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Chapter23:HealthValuesfromEcosystems
CoordinatingLeadAuthor:JulesPretty LeadAuthors:JoBarton,IanColbeck,RachelHine,SusanaMourato,GeorgeMackerronandCarly Wood

KeyFindings 23.1EcosystemsandHealth 23.1.1Overview 23.1.2HealthBenefitsAccordingtoNEABroadHabitatTypes 23.2DirectPositiveEffectsonMentalHealth 23.2.1ObservingEcosystems 23.2.2ContactWithNearbyNature 23.2.3GreenExerciseandActivities 23.2.4GreenCare 23.2.5MappinessResearchforWellbeing 23.3DirectPositiveEffectsonPhysicalHealth 23.3.1HeartRateandBloodPressure 23.3.2EncouragingPhysicalActivity 23.3.3VitaminDandLatitude 23.3.4RecoveryfromIllnessandImmunity 23.4IndirectPositiveEffects 23.4.1FacilitatingNaturebasedActivity 23.4.2FacilitatingSocialEngagement 23.4.3ProvidingWildFoods 23.4.4ProvidingaCatalystforBehaviourandLifestyleChange 23.4.5ChildhoodExperienceandBehaviour 23.4.6EpidemiologicalStudies 23.5ReducingtheIncidenceofPollutionandDiseaseVectors 23.5.1AirPurificationbyReductionofPollution 23.5.2InterceptionofNoiseandWater 23.5.3MitigationoftheHeatIslandEffect 23.6DirectThreatstoHumanHealth 23.7MethodsforEstablishingHealthValues 23.7.1QuestionnairebasedMeasuresforMentalHealth 23.7.2PhysiologicalandQuestionnairebasedMethodsforPhysicalHealth 23.7.3QuestionnairebasedMethodsforEstablishingConnectednesstoNature 23.8Conclusions References Appendix23.1ApproachusedtoassigncertaintytermstochapterKeyFindings

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KeyFindings*
Observingnatureandparticipatinginphysicalactivityingreenspaces playanimportantroleinpositivelyinfluencinghumanhealthand wellbeing1.Greenexercise,comprisingofactivityingreenplaces(in thepresenceofnature),isassociatedwithpositivehealthoutcomes, whichexceedthoseexperiencedfromexercisinginenvironments lackingnature5. Ecosystemsprovidethreegenerichealthbenefits: i)directpositive effectsonbothmentalandphysicalhealth2;ii)indirectpositiveeffects whichfacilitatenaturebasedactivityandsocialengagement(by providinglocationsforcontactwithnature,physicalactivityandsocial engagement),allofwhichpositivelyinfluencehealth,andprovidea catalystforbehaviouralchangeintermsofencouragingtheadoption ofhealthierlifestyles(improvinglifepathways,activitybehaviour, consumptionofwildfoods)2;iii)areductioninthethreatsofpollution anddiseasevectorstohealthviaavarietyofpurificationandcontrol functions,suchaslocalclimateregulation,noisereduction,and scavengingofairpollutants6. Ecosystemscanbeadirectproviderofthreatstohumanhealth1. Thesethreatsincludeinfectiousagents(e.g.Lymeborreliosis, Cryptosporidium,Plasmodiumthatcausemalaria);physicalthreats fromwildanimals(althoughthisisnotgenerallyafactorintheUK), domesticlivestockanddogs;pollutantsorcontaminantsfromplants (e.g.brackenspores,volatileorganiccompounds(VOCs),pollen); elementalthreatsthroughextremesoftemperatureorUVradiation. AlleightUKNEABroadHabitatscontributetoallthreepositiveand theonenegativeclassofhealthrelatedecosystemservices2. However,thereislimitedevidencetoindicatethathabitatswithmore biodiversityhaveagreatereffectonhealth,eventhoughtheymay encouragegreateruse7.TheUKNEABroadHabitatthathasreceived thegreatestempiricalstudyintermsofitseffectsonhealthisUrban, mainlybecausethepresenceofgreenspaceisclearlyacontrasttothe majorityofthebuiltenvironment. Localgreenspacesornearbynaturalhabitatsarevitalforall individuals3.Thereisaclearlinkbetweentheamountofaccessible greenspaceandpsychologicalwellbeing.Themorefrequentthevisits tonearbygreenspaces,thelowertheincidenceofstress7. Accesstonaturecanencourageparticipationinphysicalactivity (greenexercise)2:individualswitheasyaccesstonaturearethree timesaslikelytoparticipateinphysicalactivityand,therefore,are40% lesslikelytobecomeoverweightorobese. Greenexerciseinallhabitatsresultsinsignificantimprovementsin
1 a

wellestablished virtuallycertain

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UKNationalEcosystemAssessment:TechnicalReport bothselfesteemandmood1;however,thosehabitatswithopenwater produceasignificantlylargerdegreeofimprovementsinmentalwell being6.Thegreatesteffectsforselfesteemandmoodoccurredwithin thefirstfiveminutesofactivity.Theimprovementinbothofthese measuresappearstobelargeringreensettingscomparedtoexercising inareaslackingnature1.Thegreatesthealthoutcomesareexperienced bythosewithmentalhealthproblems,suggestingthatexercisein ecosystemscanbetherapeuticforspecificcohortsofpeople. Naturedominateddrivesincreaserecovery fromstress2.Commuters bothrecoverquickerfromstressandreducethelikelihoodof experiencingfuturestressesafternaturedominateddrives,compared tourbandominateddrives. ThereisagrowinguseofgreencareinmanycontextsintheUK, includingtherapeutichorticulture,animalassistedtherapy, ecotherapy,greenexercisetherapiesandwildernesstherapy2.Green careproduceshealth,socialandeducationalbenefits,butthesehave notyetbeenwidelyevaluated3. Mappinessresearchhasshownthatincreasedhappinesslevelsare associatedbothwithvigorousoutdoorpursuits,suchassports, runningandexercise,andwalkingandhiking,andwithlessenergetic activities,suchasgardening,birdwatchingandnaturewatching2.On average,respondentsarehappiestoutdoorsandleasthappyindoors, andreportintermediatehappinesslevelswheninavehicle.Peopleare happiestwhentheyareneitherathomenoratwork,leasthappyat work,andreportintermediatehappinesswhenathome. Experiencingnaturehasbeendemonstratedtohaveasignificant positiveimpactuponheartrateandbloodpressure2.Greensettings havearelaxingeffectonautonomicfunctions,thusdecreasingheart rateandbloodpressuremeasurements.Greensettingsleadtoa greaterincreaseinparasympatheticnervoussystemactivityanda greaterdecreaseinsympatheticnervousactivitythanbuilt environments7. Humansdependonexposuretothesunforthesynthesisofadequate amountsofvitaminD;alackofvitaminDabsorption,orvitaminD deficiency,isassociatedwithanumberofhealthproblems2.Concerns overskincancer,combinedwithadecreaseintheopportunitiesfor peopletoaccessgreenplaces,isreducingexposuretosunlightand, therefore,contributingtothedevelopmentofchronicdiseases6. Sensibleexposuretosunlightforapproximately510minutesthree timesperweekhelpstoprotectagainstthedevelopmentofskincancer andishighlylikelytobebeneficialtophysicalhealth. Greensettingsofferopportunitiesforthebuildingofsocialcapital, which,inturn,benefitshealth2.Thepresenceoftreesandgrassin
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wellestablished verylikely

