Environmental Research 214 (2022) 114081

Contents lists available at ScienceDirect

Environmental Research
journal homepage: www.elsevier.com/locate/envres

Review article

Exploring the role of exposure to green and blue spaces in preventing

anxiety and depression among young people aged 14–24 years living in
urban settings: A systematic review and conceptual framework
Isabelle Bray a, *, Rebecca Reece a, Danielle Sinnett a, Faith Martin b, Robert Hayward a
a
University of the West of England, Bristol, UK
b
Centre for Intelligent Healthcare, Coventry University, UK

A R T I C L E I N F O A B S T R A C T

Keywords: Despite the growing problem of anxiety and depression amongst young people aged 14–24 years living in urban
Healthy cities settings, reviews about the role of exposure to green and blue spaces or nature in preventing anxiety and
Green infrastructure depression tend to focus on children, adults or sometimes adolescents. This review aims to explore whether
Natural environments
exposure to green and blue spaces reduces the risk of anxiety and depression among young people aged 14–24
Mental health
years living in urban settings and provide a conceptual framework. The academic databases CINAHL plus, Global
Ecosystem services
Health, MEDLINE, ProQuest: Dissertations and Theses, PsycINFO, Scopus and OpenGrey were searched for
research published in English between January 2000 and June 2020. All study designs were eligible. All included
studies were assessed for quality. Searches identified 9208 sources with 48 meeting the inclusion criteria for the
review. Experimental studies provided evidence that walking or being in a green space improves mood and state
anxiety immediately following the intervention. Non-randomised evaluations and observational studies suggest
that social interaction, physical activity, and mindfulness mediate the relationship between exposure to green
space and mental health. We propose that the absence of noise and restorative qualities of green spaces promotes
mindfulness and interrupt rumination, which in turn reduce the risk of anxiety disorders and depression. This
review and the resulting conceptual framework provide evidence to healthcare professionals about the value of
contact with nature and green social prescribing. For policymakers, it provides evidence about the value of
bringing the benefits of forests, vegetation and nature into cities, and ensuring that these spaces are accessible
and safe for young people to use.

1. Background light of the Covid-19 pandemic (Power et al., 2020), along with access to
green space during lockdowns (Slater et al., 2020).
Urbanisation is a risk factor for poorer mental health (Krefis et al., Green space includes dedicated recreational space such as public
2018). The risks of urbanisation may be mitigated through increasing parks, and other types of green space and vegetation, for example, street
access to green space (Franklin et al., 2020). Today, 55% of the world’s trees and green roofs (Hunter et al., 2019). The relationship between
population lives in urban areas, projected to increase to 68% by 2050 green space- and mental health has been demonstrated in several sys­
(UN Department of Economic and Social Affairs, 2018). Given that 16% tematic reviews with adults. These show an association between expo­
of the 7.8 billion world population is aged 15–24 years (Worldometer, sure to greenspace and/or outdoor nature-based interventions, and
2020) and that millennials make up an ever-increasing proportion of reduced symptoms of stress, depression and anxiety, and increased
metropolitan areas (e.g. Lee, 2021), we estimate that there are more wellbeing (Houlden et al., 2018; Corazon et al., 2019). Possible mech­
than 0.7 billion 14–24-year-olds living in urban settings globally. Pro­ anisms include improved air quality, physical activity, active travel,
moting good mental health in young people is vital as 14% of 10-19 connection with nature, cognitive and physiological restoration and
year-olds experience a mental health condition (World Health Organi­ social contact (Hartig et al., 2014; Nieuwenhuijsen et al., 2017). Other
sation, 2021). Young people’s mental health is an increasing concern in recently identified potential mechanisms include exposure to

* Corresponding author.
E-mail address: [email protected] (I. Bray).

https://doi.org/10.1016/j.envres.2022.114081
Received 6 December 2021; Received in revised form 21 February 2022; Accepted 5 August 2022
Available online 13 August 2022
0013-9351/© 2022 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
I. Bray et al. Environmental Research 214 (2022) 114081

environmental microbiota (Järbrink-Sehgal and Andreasson, 2020) and that demonstrate the extent to which prevention of clinical disorder is
biogenic volatile organic compounds (Meneguzzo et al., 2021), and achieved. Rather, they focus on reduction of risk and pre-clinical
reduced light pollution (Ventriglio et al., 2021). Fewer reviews focus on distress.
population subgroups, and none consider differences in relationships The scoping review informed this systematic review. Here we take a
between nature and health by sex, ethnicity, or socioeconomic position novel and empirical approach to examining the evidence about the role
(Hartig et al., 2014). Regarding children and adolescents, previous of exposure to green and blue spaces in preventing depression and
systematic reviews have shown beneficial associations between expo­ anxiety in young people aged 14–24 years living in urban settings, and
sure and access to greenspace, and depression and anxiety symptoms, the pathways involved. We build on the conceptual framework provided
mood, mental well-being, cognitive development, stress and emotional by Hartig et al. (2014) and refined by Nieuwenhuijsen et al. (2017) but
and behavioural difficulties (McCormick, 2017; Tillmann et al., 2018; focus specifically on anxiety and depression in young people. This
Vanaken and Danckaerts, 2018; Zhang et al., 2020). These reviews are framework includes measures of green space (e.g. neighbourhood
limited by not seeking to clarify the extent to which research has vegetation, access to green space), exposure to green space (e.g. fre­
explored if and how green space can reduce the risk of developing quency and duration of use), possible mechanisms to achieving health
clinical levels of anxiety and/or depression. Furthermore, reviews have outcomes (e.g. environmental exposure, physical activity, social con­
not focused on young people aged between 14 and 24 years. This age tacts and cohesion, biogenics, and restoration and stress reduction), and
range is of great interest as most mental health conditions develop health and wellbeing outcomes (Fig. 1). Nieuwenhuijsen et al. (2017)
during these years (Kessler et al., 2003). There is also an increasing summarise the relative strength of evidence across the mechanisms, and
research interest in examining the health and wellbeing benefits of “blue emphasise that studies often measure either mechanisms (e.g. physical
spaces” - which can be defined as ‘all visible surface waters’ (Völker and activity) or the health and wellbeing outcomes.
Kistemann, 2011) including rivers, streams, ponds, lakes and coastal For the purposes of this review, our definition of exposure to green
waters - for reducing anxiety and depression amongst children and space encompasses (i) access to urban green spaces such as parks, or
young people (Reece et al., 2021), but reviews including blue spaces do vegetation (for example, as measured by the normalized difference
not focus on the age range of interest (Gascon et al., 2015). vegetation index (NDVI; Ekkel and de Vries, 2017) and (ii) exposure
The use of psychological theory to understand links between mental through activities or interventions that take place in green or natural
health and green and blue spaces has been limited for children and environments (e.g. walking or adventure training) and (iii) simulations
adolescents (Vanaken and Danckaerts, 2018). Previous literature re­ of green or natural environments (e.g. recorded sounds of nature). We
views focusing on younger people refer to theories developed in relation also include ‘blue space’ (such as lakes), although this field of research is
to adults (Zhang et al., 2020). However, existing theoretical frameworks more recent (Reece et al., 2021).
note that age is likely an important factor in understanding how access Following Wolpert et al. (2019), we use a broad definition of anxiety
to green and blue spaces might influence mental health (Nieu­ and depression, including self-report of stress or low mood. We include
wenhuijsen et al., 2017; Markevych et al., 2017). Although Attention studies that focus on primary prevention, when the aim is to prevent
Restoration Theory has been cited in relation to work with younger anxiety or depression from developing in the first place, as well as
people (Gascon et al., 2015), there is a lack of theoretical underpinning studies of secondary prevention, which aims to reduce the impact of
for the development of interventions in relation to exposure to green and anxiety and depression early once it has developed. Prevention of
blue space and how this operates to impact mental health. It is vital to depression and anxiety can be thought of as reduction in symptoms of
explore what types of green and blue spaces may be linked to mental these “disorders” that disrupt functioning (Kutcher et al., 2015; Law­
health, and to better understand from the literature the mediating rence et al., 2017), or as a reduction in processes associated with anx­
pathways and mechanisms. This will inform the development of con­ iety/depression (such as stress, rumination or lack of positive activity) or
ceptual frameworks in this area that relate specifically to this age group. improvements in mental wellbeing (O’Connell et al., 2009). For
Our earlier scoping review (Reece et al., 2021) described the state of example, in young people, experiences of sub-clinical levels of low mood
the evidence base for exposure to green and blue space to reduce the risk are strongly linked to greater risk of developing major depressive dis­
of anxiety and depression among young people living in urban settings. orders (Davey and McGorry, 2019). We therefore included these broad
It found that the literature included both observational (34%) and terms to identify studies that may improve mental health or reduce
experimental designs (28%). A very wide range of exposures were sub-clinical symptoms of mental “disorder”, as indicating reduction in
evaluated (e.g. urban green space, contact with nature). Importantly, risk of anxiety and depression (Kutcher et al., 2015). As such, in­
few studies had clinical levels of anxiety or depression as the outcome. terventions that reduce low-mood may reduce risk and increase pre­
Instead, broader terms for mental health which can be related to, or vention of depression. Similarly, stress reduction focused interventions
precursors of, anxiety and depression were more common in the liter­ form part of the prevention initiatives for both depression and anxiety
ature. This highlights that the current literature does not focus on studies (Brown et al., 2019).

Fig. 1. Socio-ecological framework for the relationship between greenspace and health and well-being (adapted from Nieuwenhuijsen et al., 2017).

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I. Bray et al. Environmental Research 214 (2022) 114081

