Exposure to green space and prevention of anxiety and depression among young people in urban settings: a global scoping review

Greenspace use and anxiety in young adults: The role of interoception

OBJECTIVE

Greenspace is linked to prevention and management of anxiety, but the underlying mechanisms remain unclear. This study aims to evaluate the association between greenspace use and anxiety in Chinese young adults, focusing on the mediating role of interoception.

METHODS

This population-based study was conducted between September and October 2023 in four local universities in China. A total of 27,755 young adults were included. Greenspace use was assessed by self-report, anxiety by the Generalized Anxiety Disorder (GAD) assessment, and interoception by the Body Perception Questionnaire (BPQ). Generalized linear mixed models (GLMMs) and mediation models were utilized to analyze associations.

RESULTS

The mean age of participants was 19.39 ± 1.64 years, with 10,944 (39.4%) being female. A total of 10,273 (37.01%) participants suffered from anxiety. GLMMs indicated that compared to their counterparts who did not visit green spaces at all in the past four weeks, those who visited once or twice, once a week, or several times a week had lower odds of anxiety. A lower level of interoception was associated with reduced odds of anxiety. Furthermore, interoception mediated much of the association between greenspace use and anxiety. These associations were robust in a series of sensitivity analyses.

CONCLUSIONS

These results suggest the crucial role of green spaces on interoception and anxiety and point to the importance of promoting student well-being through interaction with greenspace and nature. Further research is needed to better understand how interoception mediates the connection of greenspace and other aspects of the built environment with anxiety.

A Nature-Based Intervention and Mental Health of Schoolchildren: A Cluster Randomized Clinical Trial

Importance

Nature-based therapeutic or preventive interventions for mental health are increasingly popular, but their effectiveness for improving mental health is not well documented.

Objective

To investigate the effectiveness of the Open Sky School Program (École à Ciel Ouvert), a 12-week nature-based intervention for elementary schoolchildren in grades 5 and 6, for reducing mental health symptoms.

Design, Setting, and Participants

This 2-arm, cluster randomized clinical trial was conducted from February 27 to June 16, 2023, in French-language elementary schools in Quebec, Canada, with green space within 1 km. Participants were teachers and students in grades 5 and 6.

Intervention

In the intervention group, for 2 hours per week for 12 weeks, classes were taught outdoors in a nearby park or wooded area. Teachers were encouraged to engage students in basic subjects and in 10 or more mental health activities (mindfulness, philosophy, and/or art therapy). Control group schools conducted classes as usual.

Main Outcomes and Measures

The primary outcome was change in student mental health (internalizing and externalizing symptoms, social problems) based on teacher- and student-reported 30-item Social Behavior Questionnaire (SBQ) scores (3-point scale) from baseline to the immediate postintervention follow-up, assessed in per-protocol and intent-to-treat mixed-model analyses. Secondary outcomes were student self-reported changes in depressive symptoms, positive or negative affect, pro-environmental efforts and/or attitudes, and nature connectedness.

Results

A total of 33 schools participated (53 teachers, 1015 students), including 16 schools (25 teachers, 515 students) in the intervention group and 17 schools (28 teachers, 500 students) in the control group. Student mean (SD) age was 10.9 (0.75) years; 507 (50.7%) were girls. Per-protocol and intent-to-treat mixed-model analyses showed no differences in mental health symptom change between groups; for example, the adjusted mean difference in SBQ scores between the intervention and control groups for externalizing symptoms was -0.04 (95% CI, -0.13 to 0.04) in the intent-to-treat analysis and -0.06 (95% CI, -0.16 to 0.04) in the per-protocol analysis. Post hoc analyses revealed low mental health symptoms at baseline, with low variability. Slightly greater reductions in symptoms were observed in the intervention group, but only for children with higher mental health symptoms at baseline (P < .05 for interaction). For example, for children with internalizing symptoms 1 SD above the mean at baseline, internalizing symptoms decreased by 0.38 SD (mean change, -0.15; P < .001) in the intervention group vs the control group.