establishedbutincomplete evidence

establishedbutincomplete evidence 3 competingexplanations

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b urbanareasalsohasasubstantialeffectuponsocialengagementand verylikely neighbourhoodties.Areaswithtreesandgrassencourageindividuals toutiliseoutdoorspaceandincreasesthelikelihoodofsocial interaction.Greenplacescanalsoincreasesocialengagementand interactionthroughconservationactivitiesandinitiatives.Byprotecting nature,individualscanobtainsocialcontactandderivevaluefrom beinginthepresenceofnature6. 1 Ecosystemsprovidewildfoodswhichcanhaveadirecteffecton wellestablished 1 health .Today,wildfoodsactasasupplementtopurchasedfoods,as opposedtoprovidingthesolemeansofnutrition,andinterestinwild foodsisgrowing. Ecosystemsnotonlyaffectimmediatehealthandwellbeing,butalso 2establishedbutincomplete affecthealththroughoutlife2.Healthybehavioursmaybefollowedas evidence 3 competingexplanations adirectresultofanindividualssurroundings,althoughthereisno guaranteeofuptake.If1%ofthesedentarypopulationmovestoa healthypathway,1,063livesand1.44billionwillbesavedeachyear. Theearlierthisshiftoccursduringlife,thegreatertheimpactupon 3 healthandsociety . Contactwithnatureatanyagecanderiveawholenumberofbenefits 2 forphysicalandmentalhealth,contactwithnatureduringyouthcan establishedbutincomplete directlyimpactuponhealthyadultbehaviours2.Researchindicates evidence thatthefrequencyofvisitstogreenplacesduringchildhood significantlycorrelatestothenumberofvisitsduringadulthood.Alack ofexperienceofnatureasachildmaydirectlyresultinalackofcontact duringadulthood. *EachKeyFindinghasbeenassignedalevelofscientificcertainty,basedona4boxmodeland complimented,wherepossible,withalikelihoodscale.Superscriptnumbersandlettersindicatethe uncertaintytermassignedtoeachfinding.Fulldetailsofeachtermandhowtheywereassignedis presentedinAppendix23.1.

UKNationalEcosystemAssessment:TechnicalReport 23.1EcosystemsandHealth

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23.1.1Overview Thetermhealthisgenerallytakentoincorporatephysicalhealth,mentaloremotionalhealth, socialhealth,spiritualhealth,lifestyleandfunctionality.TheWorldHealthOrganizationsdefinition ofhealthisstillthemostwidelycitedandstatesthat:healthisastateofcompletephysical,mental andsocial(individual)wellbeing,andnotmerelytheabsenceofdiseaseorinfirmity(WHO1948).A universaldefinitionofwellbeingisnotavailable,asmanysourcesinterpretitdifferently.However, wellbeingisgenerallyconsideredinabroadercontext,andDefra(2007)hascollaboratedwithother governmentdepartmentsandstakeholderstodevelopasharedunderstandingofthemeaningof wellbeingwithinapolicycontext(Defra2007;Box23.1). InsertBox23.1here Ecosystemscompriseamultifacetedsetofrelationshipsbetweenthelivingorganisms,resources (includingplants,animals,fish,birdsandmicroorganisms,watersources,soil,rocks,mineralsand thelocalatmosphere)andhabitatsofanarea,whichfunctiontogetherasaunit.Ecosystemservices supportourhealthandwellbeinginavarietyofways.Theseincludetheprovisionofresourcesfor basicsurvival,suchascleanair,waterandgeneticresourcesformedicines,alongwiththeprovision ofrawmaterialsforindustryandagriculture.However,ecosystemservicesalsocontributetobetter mentalandphysicalwellbeingbyprovidingaccessibleurbanandruralspacesforrecreationand interactionwithnature.Bothobservingnaturalecosystemsandparticipatinginphysicalactivityin greenspacesplayanimportantroleinpositivelyinfluencinghumanhealthandwellbeing(Table 23.1). Itiswellknownthatregularphysicalactivityimprovesbothphysicalandmentalhealth(CDC1996; DepartmentofHealth2005a;Foresight2007;Sandercocketal.2010),andcanimprovethesurvival oftheelderlyandtheirqualityoflife(Lim&Taylor2005).Thereisalsoincreasingevidencetoshow thatexposuretonatureandgreenspacepositivelyaffectshealthandwellbeing(Maasetal.2006; Prettyetal.2006;VandenBergetal.2007;HansenKetchumetal.2009;Barton&Pretty2010). Thusgreenexercisephysicalactivityundertakeningreenplacesinthepresenceofnatureleads topositivehealthoutcomes(Table23.1).Greenexercisehasbeenshowntobemoreeffectivethan comparableactivities(whichreflecttheexercisecomponentonly)undertakenindoors(Thompson Coonetal.2011).Participatinginphysicalactivityingreensettingsisassociatedwithdecreased feelingsoftension,confusion,angeranddepression,whileexhibitinggreaterfeelingsof revitalisation(ThompsonCoonetal.2011).Outdoorexperiencesareratedasmorerestorative(Hug etal.2009)andmoreeffectiveinimprovingmoodandvitality(Ryanetal.2010).Incomparison, indooractivityisassociatedwithincreasedfrustration,anxiety,angerandsadness(Teasetal.2007). Researchshowsthathealthbenefitsariseinallurbanandruralecosystemstested,rangingfrom deepwildernesstodomesticgardensandallotments,andincludingopencountryside,forests, woodlands,nationalorcountryparks,natureorwildlifereserves,urbanparks,grasslands,hillsand valleys. Inserttable23.1here Existingresearchstudiescanbegroupedintooneoftwoprevailingcategories.Thefirstinvolves experimentalresearchwhichhaspredominantlyfocusedonstressreductionandattention restoration,oftenbyinducingstresswithintheexperimentalsetting.Thesetypesofstudiesoften administerpreandpostinterventionmeasurestoassesstheimmediateshorttermhealthbenefits 5

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ofactiveorpassiveexposuretonaturalandurbanecosystems.Theyoftentakeplacewithina controlledsettingtolimitconfoundingvariablesandattempttoisolatetheecosystemasthekey variableinfluencinghealthmeasures.Thesecondtypecomprisesepidemiologicalresearchstudies whichprimarilyreportcorrelationsbetweenecosystemuseandhealthbenefits.However,the difficultywiththistypeofanalysisisthatitisverychallengingtoestablishcausalityandoften relationshipscanonlybedescribed,notexplained.Althoughtheseassociationsregularlyemerge fromsuchexperiments,determiningcausalityisnotstraightforwardandfurtherresearchisrequired toestablishanydirectcauseeffectrelationships.Demonstratingalinkbetweenecosystemsand healthisnottothesameasprovingthatexposuretoecosystemsproducespositivehealth outcomes.Yetevidenceofcausalitywouldprovideapowerfulargumentforachangeinexisting policies.Althoughinterpretationofthecausalstructureoftheserelationshipsischallengingdueto thecomplexityofthesystem,itremainsanimportantfindinginitsownright. Ecosystemsprovidethreegenerichealthbenefits(Figure23.1): i) Directpositiveeffects a. Mentalhealth(Kaplan2001;Prettyetal.2005;Prettyetal.2007). b. Physicalhealth(Laumannetal.2003;Kampmanetal.2007;Prettyetal.2007) ii) Indirectpositiveeffects a. Facilitatingnaturebasedactivityandsocialengagement(byprovidinglocationsfor contactwithnature,physicalactivityandsocialengagement),allofwhichpositively influencehealth(Coleyetal.1997;Kuoetal.1998;WardThompson2002). b. Providingacatalystforbehaviouralchangeintermsofencouragingtheadoptionof healthierlifestyles(improvinglifepathways,activitybehaviourandtheconsumption ofwildfoods)(Wells&Lekies2006;Prettyetal.2009). iii) Reducingthethreatsandincidenceofpollutionanddiseasevectorsviaavarietyof purificationandcontrolfunctionssuchaslocalclimateregulation,noisereductionand scavengingofairpollutants(Morecroftetal.1998;Pitcairnetal.1998;Bignaletal.2004). However,ecosystemscanalsobeadirectsourceofthreatstohumanhealthincluding:infectious agents(e.g.Lymeborreliosis,Cryptosporidiumspecies,Plasmodiumspeciesthatcausemalaria); physicalthreatsfromanimals,pollutantsorcontaminantsfromplants(e.g.brackenspores,volatile organiccompounds(VOCs),pollen);andelementalthreatsthroughextremesoftemperatureorUV radiation(Frumkinetal.2004). Insertfigure23.1here Healthoutcomesdependonthetypesofecosystemsandtheservicestheyprovide,aswellasthe choicespeoplehaveanddecisionstheymake.Ifindividualsdonotengagewiththenaturalworld, eitherbyobservationorundertakingphysicalactivityingreensettings(includingurbangreenspace), thentheywillnotderivethespecificmentalorphysicalhealthbenefitsnaturecanprovide.Such choicesareaffectedbylocationofdwelling,proximityof,andaccessto,nature,andindividual choicesandenvironmentalbehaviours(DH&DCSF2009). Accesstonatureoftenvariesaccordingtocohortdemographics.Forexample,wealthierindividuals areabletoaccesscertainplacesmorereadilybecausetheyownacar;itiscommonforthemost biodiverseecosystemsarenotservedbypublictransport,whichexcludesthepoorestindividuals andotherminoritygroups.Thus,accessisdependentonthesocioeconomiccharacteristicsofthe 6

