The effect of nature exposure on the mental health of patients: a systematic review

Are we afraid of the woods? - An investigation of the implicit and explicit fear reactions to forests

The beneficial effects of nature exposure have been repeatedly documented and encourage frequent and regular contact with nature and especially highlight forests. However, in human history, forests have also been associated with negative emotions such as fear and were seen as dangerous environments. While existing literature could demonstrate that natural environments can evoke fear, the focus was on the explicit perception. Given that research has shown the significance of additional implicit processes in fear-related behaviour, we aim to explore the presence of an implicit fear response to forests. Therefore, in an online study, we investigated the explicit and implicit fear reactions to forests by a Northern German sample of N = 256. Using three explicit measurements, we investigated fear and danger perception on a semantic and visual level of the stimulus category "forest" compared to the human-made urban green space "park" and the urban setting "house". Additionally, we assessed the unconscious response tendencies towards the forest within three implicit tasks: Subliminal Priming Procedure (SPP), Affect Misattribution Procedure (AMP) and Approach-Avoidance Task (AAT). Within the analyzed sample, the subliminally presented word forest evoked a stronger positive valence response compared to park (SPP). In contrast to houses, the forest showed a stronger approach and weaker avoidance tendency (AAT). At the same time, both the three explicit and one implicit measurement (AMP) showed a stronger fear perception of forests compared to parks or houses. Considering the increasingly utilised beneficial effects of nature in interventions, these findings should be acknowledged when implementing nature exposure in interventions and treatments.

Experiences of Patients with Breast Cancer Participating in a Prehabilitation Program: A Qualitative Study

Background: Breast cancer (BC) is the most prevalent cancer diagnosis among women worldwide. Several randomized controlled trials and systematic reviews have shown the benefits of exercise before, during, and after cancer treatment to manage side effects related to cancer and its therapies. However, these are poorly implemented across the disease-span, specifically, during the preoperative setting. Methods: Patients diagnosed with BC and participating in a randomized controlled trial on the effects of a prehabilitation program based on Nordic walking, muscle strengthening, and therapeutic education were invited to participate in this qualitative substudy. Two groups of eight patients each were recorded, transcript and analyzed using a specialized software (Atlas-Ti®, version 24). Results: During the axial codification phase, 22 unique codes and 6 main themes were identified related to their experience with the program, namely, (1) information received prior to participating; (2) motivation to participate; (3) barriers; (4) facilitators; (5) perceived degree of support from healthcare workers as well as peers; and (6) satisfaction with the characteristics of the prehabilitation program. Conclusions: Patients interviewed showed great interest in prehabilitation as a way to prepare both physically and mentally for surgery. In order to implement these interventions, healthcare systems need to acknowledge barriers and facilitators as well as the need for these programs to be supervised and monitored to avoid adverse events.

Assessing nature exposure: a study on the reliability and validity of a Portuguese version of the nature exposure scale

Introduction

Engaging with nature has been widely acknowledged for its positive impact on well-being. Traditionally, assessments of nature exposure focus on estimating green space exposure and outdoor time. However, the Nature Exposure Scale (NES) offers a unique approach by evaluating the quality of nature experiences, encompassing both deliberate and spontaneous encounters.

Methods

This study aimed to assess the validity and reliability of the NES in the context of Portugal. Exploratory Factor Analysis (PCA) and Confirmatory Factor Analysis (CFA) were employed to examine the underlying structure of the scale. Additionally, reliability assessments, along with tests of convergent and divergent validity, were conducted. Data were collected from a sample of 558 adults and 241 adolescents between 2016 and 2018.

Results

The findings revealed strong internal consistency of the NES, supported by acceptable correlation values and robust factor loadings within a unidimensional model. The scale effectively predicted variations in nature exposure across diverse professional activities.

Discussion

In summary, the 4-item NES emerged as a reliable tool for assessing nature exposure in various settings, effectively bridging a gap in the Portuguese context. The scale demonstrated potential for cross-cultural research and was particularly adept at predicting nature exposure in different professional contexts. The results suggest that the NES can enhance our understanding of the impact of nature on well-being in diverse cultural settings.

Conclusion

The study underscores the reliability of the NES in assessing nature exposure in Portugal, paving the way for further exploration in Portuguese-speaking regions. The scale holds promise for advancing research on the relationship between nature and well-being, contributing valuable insights across different cultural contexts.