The inclusion of secondary as well as primary prevention is appro­ included. We excluded sources published before 2000 and not published
priate, given the high prevalence of anxiety and depression amongst in English. Participants in exclusively rural settings or diagnosed with
young people and the need to explore the mechanisms through which other mental health or developmental conditions (e.g. addiction,
green space can impact on health and wellbeing (Nieuwenhuijsen et al., behavioural problems, autism) and other clinical samples (e.g. children
2017). We did not include tertiary prevention, that is studies of clinical or young people diagnosed with diabetes) were excluded. We excluded
samples that are not representative of the general population. sources focused on athletes or competition-level sport, treatment or
Rather than conducting a traditional systematic review with narrow management of mental health outcomes, and exclusively physiological
inclusion criteria (e.g. focusing on specific mechanisms or mental health outcome measures.
outcomes), we sought to include a wide range of evidence from different The lead author carried out the title screening supported by Men­
disciplines and using any study design, in order to understand causal deley software. Full-text screening was carried out by four authors in
mechanisms and develop a conceptual framework. Mendeley and Excel. Following screening, a list of included sources was
transferred into an Excel spreadsheet for data charting. Data charting
2. Methods was carried out by four authors. We charted the authors of the source,
title, journal, year of publication, source type, country of publication,
2.1. Specifying the research question and search strategy whether the country was developed or developing, study design, pop­
ulation age, general or clinical population, intervention/exposure type,
Our research question was “Does exposure to green and blue space the outcome measure and whether that included anxiety and depression,
reduce the risk of anxiety and depression among young people aged 14–24 or potential mechanisms. These potential mechanisms included stress,
years living in urban settings and, if so, what are the causal mechanisms?” wellbeing, quality of life, mood, and mental health/illness/condition/
We aimed to search for evidence about a wide range of exposures, disorder. A broad range of evidence was required to refine the existing
outcomes and study designs, and to then select studies which would conceptual framework. We therefore assessed eligible studies against
address each aspect of the research question, including mechanisms. four key inclusion criteria. (If we had simply applied stricter inclusion
Key terms for three main concepts were created and used in the criteria with respect to age, study design, exposure or outcome, this
literature search: population, exposure, and outcome. Medical Subject would not have allowed us to explore the mechanisms and modifiers in
Headings (MeSH) were also used where possible. The search terms and the conceptual framework). These criteria (C) were chosen to select
strategy for each database can be found in Supplementary Material. The sources most relevant to our original aims, while retaining breadth of
protocol was not registered due to time constraints. evidence. They related to: the population of interest (C1: all participants
within the 14–24 years age range), study design (C2: an experimental
2.2. Database searches study design, including before-and-after studies, to assess effectiveness),
exposure (C3: access to, or contact with, urban green space) and primary
The following databases were searched; CINAHL plus, Global Health, outcome (C4: assessing anxiety and/or depression). Studies were
MEDLINE, ProQuest: Dissertations and Theses, PsycINFO, Scopus and selected for inclusion if they met at least two of these criteria. For
OpenGrey. All databases were searched in July 2020. The searches in example, the relationship between access or contact with urban green
databases; CINAHL plus, MEDLINE, ProQuest: Dissertations and Theses, space (C3) and mood in a sample of only 14–24-year-olds (C1), or an
PsycINFO, and Scopus, were last updated 6th July 2020. Global Health experimental study (C2) which involved taking participants, of whom
and OpenGrey were searched 7th July 2020. Further relevant studies 50% were aged 14–24 years, to a forest and measuring their anxiety
were added from reference lists of previously published systematic re­ (C4).
views (McCormick, 2017; Tillmann et al., 2018; Vanaken and Danck­
aerts, 2018; Zhang et al., 2020). We followed the Preferred Reporting 2.4. Data extraction and quality assessment
Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines
(Moher et al., 2009). Variables extracted for each included study were authors, year of
publication, location of study (country), sample (age, sex, other char­
2.3. Selecting the evidence acteristics), study design, exposure (or intervention) and how this was
measured, results relevant to our outcomes of interest and any infor­
We included sources from any country, published between 2000 and mation regarding mediating factors or mechanisms.
July 2020, written in English, and of any study design (including sys­ Quantitative sources were assessed for quality, including risk of bias,
tematic reviews, experimental, observational and qualitative). For using the Effective Public Healthcare Panacea Project’s Quality Assess­
studies to be eligible for inclusion, (i) at least half of the participants had ment Tool for Quantitative Studies (Effective public healthcare, 2020).
to be within the target age range (14–24 years) old, or (ii) at least half of EPHPP evaluates selection bias, study design, confounders, blinding,
the participant age-range had to overlap with this age range, or (iii) the data collection method, withdrawals and dropouts as being ‘weak’,
reported mean or median age had to be within this age range. Partici­ ‘strong’ or ‘moderate’. The EPHPP provides a global quality rating for
pants had to be living in urban settings. We included studies that each study of ‘strong’ (no weak ratings), ‘moderate’ (one weak rating),
explored both access to green and blue spaces, including those in rural or ‘weak’ (more than one weak rating). We also derived a summary score
settings accessed by urban populations (e.g. forests), and contact with for the number of criteria scored as ‘Strong’ in each study. The EPHPP is
green space through activities or interventions that take place in these considered suitable to assess the quality of a wide range of quantitative
environments (e.g. running, walking). We also included components of study designs, including interventions (Jackson and Waters, 2005;
being in these environments (e.g. sounds, sights, smells), and built en­ Deeks et al., 2003). The EPHPP has excellent inter-rater reliability for
vironments that could include green components (e.g. street trees). The overall scores (when compared to the Cochrane Collaboration Risk of
outcome measures we included were anxiety and depression, as well as Bias Tool) (Armijo-Olivo et al., 2012). It also has good construct and
those psychological variables which may provide insights into the content validity (Jackson and Waters, 2005). For other study designs,
mechanisms associated with anxiety and depression. These included CASP tools were used (CASP, 2018) to create a similar summary score
mood, life satisfaction, happiness, wellbeing, and quality of life. In order for quality assessment. For example, the CASP qualitative tool produces
to answer our research question and refine the conceptual framework a quality rating for each study from the assessment of nine closed
developed by Nieuwenhuijsen et al. (2017), papers reporting on po­ questions relating to rigour, credibility and relevance, and is widely used
tential additional mechanisms such as connectedness to nature, mind­ for quality assessment in systematic reviews (Dixon-Woods et al., 2007).
fulness, physical activity, social cohesion, and self-esteem, were also Two researchers completed quality assessments and data extractions for

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I. Bray et al. Environmental Research 214 (2022) 114081

each paper, with benchmarking between each pair of assessors. If the The included studies are organised into six groups based on type of
global score differed, this was discussed until agreement was reached. exposure.
Given the broad range of disciplines that we intended to include in our We tabulated the characteristics of each paper, including the expo­
review, we did not use the quality scores to exclude studies, but did sure, outcome measure, results, and information from each paper about
consider these in the synthesis of results and development of the con­ possible mediators or causal pathways, along with a summary quality
ceptual framework. score. Initial synthesis for each group of studies was undertaken by the
primary reviewer in regular discussion with other members of the team.
2.5. Data synthesis and development of conceptual framework The synthesis gave greater weight to higher quality evidence.
This information was used to build on the conceptual framework
Given the wide range of study designs and outcome measures (e.g. from Nieuwenhuijsen et al. (2017), describing potential causal mecha­
difference in means, incidence rate ratio) including qualitative out­ nisms linking exposure to green spaces to anxiety and depression,
comes, a narrative approach to data synthesis was adopted rather than including possible intermediary psychological processes. The pre­
meta-analysis. This included an analysis of variability in terms of setting, liminary conceptual framework (Nieuwenhuijsen et al., 2017) was based
population, exposure/intervention, and outcomes (Popay et al., 2006). on categories for exposure to green spaces on the one hand (e.g.

Fig. 2. Flow diagram of literature search and selection (following PRISMA guidelines).

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I. Bray et al. Environmental Research 214 (2022) 114081

exposure to parks), and the psychological effect (anxiety and depres­ situated near lakes and mountains, as well as outdoor rock climbing.
sion) on the other. While there were few studies that used anxiety dis­ Exposure to blue spaces was also represented with some studies evalu­
orders or clinical depression as outcomes, many studies included ating interventions such as canal walkways and sailing on the ocean.
symptoms or pre-cursors such as mood and state anxiety. The second
stage was therefore to add in these mechanisms to the framework. We 3.1.4. Outcome measures
had also extracted data on other mechanisms reported in the Nieu­ There were a wide range of outcomes measured and several studies
wenhuijsen et al. (2017) framework. These included behaviours (e.g. used more than one. Outcomes ranged from measures of mood/affect
physical activity) and environmental factors (e.g. noise) that had been and stress/anxiety experiences, closely linked to the concepts of clinical
related to green spaces, and which contributed to the causal pathway. A anxiety and depression. Further measures assessed constructs that may
small number of studies included information on perceptions of these support the prevention of anxiety and depression, for example mecha­
spaces (e.g. danger), which modified these associations. The final step nisms of mindfulness, motivation, self-determination and self-efficacy.
was to ensure the framework linked green spaces with these behav­ Measures of more general mental wellbeing outcomes were common,
ioural, environmental and psychological mechanisms and then to the such as life satisfaction and wellbeing.
psychological outcomes of anxiety and depression. Each component of
the framework was reviewed by the inter-disciplinary team, and by a PPI 3.1.5. Study design
panel of seven young people with lived experience of anxiety or The majority of studies (n = 47, 98%) were quantitative. These
depression. Finally, we summarise the available evidence for different included randomised trials (n = 18), and non-randomised intervention
subgroups of the population of interest. studies (n = 18), cohort studies (n = 5) and cross-sectional surveys (n =
6). While some of these studies included qualitative elements, only one
3. Results purely qualitative study was included.

After removal of duplicates, we screened 9208 titles and abstracts. 3.2. Quality assessment
702 sources were eligible for full text screening (Fig. 2). After further
exclusions (76% of which were due to the age range not being relevant), Assessment of publication bias via a funnel plot was not possible due
89 sources remained. The 89 sources were considered against four key to the heterogeneity of studies. Quality scores are reported for each
criteria (C1–C4), relating to the population of interest, study design, paper in Tables 1–6. There was strong initial agreement between the
exposure and outcome, as described in the Methods. Forty-eight sources reviewers for global quality scores for the 47 quantitative studies (90%).
met at least two of these criteria and were included in the review. Overall, areas of strength identified included approaches to dealing with
confounders, use of validated outcome measures and low drop-out. This
3.1. Description of included studies low attrition reflects that very few studies did follow-up post-interven­
tion. Other areas in which quality was not generally highly rated were in
3.1.1. Study location representativeness of the sample (e.g. response rates were not reported),
Of the 48 studies, 46% were located in Asia, including Japan (21% of and blinding. This is important given the self-reported nature of out­
all included studies), China, Taiwan, Indonesia, Turkey and Iran. Just comes. Quality scores were higher on average for those studies which
over one quarter of studies were conducted in Europe (27%), including compared urban streets with urban parks and forests, which were all
the United Kingdom, Germany, Austria, Switzerland, France, the Alps, experimental (mean score 3.1/6), and studies that compare physical
Bulgaria, Czech Republic, Sweden, and Norway. Some studies were activity in a green/blue environment and indoors, or evaluate physical
located in North America (19%), with 7 studies from the United States activity programmes, which were also intervention studies (mean score
and two from Canada. Three studies were based in New Zealand and one 2.8/6). The studies which evaluated outdoor adventure programs, and
study in South Africa. No studies were located in South America. education/training/employment in green environments, had a mean
score of 2.3/6 for the quantitative studies and included one high quality
3.1.2. Sample population qualitative study (scoring 7/9). Of lower quality were the studies which
Over half (58%) of the studies included in this review had a sample assessed particular aspects of being in green/blue environments (mean
population of university students. Of the 48 studies, 8 (17%) had a score 1.4/6). These were particularly weak on selection bias and
sample population of adults which overlapped with the target age range reporting blinding. Also, the observational studies of residential expo­
(14–24 years). Some of the studies focused on students in high school sure to vegetation, which tended to be cross-sectional (mean score 2.2/
education (15%), and two studies included youth participants (4%). 6), and the studies about young people’s perceptions of green spaces
Lastly, some studies had a mixed sample of university students and staff (mean score 2.0/6) had lower quality scores.
(4%) and university students and graduates (2%).
3.3. Evidence synthesis
3.1.3. Environment exposures
A wide range of environments were represented in the included 3.3.1. Studies that compare urban streets, urban parks and forests
studies. The largest proportion reported exposure to greenspaces Thirteen of the studies described experimental designs that
through being in forests, including bamboo forests (21%). Other types of compared (walking or being in) urban settings with neighbourhood
green space exposure included parks, sports fields, botanical gardens, green space or forests (Table 1; scales used to measure outcomes are
horse trekking through fields and forests, outdoor employment in listed in Supplementary Material). Over the last 10 years a body of
greenspaces, and generally being outdoors in a green space. Only three research has developed comparing exposure to forests and urban envi­
studies reported NDVI as a measure of exposure to green space. Some of ronments (Lee et al., 2011, 2014; Mao et al., 2012; Tsunetsugu et al.,
the experimental conditions involved participants being near an indoor 2013; Song et al., 2018, 2019; Lyu et al., 2019; Zeng et al., 2020; Hassan
plant or touching natural materials (such as wood). Several of the et al., 2018). This has been complimented in more recent years by
studies used simulated exposure to nature. These studies involved par­ studies on urban parks (Franek, 2013; Wallner et al., 2018; Song et al.,
ticipants listening to recorded soundscapes of natural sounds, or images 2014, 2015). The majority of interventions were for 15 min (Tsunetsugu
of nature such as scenes of forests, mountains, water, wilderness, gar­ et al., 2013; Song et al., 2014, 2015, 2018, 2019) but ranged up to three
dens, and agricultural landscapes. Two studies included used videos of days (Lee et al., 2011; Lyu et al., 2019. These experimental studies
outdoor environments and green spaces as simulated exposure to nature. measured outcomes immediately after the intervention. They provide
Other studies included evaluations of outdoor adventure programs evidence that a brief exposure to a green environment elicits a

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I. Bray et al. Environmental Research 214 (2022) 114081

