Freshwater blue space and population health: An emerging research agenda

Examining inequality in aquatic ecosystem services: Evidence from large-scale monitoring programs

We hypothesize that aquatic ecosystem services are likely to be inequitably accessible and addressing this hypothesis requires systematic assessment at regional and national scales. We used existing data from large-scale aquatic monitoring programs (National Coastal Condition Assessment, National Lakes Assessment) to examine relationships between ecosystem condition, approximating a subset of cultural and provisioning services, and inequality (population below poverty level, minority population). We also assessed whether monitoring sites equitably represented the gradient of socioeconomic backgrounds. Several water quality indicators were associated with significantly different minority and low-income percentages; however, the effect size was generally small, with the exception of nitrogen condition status. Minority communities were somewhat under-represented when comparing the distribution of all census blocks to those in proximity to monitoring sites. Analyses were sensitive to the skewed distribution of monitoring sites with a low frequency of observations at the more socially vulnerable part of the gradient. We discuss implications of these findings for improving the representation of vulnerable communities in large-scale monitoring programs.

Impact of "blue-green diet" on human health and wellbeing: A systematic review of potential determinants in shaping the effectiveness of blue-green infrastructure (BGI) in urban settings

Discourses concerning the potential health benefits of blue-green infrastructure (BGI) have gained momentum, highlighting its positive influence on human health and wellbeing. While studies have explored the concept of "Nature Pyramid" and the role of exposure to natural environments in promoting health, the role of water elements remains underexplored. Rooted in this concept, this study proposed a notion of "blue-green diet" as a framework to understand the intricate mechanisms and determinants of optimal blue-green exposure. Understanding the relationship between these determinants and their health-related impacts can facilitate the enhancement of BGI design, leading to greater effectiveness in promoting health and wellbeing and supporting sustainable urban development strategies. To enhance the comprehension of the "blue-green diet", this study conducted a systematic literature review to grasp the underlying mechanisms behind its beneficial effects, focusing on two key determinants of "blue-green diet", which are also derived from the concept of the "Nature Pyramid": (1) the type of BGI and (2) the mode of interaction with and within BGIs. Under the search of BGI's overall health impacts, this study selected 54 journal publications concerning BGI's type and interaction mode from Web of Science and Scopus since 2010. The review revealed significant disparities in the health benefits provided by different types of BGI (in terms of artificial extent and scale) and between active and passive interaction modes. It examines how to balance natural and artificial elements for enhancing the benefits of BGI and discusses the attributes of BGI that encourage diverse and meaningful interaction patterns. These efforts collectively aim to optimize BGI design and planning, increase its capacity to promote health, and extend its benefits to a wider range of individuals. Future research should encompass a broader spectrum of determinants, such as diverse BGI settings, visit frequency and duration, and user's social-cultural backgrounds.

The built environment and cancer survivorship: A scoping review

BACKGROUND

There are more than 32 million cancer survivors worldwide. The built environment is one of the contextual factors that may influence cancer survivorship. However, studies investigating the interdisciplinary field of the built environment and cancer survivorship are lacking.

OBJECTIVE

To conduct a systematic review of the existing literature regarding the relationship between the built environment and cancer survivorship, identify any knowledge gaps, and recommend future research directions.

METHODS

A systematic literature search was performed by searching OVID Medline, Embase, CINAHL, and Web of Science Core Collection.

RESULTS

Of 4235 unique records identified, 26 studies met eligibility criteria. Neighborhood walkability and greenness were the most examined built environment characteristics among the included studies. Walkability was found to be associated with various cancer survivorship experience, including increased levels of physical activity, lowered body mass index, and improved quality of life. The association between greenness and cancer survivorship outcomes were inconsistent across the included studies. Additionally, studies have reported the relationship between light and noise pollution and sleep among cancer survivors. Regarding blue space, in one qualitative study, breast cancer survivors brought up the healing properties of water.

CONCLUSION

Our scoping review demonstrated a breadth of current cancer survivorship research in the field of neighborhood walkability and greenness, but fewer studies detailing other aspects of the built environment as defined by this review, such as light pollution, noise pollution, and blue space. We identified future research directions for those interested in this interdisciplinary field, which can provide insights for urban planners and policy makers on how to best leverage the built environment to promote the health and wellbeing of cancer survivors.

Anthropogenic impacts on urban blue space and its reciprocal effect on human and socio-ecological health

Quantifying anthropogenic impacts on blue space (BS) and its effect on human and socio-ecological health was least explored. The present study aimed to do this in reference to the urban BS transformation scenario of Eastern India. To measure BS transformation, Landsat image-based water indices were run from 1990 to 2021. Anthropogenic impact score (AIS) and 7 components scores of 78 selected BS on 70 parameters related data driven from the field. Total 345 respondents were taken for human and socio-ecological health assessment. For this, depression (DEP), anxiety (ANX), stress (STR), physical activities (PA), social capital (SC), therapeutic landscape (TL) and environment building (EB) parameters were taken. The result exhibited that BS was reduced. About 50% of urban core BS was reported highly impacted. Human and socio-ecological health was identified as good in proximity to BS, but it was observed better in the cases of larger peripheral BS. AIS on BS was found to be positively associated with mental health (0.47-0.63) and negatively associated with PA, SC, TL and EB (-0.50 to -0.90). Standard residual in ordinary least square was reported low (-1.5 to 1.5) in 95% BS. Therefore, BS health restoration and management is crucial for sustaining the living environment.

