Green and blue spaces and behavioral development in Barcelona schoolchildren: the BREATHE project

Green spaces and respiratory, cardiometabolic, and neurodevelopmental outcomes: An individual-participant data meta-analysis of >35.000 European children

Studies evaluating the benefits and risks of green spaces on children's health are scarce. The present study aimed to examine the associations between exposure to green spaces during pregnancy and early childhood with respiratory, cardiometabolic, and neurodevelopmental outcomes in school-age children. We performed an Individual-Participant Data (IPD) meta-analysis involving 35,000 children from ten European birth cohorts across eight countries. For each participant, we calculated residential Normalized Difference Vegetation Index (NDVI) within a 300 m buffer and the linear distance to green spaces (meters) during prenatal life and childhood. Multiple harmonized health outcomes were selected: asthma and wheezing, lung function, body mass index, diastolic and systolic blood pressure, non-verbal intelligence, internalizing and externalizing problems, and ADHD symptoms. We conducted a two-stage IPD meta-analysis and evaluated effect modification by socioeconomic status (SES) and sex. Between-study heterogeneity was assessed via random-effects meta-regression. Residential surrounding green spaces in childhood, not pregnancy, was associated with improved lung function, particularly higher FEV1 (β = 0.06; 95 %CI: 0.03, 0.09 I2 = 4.03 %, p < 0.001) and FVC (β = 0.07; 95 %CI: 0.04, 0.09 I2 = 0 %, p < 0.001) with a stronger association observed in females (p < 0.001). This association remained robust after multiple testing correction and did not change notably after adjusting for ambient air pollution. Increased distance to green spaces showed an association with lower FVC (β = -0.04; 95 %CI: -0.07, -0.02, I2 = 4.8, p = 0.001), with a stronger effect in children from higher SES backgrounds (p < 0.001). No consistent associations were found between green spaces and asthma, wheezing, cardiometabolic, or neurodevelopmental outcomes, with direction of effect varying across cohorts. Wheezing and neurodevelopmental outcomes showed high between-study heterogeneity, and the age at outcome assessment was only associated with heterogeneity in internalizing problems.. This large European meta-analysis suggests that childhood exposure to green spaces may lead to better lung function. Associations with other respiratory outcomes and selected cardiometabolic and neurodevelopmental outcomes remain inconclusive.

Use of natural environments is associated with reduced inequalities in child mental wellbeing: A cross-sectional analysis using global positioning system (GPS) data

Exposure to natural environments may benefit child mental wellbeing whilst offering a lever to reduce health inequalities. However, understanding of these relationships is limited by evidence from indirect measures of exposure. We objectively measured children's direct use of natural environments-and use in low or high physical activity (PA) states-and associated this with their mental wellbeing. We then examined moderation by sex and household income. Using global positioning system and accelerometry data from children (n = 640), we measured mean daily time in natural environments ('total use'), which we stratified by PA level as 'passive use' (sedentary and light PA) and 'active use' (moderate and vigorous PA). Logistic regression associated exposures with dichotomised Strengths and Difficulties Questionnaire outcomes (internalising difficulties; externalising difficulties; prosocial behaviour), with interactions to examine moderation. A 10-minute increase in total use was associated with 10.5 % lower risk of abnormal internalising outcomes (OR: 0.895; 95 % CI 0.809, 0.990), and 13.2 % lower risk of abnormal externalising outcomes (OR: 0.868; 95 % CI 0.776, 0.990). This suggests that ∼ 60 min of daily total use was associated with 50 % lower risk of abnormal internalising and externalising outcomes. The relative effects of passive and active use were equal, but their associations were moderated by income independently for specific outcomes. For externalising outcomes, the risk of abnormal scores in lower-income children reduced as passive use increased (P = 0.027) but remained constant for higher-income children. For prosocial outcomes, the likelihood of normal scores increased with active use in lower-income children, but not higher-income children (P = 0.005). Sex did not moderate these associations. The findings suggest that targeted interventions supporting disadvantaged children to use natural environments could help address inequalities in mental wellbeing. Further, the moderated associations with types of use suggest the equigenic effects of natural environments may operate through multiple pathways.

The Health-Related and Learning Performance Effects of Air Pollution and Other Urban-Related Environmental Factors on School-Age Children and Adolescents-A Scoping Review of Systematic Reviews

PURPOSE OF REVIEW

This scoping review aims to assess the impact of air pollution, traffic noise, heat, and green and blue space exposures on the physical and cognitive development of school-age children and adolescents. While existing evidence indicates adverse effects of transport-related exposures on their health, a comprehensive scoping review is necessary to consolidate findings on various urban environmental exposures' effects on children's development.

RECENT FINDINGS

There is consistent evidence on how air pollution negatively affects children's cognitive and respiratory health and learning performance, increasing their susceptibility to diseases in their adult life. Scientific evidence on heat and traffic noise, while less researched, indicates that they negatively affect children's health. On the contrary, green space exposure seems to benefit or mitigate these adverse effects, suggesting a potential strategy to promote children's cognitive and physical development in urban settings. This review underscores the substantial impact of urban exposures on the physical and mental development of children and adolescents. It highlights adverse health effects that can extend into adulthood, affecting academic opportunities and well-being beyond health. While acknowledging the necessity for more research on the mechanisms of air pollution effects and associations with heat and noise exposure, the review advocates prioritizing policy changes and urban planning interventions. This includes minimizing air pollution and traffic noise while enhancing urban vegetation, particularly in school environments, to ensure the healthy development of children and promote lifelong health.

Pathways linking greenspace to behavioural problems in Polish children

Background

Previous cross-sectional studies have found a beneficial relationship between greenspace and children's behaviour. Nevertheless, evidence on the mechanisms underlying this association remains scant. We examined whether the availability of greenspace was related to fewer behavioural problems in Polish children and investigated potential mechanisms.

Methods

Data were obtained from the case-control NeuroSmog study, in which children with and without attention deficit hyperactivity disorder (ADHD) were tested from October 2020 to September 2022. The analytic sample comprised 679 children aged 10-13 years. Parents reported internalizing, externalizing, and total behavioural problems using the Child Behaviour Check List (CBCL), as well as information about the presence of a domestic garden and potential mediators: greenspace perception, neighbourhood social cohesion, and physical activity. Tree and grass covers were extracted in 500 m and 1 km buffers around lifelong residences. Structural equation modelling (SEM) was used to examine the psychosocial pathways linking the greenspace metrics to behavioural problems.

Results

Greenspace was only indirectly related to fewer behavioural problems. Specifically, tree cover was related to greater levels of physical activity which, in turn, was related to fewer internalizing and total behavioural problems. Tree cover and presence of garden were related to greenspace perception which, in turn, was associated with higher neighbourhood social cohesion which, in turn, was linked to fewer behavioural problems. The patterns of associations in children without ADHD were very similar to those in the full sample except that the associations from garden to greenspace perception and from physical activity to total behavioural problems were no longer significant. The only association persisted among girls was from neighbourhood social cohesion to behavioural problems and among boys were from tree cover to physical activity and tree cover and garden to greenspace perception.

Conclusion

Trees and garden, but not grass, are linked to fewer behavioural problems through greenspace perception, neighbourhood social cohesion, and physical activity in Polish children.

Different greenness exposure in Europe and respiratory outcomes in youths. A systematic review and meta-analysis

The existing evidence on the association between greenness and respiratory outcomes remains inconclusive. We aimed at systematically summarizing existing literature on greenness exposure and respiratory outcomes in European children and adolescents, with a preliminary attempt to qualify the distribution of dominant tree species across different geographical areas and bioclimatic regions. Overall, 4049 studies were firstly identified by searching PubMed/MEDLINE, EMBASE, Scopus, Web of Science, GreenFile and CAB direct, up to 29 August 2023. Eighteen primary studies were included in the systematic review and six were meta-analyzed. No overall significant association was observed between the Normalized Difference Vegetation Index, assessed within 500-m buffers (i.e. NDVI-500), and the odds of asthma for 0.3-increase in the exposure (OR: 0.97, 95% CI from 0.53 to 1.78). Similarly, an overall exposure to the NDVI-300 highest tertile, as compared to the lowest tertile, was not significantly associated with asthma (OR: 0.65, 95% CI from 0.22 to 1.91): heterogeneity among studies was significant (p = 0.021). We delineated some key elements that might have mostly contributed to the lack of scientific consensus on this topic, starting from the urgent need of harmonized approaches for the operational definition of greenness. Additionally, the complex interplay between greenness and respiratory health may vary across different geographical regions and climatic conditions. At last, the inconsistent findings may reflect the heterogeneity and complexity of this relationship, rather than a lack of scientific consensus itself. Future research should compare geographical areas with similar bioclimatic parameters and dominant or potentially present vegetation species, in order to achieve a higher inter-study comparability.

Urban greenspaces and child blood pressure in China: Evidence from a large population-based cohort study

BACKGROUND

With the world's population steadily shifting toward urban living, children's engagement with the natural environment seems to be diminishing. This raises significant concerns about the influence of urban greenspaces on the cardiovascular health of children.

OBJECTIVE

To assess the association between urban greenspaces exposure and blood pressure (BP) in Chinese primary schoolchildren.

METHODS

This prospective cohort study used data from the Children's growth environment, lifestyle, physical, and mental health development (COHERENCE) project in Guangzhou, China. Participants included 164,853 primary schoolchildren starting from 2016/17 to 2019/20 academic year. We assessed the surrounding greenspaces at home and school by using Sentinel-2 satellite data on the normalized difference vegetation index. Prehypertension and hypertension status were defined with BP above 90th to less than the 95th percentile, at or above the 95th percentile, respectively. The association of surrounding greenness with children's BP levels and risk of prehypertension/hypertension were examined using linear mixed-effects models and Cox proportional hazards model.