The economics of nature's healing touch: A systematic review and conceptual framework of green space, pharmaceutical prescriptions, and healthcare expenditure associations

Green spaces play a crucial role in promoting sustainable and healthy lives. Recent evidence shows that green space also may reduce the need for healthcare, prescription medications, and associated costs. This systematic review provides the first comprehensive assessment of the available literature examining green space exposure and its associations with healthcare prescriptions and expenditures. We applied Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines to search MEDLINE, Scopus, and Web of Science for observational studies published in English through May 6, 2023. A quality assessment of the included studies was conducted using the Office of Health Assessment and Translation (OHAT) tool, and the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) assessment was used to evaluate the overall quality of evidence. Our search retrieved 26 studies that met the inclusion criteria and were included in our review. Among these, 20 studies (77 % of the total) showed beneficial associations of green space exposure with healthcare prescriptions or expenditures. However, most studies had risks of bias, and the overall strength of evidence for both outcomes was limited. Based on our findings and related bodies of literature, we present a conceptual framework to explain the possible associations and complex mechanisms underlying green space and healthcare outcomes. The framework differs from existing green space and health models by including upstream factors related to healthcare access (i.e., rurality and socioeconomic status), which may flip the direction of associations. Additional research with lower risks of bias is necessary to validate this framework and better understand the potential for green space to reduce healthcare prescriptions and expenditures.

Defining young people's mental health self-care: a systematic review and co-development approach

Self-care is among the emerging types of mental health support which operate outside traditional services, although the meaning and practice of self-care for young people with mental health difficulties are currently unclear. This systematic review was pre-registered with PROSPERO (CRD42021282510) and investigated conceptualizations of self-care in academic publications which investigated or discussed self-care for young people's mental health or wellbeing. A Patient and Public Involvement (PPI) workshop facilitated young people with experience of mental health difficulties to respond to the identified concepts and co-develop a definition of self-care. Searches in PsycINFO, MEDLINE, Embase, CINAHL Plus, Scopus, Cochrane Library of Systematic Reviews, and gray literature sources resulted in 90 included publications. Content analysis indicated little conceptual consistency, with health and wellness promotion most commonly used to define self-care. The PPI workshop co-developed a definition of mental health self-care, which attendees felt should emphasize an individual process of self-awareness, self-compassion, and specific strategies to work toward emotional balance. This study highlights the gap between current academic understandings of young people's mental health self-care and young people's experience. The presented definition will enable future research to begin from an understanding of self-care which is relevant to young people with experience of mental health difficulties.

Exercise-based rehabilitation in and with nature: a scoping review mapping available interventions

INTRODUCTION

Exercise is an effective component in rehabilitation of a range of chronic conditions. There is a growing interest in the use of exercise-based nature interacted rehabilitation (EBNIR), but an overview of current evidence is missing. The objective of this scoping review was to map existing exercise-based rehabilitation interventions conducted with incidental or intentional nature interaction focusing on its populations, types of outcomes, and theoretical rationale for people with physical and mental disabilities.

METHODS

This scoping review identified peer-reviewed publications, registered upcoming trials and grey literature. To map all available knowledge, a comprehensive search of selected databases (MEDLINE; EMBASE; CINAHL; Cochrane; Web of Science; Pedro) from inception to October 2022. Data were synthesized in a thematic presentation guided by TIDieR, supplemented by a checklist developed for this study accounting nature incidental or intentional interaction.

RESULTS

Twelve studies including 856 participants met the inclusion criteria. Eleven were completed trials and one was registered in clinicaltrials.gov to be run in 2023. A total of 856 patients were enrolled in the 12 studies (range 18-262, median 50). The included studies had great variation. The incidental or intentional interacted exercise-based interventions consisted of outdoor walks, neck exercises and surfing interventions in patients with physical or mental health conditions.

CONCLUSIONS

This scoping review presents an overview of limited and diverse evidence within the field of EBNIR, in patients with physical or mental health conditions. Our review provides an overview that will be helpful in the design of future EBNIR trials.

Physical environment features that predict outdoor active play can be measured using Google Street View images

BACKGROUND

Childrens' outdoor active play is an important part of their development. Play behaviour can be predicted by a variety of physical and social environmental features. Some of these features are difficult to measure with traditional data sources.