Beaver-related restoration: An opportunity for sandy lowland streams in a human-dominated landscape

The expansion of beavers into human-dominated landscapes can help improve the ecological status of degraded streams. This study aimed to assess the changes in the ecological status of a degraded sandy-bottom stream under the influence of processes generated by the activity of a European beaver. We assumed that the processes in the beaver dam-and-pond complex significantly improved the physical, chemical, and bacteriological properties of water and improved the ecological status of a small lowland stream in a human-dominated landscape. To achieve these objectives, water for quality assessment, benthic invertebrates, and fish samples were collected, and the forms of land use and the natural values of the stream were analysed. In the upstream zone of the sandy-bottom stream flowing in a human-dominated landscape, the inflow of pollutants caused a significant reduction in water quality. The amount of nutrients was high and the amount of dissolved oxygen was low. Similarly, the number of meso- and psychrophilic bacteria was significantly higher than in the reference stream. The building activity of beavers initiated a series of positive environmental changes, and beaver ponds improved the self-purification of water in a polluted stream. In the lower part of the studied stream, after the stream passed through the beaver wetland system, the water quality improved, which was indicated by a significant improvement in physicochemical, microbiological, and biotic indicators, that is based on macrozoobenthos and fish. By constructing dams, beavers flooded large areas and created habitats for plant and animal species associated with wetlands, including amphibians, birds, and mammals. The improvement of the ecological status of the stream, combined with the preservation and restoration of wetland habitats in the catchment area, enables the use of ecosystem services provided by the streams in the human-dominated landscape and their surroundings.

The impact of outdoor blue spaces on the health of the elderly: A systematic review

Research on natural health has identified the potential benefit of outdoor blue spaces for human health and wellbeing. However, the existing evidence has relatively limited attention to the elderly. This study aims to review the available evidence on outdoor blue spaces and health outcomes among older individuals and identify knowledge gaps. In accordance with the PRISMA guidelines, specific keywords were used to search for articles published in English from inception to October 2023. Five databases (Scopus, PubMed, Web of Science, CINAHL, and PsycINFO) were searched, and 22 studies were identified in this review. We classified articles based on elderly health as general health (e.g., self-reported, perceived health and wellbeing), physical health (e.g., physical activity, physical function index), and mental health and wellbeing (e.g., depression). The findings indicated a positive correlation between outdoor blue space and the health of the elderly. In terms of the characteristics of exposure to outdoor blue spaces, direct contact (e.g., sensory-based) has not been well documented compared to indirect contact (e.g., distance, percentage, region-based). Although encouraging, the available body of evidence is limited and lacks consistency. Future research is needed to provide complementary evidence between outdoor blue spaces and elderly health.

Associations of green and blue space exposure in pregnancy with epigenetic gestational age acceleration

Early life is seen as a particularly sensitive period for environmental exposures. Natural space exposure during pregnancy has been associated with offspring health. Epigenetic gestational age acceleration, a discrepancy between clinical and DNA methylation-based gestational age, may underlie these associations. In 1359 mother-newborn pairs from the population-based Generation R Study, we examined the associations of natural space exposure, defined as surrounding greenness, distance to major green and blue (water) space, and size of the blue space during pregnancy with offspring epigenetic gestational age acceleration. Natural space exposure was based on participants' geocoded addresses, and epigenetic gestational age acceleration was calculated from cord blood DNA methylation using Bohlin's and Knight's epigenetic clocks. Sensitivity analyses were conducted in a subgroup of newborns with optimal pregnancy dating, based on last menstrual period. Surrounding greenness, measured in normalized difference vegetation index values, was intermediate (median 0.4, IQR 0.2), and 84% and 56% of the participants had a major green or blue space near their home address, respectively. We did not observe associations of natural space availability during pregnancy with offspring epigenetic gestational age acceleration. This could imply that epigenetic gestational age acceleration in cord blood does not underlie the effects of residential natural space availability in pregnancy on offspring health. Future studies could investigate whether residential natural space availability during pregnancy is associated with offspring differential DNA methylation at other CpGs than those included in the epigenetic gestational clocks.

Self-reported benefits and risks of open water swimming to health, wellbeing and the environment: Cross-sectional evidence from a survey of Scottish swimmers

Engaging with natural environments benefits human health by providing opportunities for social interactions, enhancing mental wellbeing and enabling outdoor spaces for physical exercise. Open water swimming has seen a rapid increase in popularity, partly due to the physical health benefits it can provide but also with the growing interest in (re)connecting with nature for environment-health interactions. Using a national-scale online survey of 717 open water swimmers, the aim of this study was to investigate patterns and trends in the perceived benefits and risks of open water swimming to both public health and the environment; and to understand whether these perceived risks and benefits vary across different typologies of swimmers and open water, or 'blue space', environments. Strong associations were found between the most important self-reported benefit associated with open water swimming and both participant age and the categorisation of their typical swim style. All but one of the age-groups surveyed perceived mental wellbeing benefits to be the most important benefit of open water swimming; whilst those aged over 65 identified physical rather than mental wellbeing benefits to be the most important outcome. Participants who preferred lake swimming reported greater concern regarding possible environmental damage caused by the increasing popularity of open water swimming compared to those engaging in river or sea swimming. However, the majority of participants perceived the risks to the environment from open water swimming to be minimal. Our study adds to the growing evidence that open water swimming is perceived by participants as benefitting their mental and physical wellbeing. Improved understanding of the benefits and risks of engaging with blue spaces used for open water swimming can contribute to co-designed policy development to promote safer, healthier and more sustainable outdoor recreation opportunities associated with this increasingly popular outdoor pursuit.