RESULTS

Among 164,853 eligible children aged 7.21 (0.74) years, 89,190 (54.1%) were boys. Our results showed that average systolic and diastolic BP increased by 0.48 and 0.42 standard deviations, respectively, over the 3-year follow-up. We identified 23,225 new cases of prehypertension and 35,067 of hypertension status. An interquartile range increase both in home-, school- and home-school NDVI100m was significantly associated with a reduction of 0.018-0.037 in BP z-scores and a 2.7%-7.6% lower risk of hypertension. Additionally, family socioeconomic status modified the impact of home-school greenness on BP levels. Air pollution exhibited mediating effects solely in school-greenness-BP associations, while physical activity and children's BMI mainly mediated the relationships between home-greenness and BP.

CONCLUSION

The findings of this large cohort study suggest that surrounding greenspaces are associated with lower BP levels and a decreased risk of prehypertension and hypertension in Chinese schoolchildren.

Urban green spaces and behavioral and cognitive development in children: A health impact assessment of the Barcelona "Eixos Verds" Plan (Green Axis Plan)

BACKGROUND

Urban environments lack natural features, while nature exposure in cities has been associated with health benefits, including children's neurodevelopment. Through extensive street greening, Barcelona's Eixos Verds (Green Axis) Plan enhances safety, environment, and climate resilience. We aimed to assess the Eixos Verds Plan's potential impact on children's behavioral and cognitive development due to the increased green space expected under the Eixos Verds implementation.

METHODS

We performed a quantitative health impact assessment for Barcelona children at census-tract level (n = 1068). We assessed the Eixos Verds Plan's impact by comparing baseline green space distribution with the proposed plan, translating it into percentage green area (%GA) and Normalized Difference Vegetation Index (NDVI). By combining these exposure metrics with child-specific risk estimates and population data, we estimated potential improvements in children's behavioral and cognitive development due to full Eixos Verds implementation.

RESULTS

With the full Eixos Verds implementation, citywide, %GA increased by 6.9% (IQR: 6.4%; range: 0-23.1%) and NDVI by 0.065 (IQR: 0.083; range: 0.000-0.194). Child behavioral and cognitive development outcomes are expected to improve compared to the baseline. Based on NDVI increases, children's Total Difficulties and Hyperactivity/Inattention scores, based on the Strengths and Difficulties Questionnaire (SDQ), are projected to decrease by 5% (95% CI: 0-15%) and 6% (95% CI: 0-17%). Working Memory and Superior Working Memory scores are expected to increase by 4% and 5%, respectively, based on the computerized n-back test, while the Inattentiveness score could be reduced by 1%, based on the computerized attentional test (ANT).

INTERPRETATION

Urban greening as planning tool can improve behavioral and cognitive development in city children. Methods and results of our study are applicable to many cities worldwide, and similar results for children of real-life urban greening interventions can be expected.

Associations of residential green space with internalizing and externalizing behavior in early childhood

BACKGROUND

Green space exposures may promote child mental health and well-being across multiple domains and stages of development. The aim of this study was to investigate associations between residential green space exposures and child mental and behavioral health at age 4-6 years.

METHODS

Children's internalizing and externalizing behaviors in the Conditions Affecting Neurocognitive Development and Learning in Early Childhood (CANDLE) cohort in Shelby County, Tennessee, were parent-reported on the Child Behavior Checklist (CBCL). We examined three exposures-residential surrounding greenness calculated as the Normalized Difference Vegetation Index (NDVI), tree cover, and park proximity-averaged across the residential history for the year prior to outcome assessment. Linear regression models were adjusted for individual, household, and neighborhood-level confounders across multiple domains. Effect modification by neighborhood socioeconomic conditions was explored using multiplicative interaction terms.

RESULTS

Children were on average 4.2 years (range 3.8-6.0) at outcome assessment. Among CANDLE mothers, 65% self-identified as Black, 29% as White, and 6% as another or multiple races; 41% had at least a college degree. Higher residential surrounding greenness was associated with lower internalizing behavior scores (-0.66 per 0.1 unit higher NDVI; 95% CI: -1.26, -0.07) in fully-adjusted models. The association between tree cover and internalizing behavior was in the hypothesized direction but confidence intervals included the null (-0.29 per 10% higher tree cover; 95% CI: -0.62, 0.04). No associations were observed between park proximity and internalizing behavior. We did not find any associations with externalizing behaviors or the attention problems subscale. Estimates were larger in neighborhoods with lower socioeconomic opportunity, but interaction terms were not statistically significant.

CONCLUSIONS

Our findings add to the accumulating evidence of the importance of residential green space for the prevention of internalizing problems among young children. This research suggests the prioritization of urban green spaces as a resource for child mental health.

Adapting Schools to Climate Change with Green, Blue, and Grey Measures in Barcelona: Study Protocol of a Mixed-Method Evaluation

Under the framework of the Urban Innovative Actions program of the European Commission, in 2020, 11 primary schools in Barcelona were transformed into climate shelters by implementing green, blue, and grey measures. Schoolyards were also opened to the local community to be used during non-school periods. Here we present the study protocol of a mixed-method approach to evaluate the effectiveness of the interventions in terms of improving environmental quality and health for users. We evaluated school level through the following: (1) quantitative pre-post quasi-experimental study, and (2) qualitative evaluation. The quantitative study included measures of (a) environmental variables (collected via low-cost and non-low-cost sensors), (b) students' health and well-being (collected via health questionnaires, attention levels test, and systematic observations), and (c) teachers' health and well-being (collected via thermal comfort measurements and health questionnaires). The qualitative methods evaluated the perceptions about the effects of the interventions among students (using Photovoice) and teachers (through focus groups). The impact of the interventions was assessed at community level during summer non-school periods through a spontaneous ethnographic approach. Data collection started in August 2019 and ended in July 2022. The evaluation provides the opportunity to identify those solutions that worked and those that need to be improved for future experiences, as well as improve the evaluation methodology and replication for these kinds of interventions.

Exposure to Residential Green Space and Bone Mineral Density in Young Children

Importance

Bone mass accrual is influenced by environmental and lifestyle factors. Targeted interventions at the early stages of life might decrease fracture and/or osteoporosis risk later in life.

Objective

To investigate whether early-life exposure to residential surrounding green space is associated with a change in bone mineral density in young children.

Design, Setting, and Participants

In this prospective birth cohort study (ENVIRONAGE [Environmental Influence on Aging in Early Life]), mother-child pairs from Flanders, Belgium, were recruited at birth and followed up for 4 to 6 years, between October 1, 2014, and July 31, 2021. Data analysis was conducted between January and February 2022.

Exposures

Green space was estimated for high green (>3 m vegetation height), low green (≤3 m vegetation height ), and total green (sum of high and low) within several radii (100-3000 m) around the residence after geocoding of the addresses.

Main Outcomes and Measures

Radial bone mineral density was assessed using quantitative ultrasound measurement at follow-up, measured as the mean of the axially transmitted speed of sound in meters per second. Multiple linear and logistic regression models were used while accounting for relevant covariates and potential confounders.

Results

The study population comprised 327 children (180 [55.0%] female; mean [SD] age, 4.6 [0.4] years at the follow-up evaluation). Early-life exposure to residential green space was associated with increased childhood bone health. An IQR increment in total green (21.2%) and high green (19.9%) space within 500 m was associated with an increase of 27.38 m/s (95% CI, 9.63-45.13 m/s) and 25.30 m/s (95% CI, 7.93-42.68 m/s) in bone mineral density, respectively. Additionally, an IQR increase in total (25.2%) and high (23.2%) green space within 1000 m was associated with a 67% (odds ratio, 0.33; 95% CI, 0.17-0.61) and 61% (odds ratio, 0.39; 95% CI, 0.18-0.75) lower risk of having a bone density lower than the sex-specific 10th percentile (3567.6 m/s for girls and 3522.8 m/s for boys).

Conclusions and Relevance

In this study of children aged 4 to 6 years, higher bone mineral density and a lower risk of having low bone density were associated with higher residential green space exposure during childhood. These findings highlight the importance of early-life exposure to residential green space on bone health during critical periods of growth and development, with long-term implications.

Greenspace and Land Cover Diversity During Pregnancy in a Rural Region, and Associations With Birth Outcomes

Beneficial effects on health outcomes have been observed from exposure to spaces with substantial green vegetation ("greenspace"). This includes studies of greenspace exposure on birth outcomes; however, these have been conducted largely in urban regions. We characterized residential exposure to greenspace and land cover diversity during pregnancy in rural northern New England, USA, investigating whether variation in greenspace or diversity related to newborn outcomes. Five landscape variables (greenspace land cover, land cover diversity, impervious surface area, tree canopy cover, and the Normalized Difference Vegetation Index) were aggregated within six circular zones of radii from 100 to 3,000 m around residential addresses, and distance to conservation land was measured, providing a total of 31 greenspace and diversity metrics. Four birth outcomes along with potentially confounding variables were obtained from 1,440 participants in the New Hampshire Birth Cohort Study. Higher greenspace land cover up to 3,000 m was associated with larger newborn head circumference, while impervious surface area (non-greenspace) had the opposite association. Further, birth length was positively associated with land cover diversity. These findings support beneficial health impacts of greenspace exposure observed in urban regions for certain health outcomes, such as newborn head circumference and length but not others such as birthweight and gestational age. Further our results indicate that larger radius buffer zones may be needed to characterize the rural landscape. Vegetation indices may not be interchangeable with other greenspace metrics such as land cover and impervious surface area in rural landscapes.

