quartile) was associated with a 10% and 12% higher prevalence of smoking cessation (PR = 1.10, CI = 1.02, 1.18, p = .012; PR = 1.12, CI = 1.02, 1.22, p = .016, respectively). This suggests that the association between greenspace and current smoking is due to a higher likelihood of smoking cessation, rather than lower rates of ever- smoking. The associations between greenspace, current smoking and smoking cessation were similar in magnitude to those of having high (vs. low) household income and were largely unmoderated by socioeconomic measures. IMPLICATIONS: Our findings advocate the need to protect and invest in local greenspaces, to maximise the public health benefits they may afford. Improving access to greenspace may constitute an overlooked public health strategy for reducing smoking prevalence.

Urban nature and physical activity: Investigating associations using self-reported and accelerometer data and the role of household income.

BACKGROUND: Physical inactivity is a major public health concern. Natural, or semi-natural, environments may encourage physical activity, but the influences of socio-economic factors have been under-researched. METHODS: We explored the associations between meeting physical activity (PA) guidelines and both neighbourhood green (area coverage) and blue (freshwater coverage and coastal proximity) environments for urban adults using data from the Health Survey for England [HSE] (2008/2012). We considered different domains of self-reported PA: walking (n = 18,391), sports and other exercise (n = 18,438), non-recreational (domestic/gardening/occupational; n = 18,446) and all three domains combined (n = 18,447); as well as accelerometer-derived PA data using a subsample (n = 1,774). Relationships were stratified by equivalised household income as an indicator of socio-economic status. RESULTS: After adjusting for covariates, living <5 km from the coast was associated with significantly higher odds of meeting UK 2010 guidelines through self-reported total, walking and non-recreational PA (e.g. total PA, <5 km vs. >20 km, adjusted odds ratio (ORadj) = 1.26; 95% confidence interval (CI) = 1.15-1.39) but unrelated to sports and exercise. Greater neighbourhood greenspace, however, was only associated with significantly higher odds of meeting guidelines through non-recreational PA alone (e.g. 80-100% vs. <20% ORadj = 1.32; 95% CI = 1.12-1.56). Although associations were most consistent in the lowest income quintile, income-related results were mixed. Relationships were not replicated in the smaller accelerometry subsample. CONCLUSION: Our self-report findings for the differing domains of PA as a function of neighbourhood green and blue space broadly replicated previous research, yet the reasons for the observed differences between PA domains and environments remain unclear. We did not observe any associations between environmental variables and accelerometer-measured PA; further research with larger samples is needed.

Coastal proximity and mental health among urban adults in England: The moderating effect of household income.

After adjusting for covariates, self-reported general health in England is higher among populations living closer to the coast, and the association is strongest amongst more deprived groups. We explored whether similar findings were present for mental health using cross-sectional data for urban adults in the Health Survey for England (2008-2012, N ≥25,963). For urban adults, living ≤1 km from the coast, in comparison to >50 km, was associated with better mental health as measured by the GHQ12. Stratification by household income revealed this was only amongst the lowest-earning households, and extended to ≤5 km. Our findings support the contention that, for urban adults, coastal settings may help to reduce health inequalities in England.

Public involvement in research about environmental change and health: A case study.

Involving and engaging the public are crucial for effective prioritisation, dissemination and implementation of research about the complex interactions between environments and health. Involvement is also important to funders and policy makers who often see it as vital for building trust and justifying the investment of public money. In public health research, 'the public' can seem an amorphous target for researchers to engage with, and the short-term nature of research projects can be a challenge. Technocratic and pedagogical approaches have frequently met with resistance, so public involvement needs to be seen in the context of a history which includes contested truths, power inequalities and political activism. It is therefore vital for researchers and policy makers, as well as public contributors, to share best practice and to explore the challenges encountered in public involvement and engagement. This article presents a theoretically informed case study of the contributions made by the Health and Environment Public Engagement Group to the work of the National Institute for Health Research (NIHR) Health Protection Research Unit in Environmental Change and Health (HPRU-ECH). We describe how Health and Environment Public Engagement Group has provided researchers in the HPRU-ECH with a vehicle to support access to public views on multiple aspects of the research work across three workshops, discussion of ongoing research issues at meetings and supporting dissemination to local government partners, as well as public representation on the HPRU-ECH Advisory Board. We conclude that institutional support for standing public involvement groups can provide conduits for connecting public with policy makers and academic institutions. This can enable public involvement and engagement, which would be difficult, if not impossible, to achieve in individual short-term and unconnected research projects.

Beyond greenspace: an ecological study of population general health and indicators of natural environment type and quality.