Association of greenness with the disease burden of lower respiratory infections and mediation effects of air pollution and heat: a global ecological study

Exposure to greenness is increasingly linked to beneficial health outcomes, but the associations between greenness and the disease burden of lower respiratory infections (LRIs) are unclear. We used the normalized difference vegetation index (NDVI) and the leaf area index (LAI) to measure greenness and incidence, death, and disability-adjusted life years (DALYs) due to LRIs to represent the disease burden of LRIs. We applied a generalized linear mixed model to evaluate the association between greenness and LRI disease burden and performed a stratified analysis, after adjusting for covariates. Additionally, we assessed the potential mediating effects of fine particulate matter (PM2.5), ozone (O3), nitrogen dioxide (NO2), and heat on the association between greenness and the disease burden of LRIs. In the adjusted model, one 0.1 unit increase of NDVI and 0.5 increase in LAI were significantly inversely associated with incidence, death, and DALYs due to LRIs, respectively. Greenness was negatively correlated with the disease burden of LRIs across 15-65 age group, both sexes, and low SDI groups. PM2.5, O3, and heat mediated the effects of greenness on the disease burden of LRIs. Greenness was significantly negatively associated with the disease burden of LRIs, possibly by reducing exposure to air pollution and heat.

Land uses in cities and their impacts on the water quality of urban freshwater blue spaces in the Pampean region (Argentina)

Freshwater blue spaces (FBS), such as ponds, are key elements of the urban landscape and are under strong anthropogenic pressure. Land-use types and diversity may exert a negative or positive impact on FBS' water quality depending on their nature and arrangement. The information available in this respect is remarkably scarcer for water bodies in the Global South than for the north. Thus, we aim to identify and quantify the land-use types in a 500-m buffer zone of urban ponds in the Pampean region (Argentina) to assess their impact on water quality. We based our study on 15 FBS located in neighborhoods of Buenos Aires province during cold and warm seasons. We analyzed physical, chemical, and biological variables, and estimated water conditions by means of water quality indexes (WQIs) and quality guidelines. We quantified the dominant land-use type and the diversity of uses in the ponds' buffer zones, and evaluated their relationships with WQIs. Our results showed that WQIs were negatively related to a high proportion of residential areas in the adjacent zone, while positively to recreational ones. The diversity of land uses did not influence the water quality. We propose a new WQI_pond with fewer key response variables, and as sensitive as the currently used WQI_objetive. We conclude that water quality from urban ponds in the Pampean region can be affected by dominant land-use type in the adjacent area but also the quality of their water supply sources (superficial and/or underground), clandestine wastewater discharges, and non-point pollution.

Premature mortality attributable to NO2 exposure in cities and the role of built environment: A global analysis

BACKGROUND

Environmental risks accumulate in cities, including polluted air and health disparities, but these risks can be reduced through scientific city planning. The purpose of this study was to investigate the global burden of premature mortality attributable to NO₂ exposure in urban areas and the role of the built environment in this regard.

METHODS

An approach based on health impact assessment was used to estimate the premature mortality burdens associated with NO₂ exposure in 13,169 urban areas around the world using globally gridded NO₂ and population estimates, baseline mortality, and epidemiologically derived exposure-response functions. We used the most recent WHO recommended value (i.e.,10 μg/m³) as a counterfactual concentration. Finally, the relationship between the characteristics of the built environment at the city level and the burden of NO₂-related mortality was evaluated.

RESULTS

Worldwide, 549,715(95%CI: 276204-815,023) cases of death attributable to NO₂ exposure in urban areas could be prevented if compliance with the latest WHO guideline, accounting for 2.7 % (95%CI:1.4 %-4.0 %) of total mortalities in 2019. Across cities around the world, the age-standardized mortality rate (per 100,000 people) attributable to NO₂ exposure ranged from 51.3 (95%CI:25.8-76.0) in Central Asia to 3.4(95%CI: 1.7-5.1) in Oceania. Although there was a significant decrease in premature mortality attributable to NO₂ exposure globally, considerable regional heterogeneity exists, with cities in Central Asia and Andean Latin America in particular exhibiting an upward trend. Further, we discovered a positive association between population density and street connectivity with mortality attributable to NO₂. While the increase in green and blue space were significantly associated with a lower NO₂-associated mortality.

CONCLUSION

The findings of this study provided a comprehensive understanding of the premature mortality burden due to NO₂ in cities throughout the world and the role that urban planning policies can play in reducing the health burden associated with air pollution.