Outdoor Time in Childhood: A Mixed Methods Approach to Identify Barriers and Opportunities for Intervention in a Racially and Ethnically Mixed Population

A growing body of literature suggests that outdoor time is beneficial for physical and mental health in childhood. Profound disparities exist in access to outdoor spaces (and the health benefits thereof) for children in communities of color. The objectives of this research were to: (1) identify challenges and solutions to outdoor time for children; (2) assess the importance of outdoor time for children; and (3) evaluate results stratified by race/ethnicity. Using a convergent mixed methods approach, we conducted a thematic analysis from 14 focus groups (n = 50) with outdoor educators, parents with children attending outdoor preschools, and community members with children. In addition, 49 participants completed a survey to identify challenges and solutions, perceived importance, and culturally relevant perspectives of outdoor time. The main challenges identified for outdoor time were safety concerns, inclement weather, lack of access to outdoor spaces, and parent work schedules. The primary proposed solution was integrating outdoor time into the school day. Nearly all participants, independent of racial identity, reported that outdoor time improved physical and mental health. Overall outdoor time was lower in participants from communities of color (~8 h/week) compared to their White counterparts (~10 h/week). While 50% of people of color (POC) reported that outdoor time was an important cultural value, only 18% reported that people in their respective culture spent time outside. This work contributes to accumulating knowledge that unique barriers to outdoor time exist for communities of color, and the children that live, learn, and play in these communities. Increasing outdoor time in school settings offers a potential solution to reduce identified barriers and to promote health equity in childhood.

A health data led approach for assessing potential health benefits of green and blue spaces: Lessons from an Irish case study

Research producing evidence-based information on the health benefits of green and blue spaces often has within its design, the potential for inherent or implicit bias which can unconsciously orient the outcomes of such studies towards preconceived hypothesis. Many studies are situated in proximity to specific or generic green and blue spaces (hence, constituting a green or blue space led approach), others are conducted due to availability of green and blue space data (hence, applying a green or blue space data led approach), while other studies are shaped by particular interests in the association of particular health conditions with presence of, or engagements with green or blue spaces (hence, adopting a health or health status led approach). In order to tackle this bias and develop a more objective research design for studying associations between human health outcomes and green and blue spaces, this paper discussed the features of a methodological framework suitable for that purpose after an initial, year-long, exploratory Irish study. The innovative approach explored by this study (i.e., the health-data led approach) first identifies sample sites with good and poor health outcomes from available health data (using data clustering techniques) before examining the potential role of the presence of, or engagement with green and blue spaces in creating such health outcomes. By doing so, we argue that some of the bias associated with the other three listed methods can be reduced and even eliminated. Finally, we infer that the principles and paradigm adopted by the health data led approach can be applicable and effective in analyzing other sustainability problems beyond associations between human health outcomes and green and blue spaces (e.g., health, energy, food, income, environment and climate inequality and justice etc.). The possibility of this is also discussed within this paper.

Residential green and blue spaces and working memory in children aged 6-12 years old. Results from the INMA cohort

Availability of green and blue spaces in the area of residence has been related to various health outcomes during childhood, including neurodevelopment. Some studies have shown that children living in greener and/or bluer areas score better on cognitive tasks although the evidence is inconsistent. These protective effects are hypothesized to occur in part through reductions in air pollution exposure and odds of attention-deficit/hyperactivity disorder (ADHD). This study analysed the effects of residential green and blue spaces on working memory of children in the Spanish INfancia y Medio Ambiente (INMA) birth cohort and the potential joint mediating role of air pollution and ADHD. The study samples were composed of 1738 six-to eight-year-olds (M = 7.53, SD = 0.68, 49% female) and 1449 ten-to twelve-year-olds (M = 11.18, SD = 0.69, 50% female) living in Asturias, Gipuzkoa, Sabadell or Valencia, Spain. Individual Normalized Difference Vegetation Index (NDVI) values in 100-, 300- and 500-m buffers and availability of green and blue spaces >5000 m2 in 300-m buffers were calculated using Geographic Information Systems software. Individual NO2 values for the home environment were estimated using ESCAPE's land use regression models. ADHD diagnosis was reported by participants' parents via a questionnaire. Working memory was measured with numbers and colours (in the younger group only) N-back tests (2- and 3-back d'). Mixed-effects models informed of the beneficial effects of NDVI in a 300-m buffer on numerical working memory in the younger sample although the results were not consistent for all d' scores considered and failed to detect significant effects through the candidate mediators. Availability of major blue spaces did not predict working memory performance. Provision of green spaces may play a role in children's working memory but further research is required.

Assessing the impact of blue and green spaces on mental health of disabled children: A scoping review

During recent decades, there has been a growing consideration of the role of blue and green spaces on mental health of children, but there is insufficient attention in the literature to the mental health of children with disabilities. This paper presents an overview of the evidence on how blue and green spaces affect the mental health of children with various disabilities. A database search found twenty studies eligible for the review, after several consecutive screening stages. Most studies used a cross-sectional design and were carried out in Europe. The results consistently indicate that blue and green space can reduce emotional, behavioral, and social problems in disabled children. A protective association was found between the level of blue or greenness and depressive and anxiety symptoms. Moreover, in most of the studies there were no significant changes in the result after adjusting for socioeconomic confounders. Generally, there is an identified need for more short-term exposure studies in this area, focusing on the impact of landscape design elements on mental health of disabled children. The findings of this scoping review call on urban planners, health care workers and decision makers to consider appropriate measures and interventions providing more blue and green space exposure to disabled children.

Availability, accessibility, and use of green spaces and cognitive development in primary school children

Green spaces may have beneficial impacts on children's cognition. However, few studies explored the exposure to green spaces beyond residential areas, and their availability, accessibility and uses at the same time. The aim of the present study was to describe patterns of availability, accessibility, and uses of green spaces among primary school children and to explore how these exposure dimensions are associated with cognitive development. Exposures to green space near home, school, commuting route, and other daily activity locations were assessed for 1607 children aged 6-11 years from six birth cohorts across Europe, and included variables related to: availability (NDVI buffers: 100, 300, 500 m), potential accessibility (proximity to a major green space: linear distance; within 300 m), and use (play time in green spaces: hours/year), and the number of visits to green spaces (times/previous week). Cognition measured as fluid intelligence, inattention, and working memory was assessed by computerized tests. We performed multiple linear regression analyses on pooled and imputed data adjusted for individual and area-level confounders. Availability, accessibility, and uses of green spaces showed a social gradient that was unfavorable in more vulnerable socioeconomic groups. NDVI was associated with more playing time in green spaces, but proximity to a major green space was not. Associations between green space exposures and cognitive function outcomes were not statistically significant in our overall study population. Stratification by socioeconomic variables showed that living within 300 m of a major green space was associated with improved working memory only in children in less deprived residential areas (β = 0.30, CI: 0.09,0.51), and that more time playing in green spaces was associated with better working memory only in children of highly educated mothers (β per IQR increase in hour/year = 0.10; 95% CI: 0.01, 0.19). However, studying within 300 m of a major green space increased inattention scores in children in more deprived areas (β = 15.45, 95% CI: 3.50, 27.40).

Social inequalities, green and blue spaces and mental health in 6-12 years old children participating in the INMA cohort

Availability of green and blue spaces in the area of residence has been related to various health outcomes during childhood, including mental health. These environmental exposures are not evenly distributed among socioeconomic groups, which may increase social inequalities in mental health. The mechanisms through which natural environments may promote mental health are numerous and diverse. This study aimed to explore 1) the potential associations of socioeconomic variables (SES and maternal education attainment) with mental health scores and residential greenness, blueness and NO2 metrics, and, 2) the association between greenness and blueness metrics and mental health scores of children in the Spanish INfancia y Medio Ambiente (INMA) birth cohort at two different time points. The study samples were composed of 1738 six-to eight-year-olds (49% female) and 1449 ten-to twelve-year-olds (living in Asturias, Gipuzkoa, Sabadell and Valencia, Spain. Individual Normalized Difference Vegetation Index (NDVI) values in 100-, 300- and 500-m buffers and availability of green and blue spaces >5000 m2 in 300-m buffers were calculated using Geographic Information Systems software. Residential NO2 values were estimated using land use regression models. Internalizing, externalizing and total problems scores were obtained with the Strengths and Difficulties Questionnaire (SDQ). Linear and logistic mixed-effects models revealed unequal distribution of environmental exposures by SES and maternal education but did not show statistically significant associations between greenness and blueness metrics and mental health indicators. The protective effect of green and blue spaces on children's mental health could not be confirmed in this study and therefore further research is required.

Elementary Classroom Views of Nature Are Associated with Lower Child Externalizing Behavior Problems

Exposure to nature views has been associated with diverse mental health and cognitive capacity benefits. Yet, much of this evidence was derived in adult samples and typically only involves residential views of nature. Findings from studies with children suggest that when more greenness is available at home or school, children have higher academic performance and have expedited attention restoration, although most studies utilize coarse or subjective assessments of exposure to nature and largely neglect investigation among young children. Here, we investigated associations between objectively measured visible nature at school and children's behavior problems (attention and externalizing behaviors using the Brief Problem Monitor Parent Form) in a sample of 86 children aged seven to nine years old from 15 classrooms across three schools. Images of classroom windows were used to quantify overall nature views and views of specific nature types (sky, grass, tree, shrub). We fitted separate Tobit regression models to test associations between classroom nature views and attention and externalizing behaviors, accounting for age, sex, race/ethnicity, residential deprivation score, and residential nature views (using Google Street View imagery). We found that higher levels of visible nature from classroom windows were associated with lower externalizing behavior problem scores, after confounder adjustment. This relationship was consistent for visible trees, but not other nature types. No significant associations were detected for attention problems. This initial study suggests that classroom-based exposure to visible nature, particularly trees, could benefit children's mental health, with implications for landscape and school design.