Table 1
Main characteristics and results of studies that compare urban streets, urban parks and forests.
Author Location Sample Type of study Exposure Outcome Results Mediators/modifiers/ QAb
measuresa mechanisms

Franek, Czech 4 studies using Repeated measures Walking routes with Walking speed Significant effects of Study 4 investigated 2
2013 Republic psychology experimental and without measured in all type of section on potential causal pathways
undergraduat es. designs and one greenery. studies. Study 4 perceived emotional for Studies 13, with
Age range across study is an measured reactions on the environmental factors
studies = observational emotional environment: affecting participants
19.6–20.7 yrs. survey. reactions using pleasure p < 0.001, desire to leave.
model by arousal p < 0.001,
Mehrabian and dominance p < 0.001.
Russell. Significant effects of
type of section on
perceived fascination
p < 0.001, being away
p < 0.001,
compatibility p <
0.001, coherence p <
0.001.
Hassan et al. China 60 university Randomised 15 min walk Semantic Significantly higher Blood pressure was 3
(2018) students (50% crossover trial. predetermined differential scores were observed significantly reduced –
male). Mean age courses in a bamboo method (SDM), for the adjectives relaxing effect.
= 19.6 yrs. forest and a city State-Trait “comfortable,”
area (control). Anxiety “relaxed,” and
Inventory (STAI). “natural” (p < 0.01)
after walking in the
bamboo forest than
after walking in the
city area. Total state
anxiety scores were
significantly reduced
after bamboo forest
walking compared
with the city area
walking (bamboo
forest: 35.0 ± 7.39
and city area: 41.9 ±
9.78; p < 0.01).
Lee et al. Japan 12 healthy Randomised 3-day intervention Profile of Mood Significant Forests have a positive 3
(2011) students. Male crossover trial. involving viewing a States (POMS). differences were effect on autonomic
only. Mean age broad-leaved forest found between the nervous system and
= 21.2 yrs. or an urban forest and urban sites reduces salivary cortisol.
environment for 15- for the tension- Sympathetic nervous
mins each day. anxiety subscale system suppressed in the
(forest: 42.4 ± 1.5; forest.
urban: 61.8 ± 3.4; p
< 0.01).
Lee et al. Japan 48 Japanese Randomised Self-paced walking STAI, POMS - STAI levels were Forest walking 3
(2014) participants. controlled trial in 4 in forest or urban Shortened largely decreased significantly increased
Male only. Mean different environment for Version, 13-scale after forest walking parasympathetic nervous
age = 21.1 yrs. prefectures with 12 ~12–15 min. questionnaire (33.2 ± 6.9) activity and decreased
participants in using SDM, compared with after sympathetic nervous
each. 2 groups of 6 measure of urban walking (45.2 activity compared with
completed feeling ± 8.9; p < 0.01). urban walking. Forest-
intervention and ‘refreshed’. After forest walking, oriented stimulations
control. significantly facilitate the relaxation of
decreased values were central and autonomic
found in POMS nervous activities to
subscale of tension- suppress the secretion of
anxiety (T-A, 35.6 ± stress hormones.
4.0 at the forest site
and 41.6 ± 7.6 at the
urban site; p < 0.01).
Significantly higher
scores were observed
for the “refreshed”
feeling after forest
walking (65.5 ± 10.7)
compared with those
for urban walking
(50.4 ± 13.2; p <
0.01).
Lyu et al. China 60 healthy Randomised Bamboo forest POMS. Scores of negative Systolic blood pressure 4
(2019) university controlled trial. therapy program in moods for tension- was significantly lower
students. Male Participants either a bamboo forest or anxiety, depression- after a three-day bamboo
only. exposed to a exposure to an dejection, fatigue, forest therapy session. The
(continued on next page)

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I. Bray et al. Environmental Research 214 (2022) 114081

Table 1 (continued )
Author Location Sample Type of study Exposure Outcome Results Mediators/modifiers/ QAb
measuresa mechanisms

Mean age = 21.8 bamboo forest (3 urban environment confusion and anger- SpO2 (peripheral oxygen
yrs groups of 15 over the course of 3- hostility significantly saturation) of participants
(experimental participants at days. decreased after the was higher after the
group), 21.6 yrs different forest bamboo forest bamboo forest program
(control). settings) or an program (p < 0.05). than before the program.
urban environment No difference was
(1 group of 15 found in the scores of
participants) any of these negative
moods after the urban
program.
Mao et al. China 20 healthy Randomised 2 walking trails for POMS. For the forest bathing Serum cortisol 3
(2012) university controlled trial. 1.5 h (with 10 min condition, the scores concentration was
students. Male Participants break) through a in the negative significantly lower in
only. Mean age divided into 2 forest or an urban subscales, such as subjects exposed to a
= 20.79 yrs. groups of 10. site. tension, depression, forest environment than in
anger, fatigue, and those exposed to an urban
confusion, were environment. These
lowered (p < 0.05); findings indicate that
however, the positive subjects staying in a forest
score for vigour was environment showed a
increased. reduced stress response.
Song et al. Japan 17 Japanese Within subject’s 15 min STAI, POMS. Total STAI score was The physiological 2
(2014) students. Male design. predetermined 14.3% lower after the measures suggested a
only. Mean age Participants walking course in urban park walk beneficial effect of
= 21.2 yrs. completed the an urban park compared with that walking in an urban park,
walking course in compared with after the city area similar to that expected
an urban park and nearby city area. walk (urban park: from a forest setting/
city environment. 41.6. ± 7.0 (mean ± yoga/massage, which may
standard deviation), explain the psychological
city area: 48.6 ± 6.3; outcomes.
p < 0.05).
Scores for the
negative subscales of
POMS tension-anxiety
and fatigue were
significantly lower
after walking in the
urban park than after
walking in the city
area (p < 0.05).
There were no
significant differences
in the scores for
depression, anger-
hostility, and
confusion.
Song et al. Japan 23 university Controlled clinical 15 min walking SDM, STAI, Significantly higher No significant differences 3
(2015) students. Males trial. Participants through an urban POMS. SDM scores were in walking speed. The
only. Mean age took part in both park and 15 min observed following intervention induced
= 22.3 yrs. conditions. walking through the urban park walk physiological relaxation.
the city. than those following Compared with those after
the city area walk for a brief walk in the city
the following three area, parasympathetic
adjectives: nervous activity was
“comfortable”, significantly enhanced,
“natural”, and sympathetic nervous
“relaxed” (p < 0.01). activity was significantly
The total STAI score suppressed, and heart rate
was 19.3% lower after was significantly lower
the urban park walk during a brief walk in the
than after the city urban park.
area walk (urban
park: 39.0 ± 6.3; city
area: 48.4 ± 7.5; p <
0.01). Differences
were also detected in
the POMS scores for
the negative subscales
of tension–anxiety,
anger–hostility,
fatigue, and confusion
being significantly
lower after walking in
the urban park than
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7
I. Bray et al. Environmental Research 214 (2022) 114081

Table 1 (continued )
Author Location Sample Type of study Exposure Outcome Results Mediators/modifiers/ QAb
measuresa mechanisms

after walking in the

city area (p < 0.05).
Song et al. Japan 585 Japanese Randomised cross- 15 min forest walk STAI, POMS - Scores for tension- Participants with high- 4
(2018) participants. over trial on 2 or city walk. shortened anxiety subscale on trait anxiety levels had a
Males only. Mean consecutive days. version. POMS were more effective reduction
age = 21.7 yrs. Control was a walk significantly lower in the feeling of
in an urban after walking through depression–dejection after
environment. forest areas compared walking through forest
to city areas (forest, areas compared with those
36.1 ± 5.4; city, 41.3 with normal and low-trait
± 7.7; p < 0.01). anxiety levels
(participants with high-
trait anxiety, N = 325;
participants with normal
and low-trait anxiety, N =
260; p < 0.05).
Song et al. Japan 60 Japanese Randomised 15 min walk in a STAI, POMS. The state anxiety Walking in a forest was 4
(2019) students. controlled trial forest area and city score of the STAI was associated with
Females only. with 12 area. 34.8 ± 7.2 after significantly higher
Mean age = 21 participants at each walking in a forest parasympathetic nervous
yrs. site (6 sites total). area, significantly activity and lower
Cross-over trial on lower than 45.3 ± 7.1 sympathetic nervous
2 consecutive days. after walking in a city activity and heart rate.
area (p < 0.01).
Participants felt
significantly more
“comfortable,”
“relaxed,” and
“natural” when
walking in forests
than when walking in
city areas (all p <
0.01). Significant
differences between
the forest and city
areas were observed
for all the POMS
subscales rated after
walking and for the
total mood
disturbance score.
The subscale scores
for the tension-
anxiety subscale in
forest and city areas
were 1.1 ± 1.8 vs. 2.9
± 2.8.
Tsunetsugu Japan 48 Japanese Randomised cross- Viewing 4 forest POMS, 13-scale For the POMS scores, Physiological outcomes 3
et al. participants. over trial over 2 sites from a seated questionnaire viewing the scenery in agreed with psychological
(2013) Males only. Mean days. spot for 15 min using SDM the urban areas outcomes. Suggests forest
age = 21.1 yrs. compared with techniques, increased tension- areas have positive effects
urban site. Measure of anxiety (p = 0.00). in terms of relaxation. Just
feeling The landscapes of the viewing forest landscape,
‘refreshed’. forests were evaluated not necessarily walking,
as being significantly has positive effect on
more “comfortable” mood and anxiety.
(p = 0.00, r = 0.51),
“soothing” (p = 0.00,
r = 0.53), and
“natural” (p = 0.00, r
= 0.59). Viewing the
scenery in the forests
induced significantly
higher refreshment (p
= 0.00, r = 0.55).
Wallner Austria 60 healthy pupils Repeated measures Exposure to 3 Wellbeing Significant Findings may support 3
et al. from 3 schools in controlled trial. different settings at measured using differences between 3 stress reduction and
(2018) Vienna. Mean lunchtime with 7 The Nitsch Scale, green space types for attention restoration
age = 16.6 yrs. days in between cognitive dimensions theories.
30 males, 30 each. Settings performance test. recuperation,
females. included an inner tension/relaxation,
urban small park, a state of mood,
larger park with readiness for action,
some trees, and a and readiness for
large forest. exertion.
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8
I. Bray et al. Environmental Research 214 (2022) 114081

Table 1 (continued )
Author Location Sample Type of study Exposure Outcome Results Mediators/modifiers/ QAb
measuresa mechanisms

For forest,
significantly less
decrease of wellbeing
after return to
classroom compared
to small or large
urban park (readiness
for action: p < 0.001;
readiness for exertion:
p = 0.027; state of
mood: p < 0.001;
tension/relaxation: p
< 0.001).
Concentration
performance (d2-R
test) significantly
higher after green
space exposure for all
sites (p < 0.001).
Increase post small
urban park 7.5 (SD
9.7), post large urban
park 15.5 (SD 11.7),
post forest was 5.3
(SD 11.0). Highest
performance increase
found for large park;
this increase was
significantly higher
(p = 0.008) than the
increase after stays in
the other green
spaces.
Zeng et al. China 120 university Randomised Viewing (15 min in SDM. Following the three- Physiological indices 3
(2020) students aged controlled trial. morning) and day bamboo forest supported the SDM
19–24 yrs. 60 Participants walking (15 min in therapy, participants questionnaire results.
males, 60 divided into 4 afternoon) in a showed a significant
females. (15 groups and bamboo forest or difference in their
males and 15 exposed to 1 of 4 urban environment. environmental
females in each environments. evaluation (SDM)
group). relative to those at the
urban city site. In
terms of sensory
perception,
atmosphere, climate,
place, and space, the
subjects reported a
better environmental
experience in the
bamboo forests.
a
References for measures are given in Supplementary Material
b
Quality assessment score out of 6; POMS: Profile of Mood States; POMS: Profile of Mood States – Shortened Version; SDM: semantic differential method; STAI:
State-Trait Anxiety Inventory.

short-term increase in mood and reduction in state anxiety. One study (Akers et al., 2012), listening to natural sounds was shown to be more
reported longer-lasting effects following exposure to a forest than a park restorative than anthropogenic sounds (Benfield et al., 2014), and
(Wallner et al., 2018) and estimated reductions in state anxiety are touching wood induced feelings of comfort (compared with marble; Ikei
greater following visits to forests (Lee et al., 2011; Song et al., 2019) et al., 2018). The interventions were typically brief (e.g. 5 min) and
than parks (Song et al., 2014, 2015). outcomes were measured immediately after the intervention.