Sea swimming and snorkeling in tropical coastal blue spaces and mental well-being: Findings from Indonesian island communities during the COVID-19 pandemic

The COVID-19 pandemic has considerable mental health impacts. Immersive nature-based interventions, such as swimming or snorkeling, may help mitigate the global mental health crisis caused by the pandemic. To investigate this, we collected cross-sectional data from residents of coastal villages (n = 308) in Kepulauan Selayar, Indonesia. Analysis of Covariance (ANCOVA) was used with mental well-being as the outcome variable, operationalized as the Mental Component Summary (MCS) scores from the SF-12 (12-item Short Form Health Survey). After adjusting for covariates, the activity of sea swimming or snorkeling was found to be significantly associated with better mental well-being (η² = 0.036; p < 0.01). Predictive margins analysis revealed that those who engaged in sea swimming or snorkeling for one to three days a week gained a 2.7 increase in their MCS scores, compared to those who did not. A non-linear dose-response relationship was detected: for those swimming or snorkeling more than three days per week, there was only an increase of 1.7 MCS score compared to the 0-day. Overall this study contributes to the expanding of evidence base, showing that interactions with blue spaces can be beneficial for mental health, especially in a potentially stressful time such as the current pandemic.

Management implications

The positive association between the activity of swimming or snorkeling in open seas and the mental well-being of rural coastal communities in Indonesia during the COVID-19 pandemic indicates that access to coastal blue spaces is important in a time of uncertainties and high stress. Ensuring that local communities have continuous access to these spaces is the key challenge for all relevant stakeholders, particularly in light of the growing privatization of the local coastal environment for the sake of tourism. However, considering the importance that these blue spaces hold for the mental well-being of local communities, intensive dialogue amongst these stakeholders must be pursued to ensure that the development of the area does not jeopardize the collective well-being of the people already living there.

Effects of perceived physical and aesthetic quality of urban blue spaces on user preferences–A case study of three urban blue spaces in Japan

Blue spaces, especially as important urban natural environments, provide various benefits. Despite the increasing number of relevant papers, most recent studies have focused on the association between blue space environmental quality and health, with limited research assessing the environmental quality and user preferences of urban blue spaces. This study establishes a relationship between preference and environmental quality by investigating visitors' perception of the environmental quality of urban blue spaces (physical and aesthetic). For this purpose, 296 questionnaires were collected from three urban blue spaces and a multiple linear regression analysis was executed. Model results indicated that six of nine environmental quality components had a significant effect on preference scores, with "harmony" demonstrating the highest and "visual spaciousness & diversity" the lowest effect. The current study shown that two scales provided were used to measure users' perceived levels of the physical and aesthetic quality of the Urban Blue Spaces were acceptable. These results can help in the effective use of these natural capitals in cities and provide guidance for the environmental design of blue spaces.

Association of residential greenness with incident chronic obstructive pulmonary disease: A prospective cohort study in the UK Biobank

BACKGROUND

Residential greenness has been linked to respiratory mortality, but its long-term effect on incident chronic obstructive pulmonary disease (COPD) has rarely been investigated.

METHODS

This prospective cohort study was based on over 350 000 participants aged 38-70 of the UK Biobank, followed from 2006 to 2010 baseline to 2021. COPD cases were ascertained through linkages to health administrative datasets. Residential greenness was measured by satellite-derived normalized difference vegetation index (NDVI) within the 500- and 1 000-m buffer. Effects of greenness on COPD incidence were assessed using Cox proportional hazards models. We also explored mediation by physical activity, particular matter <2.5 μm in aerodynamic diameter (PM_2.5) and nitrogen oxides (NO_x). Restricted cubic spline models were fit to assess exposure-response relationships.

RESULTS

A total of 363 212 individuals (mean [SD] age, 56.2 [8.1] years; 193 181 [53.2 %] women] were included in the analyses. 8 261 COPD cases occurred over 4 287 926 person-years of follow-up. We observed 8% lower COPD risk per IQR increase in NDVI in the 500-m buffer (95% CI: 0.89, 0.95). The association between greenness in the 500-m buffer and COPD were partially mediated by physical activity (1.0%, 95% CI: 0.2%, 1.8%), PM_2.5 (21.0%, 95% CI: 3.7%, 38.4%) and NO_x (17.0%, 95% CI: 2.8%, 31.2%). Similar results were observed for NDVI within 1 000-m buffer.

CONCLUSIONS

Long-term exposure to residential greenness was associated with lower risk of COPD incidence among UK adults. Our findings provide a rationale for greening policies as part of respiratory health promotion efforts.

Exploring the Association between Neighborhood Blue Space and Self-Rated Health among Elderly Adults: Evidence from Guangzhou, China

Blue spaces is associated with self-rated health (SRH), but little is known about the pathways underlying this association among Chinese urban elderly individuals. Based on neighborhood effect theory, this study examined the relationship between neighborhood blue spaces and SRH among elderly individuals using data from a questionnaire survey conducted in Guangzhou, remote sensing images, street views, and environmental information in the context of a Chinese megacity. In addition, multilevel linear model and mediating effect model empirical analyses were performed. Results showed that first, the SRH of the elderly was associated with individual- and neighborhood-level factors. Second, the multilevel mediation model revealed that multiple biopsychosocial pathways existed between neighborhood blue spaces and the SRH of the elderly, specifically, the blue space characteristics related to the SRH of the elderly via the mediating effect of stress. Third, owing to demographic characteristics and socioeconomic status, the stratified analyses also indicated a strong association between neighborhood blue spaces and SRH outcomes in the older and low-income groups. The mediating effect of stress in the age and income groups was also observed, and the mediation pathways and group differences were confirmed in the context of Chinese cities. This research enriches the empirical literature on blue spaces and elderly health from a multidisciplinary perspective and suggests the need for "healthy neighborhood" and "health-aging" planning in Chinese settings.