Access to urban green spaces in Hannover: An exploration considering age groups, recreational nature qualities and potential demand

City dwellers' accessibility of urban green spaces (UGS) has recently gained immense interest in research and policy. Related scientific studies thus far have focused primarily on spatial distances, largely missing considerations of UGS qualities. We analysed the entire UGS setting of Hannover considering the recreational nature quality and potential demands to identify age-appropriate green spaces by applying a geographic information system analysis of several data sets. Additionally, we assessed the accessibility of UGS for different age groups, varying recreational nature qualities, and potential demands. Results indicate that children and elderly people have poor access to UGS that offers age-related requirements to enable unrestricted nature-based recreation. Nature quality and age-related requirements play a significant role in the assessment of UGS for recreation and accessibility. We conclude that detected vulnerabilities regarding age-related recreation in cities are anchors to mainstream the issue and enhance future planning practices and research.

Sex-differences in the effects of indoor air pollutants and household environment on preschool child cognitive development

Air pollution, outdoor residential environment, indoor household characteristics, and parental mental health are potential factors associated with child development. However, few studies have simultaneously analyzed the association between the aforementioned factors and preschool child (aged 2-5 years) development. This study investigated the effects of those factors on child development and their potential modifying effects. A total of 142 participants were recruited from a birth cohort study in the Greater Taipei Area, and the evaluation was conducted at each participant's home from 2017 to 2020. Child cognitive development was assessed by psychologists using the Bayley Scales of Infant and Toddler Development and the Wechsler Preschool & Primary Scale of Intelligence. Household air pollutants, outdoor residential environment, indoor household characteristics, parental mental health, and other covariates were evaluated. Multiple regressions were used to examine the relationships between child development and covariates. Stratified analysis by child sex and parental mental health was conducted. Average indoor air pollutant levels were below Taiwan's Indoor Air Quality Standards. After adjustment for covariates, the indoor total volatile organic compounds (TVOCs) level was significantly associated with poor child development (per interquartile range increase in the TVOC level was associated with a 5.1 percentile decrease in child cognitive development). Sex difference was observed for the association between TVOC exposure and child development. Living near schools, burning incense at home, purchasing new furniture, and parental anxiety were related to child development. Indoor TVOC level was associated with poor child cognitive development, specifically with the girls. Indoor and outdoor residential environment and parental anxiety interfered with child development. TVOCs should be used cautiously at home to minimize child exposure. A low-pollution living environment should be provided to ensure children's healthy development.

The effect of greenness on allergic rhinitis outcomes in children and adolescents: A systematic review and meta-analysis

BACKGROUND

The relationship between greenness and health emerges as new public health concern. More published studies from multiple areas have explored the relationship between greenness and allergic rhinitis (AR) in children and adolescents. This study aims to determine the association between greenness and allergic rhinitis by systematic review and meta-analysis, in order to provide a more comprehensive assessment of the impact of greenness on AR in children and adolescents.

METHODS

The relative literature was systematically searched in PubMed, Embase, and Web of science lastly on September 25, 2022. Terms related to greenness and allergic rhinitis were used for searching. Summary effect estimates of greenness on AR in children and adolescents were calculated for per 10 % increase of greenness exposure with different buffer sizes by random-effects model.

RESULTS

A total of 579 studies were screened, and fourteen studies from Europe, Asia and North America were finally included. Most greenness exposure were measured by normalized difference vegetation index (NDVI). Enhanced vegetation index, outdoor-green environmental score and existed to measuring different greenness types. Greenness surrounding residences and schools were assessed. The overall effect of greenness on primary outcome was 1.00 (95%CI = 0.99-1.00). Most effect estimates of greenness were included in the NDVI-500 m group, and the pooled OR was 0.99 (95%CI = 0.97-1.01). No significant pooled estimates were found in analyses with study locations.

CONCLUSION

This study indicates no significant association between greenness exposure and AR in children and adolescents. Various exposure measures and conversion of data may affect the results of this meta-analysis. More precise assessment of personal greenness exposure in well-designed prospective studies are vital for drawing a definite association in future. Furthermore, greenness exposure surrounding schools should be paid considerable attention for its effect on AR in school-aged children and adolescents.

Illuminating Associations between Parenting and Deleterious Neighborhood Characteristics via an Exhaustive Modeling Approach

OBJECTIVE

Our goal was to illuminate associations between specific characteristics of under-resourced neighborhoods (i.e., socioeconomic deprivation, danger) and specific aspects of parenting (e.g., parental praise, parental nurturance, harsh parenting, parental control).

BACKGROUND

Prior work has highlighted associations between level of neighborhood disadvantage and the parenting of its residents. However, this work has yet to clarify the specific characteristics of the neighborhood or the types of parenting involved.

METHOD

Exhaustive modelling analyses were conducted in a sample of 1,030 families of twins (average age 8 years; 51% male, 49% female; the racial composition was 82% White, 10% Black, 1% Asian, 1% Indigenous, 6% multiracial) from the Twin Study of Behavioral and Emotional Development in Children. Neighborhood and parenting were assessed using multiple informants and assessment strategies (neighborhood informants, family informants, administrative data, videotaped parent-child interactions).

RESULTS

Neighborhood socioeconomic deprivation (i.e., limited institutional and economic structural resources) demonstrated small but consistent associations with positive parenting behaviors and maternal control, but not with negative parenting behaviors. Neighborhood danger (i.e., recorded crime, fear of crime, exposure to community violence), by contrast, demonstrated weaker associations with parenting that dissipated once we controlled for overlap with socioeconomic deprivation.

CONCLUSION

Danger and socioeconomic deprivation do not function as interchangeable characteristics of under-resourced neighborhoods, at least in terms of their association with positive parenting. Future studies should identify the specific mechanisms through which neighborhood socioeconomic deprivation is associated with supportive parenting.

The Association between Physical Environment and Externalising Problems in Typically Developing and Neurodiverse Children and Young People: A Narrative Review

The physical environment is of critical importance to child development. Understanding how exposure to physical environmental domains such as greenspace, urbanicity, air pollution or noise affects aggressive behaviours in typical and neurodiverse children is of particular importance given the significant long-term impact of those problems. In this narrative review, we investigated the evidence for domains of the physical environment that may ameliorate or contribute to the display of aggressive behaviours. We have considered a broad range of study designs that include typically developing and neurodiverse children and young people aged 0-18 years. We used the GRADE system to appraise the evidence. Searches were performed in eight databases in July 2020 and updated in June 2022. Additional articles were further identified by hand-searching reference lists of included papers. The protocol for the review was preregistered with PROSPERO. Results: We retrieved 7174 studies of which 67 are included in this review. The studies reported on green space, environmental noise and music, air pollution, meteorological effects, spatial density, urban or rural setting, and interior home elements (e.g., damp/sensory aspects/colour). They all used well validated parent and child reported measures of aggressive behaviour. Most of the studies were rated as having low or unclear risk of bias. As expected, noise, air pollution, urbanicity, spatial density, colour and humidity appeared to increase the display of aggressive behaviours. There was a dearth of studies on the role of the physical environment in neurodiverse children. The studies were heterogeneous and measured a range of aggressive behaviours from symptoms to full syndromes. Greenspace exposure was the most common domain studied but certainty of evidence for the association between environmental exposures and aggression problems in the child or young person was low across all domains. We found a large knowledge gap in the literature concerning neurodiverse children, which suggests that future studies should focus on these children, who are also more likely to experience adverse early life experiences including living in more deprived environments as well as being highly vulnerable to the onset of mental ill health. Such research should also aim to dis-aggregate the underlying aetiological mechanisms for environmental influences on aggression, the results of which may point to pathways for public health interventions and policy development to address inequities that can be relevant to ill health in neurodiverse young people.

School-Based Interventions to Support Healthy Indoor and Outdoor Environments for Children: A Systematic Review

Environmental exposures are associated with children's health. Schools are often urban exposure 'hotspots' for pollution, noise, lack of green space and un-walkable built environments. The aim of this systematic review was to explore the impact of school-based interventions on the modification of indoor and outdoor stressors related to the built and natural environment on children's exposure and health. A systematic review of seven databases was performed. We included quantitative studies on children aged 5-12, which reported intervention delivered within school settings aimed at addressing key environmental exposures including air pollution, green spaces, traffic noise or active travel; and reported physical and mental health, physical activity or active travel behavior. The quality of studies was assessed and interventions were described using a standardized framework. A narrative synthesis approach was used to describe the findings. Thirty-nine papers were included on three main intervention types: improve indoor air quality by the increase of ventilation rates in classrooms; increase children's green time or greening schools, and multicomponent interventions to increase active travel to school by changes in pedestrian facilities. No eligible intervention to reduce traffic noise at school was found. Increasing ventilation rates improved short-term indoor air quality in classrooms, but the effect on cognitive performance was inconsistent. Greening schools and increasing children's green time have consistent positive effects on cognition and physical activity, but not in behavior. Multi-component interventions can increase walking and cycling after three years. Overall, the studies were rated as having poor quality owing to weak study designs. We found modest evidence that school-based built and natural environment interventions can improve children's exposure and health.

Effects of Greenness on Myopia Risk and School-Level Myopia Prevalence Among High School-Aged Adolescents: Cross-sectional Study

BACKGROUND

Myopia is a serious public health issue. High school-aged adolescents in Beijing have an alarming prevalence of myopia. Therefore, determining myopia protective factors is essential. Green space has a certain association with myopia protective factors that can protect against myopia.