3.3.2. Studies that assess particular aspects of being in green/blue 3.3.3. Studies that compare physical activity in a green/blue environment
environments and indoors, or evaluate physical activity programmes
A further eight intervention studies (two of which were randomised) Three experimental studies compared exercise in a green or blue
assessed particular aspects of being in green or blue environments and environment with doing the same exercise indoors (Table 3). The first
reported some positive changes in various outcome measures (see intervention was a walking route (approximately 17 min) along a canal
Table 2). The aspects considered were the colour green (Akers et al., (Nistbet and Zelensji, 2011). Compared to an indoor walking route, this
2012), natural soundscapes (Benfield et al., 2014; Tedja and Tsaih, led to increased connectedness with nature, mediated by positive affect.
2015), natural scenery (Chang et al., 2008; Chan KLE, 2015), touching It also showed that participants tended to underestimate the positive
natural materials (Ikei et al., 2018), indoor exposure to plants (Buttel­ hedonic effects of the outdoor walk. The second involved cycling on a
mann and Römpke, 2014 and to animals (Hassan et al., 2017), Levels of static bike on the edge of a green field for 15 min and found greater
anger were lower when viewing green (compared with red) scenery increases in vigour, but not self-esteem, when exercising in the green

9
I. Bray et al. Environmental Research 214 (2022) 114081

Table 2
Main characteristics and results of studies that assess particular aspects of being in green/blue environments.
Author Location Sample Type of study Exposure Outcome measuresa Results Mediators/ QAb
modifiers/
mechanisms

Akers et al. UK 14 healthy Randomised 5 min simulated Profile for Mood No differences 3
(2012) participants. Males controlled cycling whilst States (POMS). reported for anxiety or
only. Mean age trial. Within viewing outdoor depression subscales
20.7 yrs. subjects. environment video in of POMS.
various colours. Anger was higher
during red colour
video compared to
green (38.6 ± 1.3 vs
37.0 ± 0.0, t13 = 4.6,
p = 0.0005, η2 =
0.619, d = 1.741) and
compared to grey
(38.6 ± 1.3 vs 37.1 ±
0.5, t13 = 4.0, p =
0.001, η2 = 0.552, d
= 1.523).
Benfield USA 133 university Randomised Watching a stress Brief Mood Significant BMIS 2
et al., participants. 72 controlled inducing video Introspection Scale change by sound
2014 females, 61 males. trial. followed by listening (BMIS). condition was shown
Mean age = 19.09 Participants to a soundscape for Pleasant-
yrs. assigned to 1 (either natural Unpleasant sub-scale
of 4 sounds, natural (F = 7.62, p < 0.001,
conditions. sounds with voices, partial η2 = .150) and
natural sounds with Positive-Tired
motorized noise, or subscale (F = 6.36, p
no sound as a < 0.001, partial η2 =
control). .126); a marginal
interaction between
sound condition and
affective restoration
was also shown for the
Negative-Relaxed
subscale (F = 2.18, p
= 0.094, partial η2 =
.048). The natural
sound condition
showed greater
recovery from the
upsetting video
compared to both the
control and
anthropogenic sound
conditions. For the
Pleasant-Unpleasant
score, participants in
the natural condition
were the only ones to
show improved affect
from post video (M =
38.89, SD = 8.22) to
post-recovery (M =
44.31, SD = 6.95).
Buttelmann Germany 71 undergraduate Controlled Sitting in a room with State-Trait Anxiety A reduction effect was 1
and students. 65 trial. either a dog, fish, Inventory (STAI) – found in all three
Römpke females. Mean age Participants plant or nothing German adaptation, experimental
(2014) = 22 yrs, range = allocated to 1 (control) for 5 min. Pet Attitude Scale conditions: in the fish
18.8–29.8 yrs. of 4 (PAS), Audience group, induced
conditions. Anxiousness Scale anxiety was reduced
(AAS). on average by 58.2%;
in the dog group by
56.2%; and in the
plant group by 45.6%.
There were significant
differences in the
decrease in induced
anxiety between
groups (one-way
ANOVA, F (3,67) =
8.232, p ≤ 0.001, npb
= 0.271).
Engaging in contact
with a dog, a fish, or a
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10
I. Bray et al. Environmental Research 214 (2022) 114081

Table 2 (continued )
Author Location Sample Type of study Exposure Outcome measuresa Results Mediators/ QAb
modifiers/
mechanisms

plant for an
intervention time of
no longer than 5 min
can result in anxiety
alleviation in a non-
clinical setting.
Chan KLE, China ‘Mostly young Within Viewing nature Relaxation level as The majority reported 0
2015 students’ (study 1) subject’s videos on a PC screen. measured on a 5-point a positive relaxing
and ‘mostly healthy design. Videos of water, self-report scale. effect after viewing
students and staff’ forest, mountains, the films; 89% scored
(study 2). Study 3 sunrise, sunset. the relaxation effect of
(patients and Experiencing watching the natural
relatives) are coloured lights in a films as fairly strong/
excluded. tent. strong. Most common
descriptors were
‘relaxing’ (33%),
followed by
‘comforting’ (15%).
The most relaxing
colours were green
(15/65 = 23%),
purple (20%), blue
(17%).
The least relaxing
colours were red (31/
62 = 50%), blue
(18%), green (7%).
Chang et al., Taiwan 110 participants – Within Viewing 12 images on Perceived Viewing natural 2
2008 students and subjects. a screen, 10 s each. E. Restorativeness Scale environments with
faculty members g. mountain, (PRS). features of 4
from a university. wilderness, gardens, restorative
sunset, view from components improved
window, water. psychological
responses. The images
ranked first on the PRS
Fascination
component and
second on
Compatibility. The
images proposed as
examples of the four
restorative
components were
generally rated as
hypothetically
selected, although not
cleanly enough to be
treated as
representing those
components.
Hassan et al., China 40 healthy Controlled Viewing a bamboo STAI. Participants’ mean Viewing a plant 1
2017 agricultural trial. plant in a room vs anxiety score indoors can lower
university students. viewing an empty pot decreased after blood pressure which
20 males. Mean (control). viewing the bamboo in turn help to can
age = 19.6 yrs. plant compared with reduce anxiety - links
control (p < 0.01). to the autonomic
STAI score females, nervous system.
bamboo view: 32.7 ±
6.7; control view: 37.9
± 7.4.
STAI score males,
bamboo view: 34.0 ±
6.7; control view: 39.2
± 7.1.
Ikei et al., Japan 19 healthy female Within Touching wood Semantic differential Participants feeling Increases in 2
2018 university students. subjects. (experimental) or method (SDM). “slightly comfortable” parasympathetic
Mean age = 21.2 marble (control) slabs after touching Hinoki activity shown.
yrs. with soles of feet. and “indifferent to Physiological
slightly relaxation effects
uncomfortable” after shown when
touching marble. touching the wood.
Touching Hinoki
induced significantly
more comfort than
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11
I. Bray et al. Environmental Research 214 (2022) 114081

Table 2 (continued )
Author Location Sample Type of study Exposure Outcome measuresa Results Mediators/ QAb
modifiers/
mechanisms

touching marble (p <

0.01).
Tedja and Taiwan 66 architecture Within Listening to 15 s Participants rated 92% of the Gentle stream and 0
Tsaih, university students. subjects. soundscape videos. perception/emotion. participants had a fountain noises can
2015 Mean age = 20.25 Sounds were of Scales divided into positive impression of be used for
yrs. Age range indoor and outdoor attractiveness and a soft, quiet, and mid restoration and
18–33. water sounds. serenity. One of the frequency sound relaxation.
sub-scales for serenity (gentle stream) due to
was ‘anxious- the listening
peaceful’ – impression of
participants had to relaxation and
rate on a 7-point comfort.
bipolar scale. (e.g. − 3 77% of the
= anxious, 3 = participants had a
peaceful, 0 = middle negative impression of
point). a loud, intense, and
broadband sound
(rain on glass roof),
due to the listening
impression of
noisiness and
agitation.
62% of the
participants preferred
the sound of rain on
water due to the
listening impression of
quiet over rain on
different materials
such as woods, metal,
glass, tent, and
pavement.
a
References for measures are given in Supplementary Material.
b
Quality assessment score out of 6. AAS: Audience Anxiousness Scale; BMIS: Brief Mood Introspection Scale; PAS: Pet Attitude Scale; POMS: Profile of Mood States;
PRS: Perceived Restorativeness Scale; SDM: semantic differential method; STAI: State-Trait Anxiety Inventory – German Adaptation.

environment (Flowers et al., 2018). The third paper compared 2018), there were some longer-term effects on general mood (Opper
horse-trekking for 30 min in a green environment with riding on an et al., 2014) and depression symptoms (Kanters et al., 2002). A
indoor simulator. This involved contact with the animal as part of the park-based prospective cohort study compared a violence prevention
intervention. and the authors reported improvements in feelings of and mental health promotion after-school program with other
anxiety and depression (Matsuura et al., 2011). Two further randomised after-school clubs, using youth crime rates as a proxy for violent
trials assessed reported improvements in mood and sleep (Kalak et al., behaviour (D’Agostino et al., 2020). They reported lower adjusted youth
2012; Walter et al., 2013) following outdoor running programmes. One arrest rates three years post-intervention for the park-based programme.
involved running twice a week for ten weeks for 30–60 min, the other A comparison of mindfulness training in a botanical garden greenhouse
five times a week for three weeks for 30–37 min. A before-and-after with conventional (indoor) mindfulness training concluded that the
study reported reductions in social anxiety following a two-month green environment particularly helped beginner meditators to overcome
climbing programme (three times a week; Ozen, 2015). Finally, one problems with concentration and stress (Lymeus, 2019). Two studies
study compared the effects of doing 15 min outdoor exercise on mood in also evaluated employment interventions in green or natural environ­
an induced goal-oriented state compared with baseline state. The results ments (Falxa-Raymond et al., 2013; Wolf and Housley, 2017). The first is
showed that improvements in mood occurred only in the baseline group a qualitative study of a group of young people who completed a training
(Legrand and Thatcher, 2011). programme and then undertook 2–3 months’ work experience in an
entry-level “green job” (Falxa-Raymond et al., 2013). More than half of
3.3.4. Studies that evaluate outdoor adventure programs, and education/ them described a positive change in their attitude towards themselves
training/employment in green/blue environments during this time. 94% of them cited gaining new knowledge and skills as
A further set of studies (Table 4) employ a range of study designs to a positive aspect. The second was a before-and-after study of a one-year
evaluate the mental health benefits of outdoor adventure opportunities. conservation program. Quantitative findings suggested improvements in
They indicate that wilderness excursions of 9–10 days lead to increased anxiety and social functioning. Qualitative themes included new skills
mindfulness and reduced stress (Mutz and Müller, 2016) and engender and training, developing friendships, co-operation and the benefits of
greater self-esteem through group belonging (Scarf et al., 2018). Studies being outdoors in terms of health and happiness (Wolf and Housley,
evaluating longer (3–15 weeks) outdoor education programs also found 2017).
measurable improvements in stress (Opper et al., 2014), self-esteem In contrast to the studies of tightly controlled interventions delivered
(McAnally et al., 2018) and social anxiety (Kardjono, 2017). Much to homogeneous samples (Tables 1–3), these studies include more
shorter interventions also resulted in positive changes in the autonomy, complex interventions, with multiple components potentially contrib­
competence, relatedness and enjoyment subscales of the Intrinsic uting towards outcomes. There is a common thread, of exposure to a
Motivation Inventory (Mackenzie et al., 2018) and a reduction in anxi­ green space or natural environment, but each intervention includes
ety (Kanters et al., 2002). Some of these evaluations included follow-up. additional elements, comprising either education or training (50%) or
Although benefits are not consistently sustained (Mackenzie et al., outdoor adventure (50%). Some also involve reflection on these