Conclusions and Relevance

In this large cluster randomized clinical trial in daily-life elementary school settings, 12 weeks of classes in green space for 2 hours per week did not reduce mental health symptoms in students aged 10 to 12 years in either the per-protocol or the intent-to-treat analysis. However, this low-cost, safe outdoor intervention may provide unmeasured or longer-term benefits for children with higher risk of mental health symptoms.

Trial Registration

ClinicalTrials.gov Identifier: NCT05662436.

Coastal cultural ecosystem services and adolescents' subjective well-being

Despite growing recognition of nature's impact on mental health, its specific effects on adolescents remain unclear. This gap hinders effective strategies for youth well-being in a world facing increasing environmental pressures. This study directly investigates the connections between coastal environments and subjective well-being in adolescents. We explore how interactions with coastal landscapes and associated cultural ecosystem services contribute to both personal and social dimensions of well-being in a sample of 202 adolescents (16 and 17 years old) from Sardinia, Italy. Our findings reveal a beneficial impact of coastal experiences, promoting positive affect, social integration, and physiological well-being. However, human pressures on these environments can lead to negative affect, while fostering a sense of social contribution. This research highlights the complex interplay between coastal environments, human impacts, and teenagers' well-being. Understanding these links empowers planners to craft coastal management strategies that balance adolescents' well-being with the long-term sustainability of coastal regions.

Effect of nature on the mental health and well-being of children and adolescents: meta-review

BACKGROUND

Urbanisation is taking place worldwide and rates of mental illness are rising. There has been increasing interest in 'nature' and how it may benefit mental health and well-being.

AIMS

To understand how the literature defines nature; what the characteristics of the nature intervention are; what mental health and well-being outcomes are being measured; and what the evidence shows, in regard to how nature affects the mental health and well-being of children and adolescents.

METHOD

A meta-review was conducted, searching three databases for relevant primary and secondary studies, using key search terms including 'nature' and 'mental health' and 'mental well-being'. Inclusion criteria included published English-language studies on the child and adolescent population. Authors identified the highest quality evidence from studies meeting the inclusion criteria. Data were extracted and analysed using descriptive content analysis.

RESULTS

Sixteen systematic reviews, two scoping reviews and five good quality cohort studies were included. 'Nature' was conceptualised along a continuum (the 'nature research framework') into three categories: a human-designed environment with natural elements; a human-designed natural environment; and a natural environment. The nature 'intervention' falls into three areas (the 'nature intervention framework'): access, exposure and engagement with nature, with quantity and quality of nature relevant to all areas. Mental health and well-being outcomes fit along a continuum, with 'disorder' at one end and 'well-being' at the other. Nature appears to have a beneficial effect, but we cannot be certain of this.

CONCLUSIONS

Nature appears to have a beneficial effect on mental health and well-being of children and adolescents. Evidence is lacking on clinical populations, ethnically diverse populations and populations in low- and middle-income countries. Our results should be interpreted considering the limitations of the included studies and confidence in findings.

Determinants of health-related quality of life in healthy children and adolescents during the COVID-19 pandemic: Results from a prospective longitudinal cohort study

Understanding health-related quality of life (HRQOL) in children and adolescents, during a pandemic and afterwards, aids in understanding how circumstances in their lives impact their well-being. We aimed to identify determinants of HRQOL from a broad range of biological, psychological, and social factors in a large longitudinal population-based sample. Data was taken from a longitudinal sample (n = 1843) of children and adolescents enrolled in the prospective school-based cohort study Ciao Corona in Switzerland. The primary outcome was HRQOL, assessed using the KINDL total score and its subscales (each from 0, worst, to 100, best). Potential determinants, including biological (physical activity, screen time, sleep, etc.), psychological (sadness, anxiousness, stress), and social (nationality, parents' education, etc.) factors, were assessed in 2020 and 2021 and HRQOL in 2022. Determinants were identified in a data-driven manner using recursive partitioning to define homogeneous subgroups, stratified by school level. Median KINDL total score in the empirically identified subgroups ranged from 68 to 83 in primary school children and from 69 to 82 in adolescents in secondary school. The psychological factors sadness, anxiousness, and stress in 2021 were identified as the most important determinants of HRQOL in both primary and secondary school children. Other factors, such as physical activity, screen time, chronic health conditions, or nationality, were determinants only in individual subscales.