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potentialbeneficiariesandnotsolelyontheecosystemqualities.Yethavingaccesstonearby greenspacecaneradicatethehealthinequalitylevelsinareasofdeprivation(Mitchell&Popham 2008).Thishighlightstheimportanceofprovidinghealthpromoting,accessiblegreenspacesto reducesocioeconomichealthinequalities. Behaviourscanalsoinfluencecorrelativerelationshipsidentifiedbetweenecosystemexposureand healthoutcomes,whichcontributestothechallengeofinterpretingthecausalstructure. Ineffect,healthoutcomesofecosystemsarenotindependentofpeoplesdemographics,choices andbehaviours.Healthbenefitsare,therefore,afunctionoftheecosystemtype,easeofaccessto natureandfrequencyofuseofgreenplaces. 23.1.2HealthBenefitsAccordingtoUKNEABroadHabitats AlleightUKNEABroadHabitatscontributetoallthreepositiveandtheonenegativeclassofhealth relatedecosystemservices.However,thereislimitedempiricalevidencetoindicatethathabitats withmorebiodiversityhaveagreatereffectonhealth(Fulleretal.2007).OneUKstudyhasshown positiveassociationsbetweenurbangreenspacespeciesrichnessandimprovedwellbeing(Fulleret al.2007),althoughtheauthorsacknowledgethechallengeofdecipheringcausality.Thereisalso empiricalevidencetoindicatethat,afterrehabilitation,Urbangreenspaceattractsmoreusers, providingagreaterhealthservice(Bartonetal.2009;Barton&Pretty2010).Inasimilarway,it couldbehypothesisedthathabitatswithgreaterbiodiversityorparticularrareordistinctivespecies (e.g.naturereserves,SitesofSpecialScientificInterest(SSSIs))mayattractmorevisitorsand, therefore,deliveragreateraggregatehealthbenefit;thishypothesiswouldfitwiththefindingsof Fulleretal.(2007). TheUKNEABroadHabitatsprovidepotentialplacesforpeopletoengageinphysicalactivity(green exercise)andsocialinteraction.Ifthesehabitatsareused,theywouldhavepositivedirecteffectson health,andreducethreatsfromdiseasevectors,pollutantsandnoise;buttheycouldpotentially provideavarietyofdirectthreatstohealth(Table23.2).Theprovisionofpositivehealthbenefitsis dependentnotonlyontheintrinsicbiologicalcharacteristicsoftheecosystems,butalsoonlocation. Anecosystemwhichisclosetoadenselypopulatedareawillprovidemanymorehealthbenefits thanaphysicallyidenticalecosysteminaremotearea,becauseitisaccessibletomoreindividuals. Therefore,theaggregatehealthbenefitisnotsolelyreliantontypeofhabitat,buteaseofaccess. TheUKNEABroadHabitatthathasreceivedthegreatestempiricalstudyintermsofitseffectson healthisUrban,mainlybecausethepresenceofnatureandgreenspaceisclearlyacontrasttomost ofthebuiltenvironment.Inaddition,themajorityofpeopleresideinurbanareasandare, therefore,moreabletoaccessUrbanhabitats.Some3.5%ofEnglandisurbanised(428,000 hectares),andtheseenvironmentscontain52,000hectaresofgreenspaceintheformofparks, allotments,cityandcommunityfarms,cemeteries,golfcourses,naturereserves,streettreesand greenroofs(notcountingprivategardens)(CABE2010). Inserttable23.2here 23.2 DirectPositiveEffectsonMentalHealth 23.2.1ObservingEcosystems 7

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Theimportanceofobservingnatureisbecomingincreasinglyrecognised.Viewingnaturethrougha windowcanhelptoincreaserecoveryfrommentalfatigueandimprovementalwellbeing(Kaplan 1992;Malleretal.2006).Naturalviewsinhospitalshelptoincreaserecoveryfromillness(Dietteet al.2003),whileaccesstonatureintheworkplaceisassociatedwithlowerlevelsofperceivedstress andgreaterjobsatisfaction(Kaplan&Kaplan1989;Malleretal.2006;Hineetal.2007). Furthermore,researchsuggeststhatprisoninmateswhosecellhasaviewofnaturehavealower frequencyofstressandpsychologicalsymptomswhencomparedtothoseinmateswholacksucha view(Moore1982).Theviewfromthehomeisalsoknowntobeimportant(Kaplan2001;Tayloret al.2002).Forchildren,greenviewshaveapositiveeffectoncognitivethinkingandconcentration, whilealsoaidingselfdiscipline(Tayloretal.2002). Thepositiveeffectofviewingnatureevenoccursiftheviewisnotoflivingnature;picturesofnature canalsoelicitimprovementsinmentalwellbeing(Hineetal.2007).Severalstudieshavecompared theeffectsonmentalwellbeingofviewingphotographicscenesofbothnatureandbuilt environments.Theresultssuggestedthatthenaturalscenes,especiallythosedepictingwater,hada morepositiveeffectonmeasuresofemotionalwellbeingsuchassadnessandhappiness,than viewingbuiltenvironments(Ulrich1981).Indeed,viewingbuiltenvironmentsledtoadeclinein attentionandinterest.In2005,Prettyetal.(2005)examinedthementalhealthbenefitsofviewing urbanandruralsceneswhileperformingphysicalactivity.Participantstookpartinfiveexercise conditions:exerciseonly;exercisewhileviewingunpleasanturbanscenes(cityscapeslacking greenspaces);exercisewhileviewingpleasanturbanscenes(buildingswithsurroundingnature); exercisewhileviewingpleasantruralscenes;andexercisewhileviewingunpleasantruralscenes (landscapesspoiltwithrubbish,abandonedcars,orpipescarryingeffluents).Theresultsindicated thatallexerciseconditionsledtoasignificantimprovementinselfesteem;however,theunpleasant conditionsreducedthepositiveeffectsofthephysicalactivity,whilethepleasantconditionsledto thegreatestimprovements.Theimprovementforbothurbanandruralsceneswascomparable, highlightingtheimportanceofurbannature.Moodwasalsosignificantlyaffectedbyviewingthe differentscenes.Boththeurbanandruralpleasantconditionsledtosignificantreductionsinfatigue andtension,andasignificantincreaseinvigour.Pleasanturbanscenesalsoledtoasignificant decreaseindepression.Bothurbanandruralconditionscanimprovementalwellbeing;however, thosescenesthatdepictthreatstothenaturalenvironmentleadtoareductioninselfesteemand mood(Prettyetal.2005). Parsonsetal(1998)reportedsimilarresultswhenreviewingtheliteratureoncommuterstressincar driversandtheeffectofthesurroundingenvironment(Malleretal.2006).Theevidenceindicated thatcommuterswhoparticipatedinnaturedominateddrivesexperiencedquickerrecoveryfrom stress,andareductioninthelikelihoodofexperiencingsubsequentstress,thanthosewhotookpart inanurbandominateddrive(Parsonsetal.1998). 23.2.2ContactWithNearbyNature Localgreenspaceandaccessiblenaturearevitalforallindividuals,whetheritisanurbanparkoran areaofruralwilderness(Hineetal.2007).Beinginthepresenceofnearbynature(whetherornot itisincidentaltosomeotheractivity,suchaswalkingtoworkorsittingonabench)playsan importantroleinhumanwellbeing(Prettyetal.2005;Hineetal.2007).Researchsuggeststhat thereisalinkbetweentheamountofaccessiblegreenspaceandpsychologicalwellbeing(Takanoet al.2002;DeVriesetal.2003),ascontactwithnaturecanhelpindividualstorecoverfromstress, protectthemfromfurtherstressandimproveconcentration(Malleretal.2002;Hineetal.2007). 8