12
 I. Bray et al.
Table 3
Main characteristics of studies evaluating physical activity programmes activity in a green/blue environment.
Author Location Sample Type of study Exposure Outcome measuresa Results Mediators/modifiers/mechanisms QAb

Flowers UK 60 undergraduate students. Randomised Indoor vs Green: Indoor - Profile for Mood States There was a marginally significant 2
et al. Mean age = 19.9 yrs. controlled trial. stationary cycling 15 min in lab (POMS) – Shortened interaction effect of treatment x
(2018) Mixed methods. with view facing blank screen Version, Rosenberg’s time on vigour (p = 0.043); the
and grey wall; Green - stationary SelfEsteem Scale. green-control group experienced a
cycling on the edge of a large greater improvement in vigour (M
sports field consisting of flat = 2.00, 95% CI 1.06–2.94) than
grass-covered area interspersed the indoor control group (M =
with trees and hedge perimeter. 0.60, 95% CI -0.461.66). The
interaction of time x treatment had
no significant effect on self-esteem.
Kalak et al. Switzerland 51 healthy high school Randomised Vigorous physical exercise Perceived Stress Scale Mood in the morning significantly 4
(2012) pupils. Mean age 18.3; controlled trial. (planned and continuous cross (PSS), coping with stress improved over time and was
female 53%. Experimental group country running, beginning on questionnaire, Curiosity significantly higher in the running
(morning running) running track then into forest, and Exploration group (RG) than the control group
and control group for 30–37 min without Inventory. (CG); the group × time interaction
(morning no interruption at a speed such that was also significant; mood in the
exercise). conversation is not possible) at morning increased significantly
7am every school day morning over time in the RG compared with
for 3 weeks (total 15 sessions). the CG. Perceived stress, positive
Control group mustered at same and negative coping strategies,
place and time but did not run. and curiosity and exploratory
behaviour did not differ
significantly between groups or
over time.
Significant findings for
13

somatosensory amplification (p <

0.01) and insomnia severity (p <
0.001) only.
Legrand France 55 first year university Students randomly Walking outside on a track by Mood measured with the Following exercise, paratelic group 2
and students from a sport and allocated to the university campus for 15 Tension Effort Stress had higher scores of pleasant mood
Thatcher physical education conditions. min. In telic condition, Inventory (TESI), meta- states (p < 0.01). Post hoc analyses
(2011) department in north eastern individual feedback was given motivational state within each group - walking
France. Mean age = 21.1 yrs. after the first lap of the track measured using the Telic resulted in significant increase in
62% male. (600 m) on pace and it needing State Measure (TSM). pleasant mood states for the
to be constant. In the para-telic participants who were in the para-
condition no feedback was given telic state, p < 0.02, but not for
on pace/ability. those who were in the telic state.
Unpleasant mood states also
revealed a significant group × time
interaction (p < 0.01). The mean
score for unpleasant mood states
did not differ significantly between

Environmental Research 214 (2022) 114081

the two groups at initial
assessment but significant after
walking (p = 0.03).
Matsuura Japan 26 students with no Controlled trial. Horse trekking for 30mins along State-Trait Anxiety No significant interactions Authors note that change of 4
et al. disabilities. No separate group for route outside between fields/ Inventory (STAI), POMS. between exercise and time in landscape, wind, and conversation
(2011) Males and females. Aged control. forest/road/meadow vs 30mins ‘tension-anxiety’ and ‘depression- with other riders are associated
19–25 yrs. on indoor riding simulator. dejection’ subscales. There were with horse trekking but not with
effects of time. Depression- using a riding simulator. Emotional
dejection scores were lower in wellbeing is also expected through
horse trekking condition compared interaction with a horse. Larger
to riding simulator exercise. variations in physiological
Anxiety-absent scores and anxiety- measures were found than in
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 I. Bray et al.
Table 3 (continued )
Author Location Sample Type of study Exposure Outcome measuresa Results Mediators/modifiers/mechanisms QAb

present scores were lower after psychological measures, and these

horse trekking than after exercise might be on the causal pathway e.g.
with riding simulator (p < 0.01). changes in parasympathetic
Horse trekking had a greater nervous activity.
psychological effect than the riding
simulator exercise.
Nistbet and Canada 150 university students. 85 Randomised Outdoor walking route along a Positive and Negative ANOVA showed that experiencers The studies showed that walking 2
Zelensji, female, 56 male, 9 controlled trial. canal vs an indoor walking route. Affect Schedule and forecasters did not differ outdoors facilitated a sense of
2011, unspecified. Mean age = Walk lasted ~17 min. (PANAS), Inclusion of significantly in their ratings of nature relatedness; the feeling of
study 1 20.8 yrs. Participants were also randomly Nature in Self (INS) positive affect but did differ in relatedness seems to have been
assigned to be experiencers or scale. their ratings of negative affect: mediated by the positive affect
forecasters of emotions. forecasters reported significantly produced by walking in nearby
less negative affect than nature. Feeling more related to
experiencers, F (1, 145) = 4.02, p nature can make you want to spend
= 0.05. The interaction for more time in nature.
negative affect was not significant.
Participants failed to fully
anticipate the hedonic benefits of
contact with nearby nature.
INS scores were higher for
experiencers who walked outdoors
(M = 4.44, SD = 1.64) than for
experiencers who walked indoors
(M = 3.05, SD = 1.61), t (70) =
3.63, p < 0.01, d = 0.86).
Nistbet and Canada 80 university students Randomised As above, but walks were along As above. Participants who walked outdoors As above. 2
Zelensji, controlled trial. different routes. underestimated the substantial
14

2011, hedonic benefits of the walk, and

study 2 participants who walked indoors
overestimated their post-walk
moods.
Outdoor walks again produced
greater state nature relatedness
(INS score: M = 4.18 for outdoor
participants and M = 3.45 for
indoor participants), and this effect
was again mediated by positive
affect (Sobel Z = 3.15, p < 0.01;
bootstrapping path = 0.62; 95% CI
= [0.22, 1.18]).
Ozen Turkey 30 university students. 17 Rock climbing was Recreational rock climbing Anxiety measured using Results suggest a significant Social cohesion as rock climbing 2
(2015) male, 13 females. practised by either on artificial walls or real the Social Anxiety Scale improvement in social anxiety was completed in groups, and
participants for two rock surfaces. The participants for Adolescents (SAS-A). levels of students participating in physical activity.

Environmental Research 214 (2022) 114081

months (two days in climbed in groups. the rock-climbing course.
weekdays and 1 day Across the three sub-scales (mean,
at the weekend). SD):
FNE pre-test = 25.96, 2.31; post-
test = 24.06, 2.04 (t = 4.59, p <
0.05);
S-SAD pre-test = 18.40, 3.63; post-
test = 17.90, 1.88 (t = 0.72, n.s.);
Y-SAD pre-test = 24.30, 2.89; post-
test = 20.73, 2.18 (t = 6.55, p <
0.05);
Total pre-test = 68.16, 6.81; post-
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 I. Bray et al.
Table 3 (continued )
Author Location Sample Type of study Exposure Outcome measuresa Results Mediators/modifiers/mechanisms QAb

test = 65.10, 4.45 (t = 3.44, p <

0.05).
There were no significant
differences between males and
females in any sub-scales or total
scores.
Walter et al. Germany 23 apprentices at Karlsruhe Randomised Aerobic endurance intervention Mood. Mood assessments: compliance 4
(2013) Institute of Technology, controlled trial. conducted over 10 weeks during with completing assessments
Germany; 52% female, Stratified for gender. winter months. Participants in reduced over time. Acute effects at
stratification of gender (50% the intervention group T1 no significant effects. Acute
female in experimental, 55% participated in instructed effects across T1-T3 no significant
control group); mean age outdoor running training twice a effects.
19.43 (±1.85) years. week. The control group Medium term mood changes – no
participants were instructed not significant effects.
15

to alter their physical activity For the mean values across the
and exercise patterns during the whole intervention period
control period; a continuous (T1–T3), energetic arousal,
endurance method was applied valence and calmness increased
to experimental group - initial immediately after a training
duration of 30 min was session (E: +10.4%; V: +17.8%; C:
continuously increased to 60 min + 6.2%) but results were not
over the 10 weeks, and intensity significant (and arousal and
was progressively increased by calmness effect sizes were low).
adding short intervals of 2min Valence findings were “marginally
above the individual training significant” at p = 0.07.
heart rate after week 6.
a
References for measures are given in Supplementary Material.
b
Quality assessment score out of 6. BAGE: Belief About Green Exercise questionnaire; INS, Inclusion of Nature in Self scale; PANAS: Positive and Negative Affect Scale; POMS, Profile of Mood States – Shortened Version;
PSS: Perceived Stress Scale; SAS-A: Social Anxiety Scale for Adolescents; STAI: State-Trait Anxiety Inventory; TESI: Tension-Effort Stress Inventory; TSM: Telic State Measure.

Environmental Research 214 (2022) 114081

I. Bray et al. Environmental Research 214 (2022) 114081

Table 4
Main characteristics and results of studies evaluating outdoor adventure programmes, and education/training/employment in green/blue environments.
Author Location Sample Type of study Exposure Outcome measuresa Results Mediators/ QAb
modifiers/
mechanisms

D’Agostino et al. USA The intervention Prospective Fit2Lead: a park- Juvenile arrest rate Adjusted Difference- 2
(2020) was offered in areas cohort study. based violence (per 10,000 youths in-Differences
with a population prevention and ages 12–17 years Poisson Regression
that was 48% male, mental health across all targeted Estimates of the
60% Hispanic, and promotion zip codes), and Association of
29% non-Hispanic afterschool change in arrest rates Program
black. In all, 33% of programme. (all offenses) per Implementation with
households were year among youth Youth Arrest Rates
single parent and ages 12–17 years Within 36 Zip Codes
33% were low across matched zip in Miami-Dade
income. The codes for 3 years County, Florida.
program served a before and after After programme
mean (SD) of 501 program implementation –
(37) youths per implementation incidence rate ratio
year; total (2013–2018). (IRR) (95%CI) 0.84
population 34,046. (0.84–0.85) p <
0.001.
Programme present –
IRR (95%CI) 2.05
(1.65–2.56) p <
0.001 Program
present × after
program
implementation –
IRR (95%CI) 0.81
(0.76–0.85) p <
0.001.
Falxa-Raymond USA 12 males, 4 females, Qualitative. Completing a Flexible open-ended Thematic analysis 7/
et al. (2013) 16/20 were BAME, training programme questions through revealed key themes; 9c
basic education and then 2–3 semi-structured motivations,
status. month’s work interview, knowledge/skills,
experience in an transcripts processed attitudes,
entry-level “green using NVivo significance of
job”. software. environmental work,
and challenges faced.
Motivations
included: inspired by
significant others
both before (88%)
and during work
placement (69%),
interest in
environment (69%),
being an “outdoor
person”,
contributing to
environmental
benefits (19%), work
pride. Attitudes
included: Change in
attitude toward self,
positive (56%) or
neutral (25%);
toward work, 31%
appreciated the
freedom offered,
13% negative toward
work; toward the
environment – 81%
had a positive
outlook toward the
environment
following the job,
and 56% had greater
awareness of local
environment.
Kanters et al. USA Medical students Cohorts 1999 Outdoor Profile for Mood There were The activities were 2
(2002) from cohorts 1997 received the experiential States (POMS). significant between- designed to create
(n = 26), 1998 (n = intervention. training activities group differences for group
57), 1999 (n = 52). Cohorts in 1997 conducted at park early semester cohesiveness and
and 1998 were close to campus anxiety-tension (F = foster social
control groups. during the year. − 16.75, p < 0.001), support.
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Table 4 (continued )
Author Location Sample Type of study Exposure Outcome measuresa Results Mediators/ QAb
modifiers/
mechanisms