OBJECTIVE

This study aims to examine the effects of green space around schools on individual myopia risk in high school-aged adolescents and the school-level myopia prevalence.

METHODS

Green space was measured using the normalized difference vegetation index (NDVI). A total of 13,380 samples of 51 high schools were selected from a 2021 Beijing Municipal Health Commission survey. Adolescent myopia was defined as a spherical equivalent of ≤-1.00 diopters in the worse eye. Generalized linear mixed models with a binomial error structure were used to analyze the effects of the NDVI on personal myopia risk and adjust them by other factors, such as demographics, exposure time, and outdoor exercise. The effects of the NDVI on school-level myopia prevalence with adjusted demographics and the relative position factors of trees were analyzed through quasibinomial regression.

RESULTS

The overall prevalence of myopia was 80.61% (10,785/13,380, 95% CI 79.93%-81.27%). Although with a 0.1 increase in the 500 and 1000 m buffer NDVIs adjusted by demographic and other factors, the high school-aged personal myopia risk significantly dropped by 16% (odds ratio [OR] 0.84, 95% CI 0.73-0.97) and 12% (OR 0.88, 95% CI 0.79-0.99), respectively. However, only the adjusted 500 m buffer NDVI (by demographics and the position of trees) with a 0.1 increase significantly reduced the school-level myopia prevalence by 15% (OR 0.85, 95% CI 0.74-0.98). Subgroup analysis showed that the adjusted effects of the 500 m buffer NDVI are significant in schoolgirls (OR 0.82, 95% CI 0.72-0.93), juniors (OR 0.82, 95% CI 0.72-0.94), the Han nationality (OR 0.84, 95% CI 0.72-0.97), 1-year exposure (OR 0.84, 95% CI 0.71-0.99) and 3-year exposure (OR 0.78, 95% CI 0.65-0.94).

CONCLUSIONS

The greenness of a 500 m buffer around schools is associated with a lower personal myopia risk among adolescents and a lower prevalence of myopia in schools. With regard to prevention and control activities, green space within a 500 m buffer around schools is suggested as an independent protective factor for adolescent myopia.

Greenspace and health outcomes in children and adolescents: A systematic review

An increasing body of evidence has linked greenspace and various health outcomes in children and adolescents, but the conclusions were inconsistent. For this review, we comprehensively summarized the measurement methods of greenspace, resultant health outcomes, and potential mechanisms from epidemiological studies in children and adolescents (aged ≤19 years). We searched for studies published and indexed in MEDLINE and EMBASE (via Ovid) up to April 11, 2022. There were a total of 9,291 studies identified with 140 articles from 28 countries finally assessed and included in this systematic review. Over 70% of the studies were conducted in highly urbanised countries/regions, but very limited research has been done in low-and middle-income countries and none in Africa. Measures of greenspace varied. Various health outcomes were reported, including protective effects of greenspace exposure on aspects of obesity/overweight, myopia, lung health, circulatory health, cognitive function, and general health in children and adolescents. The associations between greenspace exposure and other health outcomes were inconsistent, especially for respiratory health studies. We pooled odds ratios (OR) using random-effects meta-analysis for health outcomes of asthma (OR = 0.94, 95%CI: 0.84 to 1.06), allergic rhinitis (OR = 0.95; 95% CI: 0.73 to 1.25), and obesity/overweight (OR = 0.91, 95%CI: 0.84 to 0.98) with per 0.1 unit increase in normalized difference in vegetation index (NDVI). These associations have important implications for the assessment and management of urban environment and health in children and adolescents.

The association between urban greenspace and psychological health among young adults in Addis Ababa, Ethiopia

INTRODUCTION

Psychological disorders are emerging as health priorities in Sub-Saharan Africa, specifically Ethiopia. Urban greenspace - parks, trees, and other vegetation integrated into urban form - may facilitate population psychological health, but is largely understudied outside high-income countries. We explore greenspace in relation to psychological health among young adults in Addis Ababa, Ethiopia.

METHOD

Greenspace exposure was calculated using the normalized difference vegetation index (NDVI) derived from publicly available satellite imagery (2018-2019). We used tests of spatial clustering to characterize greenspace distribution. Derived NDVI values were linked to Positive Outcomes for Orphans study participants to explore cross-sectional associations between greenspace exposure and psychological health (measured 2019-2021). Two continuous scores of psychological health were examined: total difficulties from the Strengths and Difficulties Questionnaire and depressive symptoms from the 8-item Patient Health Questionnaire. Multilevel generalized linear regression, nested by administrative units, was used to estimate the association between greenspace and psychological health. We also explored effect modification by gender and having income.

RESULTS

We found greenspace is spatially clustered in Addis Ababa, with high greenspace density in the northeast region and low greenspace density in the center of the city. Our findings suggest residing in greener areas is associated with fewer emotional and behavioral difficulties (β = -1.89; 95% CI: -3.50, -0.29), but not significantly associated with depressive symptomology (β = -0.61; 95% CI: -2.33, 1.11). We observed stronger associations between greenspace and total difficulties among those reporting any income and among males, and for the association between greenspace and depression symptomology among males.

CONCLUSION

We offer initial exploration into the role of greenspace in psychological well-being in Addis Ababa, with potential implications for urban communities across Sub-Saharan Africa. Further research should continue to explore how the built and natural environment could be leveraged in similar settings to promote population psychological health.

The Impact of the Urban Built Environment on the Play Behavior of Children with ASD

Anxiety caused by the lack of social skills is the biggest problem faced by children with ASD. Playing can improve children's social skills and relieve anxiety. This study aimed to explore the influence of urban built environments on ASD children's play behavior. The participants in this study were 57 parents of children with ASD. An anonymous questionnaire was used to collect and analyze data. At the same time, retrospective semi-structured interviews with 31 parents of ASD children were performed to validate the data analysis results. The results showed that lower residential building density, higher residential greening and higher destination accessibility have positive effects on ASD children's play behavior. Excellent transportation facilities and high NDVI vegetation coverage have positive effects on the play behavior of children with ASD. More recreational facilities and recreational playability have positive impacts on the play behavior of children with ASD. The population density and number of children in the destination, as well as public facilities, influence the play behavior of children with ASD. The research results can promote the integration of this group into urban life and further promote social equity. At the same time, with the social needs of autistic children as an intermediary, it is expected to further explore new directions for sustainable urban development. Finally, combined with the research results, parents of ASD children are given proposals for how to increase the likelihood of children's play behavior by choosing appropriate urban built environments.

Integrated analysis of doubly disadvantaged neighborhoods by considering both green space and blue space accessibility and COVID-19 infection risk

The ongoing COVID-19 pandemic has taken a heavy toll on the physical and mental health of the public. Nevertheless, the presence of green and blue spaces has been shown to be able to encourage physical activities and alleviate the mental distress caused by COVID-19. However, just as the impact of COVID-19 varies by geographical region and area, the distribution of green and blue spaces is also different across different neighborhoods and areas. By using Hong Kong as the study area, we determine the local neighborhoods that suffer from both high COVID-19 infection risk as well as low green and blue space accessibility. The results show that some of the poorest neighborhoods in the territory such as Sham Shui Po, Kwun Tong and Wong Tai Sin are also among the most doubly disadvantaged in terms of COVID-19 infection risk as well as green and blue space accessibility.

Association between residential greenspace and health-related quality of life in children aged 0-12 years

INTRODUCTION

Greenspaces generate several perceived health benefits, including an overall improvement in the quality of life. However, little is known about the effects of greenspaces through pregnancy and early childhood in promoting health-related quality of life (HRQoL) among children.

METHOD

Participants were from the Mothers and their Children's Health Study (MatCH), a 2016/17 sub-study of a national prospective study since 1996 known as the Australian Longitudinal Study on Women's Health (ALSWH). Mothers (n=3,048) self-reported on their three youngest children aged under 13 years (n=5,799, mean=7.0 years, s.d=3.2 years) using the Pediatric Quality of Life Inventory (PedsQL) to measure their HRQoL. Since 1996, annual exposure to green and non-green vegetation was measured using two remote sensing indicators: Normalized Difference Vegetation Index (NDVI) and fractional cover of non-photosynthetic vegetation (fNPV), respectively, for 100 m and 500 m buffer zone around maternal residential address. Multiple exposure windows were calculated including during pregnancy, the first year of life and child's lifetime exposure. Generalised estimating equations (GEE) models, adjusting for potential confounders, were used for analyses.

RESULTS

A 1 standard deviation increase in NDVI greenness within 500 m buffer around the home at early life and during childhood was positively associated with higher HRQoL in the total scores and psychological health summary scores in the crude model only. No association was found between fNPV (non-green vegetation) at 100 m and 500 m circular buffers and children's HRQoL. The overall findings from our models remained consistent based on a series of sensitivity analyses, including the impact of maternal residential mobility status and geocoding method on the effect estimates.

CONCLUSION

Our study revealed that surrounding residential greenspace was not associated with children's HRQoL. Further longitudinal studies are required to better understand the influence of greenspace at different periods of exposure on the health and wellbeing of children.