METHODS

This study investigated the viability of a machine learning method using Google Street View images for measurement of these environmental features. Models to measure natural features, pedestrian traffic, vehicle traffic, bicycle traffic, traffic signals, and sidewalks were developed in one city and tested in another.

RESULTS

The models performed well for features that are time invariant, but poorly for features that change over time, especially when tested outside of the context where they were initially trained.

CONCLUSION

This method provides a potential automated data source for the development of prediction models for a variety of physical and social environment features using publicly accessible street view images.

Hot spring bathing practices have a positive effect on mental health in Japan

Hot springs have long been used for medical purposes throughout the world. Recently, the positive effects of hot spa-bathing on circulatory diseases have been reported, while there are few reports on the mental effects of hot spa-bathing. Therefore, the purpose of this study was to clarify the relationship between hot spa-bathing habits and mental health throughout Japan. We conducted a nationwide online survey, including questions on bathing behavior, subjective satisfaction, lifestyle, and illness. The results showed a significant positive correlation between hot spa-bathing habits and multiple subjective satisfaction levels regarding mental health effects. The factor analysis results indicated that hot spa-bathing habits tended to be associated with good mental health, high health consciousness, and disease. Our study revealed that subjective satisfaction was higher among individuals with hot spa-bathing habits, suggesting that the hot spring spa-bathing habit may have a positive influence on mental health.

The Relationship Between Nature and Immigrants' Integration, Wellbeing and Physical Activity: A Scoping Review

Exposure to nature has been suggested to promote immigrants' health and facilitate adaptation. This review summarizes previous research focusing on the relationship between nature and immigrants' integration, wellbeing and physical activity. A search strategy was developed and adapted to seven databases. After removing duplicates, 4861 records were screened, 81 met inclusion criteria. Community gardens and urban parks were the most studied environments. In these settings, embodied experiences (the interactive processes of sensing and cognition) can foster new memories that facilitate adaptation and attachment to new natural environments. Social interaction and reconnecting with pre-migration experiences through specific use patterns can promote cultural continuation, sense of belonging and wellbeing. Other health benefits such as physical activity, disease management and improved nutrition were less frequently studied. Barriers to participation and recommendations for research and practice were also identified. Use of stronger study designs and greater inclusion of immigrant groups in research, design and evaluation of nature-based initiatives is needed.

Effectiveness, cost-utility and physiological underpinnings of the FIBROWALK multicomponent therapy in online and outdoor format in individuals with fibromyalgia: Study protocol of a randomized, controlled trial (On&Out study)

Introduction: The On&Out study is aimed at assessing the effectiveness, cost-utility and physiological underpinnings of the FIBROWALK multicomponent intervention conducted in two different settings: online (FIBRO-On) or outdoors (FIBRO-Out). Both interventions have proved to be efficacious in the short-term but there is no study assessing their comparative effectiveness nor their long-term effects. For the first time, this study will also evaluate the cost-utility (6-month time-horizon) and the effects on immune-inflammatory biomarkers and Brain-Derived Neurotrophic Factor (BDNF) levels of both interventions. The objectives of this 6-month, randomized, controlled trial (RCT) are 1) to examine the effectiveness and cost-utility of adding FIBRO-On or FIBRO-Out to Treatment-As-Usual (TAU) for individuals with fibromyalgia (FM); 2) to identify pre–post differences in blood biomarker levels in the three study arms and 3) to analyze the role of process variables as mediators of 6-month follow-up clinical outcomes.

Methods and analysis: Participants will be 225 individuals with FM recruited at Vall d’Hebron University Hospital (Barcelona, Spain), randomly allocated to one of the three study arms: TAU vs. TAU + FIBRO-On vs. TAU + FIBRO-Out. A comprehensive assessment to collect functional impairment, pain, fatigue, depressive and anxiety symptoms, perceived stress, central sensitization, physical function, sleep quality, perceived cognitive dysfunction, kinesiophobia, pain catastrophizing, psychological inflexibility in pain and pain knowledge will be conducted pre-intervention, at 6 weeks, post-intervention (12 weeks), and at 6-month follow-up. Changes in immune-inflammatory biomarkers [i.e., IL-6, CXCL8, IL-17A, IL-4, IL-10, and high-sensitivity C-reactive protein (hs-CRP)] and Brain-Derived Neurotrophic Factor will be evaluated in 40 participants in each treatment arm (total n = 120) at pre- and post-treatment. Quality of life and direct and indirect costs will be evaluated at baseline and at 6-month follow-up. Linear mixed-effects regression models using restricted maximum likelihood, mediational models and a full economic evaluation applying bootstrapping techniques, acceptability curves and sensitivity analyses will be computed.