early semester vigour

activity (F = 8.96, p
< 0.01), exam period
depression- dejection
(F- 4.99, p < 0.05),
and exam period
fatigue-inertia (F =
6.09, p < 0.05).
Outdoor experiential
training had a
significant effect on
several mood states.
Measures of anxiety-
tension, vigour
activity, and
depression-dejection
mood states before
the freshman
semester were
significantly lower
for subjects in the
intervention group
than those reported
for the control group.
Kardjono, 2017 Indonesia 62 male and 16 Controlled trial. 4-week Hiking The Liebowitz Social For men, there was a Suggested 1
female freshman Program, with a Anxiety Scale reduction in anxiety mediators are
students (analysed frequency of hiking (LSAS). in both groups, but it fresh air, natural
separately) from 3 times in one week was stronger in the scenery, ‘active
the Physical difficulty of the intervention group meditation’.
Education and hiking was (p < 0.05).
Health Department gradually increased For women, there
at the Indonesian subjects were was a larger
University of encouraged to enjoy reduction in anxiety
Education. Ages and learn about in the intervention
typically ranged nature and to freely group, but this was
from 18 to 20 years. meditate. due to elevated levels
before the
intervention. There
was no evidence of
an effect (p < 0.25).
Lymeus (2019) Sweden Students (n = 159 Randomised Restoration skills Perceived No statistical data 2
recruited, but data controlled trial. training (ReST) in a Restorativeness are reported.
used from 139). botanical garden Scale (PRS), ReST is reported to
Participants greenhouse Perceived Stress help people with
experienced stress compared with Scale (PSS), Swedish stress and
or concentration traditional indoor Core Affect Scale concentration
problems in their mindfulness (SCAS) and the problems to meditate
daily lives as training. Toronto Mindfulness effortlessly and learn
students, and with Scale (TMS). important
no or little restoration skills.
meditation ReST was also
experience. attended by
generalized
attentional
performance
improvements
similar to those
achieved with CMT.
The ReST course
confers sustained
psychological health
benefits with regard
to dispositional
mindfulness and self-
perceived cognitive
functioning.
Regarding chronic
stress, the benefits
were less consistent
and less sustained.
The main finding is
that the ReST
approach to
mindfulness training
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Table 4 (continued )
Author Location Sample Type of study Exposure Outcome measuresa Results Mediators/ QAb
modifiers/
mechanisms

appears to support
beginning meditators
with concentration
problems and stress
better than
conventional
mindfulness training.
Mackenzie et al., New 22 high school Within subjects. 5-day outdoor Self-report intrinsic The analysis of The current results 3
2018 Zealand students. Mean age No control adventure-based motivation and self- variance showed complement
= 15.7 yrs. 59% group. science course at a determination main effects for steps literature
male. residential school measured with the per day, flow, identifying
near a lake, state Short Flow State intrinsic motivation, psychological
park and ski area. Scale (SFSS) and the autonomy, benefits of outdoor
Intrinsic Motivation competence, adventure, such as
Inventory. relatedness, increased outdoor
enjoyment, value skill-based self-
and learning climate efficacy,
were significant (p < autonomy, and
0.001 - p < 0.05). positive academic
Post-hoc attitudes and
comparisons motivation.
indicated that steps
per day, flow,
intrinsic motivation,
autonomy,
competence,
relatedness,
enjoyment, and
learning climate
were all significantly
higher in the OASC
setting compared to
both pre and post
school settings.
McAnally et al. New 104 boarding Cohort study. Tihoi school – Satisfaction with Life Life satisfaction St Social cohesion 2
(2018) Zealand school students. Students from 2 outdoor education Scale, Rosenberg Paul’s boys did not and physical
Males only. schools assessed programme where Self-Esteem Scale, show any change in activity were
Mean age = 14.43 during week 2 students do 3 days Strengths and scores over time important parts of
yrs. and 15 of school of outdoor activities Difficulties whereas life the programme.
year. (kayaking, rock Questionnaire satisfaction
climbing etc) per (SDQ), Remote increased among the
week as well as 4 Associates Test, boys at Tihoi (fully
days of normal School achievement, adjusted model
school classes. St Gratitude suggests
Pauls - main school questionnaire. improvements in life
with no outdoor satisfaction, coef. 1.4
programme. (− 0.2, 3.0), p =
0.091).
St Paul’s boys did not
show any change in
their self-esteem
scores over time
whereas self-esteem
increased among the
boys at Tihoi (coef.
1.5 (0.2, 2.8), p =
0.022).
The intervention was
also associated with
improvements in
gratitude (coef. 2.2
(0.7, 3.7), p =
0.005).
There was no
evidence of a
difference for any of
the other outcomes.
Mutz and Müller The Alps 12 pupils from a Pre-post design. 9-day hike across Perceived Stress Perceived stress A major focus of 3
(2016), study German high school No control the Alps ~175 km. Questionnaire (PSQ), partially decreased the excursion was
1 (14yrs). 5 females, group. The hike focuses on General Self-efficacy after intervention. around social
7 males. values of self Scale (GSES), The PSQ subscale on cohesion and
direction, initiative, Mindful Attention “worries” decreased leadership.
leadership and and Awareness Scale (effect size = -0.47,
p = 0.069). A
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Table 4 (continued )
Author Location Sample Type of study Exposure Outcome measuresa Results Mediators/ QAb
modifiers/
mechanisms

personal (MAAS), subjective moderate to large

responsibility. wellbeing (SWB). change is
demonstrated for the
PSQ subscale
“demand”, where
participants report
significantly lower
values after the
completion of the
hike (effect size =
-0.66, p = 0.022).
Results also reveal a
large increase in
mindfulness (effect
size = 1.32, p =
0.001) among
participants.
SWB was affected
substantially by the
excursion: The mean
life satisfaction score
increased
significantly (effect
size = 0.58, p =
0.034). The increase
in happiness was also
considerable but
failed to reach
significance by a
narrow margin
(effect size = 0.47, p
= 0.064).
Mutz and Müller Norway Experimental group Pre-post design. Summer excursion 8 As above. Intervention was As above 3
(2016), study - 15 undergraduate Experimental days exploring associated with
2 students from a group and wilderness and moderate to large
German university. control group being in nature. changes in almost all
Ages 19–25yrs. (did not Hiking, climbing, aspects of mental
8 male. Control participate in fishing, swimming health measured.
group – 7 students. excursion). in lakes, camping First, participants
etc. indicate reduced
stress according to
the PSQ subscales
“worries” (effect size
− 0.53, p = 0.030)
and “demand” (effect
size = - 0.92, p =
0.002). Participants
scored higher in
mindfulness (effect
size = 0.54, p =
0.027) and self-
efficacy (effect size
= 0.90, p = 0.002)
after the
intervention. Mean
life satisfaction score
increased
significantly by 0.67
points (effect size =
0.68, p = 0.010).
Participants reported
a large gain in
momentary
happiness after the
excursion (effect size
= 1.48, p < 0.001).
Opper et al. South 76 grade 10 Pre-post design ‘The Journey’- a 23- The Bar-On The results of the 3
(2014) Africa students. Males with follow-up. day outdoor Emotional Quotient MANOVA univariate
only. Ages 15–16 No control adventure Inventory (Bar-On tests show that all EQ
yrs. group. education EQ-I), The Bar-On facets differed
programme. The Emotional Quotient significantly over
students participate Inventory Youth time (p < 0.05). The
in different Version (Bar-On EQ- results indicate a
activities and reflect I; YV). significant difference
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I. Bray et al. Environmental Research 214 (2022) 114081

Table 4 (continued )
Author Location Sample Type of study Exposure Outcome measuresa Results Mediators/ QAb
modifiers/
mechanisms

on their in total EQ scores

participation. It from pre- to post1
facilitates the (medium effect size),
development of and from pre- to
emotional post2 (medium effect
intelligence. size), which suggests
that participation in
the intervention
results in an increase
in emotional
intelligence skills.
Participation in the
intervention results
in a sustainable
increase in overall
emotional
intelligence, but with
regard to the
sustainability of the
subskills acquired,
the effect on certain
skills is more lasting
(i.e. intrapersonal
skills, adaptability
and general mood)
than on others (i.e.
interpersonal skills
and stress
management).
Scarf et al. New 173 youth aged Control group 10-day voyage on a Self-esteem using the Voyage participants Group work and 1
(2018) Zealand 15–19 yrs. did not go on sailboat around Self- Description experienced an social cohesion
Experimental n = the voyage. New Zealand. Tasks Questionnaire III increase in self- were important
100, control = 73. Outcomes and activities were (SDQ III), Life esteem from Time 1 aspects of the trip.
measured on completed during Effectiveness self- to Time 2, t (99) =
day 1 and final the trip. concept sub-scale, 5.143, p < 0.001,
day of the group belonging. while control
voyage. participants did not,
t (72) = 1.283, p =
0.204. Voyage
participants (n = 97,
M = 18.155, SD =
2.977) reported
higher levels of
group belonging
than did control
participants (n = 72,
M = 14.486, SD =
3.548), F (1, 167) =
53.236, p < 0.001,
η2p = 0.242.
Study 1 revealed that
participants’ sense of
belonging to their
Watch Group
predicted increases
in self-esteem
following the 10-day
voyage. Study 2
replicated this result
and showed that the
relationship between
group belonging and
self-esteem remained
when controlling for
self-efficacy and
group esteem.
Wolf and USA 218 Washington Cohort. No Everyday work PSS, health WCC participants Employment, 3
Housley Conservation Corps control group. settings in urban overview, personal reported less social cohesion
(2017) (WCC) members forests, wildlife effectiveness perceived stress and physical
pre-test, 240 post- habitats, parks. measured using The compared to others activity.
test. Ages 1834 yrs Work involved park Review of Personal in their national age
with the majority improvements, Effectiveness with cohort both before
22–24 yrs. ecological Locus of Control and after their
restoration and (ROPELOC). service year. Paired
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Table 4 (continued )
Author Location Sample Type of study Exposure Outcome measuresa Results Mediators/ QAb
modifiers/
mechanisms

biological sample t-tests

monitoring. indicated a
significant decline in
perceived stress
during the
conservation work
period pre-test mean
(SD) = 12.74 (7.05),
post-test = 11.23
(4.76); t (214) =
2.759, p < 0.006
(norms for US
citizens under 25
years presented at
14.54–18.64).
There were
significant
differences between
pre- and post-scores
for social functioning
(difference(d) =
0.324 (CI = − 7.67 to
− 0.635); t (206) =
2.327; p = 0.021),
energy/fatigue (d =
0.345 (CI = 0.973 to
7.88); d = 0.672 (CI
= 4.41 to 11.59); t
(215) = 2.526; p =
0.012) and bodily
pain (t (215) =
4.930; p < 0.001).
The only subscale for
ROPELOC that is sig.
diff. between pre-
and post-test was
cooperative
teamwork (6.83(SD
= 0.99, CI =
0.019–0.377) versus
6.63 (1.01); t (216)
= 2.179; p < 0.030).
Themes discovered:
profession interests
and satisfaction,
communication and
teamwork, sensory
experiences,
overcoming
challenges and
learning new skills,
ecosystems
knowledge, and life
transformations.
a
References for measures are given in Supplementary Material.
b
Quality assessment score out of 6.
c
Quality assessment score out of 9 (the number of yes’s for CASP qualitative quality assessment). Bar-On EQ-I: The Bar-On Emotional Quotient Inventory; Bar-On
EQ-I-YV: The Bar-On Emotional Quotient Inventory Youth Version; GSES: General Self-efficacy Scale; LSAS: The Liebowitz Social Anxiety Scale Mindful Attention and
Awareness Scale; NEP: The New Ecological Paradigm; PRS: Perceived Restorativeness Scale; PSQ: Perceived Stress Questionnaire; PSS: Perceived Stress Scale; POMS:
Profile of Mood States; ROPELOC: The Review of Personal Effectiveness with Locus of Control assessment; SDQ: Strengths and Difficulties Questionnaire; SDQ: III Self-
Description Questionnaire III; SCAS: Swedish Core Affect Scale; SFSS: Short Flow State Scale; TMS: Toronto Mindfulness Scale.