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Furthermore,themorefrequentthevisitstonearbynaturalspaces,thelowertheincidenceofstress (Grahn&Stigsdotter2003). Nearbynatureisalsoimportantforthementalwellbeingofchildren(Kaplan&Kaplan1989; Thomas&Thompson2004;WardThompsonetal.2008).Evidencesuggeststhatthewellbeingof childreniscloselylinkedtotheirabilitytoaccessnaturalsettingsclosetotheirhomes(Thomas& Thompson2004).Wells(2000)conductedalongitudinalstudywithchildrenoflowincomeurban familiesandassessedtheeffectsofnatureontheircognitivefunctioning.Whenthefamilieswere relocatedtohouseswithmorenearbynaturetheyhadhigherlevelsofcognitivefunctioningand theirabilitytodirectattentioncontinuedforseveralmonthsaftermoving.However,thesefindings shouldbetreatedwithcautionbecauseitcouldbearguedthatthesetypesoffamilieswereableto selectthesetypesofpreferredhomes.Therefore,causeandeffectcanbedifficulttodisentangle anddecipher(Wells2000). Inaddition,WellsandEvans(2003)foundthatchildrenwitheasyaccesstonatureweremoreableto copewithstressfullifeeventsandweregenerallylessstressedindividualsthanthoseinurban habitatslackinggreenspace(Wells&Evans2003).However,theissueofcauseandeffectisstill indeterminateasitremainsunclearwhetherhavingcontactwithnatureaidsthedevelopmentof stresscopingmechanismswhichareusedinlaterlife;whethernearbynatureprovidesthe opportunityforstressrecoveryandreplenishesattentionalfatigue;whethergreenspaceprovides theopportunitytoplaywithotherchildren(socialcontact);orwhetheritisacombinationofmany factors.However,accesstonatureduringyouthisofgreatimportance,particularlyaschildhood experiencesofnaturepredictcontactduringadulthood(WardThompsonetal.2008). Inhealthcaresettings,gardensareofparticularimportancetomentalwellbeing(Ulrich2002). Gardensinhospitalshaveanumberofpositiveeffectsonindividualsbyhelpingthemtofeelmore relaxedandabletocope,reducingstress,andimprovingmood(CooperMarcus&Barnes1995; Whitehouseetal.2001).Evenshortvisitsoffiveminutesindurationtothesegardenshavebeen demonstratedtohaveapositiveeffectonthementalwellbeingofpatients(CooperMarcus& Barnes1995;Whitehouseetal.2001). 23.2.3GreenExercise Naturalecosystemscanprovideanenvironmentalsettingforgreenexercise(Prettyetal.2005; Bowleretal.2010).Bothphysicalactivityandexposuretonaturehaveseparatelybeen demonstratedtoprovidebenefitsformentalwellbeing,thus,bycombiningthetwo,greenexercise hassynergistichealthbenefits(Prettyetal.2003;Prettyetal.2005;Prettyetal.2007;Hineetal. 2007;Peacocketal.2007).Forinstance,walkingingreenspacesismoreeffectiveatenhancingself esteemandmoodthanwalkingindoors,suggestingagreateramalgamatedhealthbenefitthan eithercomponentprovidesalone(Mind2007;Peacocketal.2007). Prettyetal.(2007)examinedthepsychologicalhealthbenefitsofparticipatingintendifferentgreen exerciseactivities(includingwalking,fishing,horseriding,cyclingandconservationactivities)infour differentregionsintheUK.Theresultsofthestudyfoundthatgreenexerciseledtosignificant improvementsinselfesteemandmood,especiallyinthemoodsubscalesofanger,confusion, depressionandtension(Prettyetal.2007).Furthermore,improvementsinselfesteemandmood werenotaffectedbythetype,intensityordurationoftheexercise,orbythedifferentregions themselves(Prettyetal.2007). 9

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Bartonetal.(2009)examinedthementalwellbeingeffectsofwalkinginfourUKnationalheritage sites(DunwichHeath,Suffolk;FlatfordMill,Suffolk;HatfieldForest,Essex;WickenFen, Cambridgeshire).InlinewiththeresultsproducedbyPrettyetal.(2007),bothselfesteemandtotal mooddisturbanceweresignificantlyenhancedasaresultofparticipatinginthegreenexercise (Bartonetal.2009).Furthermore,feelingsofanger,confusion,depression,fatigueandtensionwere reducedasaresultofthegreenexercise,whilefeelingsofvigourwereincreased(Bartonetal. 2009).However,incontrasttotheresultsofPrettyetal.(2007),thestudysuggestedthattherewas arelationshipbetweenthedurationofthegreenexerciseandthedegreeofimprovementsin mentalwellbeing:participantswalkingforthelongestperiodoftimedisplayedthegreatest improvementsinmood(Bartonetal.2009). BartonandPretty(2010)undertookametaanalysisonthementalhealthoutcomesofmany differenttypesofgreenexerciseindifferenthabitats,forvaryinglengthsoftime,andbydifferent agecohortsandgender.Habitatsincludedwoodland,forests,watersides,urbangreenareas, farmlandandnaturalhabitats,andtheactivitiesincludedwalking,horseriding,sailingandgardening (Barton&Pretty2010).Greenexerciseinallhabitatsresultedinsignificantimprovementsinboth selfesteemandmood;however,thosehabitatswithopenwaterproducedasignificantlylarger degreeofimprovementinmentalwellbeing.Furthermore,selfesteemandmoodwasmost improvedduringthefirstfiveminutesofactivity,butthiseffectgraduallydeterioratediftheexercise lastedbetween10minutesandhalfaday(Barton&Pretty2010).Nevertheless,theeffectivenessof thegreenexerciseinimprovingmentalwellbeingincreasedagainiftheactivitylastedforawhole day.TheresultsareincontrasttothoseproducedbyPrettyetal.(2007),implyinganeedforfurther researchinthisarea. Themetaanalysisalsorevealedthattheeffectivenessofthegreenexercisewasinfluencedbyits intensity(Barton&Pretty2010).Forselfesteem,lightintensityexerciseproducedthegreatest improvements,withtheeffectsdeterioratingastheintensityofexerciseincreased;asimilar responsewasnotedformood.However,thelowesteffectoneithermeasurewasseenduring moderateexercise;theeffectsincreasingonceagainforvigorousexercise. Withregardstothedifferentagecohortsofparticipants,themetaanalysisrevealedthatthefewest healthoutcomesoccurredfortheelderly,whilethegreatesthealthoutcomeswereexperiencedby thosewithmentalhealthproblems,suggestingthatexerciseinecosystemscanbetherapeuticfor specificcohortsofpeople(Barton&Pretty2010). Essentially,theevidenceimpliesthatthereisasynergistichealthbenefitfromexercisinginareas containingnature(includingurbangreenspace)comparedtoexercisinginurbanareaslackingnature orindoorenvironments.Alltypesofhabitatarebeneficial,fromexperiencesindeepwildernessto gardeninginlocalallotments.Theoptimaldoseofgreenexercisemaybedependentonmany variables,butitisclearthatbothurbanandcountrysidehabitatscanprovidetheidealsettingto facilitateactivityandaffordgreaterhealthbenefits. 23.2.4GreenCare Greencareisaninclusivetermformanycomplexanddiversenaturebasedinterventionsthatuse natureandthenaturalenvironmentasaframeworkinwhichtocreatehealthandwellbeing benefitsforvulnerablegroupsofpeople(Sempiketal.2010).Greencarehasemergedfromtheidea thatcontactwithnaturecouldbeeffectiveintherapeuticapplications(Figure23.2)(Pretty2006; Peacocketal.2007;Hineetal.2008a).IntheUK,thereisagrowingmovementtowardsgreencare 10