Ethics and dissemination: This study has been approved by the Ethics Committee of the Vall d’Hebron Institute of Research. The results will be actively disseminated through peer-reviewed journals, conference presentations, social media and various community engagement activities. Trial registration number NCT05377567 (clinicaltrials.gov).

Psychophysiological restorative potential in cancer patients by virtual reality (VR)-based perception of natural environment

The positive significance of nature to human’ self-reported well-being has been widely confirmed, but less attention has been paid to the study of cancer patients, as well as the role of time on the restorative effects. Therefore, using virtual reality (VR) and the inclusion of patients with esophageal and gastrointestinal cancer as participants, this study conducted indoor experiments to explore patients’ psychophysiological recovery through the perception of five different environmental types with three to five interventions per week. There were 63 participants selected from the People’s Hospital in Shaanxi Province. Depending on their psychophysiological state, they would participate in three to five interventions in a week to compare the number of interventions needed to achieve maximum restoration. The five environmental types utilized varied in land cover, vegetation structure, and landscape characteristics, and were identified as blue space (BS), open green space (OGS), semi-open green space (SOS), closed green space (CGS), and gray space (GrS). Before and after viewing landscapes, the changes of psychophysiological indicators were measured to explore the influence of different environmental types on participants. The results showed that the participants preferred and received the highest perceived restorative potentials in BS and lastly, GrS. The green and blue spaces measurably increased positive emotions and perceived restoration while a decreasing negative emotions and the heart rate (HR) compared with the GrS. Participants had the highest level of relaxation while their eyes were closed in the EEG baseline stage. Moreover, participants received the most relaxation when they contacted with nature three times a week, which indicated that excessive natural participation may not be conducive to the sustained development of cancer patients’ psychophysiological health. Instead of field appreciation, VR could be utilized to increase the access of cancer patients to nature and then be used as an approach to landscape interaction.

Exploring factors influencing uptake and adherence to a home-based prehabilitation physical activity and exercise intervention for patients undergoing chemotherapy before major surgery (ChemoFit): a qualitative study

OBJECTIVES

Preoperative exercise training can improve cardiorespiratory fitness before major surgery. However, little is known about what influences participation and adherence in high-risk patient groups. We identified barriers and facilitators to uptake, engagement and adherence to a presurgical, home-based physical activity and exercise intervention called ChemoFit delivered during chemotherapy and before major oesophagogastric surgery.

DESIGN

A qualitative study using focus group discussions and individual semi-structured interviews was conducted. All were audio-recorded, transcribed verbatim and data thematically analysed.

SETTING

Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NHS Hospitals Foundation Trust.

PARTICIPANTS

Patients with oesophagogastric cancer who participated in the ChemoFit intervention recruited between March 2020 and January 2021.

INTERVENTION

A home-based physical activity and exercise intervention involving cardiovasular and strength exercise using resistance bands and pedometers to monitor step count. Weekly telephone calls provided feedback, support and positive reinforcement.

RESULTS

Twenty-two participants (18 men, 4 women; aged 67±8 years old) took part in a focus group discussion (n=17) or a semi-structured interview (n=5). Fifteen themes were identified from the data generated. Participants reported that the intervention was physically and mentally beneficial, and data highlighted features of the intervention that influenced uptake and adherence. An opportunity to increase the likelihood of surviving the pending operation was reported by participants as the most salient factor to engagement, and using the intervention as a distraction from illness and taking steps to positively influence the situation were the most salient factors to adherence.

CONCLUSIONS

Uptake to the ChemoFit intervention was encouraged by provision of information that participation could reduce surgical risk and that participants could play an active role in risk reduction. Adherence was facilitated by the intervention being considered a positive distraction and participants being able to do something that could ultimately provide benefit. While participants reported difficulties and avoidance with some of the exercises recommended, understanding the importance of physical activity and exercise as part of their treatment regimen led to individual adaptations to intervention components to reach individual goals.