CONCLUSION

Recent mental health, more than biological, physical, or social factors, played a key role in determining HRQOL in children and adolescents during pandemic times. Public health strategies to improve mental health may therefore be effective in improving HRQOL in this age group.

WHAT IS KNOWN

• Assessing health-related quality of life (HRQOL) in children and adolescents aids in understanding how life circumstances impact their well-being. • HRQOL is a complex construct, involving biological, psychological, and social factors. Factors driving HRQOL in children and adolescents are not often studied in longitudinal population-based samples.

WHAT IS NEW

• Mental health (stress, anxiousness, sadness) played a key role in determining HRQOL during the coronavirus pandemic, more than biological or social factors. • Public health strategies to improve mental health may be effective in improving HRQOL in children.

Green space exposure on depression and anxiety outcomes: A meta-analysis

BACKGROUND

The development of urbanization has led to emerging mental health issues. Green space was becoming increasingly important for mental health. Previous studies have demonstrated the value of green space for a variety of outcomes connected to mental health. However, uncertainty remains regarding the association between green spaces and the risk of depression and anxiety outcomes. This study aimed to integrate present evidence from observational studies to define the association of exposure to green space with depression and anxiety.

METHODS

A thorough electronic search of PubMed, Web of Science and Embase database was performed. We transformed the odds ratio (OR) of different green increments into per 0.1 unit increase in normalized difference vegetation index (NDVI) and per 10% increase in percentage of green space. Cochrane's Q and I2 statistics were used to assess study heterogeneity, and random-effects models were employed to calculate combined effect estimation OR with 95% confidence intervals (CIs). Pooled analysis was completed using Stata 15.0.

RESULTS

According to this meta-analysis, a 10% increase in the proportion of green space was linked to a lower risk of depression (merged OR (95% CI) = 0.963 (0.948, 0.979)) and anxiety (merged OR (95% CI) = 0.938 (0.858, 1.025)) and a 0.1 unit increase in NDVI was linked to a lower risk of depression (merged OR (95% CI) = 0.931 (0.887, 0.977)).

CONCLUSIONS

Results of this meta-analysis supported improving green space exposure in preventing depression and anxiety. Higher green space exposure might be helpful for depression and anxiety disorders. Therefore, improving or preserving green space should be regarded as a promising intervention for public health.

Natural environments, psychosocial health, and health behaviors in a crisis - A scoping review of the literature in the COVID-19 context

The COVID-19 outbreak led to major restrictions globally, affecting people's psychosocial health and their health behaviors. Thus, the purpose of this scoping review was to summarize the available research regarding nature and health in the COVID-19 context. Keywords relating to natural environments and COVID-19 were combined to conduct a systematic online search in six major databases. Eligibility criteria were a) published since 2020 with data collected in the COVID-19 context b) peer-reviewed, c) original empirical data collected on human participants, d) investigated the association between natural environments and psychosocial health or health behaviors, and e) English, German, or Scandinavian languages. Out of 9126 articles being screened, we identified 188 relevant articles, representing 187 distinct studies. Most research focused on adults in the general population and was predominantly conducted in the USA, Europe, and China. Overall, the findings indicate that nature may mitigate the impact of COVID-19 on psychological health and physical activity. Through a systematic thematic analysis of the extracted data, three primary themes were identified: 1) type of nature assessed, 2) psychosocial health and health behaviors investigated, and 3) heterogeneity in the nature-health relationship. Research gaps in the COVID-19 context were identified regarding I) nature characteristics that promote psychosocial health and health behaviors, II) investigations of digital and virtual nature, III) psychological constructs relating to mental health promotion, IV) health-promoting behaviors other than physical activity, V) underlying mechanisms regarding heterogeneity in the nature-health relationship based on human, nature, and geographic characteristics, and VI) research focusing on vulnerable groups. Overall, natural environments demonstrate considerable potential in buffering the impact of stressful events on a population level on mental health. However, future research is warranted to fill the mentioned research gaps and to examine the long-term effects of nature exposure during COVID-19.