Developing an Integrated "Regression-QMRA method" to Predict Public Health Risks of Low Impact Developments (LIDs) for Improved Planning

Worldwide Low Impact Developments (LIDs) are used for sustainable stormwater management; however, both the stormwater and LIDs carry microbial pathogens. The widespread development of LIDs is likely to increase human exposure to pathogens and risk of infection, leading to unexpected disease outbreaks in urban communities. The risk of infection from exposure to LIDs has been assessed via Quantitative Microbial Risk Assessment (QMRA) during the operation of these infrastructures; no effort is made to evaluate these risks during the planning phase of LID treatment train in urban communities. We developed a new integrated "Regression-QMRA method" by examining the relationship between pathogens' concentration and environmental variables. Applying of this methodology to a planned LID train shows that the predicted disease burden of diarrhea from Campylobacter is highest (i.e. 16.902 DALYs/1000 persons/yr) during landscape irrigation and playing on the LID train, followed by Giardia, Cryptosporidium, and Norovirus. These results illustrate that the risk of microbial infection can be predicted during the planning phase of LID treatment train. These predictions are of great value to municipalities and decision-makers to make informed decisions and ensure risk-based planning of stormwater systems before their development.

A bibliometric analysis of the study of urban green spaces and health behaviors

Urban green space can supply a range of ecosystem services and general health benefits for people. This paper reviewed and analyzed 607 papers related to urban green space and health behaviors from 2002 to 2021 in the Web of Science core collection by using Citespace 6.1.R2 software. The scientifically bibliometric analysis and visual analysis were conducted to analyze the basic characteristics, literature co-citation analysis, research hotspots, and frontier trends. The findings show that 11 co-citation clusters indicate the research intellectual base. Also, 19 main keywords with a high frequency and 20 main keywords with a high centrality were extracted. Burst detection analysis reveals three research frontier trends: the correlation between urban green space and health behavior; the driving and impact factors; and the study of environmental justice and social equity. This paper aims to systematically review the progress and basic situation of urban green spaces and health behaviors research around the world, which helps to gain a comprehensive understanding of this field, as well as provide value and references for subsequent research.

The Impact of Time Spent in Natural Outdoor Spaces on Children's Language, Communication and Social Skills: A Systematic Review Protocol

There has been increasing interest over the past decade with regard to the health and wellbeing implications of time spent outdoors in nature for children. Universal systematic reviews of evidence report benefits to physical health, social-emotional mental health and wellbeing, cognition and academic learning. Internationally, there is indicative evidence to suggest outdoor engagement with nature may also impact children's language and communication skills, skills that are critical to development, education, social relationships and life opportunities. Yet, at present such evidence has not been synthesised. Despite evidence for the benefits of the outdoors, the amount of time children are spending outdoors is in rapid decline, and has been further exacerbated by the COVID-19 pandemic. Alongside this are increasing numbers of children starting primary education with significant speech, language and communication needs (SLCN) which remain persistent over time. With established wide-reaching benefits of nature to children's physical and mental health and psychological development, there is a need to further explore the more specific impacts of the natural environment on children's language, communication and social skills, which could provide a unique opportunity to consider nature as a universal public health intervention for SLCN. The current review will aim to synthesise existing qualitative and quantitative evidence of the impact of time spent in natural outdoor spaces on the language, communication and social skills of 2-11-year-old children. Literature will be searched across seven databases and considered for inclusion against inclusion and exclusion criteria. Potential implications of the review include informing public health practice and policy for child development and education, informing priorities for speech, language, and communication interventions, and providing directions for future international research.

Residential green space associated with the use of attention deficit hyperactivity disorder medication among Dutch children

Several studies have observed an inverse relationship between attention deficit hyperactivity disorder (ADHD)-related behavior of children, as reported by parents or teachers, and the amount of green space in their residential environment. Research using other, more objective measures to determine ADHD prevalence is scarce and could strengthen the evidence base considerably. In this study, it is investigated whether a similar beneficial association will be observed if the use of ADHD-related medication is selected as an outcome measure. More specifically, registry data from a health insurance company on the reimbursement of ADHD-related medication in 2011 were available for 248,270 children between 5 and 12 years of age. Amounts of green space within 250 and 500 m of the home address were calculated. Multilevel logistic regression analyses for the prevalence of use were conducted, including the following covariates: sex, age, urbanity of the neighborhood, neighborhood socioeconomic status (SES), and percentage of people with a non-Western migration background in the neighborhood population. Results showed that the amount of green space was inversely related to the prevalence of use of ADHD medication. Moreover, the relationship was strongest among children living in the least wealthy neighborhoods and absent among those living in the wealthiest neighborhoods. Results also show that in less wealthy neighborhoods, there is, on average, less green space available nearby: children who are likely to benefit most from nearby green space tend to have the least of it.

Effects of residential greenness on attention in a longitudinal study at 8 and 11-13 years

In an urbanizing world, with 55% of the population living in cities, it is essential to design friendly and healthy ones. An emerging body of evidence has associated greenspace exposure with improved cognitive development, including attentional function; however, the longitudinal studies looking at the association with attentional function are still scarce. Therefore, the objective of this study was to analyze the association of the exposure to greenspace and attention in school children. This study was based on 751 participants at 8 years and 598 at 11-13 years of two sub-cohorts of the INMA cohort study in Gipuzkoa and Asturias, Spain. Greenspace exposure at home was characterized using four indicators: (i) average of Normalized Difference Vegetation Index (NDVI) and (ii) Vegetation Continuous Field (VCF) in buffers of 100 m, 300 m, and 500 m around the residential address, (ii) availability of a green space within 300 m from the residential address, and (iv) residential distance to green spaces. Participants' attention was characterized twice at ages of 8 and 11 years, using the computerized Attentional Network Test (ANT). General linear models were used for the cross-sectional analyses and linear mixed effects model for the longitudinal analyses. Our cross-sectional analyses showed a statistical significant protective association between average NDVI at 300 m and inattentiveness (-7.20, CI 95%: 13.74; -0.67). In our longitudinal analyses, although we generally observed beneficial associations between greenspace exposure and attention, none attained statistical significance. No statistically significant indirect effect were seen for NO₂. Our findings add to the emerging body of evidence on the role of green spaces in neurodevelopment, which can provide the evidence base for implementing intervention aimed at promoting neurodevelopment in urban children.

Greenspace exposure and children behavior: A systematic review

We systematically reviewed the existing evidence (until end of November 2021) on the association between long-term exposure to greenspace and behavioral problems in children according to the PRISMA 2020. The review finally reached 29 relevant studies of which, 17 were cross-sectional, 11 were cohort, and one was a case-control. Most of the studies were conducted in Europe (n = 14), followed by the USA (n = 8), and mainly (n = 21) from 2015 onwards. The overall quality of the studies in terms of risk of bias was "fair" (mean quality score = 5.4 out of 9) according to the Newcastle-Ottawa Scale. Thirteen studies (45%) had good or very good quality in terms of risk of bias. The strength and difficulty questionnaire was the most common outcome assessment instrument. Exposure to the greenspace in the reviewed studies was characterized based on different indices (availability, accessibility, and quality), mostly at residential address locations. Association of exposure to different types of greenspace were reported for nine different behavioral outcomes including total behavioral difficulties (n = 16), attention deficit hyperactivity disorder (ADHD) symptoms and severity (n = 15), ADHD diagnosis (n = 10), conduct problems (n = 10), prosocial behavior (n = 10), emotional symptoms (n = 8), peer-relationship problems (n = 8), externalizing disorders (n = 6), and internalizing disorders (n = 5). Most of the reported associations (except for conduct problems) were suggestive of beneficial association of greenspace exposure with children's behaviors; however, the studies were heterogeneous in terms of their exposure indicators, study design, and the outcome definition.

The role of physical environmental characteristics and intellectual disability in conduct problem trajectories across childhood: A population-based Cohort study

BACKGROUND

The paucity of research investigating the role of the physical environment in the developmental progression of conduct problems and the potential moderating effects of intellectual disability (ID) is surprising, given the clinical relevance of elucidating environmental determinants of disruptive behaviours.

AIMS

To use data from a large UK cohort study to assess associations between physical environmental exposures, ID, and conduct problem trajectories.

METHOD

The sample included 8168 Millennium Cohort Study children (1.9% with ID). Multilevel growth curve modelling was used to examine the role of physical environment characteristics in the developmental trajectories of conduct problems after adjustments for ID status.

RESULTS

Exposure to external environmental domains was not associated with differences in children's conduct problems across development. Alternatively, internal aspects of the household environment: spatial density (b = 0.40, p < .001) and damp problems (b = 0.14, p < .001) were both significantly associated with increased trajectories. Various individual and familial covariates were positively associated with conduct problems over time, including: presence of ID (b = 0.96, p < .001), autism spectrum disorder (b = 1.18, p < .001), male sex (b = 0.26, p < .001), poverty (b = 0.19, p < .001), maternal depression (b = 0.65, p < .001), and non-nuclear family structure (b = 0.35, p < .001). Positive ID status appeared to moderate the effects of internal household spatial density, reporting a non-linear negative association with spatial density and conduct problems across development (b = -1.08, p < .01).

CONCLUSIONS

Our findings highlight the potential harmful consequences of poor internal residential conditions on children's development of disruptive behaviours.

Multisite greenness exposure and oxidative stress in children. The potential mediating role of physical activity

Residential greenness exposure has been reported to positively impact health mainly by reducing overweight/obesity risk, improving mental health and physical activity. Less is known on biological pathways involved in these health benefits. We aimed to investigate the association between multisite greenness exposure and oxidative stress in children and explore the potential mediating role of physical activity in this association. This cross-sectional study involved 323 healthy subjects (8-11 y) from five schools in Asti (Italy). Children's parents filled a questionnaire providing the residential address, parental education, and physical activity frequency. Oxidative stress was quantified in spot urine by isoprostane (15-F_2t-IsoP) using ELISA technique. Residential and scholastic greenness were defined by the Normalized Difference Vegetation Index (NDVI) in buffers with 100, 250, 300, 500 and 1000 m radii, and vegetated portion was also estimated. Multisite exposures were derived accounting for NDVI around home and school, weighted for time spent in each location. Linear mixed models, age-adjusted, with schools as random intercept, tested the association between 500 m-radius buffer multisite grenness variables and log (15-F_2t-IsoP), reporting decreased oxidative stress per interquartile range (IQR) increase in multisite NDVI (β: 012, 95%CI -0.240 to 0.004) and multisite vegetated portion (β: 0.14, 95%CI -0.270 to -0.006). The mediation analysis did not support the hypothesis that physical activity frequency could mediate these associations. Multisite greenness exposure is associated with decreased oxidative stress in children and our data did not support the mediating role of physical activity.