TRIAL REGISTRATION NUMBER

NCT04194463.

Green Space for Mental Health in the COVID-19 Era: A Pathway Analysis in Residential Green Space Users

Residential green space is among the most accessible types of urban green spaces and may help maintain mental health during the COVID-19 pandemic. However, it is insufficiently understood how residents use residential green space for exercise during the epidemic. The pathways between residential green space and mental health also merit further exploration. Therefore, we conducted an online study among Chinese residents in December 2021 to capture data on engagement with urban green space for green exercise, the frequency of green exercise, perceived pollution in green space, perceptions of residential green space, social cohesion, depression, and anxiety. Among the 1208 respondents who engaged in green exercise last month, 967 (80%) reported that green exercise primarily occurred in residential neighborhoods. The rest (20%) reported that green exercise occurred in more distant urban green spaces. The most common reasons that respondents sought green exercise in urban green spaces were better air and environmental qualities. Structural equation modeling (SEM) was then employed to explore the pathways between the perceived greenness of residential neighborhoods and mental health among respondents who used residential green space for exercise. The final model suggested that residential green space was negatively associated with anxiety (β = −0.30, p = 0.001) and depression (β = −0.33, p < 0.001), mainly through indirect pathways. Perceived pollution and social cohesion were the two mediators that contributed to most of the indirect effects. Perceived pollution was also indirectly associated with green exercise through less social cohesion (β = −0.04, p = 0.010). These findings suggest a potential framework to understand the mental health benefits of residential green space and its accompanying pathways during the COVID-19 era.

Mental health clinicians' perceptions of nature-based interventions within community mental health services: evidence from Australia

Background

Mental health conditions are one of the largest burdens of disease in Australia and globally. There is a need to seek innovative and alternative interventions that can prevent and alleviate mental health symptoms. Nature-based interventions (NBIs), namely programs and activities where individuals engage with natural environments with the aim of improving their health and wellbeing (e.g., nature walking groups), may be such an alternative. This study aimed to explore the perceptions of mental health clinicians on the potential benefits of, and barriers to, implementing NBIs within a community mental health setting.

Methods

This study used a qualitative, exploratory research design. Fifteen mental health clinicians were recruited from the Illawarra Shoalhaven Local Health District, Australia, and interviewed (September–October 2021) about their perceptions of NBIs within mental health settings. The semi-structured interviews were analysed using an inductive thematic approach and managed with NVivo.

Results

Mental health clinicians viewed spending time in nature as relaxing, refreshing, and therapeutic. Many described it as part of their lifestyle and encouraged consumers to engage in nature-based activities on their own time. If NBIs were to be introduced as part of mental health services, clinicians expressed willingness to promote them to their consumers. Clinicians listed many potential benefits of NBIs for mental health consumers including improved mood, calmness and relaxation, a sense of empowerment, and social connections. Despite these benefits, clinicians were concerned about a variety of barriers to NBIs including consumers’ mental health symptoms such as anxiety or lack of motivation, scepticism, and geographic accessibility, as well as organisational barriers such as policies around safety risk.

Conclusion

Responding to the individual and organisational factors that could hinder the implementation of NBIs while building on the existing evidence of the positive impact of nature on health and wellbeing and, as demonstrated in this study, mental health clinicians’ interest and supportiveness of NBIs, mental health services should consider the implementation of NBIs as part of routine practice.

The Effects of Green and Urban Walking in Different Time Frames on Physio-Psychological Responses of Middle-Aged and Older People in Chengdu, China

Nighttime walking is becoming a popular exercise for many middle-aged and older people in Asian countries. However, the health benefits of nighttime walking in urban areas and green spaces are still unclear. This study evaluated the physiological and psychological responses of 48 middle-aged and older people who walked 1.6 km through a green space and an urban area during daytime and nighttime. The Positive and Negative Affect Schedule (PANAS), Profile of Mood States (POMS), Perceived Restorativeness Scale (PRS), and Restorative Outcome Scale (ROS) were employed to measure the psychological responses, and pulse rate and blood pressure (SBP, DBP and MAP) were measured to evaluate the physiological responses. The results showed that the daytime green walking induced psychological improvements and lowered blood pressure (p < 0.05), while the daytime urban walking resulted in slight deterioration of all the measured parameters (p > 0.05). On the other hand, the nighttime green walking induced lowered blood pressure (p < 0.05), whilst the nighttime urban walking resulted in psychological improvements and lowered blood pressure (p < 0.05), and no significant difference was found in any measured parameter between the two nighttime walking groups. In conclusion, urban areas are noisy and irritating in the daytime, and not suitable for walking, but may become pleasurable and attractive at night. The psychological benefits of green walking may decrease at night, and nighttime walking in either an urban area or a green space may achieve similar health benefits. Therefore, we recommend that urban citizens start nighttime walking in a green space or an urban area to keep fit when the air is less polluted.