Living near coasts is associated with higher suicide rates among females but not males: A register-based linkage study in the Netherlands

Exposure to blue spaces may promote psychological wellbeing and reduce mental distress. Whether these effects extend to suicide is unknown. We used register data from 14 million Dutch adults aged 18-64-years between 2007 and 2016 in a nested case-control study to estimate associations between blue space exposures and suicide risk. Each suicide case was matched to ten randomly selected controls. Two blue space exposures were assigned over a ten-year residential address history: distance to the closest inland blue space and distance to the coast. We fitted (gender-stratified) conditional logistic regressions to the data. Possible effect modifications by income were also examined. In total, our analyses included 9757 cases and 95,641 controls. Effect estimates for distance to the closest inland blue space in the total population showed that people living farthest away from inland blue space were at-risk. Suicide risk was lower among women who lived farther away from the coast; no significant effect was observed for men. No evidence was observed that income modified these associations. Our findings provide suggestive evidence that living close to the coast is associated with greater suicide risk for women, while living closer to inland blue spaces may add to the resilience against suicide in the total population. Past research shows that coastal proximity protects against milder forms of mental illness, but these protective effects do not appear to hold for suicide. Blue space interventions for women with severe mental illness or propensities to engage in self-harm should be approached with caution.

Associations of parks, greenness, and blue space with cardiovascular and respiratory disease hospitalization in the US Medicare cohort

Natural environments have been linked to decreased risk of cardiovascular disease (CVD) and respiratory disease (RSD) mortality. However, few cohort studies have looked at associations of natural environments with CVD or RSD hospitalization. The aim of this study was to evaluate these associations in a cohort of U.S. Medicare beneficiaries (∼63 million individuals). Our open cohort included all fee-for-service Medicare beneficiaries (2000-2016), aged ≥65, living in the contiguous U.S. We assessed zip code-level park cover based on the United States Geological Survey Protected Areas Database, average greenness (Normalized Difference Vegetation Index, NDVI), and percent blue space cover based on Landsat satellite images. Cox-equivalent Poisson models were used to estimate associations of the exposures with first CVD and RSD hospitalization in the full cohort and among those living in urban zip codes (≥1000 persons/mile2). NDVI was weakly negatively correlated with percent park cover (Spearman ρ = -0.23) and not correlated with percent blue space (Spearman ρ = 0.00). After adjustment for potential confounders, percent park cover was not associated with CVD or RSD hospitalization in the full or urban population. An IQR (0.27) increase in NDVI was negatively associated with CVD (HR: 0.97, 95%CI: 0.96, 0.97), but not with RSD hospitalization (HR: 0.99, 95%CI: 0.98, 1.00). In urban zip codes, an IQR increase in NDVI was positively associated with RSD hospitalization (HR: 1.02, 95%CI: 1.00, 1.03). In stratified analyses, percent park cover was negatively associated with CVD and RSD hospitalization for Medicaid eligible individuals and individuals living in low socioeconomic status neighborhoods in the urban population. We observed no associations of percent blue space cover with CVD or RSD hospitalization. This study suggests that natural environments may benefit cardiorespiratory health; however, benefits may be limited to certain contexts and certain health outcomes.

Blue sky as a protective factor for cardiovascular disease

Objective

Blue sky has been considered to boost outdoor physical activity and social interaction, ameliorate work pressure and life stress, and enhance people's sense of happiness. However, the direct association between blue sky exposure and cardiovascular disease (CVD) still lacks epidemiological evidence. In this study, we aimed to quantify their relationship via a nationwide prospective cohort in China.

Method

We extracted the baseline data from the China Hypertension Survey (CHS), by enrolling 22,702 participants aged ≥ 35 years without self-reported medical history of CVD from 14 provinces of China between 2012 and 2015 and followed up from 2018 to 2019. A blue day was marked out with no rain, low cloud cover ≤ climatological mean at each station, and visibility at 2 pm ≥ 21.52 km. We calculated the number of blue days at baseline survey year to evaluate the chronic individual blue day exposure. Cox proportional hazards models were employed to calculate the multivariable-adjusted hazard ratio (HR). We implemented subgroup analyses as well to identify potential effect modifications.

Results

A total of 1,096, 993, and 597 incident cases of all-cause mortality, fatal or nonfatal CVD, and stroke occurred during a median follow-up around 5 years, respectively. A 10-day increase in annual blue day exposure was associated with a 3% (95% confidence interval [CI]: 1-6%) and 7% (95% CI: 5-10%) decreased risk of fatal or nonfatal CVD and stroke, respectively. Compared with those exposed to the worst tertile of blue days at baseline, subjects who exposed to the best tertile had a 32% (95% CI: 19-43%) and 43% (95% CI: 29-55%) lower likelihood of developing fatal or nonfatal CVD and stroke, respectively. Negative consistent exposure-response relationships were generally observed between them in the restricted cubic spline model. In the stratified analyses, the cardioprotective effects of blue sky were stronger for females, rural residents, and individuals residing in heavily contaminated areas.

Conclusion

This study indicates that blue sky may serve as an independent environmental protective factor against CVD, and informs future policies on fighting air pollution and protecting the blue sky in China.

Daily space-time activities, multiple environmental exposures, and anxiety symptoms: A cross-sectional mobile phone-based sensing study

BACKGROUND

Few mobility-based studies have investigated the associations between multiple environmental exposures, including social exposures, and mental health.