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inmanycontextsrangingfromsocialandtherapeutichorticulture,animalassistedinterventions, ecotherapy,greenexercisetherapiesasatreatmentoption,andcarefarming(Sempiketal.2003; Sempik2007;Hineetal.2008a).Greencareisdifferenttogreenexerciseinthatitisusedasa therapyorinterventionforspecificgroups,suchaspsychiatricpatients,peoplewithlearning disabilities,disaffectedyouthandseveralotheratriskpopulations,whilegreenexerciseismoreofa therapeuticexperience(Pretty2006;Hineetal.2008a).Theaimofgreencareistoproducehealth, socialandeducationalbenefits(Hineetal.2008a). Insertfigure23.2here Therearesixkeytypesofgreencareoptions: i) Socialandtherapeutichorticultureisdefinedasparticipationbyarangeofvulnerable peopleingroupsandcommunitieswhoseactivitiesarecentredaroundhorticultureand gardening.Itisdistinctfromdomesticgardeningbecauseitoperatesinanorganisedand formalisedenvironment(Sempiketal.2003;Samson&Pretty2005).Socialandtherapeutic horticulturehasbeendemonstratedtopromotepsychologicalwellbeingandhasalsobeen utilisedinthetreatmentofdisease. ii) Animalassistedinterventionsinvolvetheuseofanimalsintherehabilitationandsocialcare ofhumans(Kruger&Serpell2006;Bokker2006).Companionanimalscanalsoplaya therapeuticroleforpeoplewithpsychiatricdisorders,physicallyillpeople,thosewith emotionaldisorders,theelderlyandchildren(Fine2006).Likehumanrelationships,animal humanrelationshipscanhelptobufferagainststressresponsesandillness(McNicholas& Collis2006). iii) Carefarmingisdefinedasthetherapeuticuseofagriculturallandscapesandfarming practices(Hassink2003;NCFI2011)anditsuseisincreasingbothwithintheUKandEurope (Hineetal.2008a).Oncarefarms,componentsofeitherthewholeorpartofthefarm environmentareutilisedtoprovidehealth,socialoreducationalcareservicesthrougha supervised,structuredprogrammeoffarmingrelatedactivities.Resultsfromstudiesinto thementalhealthbenefitsofthesecarefarmswithintheUKhavefoundthattheirusecan resultinsignificantimprovementsinbothselfesteemandmood,withsignificantalterations inallmoodfactors(Pretty2006;Peacocketal.2007;Hineetal.2008a). iv) Greenexercisetherapyisdefinedasfacilitatedgreenexerciseactivities.Evidencesuggests thattheseactivitiesmayhavetherapeuticapplications(Prettyetal2007;Peacocketal. 2007);forexample,theymayprovideaneffectivetreatmentformildtomoderate depressionthroughreconnectionwithnatureandthepositivementalhealthbenefitsthat comehandinhandwiththis(Samson&Pretty2005;Prettyetal.2007).Currently, approximately21%ofgeneralpractitionersuseexerciseasatherapyinthetreatmentof mentaldisorders(MentalHealthFoundation2009).Greenexercisetherapymaybeeven moreeffectivethanexercisealoneandcould,therefore,beutilisedasanalternativeor complimentarytreatmenttherapytoantidepressants(Samson&Pretty2005). v) Ecotherapyencompassesallnaturebasedmethodsaimedatthereestablishmentofhuman andecosystemreciprocalwellbeing(Sempiketal.2010).Contactwithnaturalecosystems enhancesphysical,psychologicalandsocialhealthforpeople,communitiesandecosystems. Ecotherapyencouragesreconnectionwithnatureandthereforefacilitatesbehaviouraland socialchangeswhichcandirectlyinfluencementalhealthandwellbeing(Burls2008). 11

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vi) Wildernesstherapyisdescribedasanexperientialprogramme(e.g.OutwardBound)that takesplaceinwildernessoraremoteoutdoorsetting(Conner2007).Ithasbeenwidely usedintheUSAformanyyears,butisarelativelynewconceptintheUKandismost commonlyusedforadolescentswithbehaviouralproblems(Prettyetal.2009)andadults withmentalhealthissues(Hineetal.2011).Programmesprovidehealthyexerciseanddiets, groupandindividualtherapysessions,andseparateparticipantsfromdailynegative influences,placingtheminasafeoutdoorenvironment.Evidenceregardingthebenefitsof wildernesstherapyhasindicatedthatitcanfacilitatebehaviourchange,addressproblem behaviours,improvementalwellbeingandselfesteem,reduceBodyMassIndex(BMI)and provideopportunitiesforemotionalgrowth(Moote&Wadarski1997;Hans2000;Russell& PhillipsMiller2002;Samson&Pretty2005;Russell2006;Conner2007;Hineetal.2009; Bharucha&Pretty2010;Godfrayetal.2010;Hineetal.2011). 23.2.5MappinessResearchforWellbeing Subjectivewellbeingisrelatedtohappinessandhasbecomeincreasinglyimportanttoeconomists (Layard2005;Dolanetal.2008;Frey2008;Mourato&MacKerron2010).Theestablishedinfluences onhappinessincludeincome(positivelycorrelatedwithsubjectivewellbeing);theincomesof others,rivalry(negative)and/orambition(positive);anindividualsownlaggedincome;andreduced responsesduetohabituation(negative).Furtherfactorsincludeunemployment;separation,divorce andwidowhood;andpoorhealth(allnegativelycorrelated).Socialcapitalindicatorsandrelational goodsareimportant,suchasmembershipofinterestgroupsorfriendlyrelationswithneighbours; trust;andbeliefinagod(allpositivelycorrelated).Importantenvironmentalqualityparameters includeclimate,noise,airquality,andaccesstogreenspaces.MouratoandMackinnon(2010) investigatedwellbeingintheUKbyusingasatellitegeolocated,largescale,smartphonebased ExperienceSamplingMethodstudy(Mappiness)toexplorelinksbetweeninstantaneousmood statesandtheimmediateenvironment. Onaverage,respondentswerehappiestoutdoorsandleasthappyindoors,andreported intermediatehappinesslevelswheninavehicle.Increasedhappinesslevelswereassociatedboth withvigorousoutdoorpursuits,suchassports,runningandexerciseandwalkingandhiking,and withlessenergeticactivitiessuchasgardeningandbirdwatchingandnaturewatching.High energypursuits,suchassports,runningandexercise,wereassociatedwitha6%increasein happiness,andmorecontemplativeactivities,suchasnaturewatching,werelinkedwitha3% increaseinhappiness.Respondentswerehappiestwhenneitherathomenoratwork,leasthappyat work,andreportedintermediatehappinesswhenathome.Whenoutdoors,higherhappinesslevels wereassociatedwithhighertemperatures,whilerainandwindarelinkedtolowerhappiness. Importantly,therewasaclearlinkbetweenbeingoutdoorsinparticularhabitattypesandhappiness levels.Almostallhabitattypes(withtheexceptionofinlandbareground)werelinkedwithhigher happinesslevelsthanurbanhabitats.MarineandCoastalMargins,Mountains,Moorlandsand Heaths,andConiferousWoodlandswereassociatedwiththehighestincreasesinhappiness.Thekey findingsfromMappinessaresummarisedinTable23.3. InsertTable23.3here 23.3DirectPositiveEffectsonPhysicalHealth 23.3.1HeartRateandBloodPressure 12