experiences (Opper et al., 2014; Mutz and Müller, 2016; Scarf et al., outcomes. Exposure to vegetation is commonly measured using NDVI,
2018), which could be another important element. Evaluations of such ‘an indicator of greenness based on land surface reflection of visible
interventions have studied group dynamics but have less often included (red) and near-infrared parts of the spectrum’ (Ekkel and de Vries,
mental health and subjective wellbeing as outcomes (Mutz and Müller, 2017).
2016). Dzhambov (2018) provides a longitudinal analysis of NDVI and
mental health, including symptoms of depression and anxiety, at
3.3.5. Studies of exposure to residential vegetation and blue spaces one-year follow-up. The authors found a relationship between exposure
Five observational studies (Table 5) consider the relationship be­ to neighbourhood green/blue space and mental health, as measured by
tween residential exposure to vegetation or blue spaces and a variety of the 12-item General Health Questionnaire (Goldberg and Williams,

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Table 5
Main characteristics and results of studies of exposure to residential vegetation and blue spaces.
Author Location Sample Type of study Exposure Outcome measuresa Results Mediators/modifiers/ QAb
mechanisms

Bezold United 9385 participants Cross- Normalized Depressive symptoms Adjusting for race/ 3
et al., States ages 12–18 years in sectional difference were measured using ethnicity, paternal
2018 the 1999 wave of the vegetation self-reported responses education, maternal
Growing Up Today index (NDVI) at to the McKnight Risk history of depression,
Study. 59% female, 250 m and Factor Survey census region, census
93% non-Hispanic 1250 m from tract percent white, and
white. All were subject’s estimated PM2.5
children of nurses. residence. exposure, an inter-
Presence of blue quartile range (IQR)
space within increase in peak
these buffer greenness in the 1250 m
zones. buffer around each
participant’s home was
associated with 11%
lower odds of high
depressive symptoms in
fully adjusted models
(OR 0.89, 95% CI
0.79–0.99). Annual
average NDVI in the
1250 m buffer was also
associated with lower
odds of depressive
symptoms (OR per IQR
increase 0.90, 95% CI
0.83, 0.99). Results for
both peak and average
NDVI at 250 m were
slightly attenuated
compared to the 1250 m
results, but the direction
of association was
consistent.
Presence of blue space
in either 250 m or 1250
m was not statistically
significantly associated
with depressive
symptoms. This was
true when all types of
water were considered
simultaneously and
when interior and
coastal water bodies
were considered
separately. The results
for coastal areas
suggested a protective
effect of living within
250 m of the coast, but
the confidence intervals
were very wide (OR
0.29, 95% CI
0.04,2.01).
Dzhambov Bulgaria 109 medical Cross- NDVI, General Health NDVI and blue space Residential noise, air 2
(2018) university students sectional residential Questionnaire (GHQ- had a stronger pollution and
aged 1835 yrs (mean survey with 1- exposure to blue 12) – Bulgarian correlation with lower annoyance from
= 21 yrs). year follow space. translation. GHQ-12 scores (better environmental
up. mental health) at pollution.
follow-up (− 0.26, p <
0.05) compared with
baseline (− 0.14). In the
cross-sectional analysis,
NDVI did not directly
correlate with GHQ-12,
but it was indirectly
associated with lower
GHQ-12 through higher
physical activity and
restorative quality. In
the longitudinal
analysis, higher NDVI
significantly correlated
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Table 5 (continued )
Author Location Sample Type of study Exposure Outcome measuresa Results Mediators/modifiers/ QAb
mechanisms

with lower GHQ-12, but

none of the indirect
effects were significant.
Living close to blue
space (<300 m) was
associated with lower
GHQ-12 in both the
cross-sectional (− 0.18)
and longitudinal
analyses (− 0.22, p <
0.05), but physical
activity and restorative
quality mediated this
association only in the
cross-sectional analysis.
Dzhambov Bulgaria 581 undergraduate Cross- NDVI and Tree Generalized Anxiety The models for anxiety Perceived greenness, 2
et al., medical students. 529 sectional Cover Density Disorder 7-item (GAD7) and depression restorative quality of
2019 included for analyses. survey. map 2015. scale and the Patient indicated that higher the neighbourhood,
Mean age = 21.74 yrs. Health Questionnaire 9- greenspace, both dispositional
item (PHQ-9), NDVI, objective and perceived, mindfulness,
Mindful Attention was consistently rumination, and
Awareness Scale associated with better resilience to stress.
(MAAS), Perceived mental health. The
Restorativeness Scale associations between
(PRS). NDVI and both anxiety
and depression showed
a pattern of increasing
magnitude from smaller
to larger buffers, while
the opposite pattern
held for relationship
between tree cover and
depression. More
greenspace was
consistently associated
with reduced scores on
the anxiety and
depression scales.
Restorative quality was
related to lower
rumination, higher
resilience, and lower
anxiety and depression.
Higher restorative
quality was associated
with lower rumination
and better mental
health.
Herrara Germany 1632 16–18-year-olds Cohort study. NDVI School-related, Higher greenness Mediation analysis 2
et al., followed to 20–23 university-related or (quartile 4 vs quartile 1) confirmed that
2018 years. job-related self-reported was associated with less physical activity is
chronic stress was work discontent (OR not a mediator.
assessed by the Trier 0.89; 95% CI 0.80 to
Scale for Assessment of 0.99) and less work
Chronic Stress using overload (OR 0.87; 95%
work discontent and CI 0.78 to 0.96).
work overload Prevalence of high
subscales as outcomes levels of work
discontent and work
overload decreased by
increasing level of
greenness in a buffer of
500 m around the home.
For work discontent,
results suggest a linear,
inverse dose-response
pattern across quartiles
while for work overload
we observed a ‘J-shape’
association. For
students, the OR for
work overload was <1
for all quartiles
compared with the first
quartile of NDVI. For
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Table 5 (continued )
Author Location Sample Type of study Exposure Outcome measuresa Results Mediators/modifiers/ QAb
mechanisms

workers, no statistically
significant difference
for work overload and
work discontent was
seen by NDVI quartiles.
Wang et al. USA Adults, teenagers and Secondary NDVI The Kessler 6 (K6) Scale. Strong evidence for 2
(2019) children in 81,102 analysis of the decreased odds of
households. California serious psychological
Health distress with increased
Interview greenness surrounding
Survey (cross- residence in teens, even
sectional). after adjusting for major
socio-demographic
factors and
neighbourhood socio-
economic status.
a
References for measures are given in Supplementary Material.
b
Quality assessment score out of 6; GAD-7: Generalized Anxiety Disorder 7-item scale; GHQ-12: General Health Questionnaire – Bulgarian translation; K6: The
Kessler 6 Scale; MAAS: Mindful Attention Awareness Scale; NDVI: The Normalized Difference Vegetation Index; PRS: Perceived Restorativeness Scale.

1988). Herrara et al. (2018) also provide longitudinal evidence, which are associated with preference, suggesting that it is important to
may offer an insight into mechanisms. They report that greater levels of consider personal preferences if the impacts of green spaces are reliant
residential greenness when participants were aged 16–18 years are on their use. Taken together, this set of studies suggest that greener
associated with lower levels of work stress when they reach age 20–23 environments are preferred, and are associated with restoration, partly
years. This suggests a protective effect when transitioning to university by reducing perceived noise levels.
or working life. In cross-sectional analyses the association between
NDVI and mental health appears to be mediated by physical activity and 3.4. The conceptual framework
restoration, though this does not hold in longitudinal analyses
(Dzhambov, 2018). A later cross-sectional study found that NDVI was Based on the literature reviewed, we built on the existing literature
negatively associated with both anxiety and depression symptoms. The to provide a conceptual framework that links particular elements of
following variables were reported as mediators – perceived greenness, exposure to green spaces to the psychological outcomes of anxiety dis­
the restorative quality of the neighbourhood, dispositional mindfulness, orders and depression (Fig. 3). The model includes evidence about the
rumination and resilience to stress (Dzhambov et al., 2019). Another modifying effects of young people’s perceptions of exposure to vegeta­
cross-sectional study reported a negative association between NDVI and tion and trees, mechanisms including the behaviours facilitated by green
serious psychological distress. The outcome measure was the Kessler 6 spaces (e.g. physical activity) and environmental exposures (e.g. noise
scale (Kessler et al., 2003), which measures symptoms of anxiety and and air pollution). We suggest tentative psychological mechanisms to
depression. The authors found that the relationship was mediated by explain how the restorative qualities of green spaces might lead to
pollution and social cohesion (Wang et al., 2019). A final cross-sectional increased mindfulness and interrupted rumination (Bratman et al.,
study provides further evidence that NDVI is associated with reduced 2015). Our model also suggest that a reduction in negative stimulation
symptoms of depression but an association was not found for presence of could enable restoration and possibly a reduction in the risk of anxiety
blue space (Bezold et al., 2018). disorder and depression. The framework demonstrates that there is
experimental evidence linking elements of exposure to green spaces to
3.3.6. Studies of young people’s perceptions of green spaces mechanisms related to reduced environmental exposure to noise and air
Another group of studies provided insight into how green spaces are pollution, and transitory psychological states such as mood and relax­
perceived by young people, and how this could mediate the relationship ation. It also highlights a lack of evidence linking these to the outcomes
between green space and mental health (Table 6). An experimental of anxiety disorder or depression. Observational studies and evaluations
study compared perceptions of bamboo forests with those of an urban of interventions provide some evidence of links between other potential
environment (Zeng et al., 2020). The forest was rated as providing a mechanisms (e.g. improved social cohesion and resilience) and these
better environmental experience in terms of sensory perception, atmo­ outcomes.
sphere, climate, space and place. An observational study compared
different views in Tokyo (Asgarzadeh et al., 2014). More trees in the 3.5. Analysis by subgroup
view increased spaciousness and monotony. Oppressiveness was
reduced in views with more trees and more sky and increased in views Few studies compared results for males and females, despite clear
with more buildings. Finally, increasing distance to trees reduced differences in the epidemiology of mental health disorders in adulthood
perceived oppressiveness and danger. This would suggest that the which emerge during adolescence. One exception, Kardjono (2017),
optimal environment in one in which trees and sky dominate rather than suggests that a 4-week hiking programme reduced social anxiety for
buildings, but with some distance to the trees. An experimental study by males, but induced pre-intervention anxiety for females. In an evalua­
Wilson et al. (2016) found that walking in an urban park is perceived as tion of a climbing programme, Ozen (2015) found that a climbing
being more restorative than walking on a busy street near traffic. It also intervention reduced social anxiety overall, with no differences between
reported that perceived noise mediates perceived restoration. Yang et al. men and women. Of the thirteen experimental studies described in
(2011) showed that plants cause ‘psychological noise reduction’. In Table 1, eight included only males. The one study that included only
other words, a green environment reduces perceived noise levels. Ali­ females reported similar results, suggesting that exposure to forests or
zadeh et al. (2018) examined personal preferences for different green parks have similar effects for males and females (Song et al., 2019). In
(forests, agricultural) and natural (mountains) landscapes and pre­ terms of age groups, most of the experimental studies (Tables 1–3) were
dictors of these. They found that personality type and the subject studied carried out with student samples of very similar ages. This means that

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I. Bray et al. Environmental Research 214 (2022) 114081

Table 6
Main characteristics and results of studies of young people’s perceptions of green spaces.
Author Location Sample Type of study Exposure Outcome measuresa Results Mediators/ QAb
modifiers/
mechanisms