OBJECTIVE

To assess how exposure to green space, blue space, noise, air pollution, and crowdedness along people's daily mobility paths are associated with anxiety symptoms.

METHODS

358 participants were cross-sectionally tracked with Global Positioning System (GPS)-enabled mobile phones. Anxiety symptoms were measured at baseline using the Generalized Anxiety Disorder-7 (GAD-7) questionnaire. Green space, blue space, noise, and air pollution were assessed based on concentric buffers of 50 m and 100 m around each GPS point. Crowdedness was measured by the number of nearby Bluetooth-enabled devices detected along the mobility paths. Multiple linear regressions with full covariate adjustment were fitted to examine anxiety-environmental exposures associations. Random forest models were applied to explore possible nonlinear associations and exposure interactions.

RESULTS

Regression results showed null linear associations between GAD-7 scores and environmental exposures. Random forest models indicated that GAD-7-environment associations varied nonlinearly with exposure levels. We found a negative association between green space and GAD-7 scores only for participants with moderate green space exposure. We observed a positive association between GAD-7 scores and noise levels above 60 dB and air pollution concentrations above 17.2 μg m^-3. Crowdedness was positively associated with GAD-7 scores, but exposure-response functions flattened out with pronounced crowdedness of >7.5. Blue space tended to be positively associated with GAD-7 scores. Random forest models ranked environmental exposures as more important to explain GAD-7 scores than linear models.

CONCLUSIONS

Our findings indicate possible nonlinear associations between mobility-based environmental exposures and anxiety symptoms. More studies are needed to obtain an in-depth understanding of underlying anxiety-environment mechanisms during daily life.

The needs of cancer patients during the COVID-19 pandemic-psychosocial, ethical and spiritual aspects-systematic review

The COVID-19 pandemic resulted in unprecedented changes in the functioning of the health care system, which were connected with the occurrence of new challenges for both the health care system's employees and for the patients. The purpose of the present article is to analyze the needs of persons with oncological diseases. Taking into account the multiple aspects of the term health, psychological, social, and existential needs of the patients were analyzed. This article is directed mainly at persons who remain in a direct therapeutic relation with a patient. It is to facilitate recognizing the needs of ill people and to increase sensitivity to the issue of maintaining or improving the well-being of patients which requires paying special attention to their psychological, social, and existential needs during the period of hindered access to the health care system. This systematic review takes advantage of quantitative and qualitative methods of text analysis with phenomenological analysis factored in. The COVID-19 pandemic resulted in the appearance of new problems in the population of oncological patients or it made the existing problems more severe. As a consequence, it made it significantly more difficult to meet their needs on various levels and sometimes it even made it impossible. It seems necessary to determine and introduce strategies to ensure that patients with oncological diseases have access to psychological and spiritual support in the period of the pandemic.

Freshwater Wild Swimming, Health and Well-Being: Understanding the Importance of Place and Risk

Spending time in or around bodies of water or ‘blue spaces’ can benefit human health and well-being. A growing body of evidence suggests immersion in blue space, e.g., participating in ‘wild’ swimming, can be particularly beneficial for both physical and mental health. To date, wild swimming and health research has primarily focused on the experience of individuals who swim in the sea. Empirical studies of the health-promoting potential of swimming in freshwater environments, such as lochs and lakes, are lacking, despite the popularity of this practice in many countries and the vastly different physical and hydrological properties of freshwater and coastal environments. The aim of this study was to explore the relationship between loch (lake) swimming and health and well-being for adults living in Scotland and determine the importance of perceptions of place and risk in this relationship. Semi-structured interviews were conducted with twelve wild swimmers who regularly swim in lochs in Scotland. Interview data were analysed thematically using Nvivo. The findings suggest loch swimming has a variety of health and well-being benefits that can be categorised over three domains of health: physical, mental and social. Of these domains, mental health benefits e.g., mindfulness promotion, resilience building and increasing one’s ability to listen to their body, were particularly prominent. Our findings also highlight important physical and hydrological characteristics of loch environments, e.g., calm water conditions (relative to the sea), which contribute to positive wild swimming experiences. Finally, the perceived risks of loch swimming and mitigation strategies for these risks are established. Collectively, our findings further support the notion that wild swimming is a unique health-promoting practice. Our findings also highlight differences (in terms of experience and perceived risk) between swimming in freshwater and coastal environments, which can inform public health and water management policy.

Amount of and proximity to blue spaces and general health among older Chinese adults in private and public housing: A national population study

A growing body of research indicates that exposure to outdoor blue spaces is associated with better physical and mental health. However, few studies have explored the associations between different blue space indicators (e.g., amount of and proximity to freshwater and seawater) and general health. Moreover, research has rarely attempted to address the residential selection bias associated with the salutogenic effect of access to blue spaces. Therefore, this study explores the associations between the amount (percentage of blue space within a 1 km circular buffer) of and proximity (Euclidean distance to the edge of the nearest blue space) to blue space and older adults' general health across the entire country of China using the micro-data sample of one-percent national population sample survey in 2015. It adds to the existing literature by taking into account the neighbourhood selection mechanism for different housing tenures and examining the salutogenic effect of blue spaces separately for public housing residents and private housing residents. The results indicated that greater neighbourhood seawater coverage and living near a coastline were associated with better general health among older adults in both private and public housing, while the percentage of freshwater blue spaces within neighbourhoods and the distance to freshwater blue spaces were associated with better general health among private housing residents only. The blue spaces-general health associations were stronger among urban participants, participants in deprived neighbourhoods, males, participants aged under 80 years, and low- and medium-educated participants. Our findings indicated that living near the coast was beneficial to older adults' health, and residential selection bias confounded the association between freshwater blue spaces and health.