BACKGROUND: Many studies suggest that exposure to natural environments ('greenspace') enhances human health and wellbeing. Benefits potentially arise via several mechanisms including stress reduction, opportunity and motivation for physical activity, and reduced air pollution exposure. However, the evidence is mixed and sometimes inconclusive. One explanation may be that "greenspace" is typically treated as a homogenous environment type. However, recent research has revealed that different types and qualities of natural environments may influence health and wellbeing to different extents. METHODS: This ecological study explores this issue further using data on land cover type, bird species richness, water quality and protected or designated status to create small-area environmental indicators across Great Britain. Associations between these indicators and age/sex standardised prevalence of both good and bad health from the 2011 Census were assessed using linear regression models. Models were adjusted for indicators of socio-economic deprivation and rurality, and also investigated effect modification by these contextual characteristics. RESULTS: Positive associations were observed between good health prevalence and the density of the greenspace types, "broadleaf woodland", "arable and horticulture", "improved grassland", "saltwater" and "coastal", after adjusting for potential confounders. Inverse associations with bad health prevalence were observed for the same greenspace types, with the exception of "saltwater". Land cover diversity and density of protected/designated areas were also associated with good and bad health in the predicted manner. Bird species richness (an indicator of local biodiversity) was only associated with good health prevalence. Surface water quality, an indicator of general local environmental condition, was associated with good and bad health prevalence contrary to the manner expected, with poorer water quality associated with better population health. Effect modification by income deprivation and urban/rural status was observed for several of the indicators. CONCLUSIONS: The findings indicate that the type, quality and context of 'greenspace' should be considered in the assessment of relationships between greenspace and human health and wellbeing. Opportunities exist to further integrate approaches from ecosystem services and public health perspectives to maximise opportunities to inform policies for health and environmental improvement and protection.

Geography of suicide in Taiwan: spatial patterning and socioeconomic correlates.

In industrialised Western nations suicide rates tend to be high in inner city areas and socially fragmented neighbourhoods. Few studies have investigated spatial variations in suicide in non-Western settings. We estimated smoothed standardised mortality ratios (1999-2007) for suicide for each of the 358 Taiwanese districts (median population aged 15+: 27,000) and investigated their associations with area characteristics using Bayesian hierarchical models. The geographic distribution of suicide was similar in men and women; young people showed the greatest spatial variation in rates. Rates were highest in East Taiwan, a mostly mountainous rural area. There was no evidence of above average rates in large cities. Spatial patterns of method-specific suicide rates varied markedly, with solids/liquids poisonings showing the greatest geographic variation and hangings the least. Factors most strongly associated with area suicide rates were median household income, population density and lone-parent households. Spatial patterning of suicide in Taiwan differed from that observed in Western nations. Suicide prevention strategies should take into account unique local patterns.

International impacts of regulatory action to limit antidepressant prescribing on rates of suicide in young people.

PURPOSE: Concerns that selective serotonin reuptake inhibitors (SSRIs) may increase the risk of suicidal behaviour amongst young people led to regulatory action in 2003/4 in many countries. Antidepressant prescribing to young people in various countries declined, but subsequent analyses have demonstrated mixed effects on population suicide rates. METHODS: Annual, national suicide mortality rates from 1990 to 2006 for 10-19 year-olds in World Health Organisation (WHO) Mortality Stratum A countries were studied using the WHO mortality database. Departures from country-specific trends in 2004-2006 relative to overall trends 1990-2006 were calculated to estimate the impact of regulatory actions in 2003/4. RESULTS: There was no consistent change in rate after 2003, with some countries experiencing more and some fewer suicides than expected. Amongst 15-19 year olds the rate ratio was 0.999 (95%CI: 0.971-1.028), and in 10-14 year olds was 0.999 (95%CI: 0.929-1.074). There was some evidence of differential results for males and females. In 15-19 year olds there were 1.8% fewer (95%CI: -5.0 to +1.5%) suicides than expected amongst males and 8.1% more (95%CI: +1.9 to +14.6%) suicides than expected amongst females during 2004-2006. Rate ratios for 10-14 year-olds demonstrated a similar pattern, but with much greater uncertainty. CONCLUSIONS: There was no evidence of an overall effect on suicides of regulatory action to restrict prescribing of SSRIs to young people, although there was weak evidence of an increase in suicide amongst young women internationally.

Environmental equity, air quality, socioeconomic status, and respiratory health: a linkage analysis of routine data from the Health Survey for England.

STUDY OBJECTIVE: To assess relations between socioeconomic status and local air quality, and combined effects on respiratory health, in the context of environmental and health inequality. DESIGN: Data on people taking part in the Health Survey for England were attributed with a small area index of air pollution using annual mean concentrations of nitrogen dioxide, sulphur dioxide, benzene, and particulates (PM10). Regression models were used to measure associations between social class, air quality, forced expiratory volume in one second (FEV1), and self reported asthma. PARTICIPANTS: Participants aged 16-79 in the Health Survey for England 1995, 1996, and 1997. MAIN RESULTS: Urban lower social class households were more likely to be located in areas of poor air quality, but the association in rural areas was, if anything reversed. Low social class and poor air quality were independently associated with decreased lung function (FEV1), but not asthma prevalence, after adjustment for a number of potential confounders. Social class effects were not attenuated by adjustment for air quality. In men, a differential effect of air pollution on FEV1 was found, with its effect in social classes III to V about double that in social classes I and II (p value for interaction = 0.04). This effect modification was not seen for women. CONCLUSIONS: Further evidence of environmental inequity in the UK is provided. The association between FEV1 and local air quality is of similar magnitude to that with social class, and the adverse effects of air pollution seem to be greater in men in lower social classes.