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Experiencingnaturehasbeendemonstratedtohaveasignificantimpactuponheartrateandblood pressure.Laumannetal.(2003)demonstratedthatviewingnatureledtoasignificantreductionin heartratefromthebaselinelevel.However,viewingurbanlandscapesdidnotsignificantlyreduce theparticipantsheartrate.Bloodpressureisalsoreducedasaresultofviewingnature(Prettyetal. 2005).Prettyetal.(2005)showedthatmeanarterialbloodpressure(MABP)significantlyreduced fiveminutesafterexercisingatamoderateintensity.However,whenengaginginthesameintensity ofexercisewhileviewingpleasantruralscenes,agreaterreductioninMABPwasrecorded(Prettyet al.2005).ViewingunpleasantruralscenesalsoledtoreductionsinMABP;butviewingurbanscenes, bothunpleasantandpleasant,didnotreducebloodpressureand,infact,increasedthe measurementsrelativetotheexerciseonlycontrol.Thus,viewingnaturecanhavearelaxingeffect onautonomicfunctions(theunconsciousregulationofinternalbodilyactivity),decreasingheartrate andbloodpressuremeasurements(Laumannetal.2003;Prettyetal.2005).Spendingtimeingreen settingsleadstoagreaterincreaseinparasympatheticnervoussystemactivity(theslowingof autonomicfunctionsatrest)andgreaterdecreaseinsympatheticnervousactivity(accelerated functionsassociatedwiththefightorflightresponse)thanspendingtimeinurbansettings(Lietal. 2007). 23.3.2EncouragingPhysicalActivity Naturecanencourageparticipationinphysicalactivity:individualswitheasyaccesstonatureare threetimesmorelikelytoparticipateinphysicalactivitythanthosewithpooreraccessand, therefore,40%lesslikelytobecomeoverweightorobese(Wellsetal.2007;Bowleretal.2010).The issueofcauseandeffectisdifficulttoidentifyasindividualsmaychoosetolivenearhabitatswhich facilitateactivityiftheyenjoyexercisingingreenspaces.Therefore,thiscohortmayengageinmore activitiessimplybecausetheychosetoresideclosetothattypeofhabitat,ratherthanadoptingnew activebehavioursbecausegreenspacebecameaccessible.However,byencouragingphysicalactivity throughparticipationingreenexercise,suchhabitatscanprovideawholenumberofphysicalhealth outcomes. PhysicalactivitycanreducetheriskofdevelopingCardiovascularDiseaseandtheassociatedrisk factors,suchashypertension,highbloodlipidsandelevatedbloodpressure,andcanalsoreducethe likelihoodofdevelopingType2Diabetes(Blair&Connelly1996;Biddleetal.2004;Departmentof Health2004).Furthermore,individualswhoregularlypartakeingreenexercisearelesslikelyto becomeoverweightorobese,andmayalsohavebetterbonehealthandareducedriskof developingOsteoporosis(Biddleetal.2004;DepartmentofHealth2005b).Thus,thenatural environmentsupportsphysicalhealththroughtheprovisionofopportunitiesforexercise(Wellset al.2007). Urbanhabitatsarelessencouragingofphysicalactivitythanotherhabitattypesandoftenrestrict accesstonature(Wellsetal.2007).Urbandesignandplanningsometimesreducesopportunitiesfor individualstoparticipateinphysicalactivity,contributingtolargeincreasesinphysicalinactivityand theprevalenceofoverweightandobeseindividuals(Wellsetal.2007).Nonetheless,urbanparks promotehealthylivingforresidentsofUrbanhabitatsbyencouragingparticipationingreenexercise activitiessuchaswalkingandcycling(Ross2000;Berrigan&Troiano2002;Craigetal.2002;Handy etal.2002;Parksetal.2003).IntheUK,urbanparksattract2.5billiondayvisitsperyear(DLTR 2002),soasurbansprawlcontinues,theimportanceofaccesstonearbynatureisparamount.Urban lifeexposespeopletomanystressors,suchastrafficnoise,crowdingandfearofcrime(Vanden Bergetal.2007),andoftenaccesstonatureandgreenspaceislimitedorofpoorquality.Thetypeof natureclosetowherepeopleliveandwork,intheformofparks,gardens,treelinedstreets, 13

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communalsquaresandallotments,isstrategicallyimportantforthequalityoflifeofurbandwellers andforthesustainabilityoftownsandcities(Chiesura2004).Hence,individualsneedeasyaccessto natureandgreenspace,astheseencouragephysicalactivityandresultinanumberofbenefitsfor physicalhealth. 23.3.3VitaminDandLatitude HumansdependonexposuretothesunforthesynthesisofadequateamountsofvitaminD.Some 90%ofthehumanrequirementforvitaminDcomesfromthesun(Hollick2005;Kampmanetal. 2007).UltravioletB(UVB)radiationisabsorbedbydehydrocholestrolintheskin,whichis transformedandfurtherconvertedtovitaminD3.Thisisthenmetabolisedbythelivertoitsactive form(Hollick2005).OutdoorcontactwithnatureallowshumanstoabsorbthevitaminDrequiredin thehumanbody.However,alackofvitaminDabsorption,orvitaminDdeficiency,isassociatedwith anumberofhealthproblems. VitaminDdeficiencycanleadtopoorbonehealth,increasingthelikelihoodofthedevelopmentof diseasessuchasOsteoporosisandOsteomalacia.VitaminDdeficiencyhasalsobeenassociatedwith thedevelopmentofRicketsinchildren.Furthermore,alackofvitaminDcanleadtocancercell growth,anincreasedriskofheartfailureandCardiovascularDisease,ArthritisandType1Diabetes (Hollick2005;Kampmanetal.2007).Inastudyfollowingchildrenfromage1intoadulthood,those individualswhoreceivedadequatevitaminDdecreasedtheirriskofdevelopingdiabetesby80% (Hollick2005;Kampmanetal.2007). Latitudecanalsohaveanimpactuponphysicalhealth.Areasathighlatitudeshavebeenassociated withareducedriskofdevelopingMultipleSclerosisandalsoareducedriskofdevelopingcancer (Hollick2004;Kampmanetal.2007).However,Norwayappearstobeanexceptiontothisfinding. Thisislikelytobetheresultofincreasedsummeroutdooractivitiesinchildhood,whichhavebeen demonstratedtoprotectagainstMultipleSclerosis(Hollick2004).Contactwithnatureandsunlight areessentialtophysicalhealth.However,concernsoverskincancer,combinedwiththereductionin theopportunitytoaccessnature,arereducingexposuretosunlightandcontributingtothe developmentofchronicdiseases(Hollick2004)(Hollick,2004).Sensibleexposuretosunlightfor approximately510minutesthreetimesperweekhelpstoprotectagainstthedevelopmentofskin cancerandishighlylikelytobebeneficialtophysicalhealth(Hollick2004). 23.3.4RecoveryfromIllnessandImmunity Accesstonaturecanalsoaidrecoveryfromillness(Kaplan2001;Malleretal.2006).Astudy revealedthathospitalpatientswithaviewofnaturefromtheirhospitalroomrecoveredfrom surgeryandillnessfasterthanthosewhohadaviewofabuiltenvironment(Malleretal.2006).They spentlesstimeinhospitalandnursingstaffalsoreportedfewernegativecommentsintheirmedical records.Furthermore,thosepatientswithaviewofnaturerequiredfewerpainkillersfortheirillness andhadlesspostoperativecomplications.Asimilarpatternwasnotedinprisonenvironments: thoseinmateswithanaturalviewfromtheircellreportedalowerfrequencyofstresssymptoms, includingdigestiveillnessandheadaches,andhadanoverallreducednumberofsickcalls(Moore 1982;West1985).Accesstonaturecanalsohelptoreducetherequirementsofthehealthcare services(Kaplan2001;Malleretal.2006). Thereisevidencetosuggestthatsomehabitatsmayhelptoenhanceimmunitytodisease(Lietal. 2007;Parketal.2010).Spendingtimeinaforestenvironmenthasbeendemonstratedtoincrease 14