A novel approach of creating sustainable urban planning solutions that optimise the local air quality and environmental equity in Helsinki, Finland: The CouSCOUS study protocol

Background

Air pollution is one of the major environmental challenges cities worldwide face today. Planning healthy environments for all future populations, whilst considering the ongoing demand for urbanisation and provisions needed to combat climate change, remains a difficult task.

Objective

To combine artificial intelligence (AI), atmospheric and social sciences to provide urban planning solutions that optimise local air quality by applying novel methods and taking into consideration population structures and traffic flows.

Methods

We will use high-resolution spatial data and linked electronic population cohort for Helsinki Metropolitan Area (Finland) to model (a) population dynamics and urban inequality related to air pollution; (b) detailed aerosol dynamics, aerosol and gas-phase chemistry together with detailed flow characteristics; (c) high-resolution traffic flow addressing dynamical changes at the city environment, such as accidents, construction work and unexpected congestion. Finally, we will fuse the information resulting from these models into an optimal city planning model balancing air quality, comfort, accessibility and travelling efficiency.

Waterscapes for Promoting Mental Health in the General Population

The WHO estimates that, with the development of urbanization, 25% of the population is suffering from psychological and mental distress. Preliminary evidence has suggested that aquatic environments and riparian areas, i.e., waterscapes, can benefit psychological and mental wellbeing. The aim of this study was to identify the processes of waterscape psychological and mental health promotion through aliterature review. We propose a design framework of waterscapes for achieving psychological and mental health in the general population that often visits waterscapes, which has the function of therapeutic landscapes through values of accessibility, versatility, habitats, and biodiversity. According to theories, waterscapes can improve psychological and mental health to divert negative emotions through mitigation (e.g., reduced urban heat island), instoration (e.g., physical activity and state of nature connectedness), and restoration (e.g., reduced anxiety/attentional fatigue). By accessing water (e.g., streams, rivers, lakes, wetlands, and the coast) and riparian areas, people can get in close contact with nature and spend more time in activities (e.g., walking, exploring, talking, and relaxing). Waterscapes with healing effects can enhance psychological resilience to promote people's psychological and mental health. Future research should focus on ensuring an adequate supply of waterscapes and promoting the efficiency of waterscape ecosystem services on mental health. Moreover, fora deep understanding of the complexity of nature-human health associations, it is necessary to explore more consistent evidence for therapeutic waterscapes considering the characteristics and functional mechanisms of waterscape quality, in terms of freshness, luminescence, rippling or fluidity, and cultural value, to benefit public health and biodiversity conservation.

Relationship between Green and Blue Spaces with Mental and Physical Health: A Systematic Review of Longitudinal Observational Studies

There is growing interest in the ways natural environments influence the development and progression of long-term health conditions. Vegetation and water bodies, also known as green and blue spaces, have the potential to affect health and behaviour through the provision of aesthetic spaces for relaxation, socialisation and physical activity. While research has previously assessed how green and blue spaces affect mental and physical wellbeing, little is known about the relationship between these exposures and health outcomes over time. This systematic review summarised the published evidence from longitudinal observational studies on the relationship between exposure to green and blue space with mental and physical health in adults. Included health outcomes were common mental health conditions, severe mental health conditions and noncommunicable diseases (NCDs). An online bibliographic search of six databases was completed in July 2020. After title, abstract and full-text screening, 44 eligible studies were included in the analysis. Depression, diabetes and obesity were the health conditions most frequently studied in longitudinal relationships. The majority of exposures included indicators of green space availability and urban green space accessibility. Few studies addressed the relationship between blue space and health. The narrative synthesis pointed towards mixed evidence of a protective relationship between exposure to green space and health. There was high heterogeneity in exposure measures and adjustment for confounding between studies. Future policy and research should seek a standardised approach towards measuring green and blue space exposures and employ theoretical grounds for confounder adjustment.

Spatio-temporal variations in physicochemical water quality parameters of Lake Bunyonyi, Southwestern Uganda

The current study was carried out to examine the spatial and temporal variations of physicochemical water quality parameters of Lake Bunyonyi. The observations were made on the surface water of Lake Bunyonyi for 1 year to determine the water quality. The basic 12 variables used to determine the quality of water were measured monthly at nine stations. Water temperature, dissolved oxygen (DO), turbidity, electric conductivity (EC), pH and Secchi depth (SD) were measured in the field, while parameters like total nitrogen (TN), total phosphorus (TP), nitrite-nitrogen (NO2-N), nitrate-nitrogen (NO3-N), soluble reactive phosphorus (SRP) were determined following APHA 2017 standard guidelines for physicochemical analysis. Taking into account standard guidelines for drinking water by the Uganda National Bureau of Standards (UNBS) and the World Health Organization (WHO), the water quality index (WQI) was used to determine the water quality. Temperature, DO, pH, turbidity and EC did not differ significantly among the study stations (p > 0.05) but showed significant temporal variations among the study months (p < 0.05). Likewise, TN, TP, NO2-N, NO3-N and SRP did not differ significantly among the study stations (p > 0.05) but showed significant temporal variations among the study months (p < 0.05). The WQI values ranged from 28.36 to 49 across and from 28.2 to 56.2 between study months with an overall mean value of 36.9. The measured water quality variables did not exceed the UNBS and WHO standards for drinking water in all months and at all stations. According to these values, the water quality of Lake Bunyonyi generally belongs to the ‘good’ class in terms of drinking water quality based on the WQI classification. The study findings are fundamentally important for policy makers in setting guidelines for effective lake management.