The Impact of Sustained Exposure to Air Pollutant on the Mental Health: Evidence from China

Emerging evidence suggests that poor mental health is particularly pronounced among Chinese residents, who are exposed to nearly the worst air pollution worldwide. However, the correlations between air pollutant concentration and mental health have not been consistently reported in previous studies. Methodologically speaking, a sufficiently rigorous design is required to demonstrate the causal relationship between the two factors. In this study, we aimed to infer the causal relationship between air pollutant concentration and mental health. In this panel research, the data were compiled through a combination of statistics from the China Family Panel Study, China Environmental Statistics Yearbook, World Meteorological Association, and China National Bureau of Statistics. Ultimately, this study enrolled 65,326 individuals whose mental health, air pollutant concentration, and other demographic information was available and robust. The RD design of this study utilizes the discontinuous variation in air pollutant concentrations and mental health as one crosses the Huai River boundary, which is an arbitrary heating policy that caused the difference in air pollutant concentrations between the north and south of China. In this study, we found that a 10 μg/m3 increase in air pollutant concentrations (air particulate matter smaller than 10 μm (PM10)) leads to a 4.9-unit decrease in the mental health of the Chinese residents(coeff = 0.49, SD = 0.07, p < 0.05), equivalent to 36% of the average of Chinese residents. In the heterogeneity model, the impairment of mental health by air pollutant concentrations was more pronounced in male residents (coeff = 1.37, SD = 0.10, p < 0.05) compared to female residents (coeff = 0.42, SD = 0.04, p < 0.05) and smokers (compared to non-smokers). The robustness of the results is ensured by changing the RD bandwidth and polynomial order, and by two unique sensitivity analyses. The results indicate that air pollutant concentrations significantly impair the mental health of Chinese residents, which provides empirical evidence supporting the Chinese government’s decision to invest more in combating air pollution and ensuring the mental health of Chinese residents.

Influence of Flexible Classroom Seating on the Wellbeing and Mental Health of Upper Elementary School Students: A Gender Analysis

While traditional seating (also known as fixed seating or fixed classroom) remains the preferred classroom seating arrangement for teachers, a new type of seating arrangement is becoming more common in schools: the flexible classroom (also known as flexible seating). The purpose of this type of arrangement is to meet the needs of students by providing a wide variety of furniture and workspaces, to put students at the center of learning, and to allow them to make choices based on their preferences and the objectives of the task at hand. This study aimed to examine the influence of flexible seating on the wellbeing and mental health of elementary school students. This article presents the results of exploratory research conducted in Quebec among Grade 5 and 6 students comparing the wellbeing and mental health of students in fixed and flexible classrooms. The study was conducted with 107 students in three Grade 5 and 6 flexible classrooms (n = 51) and three Grade 5 and 6 fixed classrooms (n = 56). It is based on a quasi-experimental, quantitative design with post-test only and a control group. The groups were matched based on natural conditions (i.e., from a convenience sample). Furthermore, the study included a gender-differentiated analysis for each group. The results showed that flexible classroom seating had a positive influence on the girls’ wellbeing and mental health. In contrast, for the boys, fixed classroom seating was most conducive to their wellbeing and mental health. However, our study has some limitations that are discussed in the article.

Residential Greenspace Is Associated with Lower Levels of Depressive and Burnout Symptoms, and Higher Levels of Life Satisfaction: A Nationwide Population-Based Study in Sweden

Population-based studies of individual-level residential greenspace and mental health outcomes are still limited. Thus, the present study investigates greenspace–mental health associations—including depressive symptoms, burnout symptoms, and life satisfaction—in a population-based sample of adults, the Swedish Longitudinal Occupational Survey of Health, in 2016 (n = 14,641). High-resolution land cover of greenspace and green–blue-space was assessed at 50, 100, 300 and 500 m buffers around residential addresses. Higher residential greenspace and green–blue-space were associated with lower levels of depressive and burnout symptoms among non-working individuals and with higher life satisfaction in the whole study population, after controlling for age, sex, individual income, and neighborhood socioeconomics. The immediate residential-surrounding environment (50 m) consistently showed the strongest associations with the outcomes. Having a partner was associated with better mental health outcomes and with having more residential greenspace, and adjusting for this rendered greenspace–health associations mostly statistically non-significant. In conclusion, higher levels of greenspace and green–blue-space in the immediate residential-surrounding environment were associated with better mental health outcomes in the present study, which contributes additional nuances to prior studies. The importance of residential greenspace for public health, urban planning, and development is discussed.

Effects of the physical and social environment on youth cognitive performance

Individual differences in children's cognitive abilities impact life and health outcomes. What factors influence these individual differences during development? Here, we test whether children's environments predict cognitive performance, independent of well-characterized socioeconomic effects. We analyzed data from 9002 9- to 10-year olds from the Adolescent Brain Cognitive Development Study, an ongoing longitudinal study with community samples across the United States. Using youth- and caregiver-report questionnaires and national database registries (e.g., neighborhood crime, walkability), we defined principal components summarizing children's home, school, neighborhood, and cultural environments. In two independent samples (ns = 3475, 5527), environmental components explained unique variance in children's general cognitive ability, executive functioning, and learning/memory abilities. Furthermore, increased neighborhood enrichment was associated with an attenuated relationship between sociodemographics and general cognitive abilities. Thus, the environment accounts for unique variance in cognitive performance in children and should be considered alongside sociodemographic factors to better understand brain functioning and behavior across development.

The influence of early-life residential exposure to different vegetation types and paved surfaces on early childhood development: A population-based birth cohort study

BACKGROUND

Growing evidence suggests that exposure to green space is associated with improved childhood health and development, but the influence of different green space types remains relatively unexplored. In the present study, we investigated the association between early-life residential exposure to vegetation and early childhood development and evaluated whether associations differed according to land cover types, including paved land.

METHODS

Early childhood development was assessed via kindergarten teacher-ratings on the Early Development Instrument (EDI) in a large population-based birth cohort (n = 27,539) in Metro Vancouver, Canada. The residential surrounding environment was characterized using a high spatial resolution land cover map that was linked to children by six-digit residential postal codes. Early-life residential exposure (from birth to time of EDI assessment, mean age = 5.6 years) was calculated as the mean of annual percentage values of different land cover classes (i.e., total vegetation, tree cover, grass cover, paved surfaces) within a 250 m buffer zone of postal code centroids. Multilevel models were used to analyze associations between respective land cover classes and early childhood development.

RESULTS

In adjusted models, one interquartile range increase in total vegetation percentage was associated with a 0.33 increase in total EDI score (95% CI: 0.21, 0.45). Similar positive associations were observed for tree cover (β-coefficient: 0.26, 95% CI: 0.15, 0.37) and grass cover (β-coefficient: 0.12, 95% CI: 0.02, 0.22), while negative associations were observed for paved surfaces (β-coefficient: -0.35, 95% CI: -0.47, -0.23).

CONCLUSIONS

Our findings indicate that increased early-life residential exposure to vegetation is positively associated with early childhood developmental outcomes, and that associations may be stronger for residential exposure to tree cover relative to grass cover. Our results further indicate that childhood development may be negatively associated with residential exposure to paved surfaces. These findings can inform urban planning to support early childhood developmental health.

Park access and mental health among parents and children during the COVID-19 pandemic

BACKGROUND

Time spent outdoors and in nature has been associated with numerous benefits to health and well-being. We examined relationships between park access and mental health for children and parents during the COVID-19 pandemic. We also explored associations between park access and co-participation of parent and child in time outdoors, and child and parent physical activity.

METHODS

We used data from 1,000 respondents to a nationally representative U.S. survey of parent-child dyads during October-November 2020. Park access was defined as an affirmative response to: "do you have a park that you can safely walk to within 10 min of your home?" Child mental health was operationalized as the Strengths and Difficulties Questionnaire (SDQ) total difficulties score. The Patient Health Questionnaire-4 (PHQ-4) total score assessed parent mental health and the International Physical Activity Questionnaire (IPAQ) assessed parent physical activity. Child physical activity and co-participation in outdoor activity were reported as number of days in the prior week. Linear regression was used to examine relationships between park access and health outcomes in models adjusted for child and parent characteristics and COVID-19 impact.

RESULTS

Our sample included 500 parents of children ages 6-10 years, and 500 parent-child dyads of children ages 11-17 years. Park access was associated with a lower SDQ total score among children (β: -1.26, 95% CI: -2.25, -0.27) and a lower PHQ-4 total score among parents (β: -0.89, 95% CI: -1.39, -0.40). In models stratified by child age, these associations were observed for SDQ scores among adolescents ages 11-17 and for PHQ-4 scores among parents of children ages 6-10 years. Park access was also associated with 0.50 more days/week of co-participation in outdoor time (95% CI: 0.16, 0.84), and higher levels of parent physical activity (β: 1009 MET-min/week, 95% CI: 301, 1717), but not child physical activity (β: 0.31 days/week, 95% CI: -0.03, 0.66).

CONCLUSIONS

Park access was associated with better mental health among children and parents, and more parent physical activity and parent-child co-participation in outdooractivity during the COVID-19 pandemic. Access to nearby parks may be an important resource to promote health and well-being, for both individuals and families.