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naturalkillerTcellactivity,avitalcomponentintherejectionoftumoursandcellsinfectedby viruses.Contactwithforestenvironmentsalsoincreaselevelsofperforin,asubstancefoundinthe presenceofnaturalkillerTcells,andgranulysinwhichdestroysinfectedbodycells(Parketal.2010). Additionally,studieshavenotedanincreaseintheinductionofintracellularanticancerproteinsin subjectsthatspendtimeinforestenvironments(Parketal.2010). 23.4IndirectPositiveEffects 23.4.1FacilitatingNaturebasedActivity Accesstonature,viaanyofthethreelevelsofengagement(viewfromthewindow;functional engagement;activeparticipation),canhelptofacilitatenaturebasedactivity.Ifnatureiswithin closeproximity,therearehealthbenefitsfromsimplyviewingitthroughawindow(Ulrich1984; Prettyetal.2005),beinginitspresence(DeVriesetal.2003),oractivelytakingpartingreen activitiesandwildernesstrails(DavisBerman&Berman1989;Hartigetal.2003;Prettyetal.2007). Researchsuggeststhatindividualswhoarereadilyabletoaccessgreenspaces,whethertheyarevast areasofwildernessorurbanparks,arethreetimesmorelikelytoparticipateinphysicalactivitythan thosethatcannotaccessitsoeasily(Wellsetal.2007;Bowleretal.2010).Furthermore,thenature basedactivitiesassociatedwiththetwolatterlevelsofengagementcan,inturn,leadtoanumberof healthbenefits.Activitiessuchaswalking,gardening,fishing,huntingandhorseridingnotonly providethosehealthbenefitsassociatedwithcontactwithnature,butalsoprovidebenefitsthrough participationinphysicalactivity(Samson&Pretty2005;Prettyetal.2007;Barton&Pretty2010). 23.4.2FacilitatingSocialEngagement Highlevelsofsocialcapitalcanhaveadirecteffectonmarkersofindividualandcommunitywell being(Kawachietal.1997;Pretty&Ward2001;Wood&GilesCorti2008).Socialcapitalcaptures theideathatsocialinteractionandsocialnormsareanimportantpartofthebasisforsustainable livelihoodsandcommunities(Pretty&Ward2001).Levelsofsocialinteractioncanbedirectly influencedbytheavailabilityofgreenspace(Coleyetal.1997;WardThompson2002).Modern Urbanhabitatslackinggreenspacetendtorestrictsocialcontactasindividualsarenotattractedto theirsurroundingenvironmentssotendtostayindoors,awayfromothers(Coleyetal.1997). However,urbangreenspace,intheformofparks,streetsandallotments,canfacilitatesocialcontact andgiverisetostrongerneighbourhoodties(Coleyetal.1997;Kuoetal.1998;WardThompson 2002).Evidencesuggeststhatthepresenceoftreesandgrassinurbanareasencouragesindividuals toutiliseoutdoorspace,increasingthelikelihoodofsocialinteraction.Thehigherthenumberof treesandvegetationinanarea,themorepeoplethatuseitandthemoretimetheyspendwithinit (Coleyetal.1997;Kuoetal.1998).Urbanparksgiveindividualstheopportunitytomeetnewpeople anopportunitythatisnotsoreadilyprovidedelsewhereinmodernsociety(WardThompson 2002). Socialengagementandinteractioncanalsobeincreasedthroughparticipationinoutdoor conservationanddevelopmentactivitiesandinitiatives(Pretty&Smith2004;ParliamentaryOffice ofScienceandTechnology2007).Theseactivitiescanconnectpeoplethroughgroupsandnetworks, andbuildstrongercommunities,particularlyinUrbanareaswheregreenspacesuchaswoodlands aregenerallydeclining(Pretty&Smith2004;ParliamentaryOfficeofScienceandTechnology2007). Byprotectingnature,individualscanobtainsocialcontactandderivevaluefrombeinginthe presenceofnature(Pretty&Smith2004). 15

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23.4.3ProvidingWildFoods Ecosystemsprovidewildfoodsthatcanhaveadirecteffectonhealth.Formanythousandsof generations,farmers,huntergatherers,fishersandforagershaveutilised,managedandamended wildfoodsfromtheirsurroundinghabitatsinordertoprovideasourceofnutritionforthemselves andothers(WHO2005;Bharucha&Pretty2010).Historically,wildplantsandfoodwerethesole sourceofnutritionforhuntergatherandforagercultures,andso,havelongstandingculturalvalue aswell. Today,wildfoodshelptolinkpeopletolocalhabitatsandincreasesocialengagement,thus impactinguponhealth.TheFoodandAgricultureOrganizationoftheUnitedNationsestimatesthat onebillionpeopleusewildfoodsintheirdietatsometimeduringatypicalyear(Aberoumand, 2009).Inmanypartsoftheworld,wildfoodsremainimportanttohealth:themeanuseofwild foodsbyagriculturalandforagercommunitiesin22countriesofAsiaandAfrica(36studies)is90 100speciesperlocation(Bharucha&Pretty2010).IntheUK,however,theynowtendtobenomore thanasupplementtopurchasedfoods(Bharucha&Pretty2010).Yetoldergenerationscanstill recallwhenthewildharvesthadacriticalnutritionalvalueandproductsrangedfromautumn berriesandnuts,torabbits,wildfowlandbirdseggs. Theuseofwildfoodsandtheprevalenceoftraditionalecologicalknowledgeappeartobedeclining inindustrialisedcountries(Mabey1996;Pilgrimetal.2008).InNewZealand,however,morethan60 speciesarestillincommonuse,largelybecauseoftraditionsofMorigroups.Theseinclude muttonbird(sootyshearwater,Puffinusgriseus),seagull,possum,rabbit,deer,wildpig,goat, salmon,trout,eel,watercress,sealettuce,gorseandmanyberries(Newman&Moller2005; Stephenson&Moller2009).IntheWallisLakecatchment,Australia,88speciesareingeneraluse (Grayetal.2005).IntheswampsofLouisiana,USA,largenumbersofpeoplestillhuntandfish regularlyfortheirownfood(Roland2006).WithregardstoEurope,Pieroni(1999)suggeststhatthe geographicalisolationoftheupperSerchioValleyinTuscanyhaspermittedarichpopular knowledgetobemaintained,and,asaresult,gastronomictraditionshavesurvivedfrompre Romantimes:120speciesstillformawellpreservedpharmacopoeiaoffoodandmedicine(Pieroni 1999).InotherregionsofcontinentalEurope,wildfoodusepersists:123ediblespeciesarestillused inSpain(Tardioetal.2003);andinmanyMediterraneancountries,wildfoodsarestillprevalent enoughtobeconsideredanimportantpartoflocaldiets(Leontietal.2006). IntheUK,wildfoodsremainanimportantculturallinktocertainhabitats.Wildfowlingwasvery commonincoastalcommunities,forexample,untilthemid20thCentury(Tennyson1949; WentworthDay1949,1950),andduckdecoyswereanimportantsourceofbothfoodandincome duringthe18thCentury(Heaton2001).Attheirheight,therewere29duckdecoysinEssex,14in Suffolkand26inNorfolk,andeachcouldharvest5,000birdsperyear.Thelastworkingduckdecoy inEastAngliaclosedin1968.Yetwildfowlingremainsanimportantactivityandfoodforsmall groupsincoastalareas(Pretty2011).Insomecommunities,thewildharvestremainsasignificant culturalevent.Forexample,forgenerationsmenfromthefishingvillageofNessontheIsleofLewis, Scotland,havetravelled60kmeachAugusttotheislandofSulaSgiertogatheryounggannets (Morusbassanus)(Pretty2011).Some2,000oftheseguga(Gaelicforyounggannet)arecollected fromnestsontherockfacesandkilled;theyarelatersaltedandstoredforlocalconsumptionasthe meatisahighlyvalued.Thereisnoevidencethatthegatheringhasanyadverseeffectontheoverall populationofthegannetcolony. 16