The value of blue-space recreation and perceived water quality across Europe: A contingent behaviour study

This study estimates the value of recreational visits to blue-space sites across 14 EU Member States, representing 78% of the Union's population. Across all countries surveyed, respondents made an average of 47 blue-space visits per person per year. Employing travel cost and contingent behaviour methods, the value of a visit is estimated at €41.32 which adds up to a recreational value of €631bn per year for the total adult population surveyed. Using the Bathing Water Directive's water quality designation, the analysis shows that a one-level improvement in water quality leads to 3.13 more visits (+6.67%), whereas a one-level deterioration leads to 9.77 fewer annual visits (-20.83%). This study provides valuations of benefits of recreation and changes of recreational values due to changes in surface water quality, which can be compared to the implementation and monitoring costs of efforts under the EU's Bathing Water, Water Framework and Marine Strategy Framework Directives.

Modelling and mapping eye-level greenness visibility exposure using multi-source data at high spatial resolutions

The visibility of natural greenness is associated with several health benefits along multiple pathways, including stress recovery and attention restoration mechanisms. However, existing methodologies are inadequate for capturing eye-level greenness visibility exposure at high spatial resolutions for observers located on the ground. As a response, we developed an innovative methodological approach to model and map eye-level greenness visibility exposure for 5 m interval locations within a large study area. We used multi-source spatial data and applied viewshed analysis in conjunction with a distance decay model to compute a novel Viewshed Greenness Visibility Index (VGVI) at more than 86 million observer locations. We compared our eye-level visibility exposure map with traditional top-down greenness exposure metrics such as Normalised Differential Vegetation Index (NDVI) and a Street view based Green View Index (SGVI). Furthermore, we compared greenness visibility at street-only locations with total neighbourhood greenness visibility. We found strong to moderate correlations (r = 0.65-0.42, p < 0.05) between greenness visibility and mean NDVI, with a decreasing trend in correlation strength at increasing buffer distances from observer locations. Our findings suggest that top-down and eye-level measurements of greenness are two distinct metrics for assessing greenness exposure. Additionally, VGVI showed a strong correlation (r = 0.481, p < 0.01) with SGVI. Although the new VGVI has good agreement with existing street view based measures, we found that street-only greenness visibility values are not wholly representative of total neighbourhood visibility due to the under-representation of visible greenness in locations such as backyards and community parks. Our new methodology overcomes such underestimations, is easily transferable, and offers a computationally efficient approach to assessing eye-level greenness exposure.

Green and Blue Space Availability and Self-Rated Health among Seniors in China: Evidence from a National Survey

Many empirical studies have shown evidence of multiple health benefits provided by green and blue spaces. Despite the importance of these spaces, investigations are scarce in details for blue spaces rather than green. Moreover, most research has focused on developed regions. A limited number of studies on blue spaces can be found in China with a focus on the city level. Outcomes have been mixed due to varying research scales, methodologies, and definitions. This study relies on a national-level social survey to explore how the self-rated health (SRH) of senior individuals is associated with local green and blue space availability in urban and rural areas. Results indicate that the coverage ratio of overall green spaces and waterbodies around a resident’s home have marginal effects on SRH status in both urban and rural areas. In urban areas, living close to a park can is marginally beneficial for older people’s health. Regarding different types of blue spaces, the presence of a major river (within 0.3–0.5 km) or coastline (within 1 km and 1–5 km) in the vicinity of home negatively affects SRH among the elderly in urban areas. Close proximity to lakes and other types of waterbodies with a water surface larger than 6.25 ha did not significantly influence SRH. These findings not only evaluate general health impacts of green/blue space development on senior populations across the county but inform decision makers concerning the health-promoting qualities and features of different green/blue spaces to better accommodate an aging population in the era of urbanization.

Filling the Gap between Ecosystem Services Concept and River Basin Management Plans: The Case of Greece in WFD 20+

The ecosystem services (ES) concept is embedded in all new European directives but its integration in the Water Framework Directive (WFD) is absent, despite the latter being the major legislative tool. The research aims to assess the knowledge of ES that lies within the River Basin Management Plans (RBMPs) in Greece so as to further depict their representation in the relevant planning tools, to support policy making and express the implementation experience to Member States for assisting EU reloading processes. The information on the ES’ status was extracted by the official RBMPs, processed and grouped following Common International Classification of Ecosystem Services (CICES) classification. The prioritization of ES included in the programs of measures (PoMs) further showed the targeting for each River Basin District (RBD). The results were not homogenous for the RBDs, revealing different needs in measures and indicating there is a lack in “communication” between the relevant EU and national regulations. Moreover, a wide suite of water-related ES is hindered in addressing multiple benefits coming from provisioning, regulating and cultural ES. For a proper WFD reload and continuation, the infusion of the ES concept and prerequisites in its objective, and the reviewing of the RBMPs’ target and the suggestion of integrated PoMs are necessary steps that could deliver added value in such legislation.