Does exposure to greenness improve children's neuropsychological development and mental health? A Navigation Guide systematic review of observational evidence for associations

BACKGROUND

Contact with nature may have a key role in child brain development. Recent observational studies have reported improvements in children's neuropsychological development and mental health associated with greenness exposure. In a rapidly urbanizing word, researchers, policymakers, healthcare workers and urban planners need to work together to elaborate evidence-based policies and interventions to increase the availability of quality green space with the potential to enhance childhood development.

OBJECTIVE

To review the observational evidence assessing the effect of exposure to greenness on children's neuropsychological development and mental health.

METHODS

The protocol for the review was preregistered at PROSPERO (CRD42020213838). The Navigation Guide systematic review methodology was followed. Search strategies were formulated and adapted to each database. Searches were performed in PubMed, Scopus, Web of Science and EBSCO's GreenFILE on October 5, 2021. Additional articles were further identified by hand-searching reference lists of included papers.

RESULTS

A systematic search of 4 databases identified 621 studies, of which 34 were included in the review. The studies included investigated diverse domains within neuropsychological development and mental health, such as attention, working memory, intelligence, cognitive development, academic performance, well-being, attention-deficit/hyperactivity disorder symptoms, and behavior. Most of the studies were rated as having high or probably high risk of bias in the assessment.

DISCUSSION

Although nearly all studies showed a positive association between greenness exposure and the outcomes studied, the heterogeneity in the methods used to assess exposure and the diversity of domains within each main outcome has made it difficult to draw clear conclusions. Future studies should adopt a longitudinal design to confirm the causality of the associations and include measures to determine which characteristics of greenness have the greatest influence on each domain. Researchers should also try to explore pathways linking exposure to greenness with the neuropsychological development and mental health, by implementing mechanistic studies.

Frequent occurrence of respiratory symptoms in children is associated with exposure to air pollution, land use types, and parental mental health in the Greater Taipei area

Although studies have investigated the individual effects of air pollution, land use types, and parental mental health on children's respiratory health, few studies have examined the effects of these risk factors simultaneously in children aged <2 years. We investigated the effects of exposure to air pollution, land use types surrounding residences, and parental mental health on the frequent occurrence of respiratory symptoms in children aged <2 years in the Greater Taipei area. Participants were recruited from an ongoing Taiwanese birth cohort study. We analyzed the data of the participants who had been recruited from January 2011 to April 2014 and had responded to the follow-up questionnaires at 6, 12, and 24 months. Self-administered questionnaires were used to collect participants' sociodemographic background and health, such as respiratory symptoms, and parental mental health. Pre- and postnatal pollution levels were estimated using the spatial interpolation technique (ordinary kriging) at children's residential addresses. Land use types surrounding participants' homes were evaluated by performing buffer analysis. Multiple logistic regression analyses were conducted to examine the effects of risk factors on the frequent occurrence of child respiratory symptoms in children aged 6, 12, and 24 months. We included 228, 360, and 441 children aged 6, 12, and 24 months, respectively. Our results indicated that postnatal exposure to PM_2.5 and O₃ was positively associated with children's respiratory symptoms. Traffic-related land-use types, sports facilities, and commercial land surrounding homes exerted adverse effects on children's respiratory symptoms, whereas the presence of schools in the neighborhood was beneficial. Parental mental health was also associated with children's respiratory symptoms. Postnatal exposure to air pollution and land use types surrounding residences were associated with respiratory health in children aged <2 years. The residential environment is a critical factor affecting children's respiratory health of children aged <2 years.

Residential and school green and blue spaces and intelligence in children: The Generation XXI birth cohort

Green and blue spaces have numerous health benefits. It has been hypothesized that contact with these spaces can have an important role in cognitive development, because it provides children with unique stimuli that can help develop curiosity, creativity, awareness, and control. This study aimed to estimate the association between exposure to green and blue spaces and the various measures of intelligence quotient (IQ) among children from Porto Metropolitan Area (Portugal). This investigation used data from the Generation XXI birth cohort. Exposure was assessed by Geographic Information Systems using vegetation indexes and measures of accessibility to urban green spaces and blue spaces in the surroundings of the residence and school, measured at 0, 4, 7 and 10 years. The outcome was the verbal, performance, and global IQ, measured using the Wechsler Intelligence Scale for Children (WISC-III), administered at age 10. Associations were estimated using crude and adjusted multilevel models. The mediation role of air pollution and physical activity was quantified. This study included 3827 children. The adjusted models showed that having green spaces up to 800 m of the residence was positively associated with performance IQ (1.30 95%CI [0.26; 2.35]) and global IQ (1.27 [0.18; 2.36]). No clear associations were observed regarding accessibility to blue spaces. Physical activity appeared to have a minor mediation role. Children with urban green spaces around their residences had higher performance and global IQ. Local actors in the sectors of public health and urban planning should promote the creation of green spaces close to residential areas.

Simulating crowding of urban green areas to manage access during lockdowns

During the COVID-19 emergency, cities around the world introduced measures to guarantee physical distancing that restricted access to urban parks and green areas, with potentially negative effects on citizens' health and wellbeing. This study aims at providing insights to manage access to urban green space in physical distancing times, when the risk of crowding should be avoided. Using the city of Trento (Italy) as a case study, the study simulates policy scenarios corresponding to different restrictions and assesses their effects on green space access and crowding. Policy scenarios are obtained by combining different distances that people are allowed to travel, different types of green areas available for public use (only urban parks or parks and schoolyards), and different target populations (all residents or only people with no private gardens). The results unveil the trade-off between access and crowding of green areas, and can be used to suggest policy interventions and regulations that can be adopted in an emergency. Particularly, the study shows that: i) The relationship between distance threshold and the percentage of people with access to green areas is non-linear, and this should be carefully considered when proposing travel restrictions; ii) Changing the maximum travel distance does not produce major effects on the number of crowded green areas, hence additional or alternative measures need to be adopted; iii) Off-the-shelf measures, such as opening schoolyards, are beneficial and can be implemented rapidly in an emergency. Finally, the study reveals "hotspots" of green space deprivation/overcrowding in the city that should be addressed by urban planning to ensure that green space continues to benefit citizens also during emergency conditions.

Early life exposure to residential green space impacts cognitive functioning in children aged 4 to 6 years

INTRODUCTION

During early childhood, neuronal networks are highly susceptible to environmental factors. Previous research suggests that green space exposure is beneficial for cognitive functioning. Here, we investigate the associations between residential green space exposure and behavioral problems and cognitive development in children aged four to six years.

METHOD

We included children participating in the ENVIRONAGE birth cohort. Residential green spaces were calculated based on high-resolution land cover data within several buffers (50-1,000 m) around the residence. The children's behavior was assessed with the Strengths and Difficulties Questionnaire (SDQ) among 411 children. In addition, to evaluate cognitive function, 456 children completed four tasks of the Cambridge Neuropsychological Test Automated Battery (CANTAB). We used multivariate logistic and linear regression models while accounting for potential confounders and covariables.

RESULTS

An interquartile (IQR) increase of residential green space within 50 m was associated with a 38% (95% CI: 56;14) lower odds of a child having hyperactivity problems. Additionally, we found a beneficial influence of residential green space in close proximity (50-100 m) on the attention and psychomotor speed, represented by the Motor Screening Task. For example, we found a decrease of 0.45 (95% CI: -0.82;-0.09) pixel units from target center with an IQR increase of residential green space in a 50 m buffer. In addition, we observed an improved visual recognition/working memory, represented by the Delayed Matching to Sample Task within all included buffers (50-1000 m). For example, we observed a decrease of 4.91% (95 %CI: -7.46;-2.36) probability of an error occurring if the previous trial was correct and a 2.02% (95 %CI: 0.08; 3.97) increase of correct trials with an IQR increase of green space within a 100 m buffer.

CONCLUSION

This study provides additional indications for a beneficial influence of green space exposure on the development of behavioral problems and cognitive function as young as four years of age.

Natural and built environments and blood pressure of Alpine schoolchildren

BACKGROUND

Early life environments may influence children's blood pressure (BP), but evidence on the combined effects of natural and built environment exposures is scarce. The present study investigates the associations of natural and built environment indicators, traffic noise, and air pollution with BP in children living in Alpine valleys.

METHODS

In 2004/2005, 1251 school children (8-12 years old) were sampled for a cross-sectional survey in several Austrian and Italian mountain valleys. Children's mothers completed a questionnaire. The outcomes of interest were systolic and diastolic BP measured with a calibrated oscillometric device. Indicators of land cover assigned to the residential and school coordinates within 100 and 1000 m included normalized difference vegetation index (NDVI), tree canopy cover, and a broader naturalness indicator titled distance to nature (D2N). The presence of a home garden was also measured via self-report. Imperviousness density served as a proxy for the built environment. Residential air pollution (NO₂) and noise (L_den) from traffic were calculated using bespoke modeling. NO₂, L_den, physical activity, and body mass index (BMI) were treated as mediating pathways.

RESULTS

Higher NDVI and tree cover levels in residential and school surroundings and home gardens were consistently associated with lower BP. The built environment was associated with higher BP. Counterintuitive inverse associations between NO₂ and L_den and BP were also found. Structural equation modeling showed that higher levels of greenspace and presence of a home garden were weakly associated with more outdoor play spaces, and in turn with lower BMI, and ultimately with lower BP.

CONCLUSIONS

Exposure to natural environments may help maintain normal BP in children, while built environment may increase children's BP. Outdoor play and less adiposity in greener areas may mediate some of these associations. Evidence on air pollution and noise remains controversial and difficult to explain.