Effectiveness of a Multicomponent Treatment for Fibromyalgia Based on Pain Neuroscience Education, Exercise Therapy, Psychological Support, and Nature Exposure (NAT-FM): A Pragmatic Randomized Controlled Trial

A recent study (FIBROWALK has supported the effectiveness of a multicomponent treatment based on pain neuroscience education (PNE), exercise therapy (TE), cognitive behavioral therapy (CBT), and mindfulness in patients with fibromyalgia. The aim of the present RCT was: (a) to analyze the effectiveness of a 12-week multicomponent treatment (nature activity therapy for fibromyalgia, NAT-FM) based on the same therapeutic components described above plus nature exposure to maximize improvements in functional impairment (primary outcome), as well as pain, fatigue, anxiety-depression, physical functioning, positive and negative affect, self-esteem, and perceived stress (secondary outcomes), and kinesiophobia, pain catastrophizing thoughts, personal perceived competence, and cognitive emotion regulation (process variables) compared with treatment as usual (TAU); (b) to preliminarily assess the effects of the nature-based activities included (yoga, Nordic walking, nature photography, and Shinrin Yoku); and (c) to examine whether the positive effects of TAU + NAT-FM on primary and secondary outcomes at post-treatment were mediated through baseline to six-week changes in process variables. A total of 169 FM patients were randomized into two study arms: TAU + NAT-FM vs. TAU alone. Data were collected at baseline, at six-week of treatment, at post-treatment, and throughout treatment by ecological momentary assessment (EMA). Using an intention to treat (ITT) approach, linear mixed-effects models and mediational models through path analyses were computed. Overall, TAU + NAT-FM was significantly more effective than TAU at posttreatment for the primary and secondary outcomes evaluated, as well as for the process variables. Moderate-to-large effect sizes were achieved at six-weeks for functional impairment, anxiety, kinesiophobia, perceived competence, and positive reappraisal. The number needed to treat (NNT) was 3 (95%CI = 1.6-3.2). The nature activities yielded an improvement in affective valence, arousal, dominance, fatigue, pain, stress, and self-efficacy. Kinesiophobia and perceived competence were the mediators that could explain a significant part of the improvements obtained with TAU + NAT-FM treatment. TAU + NAT-FM is an effective co-adjuvant multicomponent treatment for improving FM-related symptoms.

Efficacy of a Multicomponent Intervention for Fibromyalgia Based on Pain Neuroscience Education, Exercise Therapy, Psychological Support, and Nature Exposure (NAT-FM): Study Protocol of a Randomized Controlled Trial

The study protocol of a prospective and randomized controlled trial for the assessment of the efficacy of nature activity therapy for people with Fibromyalgia (NAT-FM) is described. The primary outcome is the mean change from baseline in the Revised Fibromyalgia Impact Questionnaire (FIQR) score at post-treatment (12 weeks) and at 9 months of follow-up, and secondary outcomes are changes in the positive affect, negative affect, pain, fatigue, self-efficacy, catastrophising, and emotional regulation. A total of 160 patients with fibromyalgia will be divided into two arms: treatment-as-usual (TAU) and NAT-FM+TAU. Pre, during, post, +6, and +9 months assessments will be carried out, as well as an ecological momentary assessment (EMA) of intrasession and intersessions. Results will be subjected to a mixed group (NAT-FM+TAU vs. TAU) × phase (pre, post, +6 months, +9 months) general linear model. EMA intrasession measurements will be subjected to a 2 (pre vs. post) × 5 (type of activity) mixed-effects ANOVA. EMA between-session measurements obtained from both arms of the study will be analysed on both a time-domain and frequency-domain basis. Effect sizes and number needed to treat (NNT) will be computed. A mediation/moderation analysis will be conducted.

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

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