Alizadeh Iran 384 volunteer high Cross-sectional 15 scenes of Preferences were There were some 2
et al. school students survey. mountains, forest, recorded using a 7point associations between
(2018) (192 girls, 192 and agricultural Likert scale, Cattell both personality type
boys). Mean age = landscapes were Sixteen Personality and subjects studied and
16.3 yrs. Range = shown to Factor Questionnaire preferences for
15–18 yrs. participants in (16 PF). environments, but the
random order. percentage of variance
explained by these
variables was low.
Asgarzadeh Japan 20 architecture and Repeated 15 scenes (3 Perceptions of Significant associations 2
et al. design students and measures evaluation oppressiveness, and between distance
(2014) graduates. 50% observational locations for 5 spaciousness, variables (distance to
females. survey. building dangerousness, and trees and distance to
compounds) on a pleasantness, buildings) with
Tokyo street. monotony, beauty, perceptions of
strength, heaviness and oppressiveness and
fuzziness. Each question danger. Being farther
used a semantic from trees lowered
differential rating oppressiveness (− 0.25;
system from 1 to 7. p < 0.01) and
dangerousness (− 0.15;
p < 0.05). The second
model included tree-
related variables (solid
angle of trees, increased
distance from trees),
and building’s solid
angle as independent
variables: with a greater
solid angle view of
trees, spaciousness
increased (0.43; p <
0.01), monotony
(− 0.45; p < 0.01) and
fuzziness (ambiguity)
decreased (− 0.54; p <
0.01). The third model
included ground
surface, trees, sky, and
total building’s solid
angles as independent
variables, and suggested
that trees (− 1.13; p <
0.01) and view of sky
(− 0.43; p < 0.01) can
decrease
oppressiveness.
Oppressiveness (− 0.33;
p < 0.05) and perceived
spaciousness of the
environment (− 0.45; p
< 0.05) also decreased
significantly with
dominant views of
ground surface.
Oppressiveness
increased significantly
when the solid angle of
the visible buildings
increased but with the
presence of trees, the
building’s
oppressiveness was
reduced.
Wilson et al. USA 112 undergraduate Within-person One-mile (approx. Short-version Revised Higher levels of Higher levels of 4
(2016) students in a randomised 20mins) paved Restoration Scale perceived restoration in perceived noise and
general education trial. walking trail (SRRS). the natural danger in the street
class. through an urban environment (p < 0.05). environment (p <
park (compared 0.05). Perceived
with sidewalk noise was a strong
next to busy predictor of
highway). perceived
(continued on next page)

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I. Bray et al. Environmental Research 214 (2022) 114081

Table 6 (continued )
Author Location Sample Type of study Exposure Outcome measuresa Results Mediators/ QAb
modifiers/
mechanisms

restoration, but
perceived danger was
not an independent
predictor.
Yang et al. China 40 randomly Non- Participants were Subjective emotional 90% of the subjects There was a highly 0
(2011) selected randomised exposed to evaluation believed that landscape significant
participants from a experiment. simulated noises questionnaire plants could contribute asymmetry between
forestry university. and videos of completed after each to noise reduction. the EEG activity of
20 male, 20 female. noisy street scenes scene. Participants believed the vegetation scene
Mean age = 23 yrs. and adjacent that hedges are the most and traffic scene
green spaces via effective barrier (80%), groups.
video glasses. and overestimated the
sound reduction effect
of hedges. Landscape
plants provide excess
noise attenuating effects
through subjects‘
emotional processing -
“psychological noise
reduction”.
a
References for measures are given in Supplementary Material.
b
Quality assessment score out of 6; 16 PF: Cattell Sixteen Personality Factor Questionnaire; SRSS: Short-version Revised Restoration Scale.

Fig. 3. Conceptual framework based on the literature in the review (Thicker lines represent evidence from experimental studies and thinner lines represent evidence
from nonrandomised evaluations and observational studies. Colour coding differentiates pathways from each feature of green space). (For interpretation of the
references to colour in this figure legend, the reader is referred to the Web version of this article.)

results cannot be compared by age. Educational or adventure pro­ It is notable that much of the experimental research considered in
grammes were positively evaluated for both school-age teenagers and this review focuses on forests as the exposure or intervention. Some
students (Table 4). There is evidence that neighbourhood green space is studies reported elevated state-anxiety immediately prior to a walk in a
less strongly linked to depression for high school students than middle forest, which suggests that this can be an unfamiliar or even threatening
school (Bezold et al., 2018). There was no evidence of effect modifica­ environment.
tion by sex. One study found some evidence that young people’s preferences for
Few studies in this review considered ethnicity as a moderator. While mountains, forest and agricultural landscapes is linked to personality
61% of the experimental studies (Tables 1–3) were carried out in Asia, type (Alizadeh et al., 2018). We also found some evidence that the im­
the predominantly observational studies (Tables 4–6) have a global pacts of exposure to green spaces and outdoor exercise might be
spread. Included studies did not consider effectiveness in different so­ moderated by personality type (Song et al., 2018) or by psychological
cioeconomic groups. Many of the experimental studies used students as state (Legrand and Thatcher, 2011). For example, those with high-trait
participants, who are unlikely to represent all socioeconomic groups. anxiety levels experienced a greater reduction in feeling of “depres­
Two US studies reported ethnic and sociodemographic diversity within sion–dejection” after walking through forest areas than those with
their sample, but neither of these studies report results for different normal and low-trait anxiety levels (Song et al., 2018). Differences in
groups (Falxa-Raymond et al., 2013; D’Agostino et al., 2020). goal-orientation explain why individuals do not all respond in the same

26
I. Bray et al. Environmental Research 214 (2022) 114081

way to exercise (Legrand and Thatcher, 2011). encourage ‘effortless mindfulness’. This is supported by one study that
found a green setting when learning mindfulness was particularly
4. Summary helpful for beginners (Lymeus, 2019). An evaluation of a hiking pro­
gramme encouraged participants to reflect on the natural surroundings
There is good evidence that a 15-min walk in a forest or park can and engage in ‘active mindfulness’. It has been found that regular
improve mood and state anxiety compared to an urban environment mindfulness can promote trait mindfulness (Quaglia et al., 2016). This
(Song et al., 2018, 2019). It is not clear, however, whether this corre­ provides a possible mechanism to a sustained reduction in the risk of
sponds to a reduced risk of developing anxiety or depression. The im­ psychological disorders.
pacts of different components of nature can be broken down, and such
studies provide evidence of the restorative qualities of viewing or 5.1. Recommendations for research
listening to nature, with associated improvements in mood and relaxa­
tion (Benfield et al., 2014; Tedja and Tsaih, 2015; Chang et al., 2008; In order to understand if exposure to green space prevents anxiety
Chan KLE, 2015). There is less good evidence about the social and and depression amongst people aged 14–24 years, it is essential that
psychological processes, such as activation or rumination, resulting from more studies examine longer-term follow-up. Further research must
the opportunities for physical activity and restoration afforded by green explore the type and frequency of exposure associated with longer-
space, or how these link to psychological disorders. There is limited lasting impacts indicative of prevention of anxiety and/or depression.
evidence about how young people perceive green spaces, and how this Another recommendation for future research is to measure changes in
affects their use of green space. There is also limited evidence of poor psychological processes such as rumination and activation that are key
quality about the effects of exposure to blue spaces for young people’s to anxiety and depression. Such research should utilise psychological
mental health. theory to underpin explorations of the impact of green space on mental
health.
5. Discussion The studies used a wide variation of interventions/exposures,
considering different types of green space, different durations and
We synthesised a wide range of evidence about the role of access to varying activities. To allow an improved dialogue with mental health
green space in preventing anxiety and depression amongst 14–24 year science, these interventions could adopt a more structured way of
olds, and developed a tentative conceptual framework linking exposures reporting the contents of the exposure, similar to those laid out in the
to outcomes, via a number of mechanisms including psychological TIDieR guidelines (Hoffmann et al., 2014). Systematic reporting would
processes. We found evidence that exposure to forest environments leads then allow investigations into impacts of green space on mental health to
to greater momentary mental wellbeing compared to being on an urban be more readily evaluated, replicated and potentially implemented.
street, and that urban parks can deliver similar benefits to forests. These Although it was included in our search terms, we found few studies
studies did not provide evidence about longer-term outcomes such as about the benefits of blue spaces for young people’s mental health, and
symptoms or diagnoses of anxiety or depression. However, the evidence these studies tended to be of poorer quality. This reflects the finding of
from observational studies that residential exposure to vegetation is our earlier scoping review (Reece et al., 2021), in which only 2% of
associated with reduced risk of depressive symptoms for young people is sources related to blue spaces. However, this is a rapidly growing area of
crucial in terms of implementing change that will have broad reach and research. In terms of potential mechanisms, more work is needed on the
lasting benefits (Vanaken and Danckaerts, 2018). Observational studies importance of microbial exposure. Future studies should also consider
also provide some insights into causal mechanisms, such as links be­ the role of demographic variables, previous experiences (e.g. with out­
tween green space and restorative properties leading to reduced rumi­ door activities) and individual preferences (for different environments).
nation (Dzhambov, 2018; Dzhambov et al., 2019). While adolescents
spend more of their time further from home than children, young people 5.2. Recommendations for practice
are less likely to own cars or have access to private gardens. Neigh­
bourhood green space and vegetation is therefore crucial to their Recommendations for practice should be interpreted with some
well-being (as recognised in the Sustainable Development Goals; UN caution, as there is limited evidence of mixed quality regarding pre­
Environment Programme, 2020). vention. Recommendations might include consideration of social pre­
The importance of green space is partly because it enables many scribing of adventure interventions for young people at risk of anxiety
other activities that benefit mental health. Hartig et al. (2014) and then and depression and, at a population level, the integration of outdoor
Nieuwenhuijsen et al. (2017) suggest four mechanisms through which adventure opportunities into educational curricula. Evaluations of such
exposure to natural environments may affect mental health. These are interventions provide some limited evidence of sustained effects on
environmental exposure/air quality, physical activity, social contacts general mood and feelings of depression (Opper et al., 2014; Kanters
and cohesion, and restoration and stress reduction. Less researched et al., 2002). However, there is as yet no clear evidence about the type,
mechanisms include microbial exposure and biogenic volatile organic length or frequency required to have a lasting impact, which may be a
compounds. It is hard to disentangle the impacts of green space and such barrier to prescribing. . High-quality longitudinal studies are still needed
mediators, and the psychological processes by which green space may to estimate the long-term effects of regular exposure to green space on
reduce the risk of anxiety or depression are unclear. Many of the clinical measures of anxiety and depression. However, based on the
included studies cite Attention Restoration Theory (Kaplan and Kaplan, studies we reviewed and the insights of our panel, we conclude that
1989; Ohly et al., 2016). This theory suggests green space engages in­ access to green space is likely to enhance other interventions to improve
direct attention and thus provides rest for directed attentional capacity, mental health, such as physical activity (Nistbet and Zelensji, 2011;
and therefore presumably interrupts unhelpful rumination or worry. The Matsuura et al., 2011), mindfulness practice (Lymeus, 2019) and
papers reviewed suggest that green spaces promote mindfulness, medi­ problem-solving. It also has multiple additional benefits (Hunter et al.,
ated by physical activity and restorative qualities. We hypothesize that 2019) in terms of health and wellbeing for the rest of the urban popu­
this in turn reduces rumination (Short et al., 2020) and improves psy­ lation, improving thermal comfort and biodiversity in cities, and
chological outcomes. Others have suggested that greenspace reduces the reducing pollution and risk of flooding. These all have implications for
tendency to ruminate and thereby increases adaptive coping through the future health of today’s young people.
enhanced psychological resilience (Marselle et al., 2019). Similar ben­
efits might be afforded by the practice of mindfulness (Chi et al., 2018),
but this requires training and effort. It seems that green environments

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I. Bray et al. Environmental Research 214 (2022) 114081

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