Making the case for citizenship-oriented mental healthcare for youth in Canada

Purpose

Varying stakeholders have highlighted how recovery-oriented mental health services such as youth mental health services have traditionally focused on supporting individual resources to promote recovery (e.g., agency) to the exclusion of addressing structural issues that influence recovery (e.g. poverty). One response to this criticism has been work helping people with mental health problems recover a sense of citizenship and sense of belonging in their communities. Work on citizenship has yet to influence youth mental healthcare in Canada’s provinces and territories. This paper aims to highlight ways that youth mental healthcare can better help youth recover a sense of citizenship.

Design/methodology/approach

The arguments described in this paper were established through discussion and consensus among authors based on clinical experience in youth mental health and an understanding of Canada’s healthcare policy landscape, including current best practices as well as guidelines for recovery-oriented care by the Mental Health Commission of Canada.

Findings

Here, this study proposes several recommendations that can help young with mental health problems recover their sense of citizenship at the social, systems and service levels. These include addressing the social determinants of health; developing a citizenship-based system of care; addressing identity-related disparities; employing youth community health workers within services; adapting and delivering citizenship-based interventions; and connecting youth in care to civic-oriented organizations.

Originality/value

This paper provides the first discussion of how the concept of citizenship can be applied to youth mental health in Canada in multiple ways. The authors hope that this work provides momentum for adopting policies and practices that can help youth in Canada recover a sense of citizenship following a mental health crisis.

Critical life course interventions for children and adolescents to promote mental health

Childhood and adolescence are key developmental periods in the life course for addressing mental health, and there is ample evidence to support significant, increased investment in mental health promotion for this group. However, there are gaps in evidence to inform how best to implement mental health promotion interventions at scale. In this review, we examined psychosocial interventions implemented with children (aged 5–10 years) and adolescents (aged 10–19 years), drawing on evidence from WHO guidelines. Most psychosocial interventions promoting mental health have been implemented in school settings, with some in family and community settings, by a range of delivery personnel. Mental health promotion interventions for younger ages have prioritised key social and emotional skills development, including self-regulation and coping; for older ages, additional skills include problem-solving and interpersonal skills. Overall, fewer interventions have been implemented in low- and middle-income countries. We identify cross-cutting areas affecting child and adolescent mental health promotion: understanding the problem scope; understanding which components work; understanding how and for whom interventions work in practice; and ensuring supportive infrastructure and political will. Additional evidence, including from participatory approaches, is required to tailor mental health promotive interventions to diverse groups’ needs and support healthy life course trajectories for children and adolescents everywhere.

Exploring the role of exposure to green and blue spaces in preventing anxiety and depression among young people aged 14-24 years living in urban settings: A systematic review and conceptual framework

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

The mental health of children and young people living in big cities in a revolving postpandemic world

PURPOSE OF REVIEW

The world's population is increasingly urban, with most children and young people growing up and living in cities. Evidence suggests that urbanicity is linked to an increased risk for the development of mental health disorders. Rather than an accumulation of risk factors, urbanization is a complex process that profoundly structures living conditions. In this sense, it is timely to discuss what are the social and structural determinants of mental health of children and young people in such settings.

RECENT FINDINGS

Three domains of determinants of mental health were selected for discussion: economics and living conditions, crime and violence, and urban layouts. For each, we debated realities faced by urban children and young people, providing an overview of recent evidence on implications for mental disorders and well being. We also discuss the potential impacts of the covid-19 pandemic on each domain, as well as recommendations for future action.

SUMMARY

Structural factors are of major relevance for the mental health of children and young people living in cities. The agenda of mental health promotion and prevention must include whole-of-society interventions aimed at improving living conditions, including economic and social capital, violence prevention and urbanistic planning.