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Thereissomeevidencethatwildfoodsarenowreceivinggreaterprominenceinbutchersand supermarkets,withvenison(deer),rabbitsandgamebecomingincreasinglyavailableandbeing purchased.IntheUK,deernumbersareincreasingbecauseofgrowingwoodlandcover,warmer winters,improvedurbanhabitatmanagement,andthedevelopmentofmoregolfcourses.Overthe past20years,theareaofwoodlandintheUKhasincreasedby600,000hectarestosome2.6million hectares,andtherearenowthoughttobe500,000roe(Capreoluscapreolus),360,000red(Cervus elaphus)and100,000fallow(Damadama)deer,alongwith50,000muntjac(Muntiacusreevesi),sika (CervusNippon)andChinesewater(Hydropotesinermis)deer.Duetotheirgrazinghabits,whichcan decimateplantgrowth,inmanyhabitats,numbersofdeerhavetobecontrolled,andthisprovidesa readysourceofvenison.Suchhuntingandshootingalsobringsincomeandpeopleintothe countryside. Inaddition,eachyear,some20millionpheasants(Phasianuscolchicus)and400,000mallards(Anas platyrhynchos)areraisedandreleasedforshootinginandaroundwoodlandsandwetlandsinthe UK.Ithasbeenshownthatlandownerswhobothhuntandmaintaingamebirdstocksconserve7%of theirfarmsaswoodland,whereasthosewhodoneitherkeeplessthan1%aswoodland(Oldfieldet al.2003). 23.4.4ProvidingaCatalystforBehaviourandLifestyleChange Contactwithnaturenotonlyaffectsimmediatehealthandwellbeing,butalsohealththroughout life.Lifecoursesandpathways,throughwhichalllivesareshaped,canbemappedoutintoafunnel (Figure23.3).Figure23.3representsthetwoextremepathways,healthyAandunhealthyB. However,therearenumerouspathwaysthatlieinbetween,consistingofvariedconfigurationsand patternsofbehaviours(Prettyetal.2009). InpathwayA,thehealthypathway,peopletendtolivelongerandhaveabetterqualityoflife (Prettyetal.2009).Thisincreaseinlifeexpectancyandqualityoflifeisadirectresultofincreased levelsofphysicalactivity,agreaterconnectiontopeopleandsociety,contactwithnature,andthe consumptionofhealthyfoods(Prettyetal.2009).Thesehealthybehavioursmaybefollowedasa directresultofanindividualssurroundingenvironment.Theabilitytoaccessgreensettingshas beendemonstratedtoencouragecontactwithnatureandparticipationinphysicalactivity,bothof whichencouragetheadoptionofotherhealthylifestylechoicessuchassocialengagementand consumptionofhealthyfoods(Wellsetal.2007;Prettyetal.2009;Bowleretal.2010).The availabilityofgreenspaceis,therefore,criticaltohealthybehaviours.Onthehealthypathway, individualshaveabetterlevelofmentalhealth,engagewithnatureregularly,aremoreresilientto stress,aremembersofsocialgroupsandkeeplearning(Foresight2008;Prettyetal.2009). Bycontrast,thesecondlifecourseinFigure23.3,pathwayB,istheunhealthypathway.Inthis pathway,individualshavealowerlifeexpectancyandapoorerqualityoflife,resultingfrominactive andsedentarybehaviour,disconnectionfromsocietyandpeople,alackofconnectionwithnature, andtheconsumptionofenergydenseandunhealthyfoods(Prettyetal.2009).Individualsonthe unhealthypathwayalsohavemorestressfuljobs,alowersocioeconomicstatus,liveinareaswhere activetravelisdifficult,andhaveanincreasedlikelihoodofbeingmentallyill,overweightorobese (Foresight2007;Prettyetal.2009). Inanincreasinglyurbanisedsociety,thelikelihoodoffollowingthispathwayisbecomingincreasingly likely.Asurbanareascontinuouslygrowanddiffuseintoruralareas,individualsrelyheavilyoncars fortransportation,andareseparatedfromneighbouringcommunities(Prettyetal.2009).In 17

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modernhumanhistory,inactivity,disengagementfromnature,consumptionofunhealthyfoodsand socialisolationarecommonbehaviours.Urbanareasdonotprovidevastopportunitiesforphysical activityoractivetransport(e.g.cycling),andgreenspaceiscontinuouslydecreasing(Biddleetal. 2004;Louv2005;Prettyetal.2007;Prettyetal.2009).Theunhealthybehavioursencouragedby moremodernurbanenvironmentsareresultinginpoorhealthandwellbeing(Prettyetal.2009) andsomeenvironmentsmaybeconsideredasobesogenic(Foresight,2007).

Althoughanindividualmayspendsometimeonaparticularlifepathway,itispossibletochange behaviourandtakeanalternativepathway(Prettyetal.2009).Individualsmaymovetoamore healthypathwayasadirectresultofadoptinghealthybehavioursthatrequirespendingtime outdoors.Forexample,anindividualmaytakepartinawildernesstrailoractivityawayfromtheir normalenvironment,butmaycontinuetohavecontactwithnatureevenwhenthetrailhasfinished. Thischangeinbehaviourmayalsoleadthemtowardstheadoptionofotherhealthybehaviours, suchasphysicalactivity.However,individualsmayalsomovefromahealthytoanunhealthy pathwayasaresultofaparticularexperience.Yetresilientindividuals,whoregularlyperform physicalactivityandhavecontactwithnature,aremorelikelytobeabletocopewiththesestressful lifeeventsandwill,therefore,continueonthehealthypathway(Prettyetal.2009). Bymovingfromanunhealthytoahealthypathway,individualswillexperiencesignificant improvementsinqualityoflifeandwellbeing.Furthermore,thisshiftwillsavesociety approximately2,423perpersonperyearinhealthcarecosts(Prettyetal.2009).Indeed,ifjust1% ofthesedentarypopulationmovestoahealthypathway,1,063livesand1.44billionwillbesaved eachyear(NICE2009).Theearlierthisshiftoccursduringlife,thegreatertheimpactwillbeupon healthandsociety. InsertFigure23.3here

23.4.5ChildhoodExperienceandBehaviour Experienceofnatureduringchildhoodcanimpactuponadultbehaviourandlifepathways.Although contactwithnatureatanyagecanderiveawholenumberofbenefitsforphysicalandmental health,contactwithnatureduringyouthcandirectlyimpactuponhealthyadultbehaviours. Researchindicatesthatthefrequencyofvisitstogreenplacesduringchildhoodsignificantly correlatestothenumberofvisitsduringadulthood(WardThompsonetal.2008;Prettyetal.2009). Therefore,alackofexperienceofnatureasachildmaydirectlyresultinalackofcontactduring adulthood.Beingdisconnectedfromnatureischaracteristicofanunhealthylifepathwayandmay reducetheopportunitiesforadoptingotherhealthybehaviours(Prettyetal.2009). Contactwithnatureduringchildhoodcanalsoinfluenceenvironmentalattitudesandbehaviours duringadulthood.Evidencesuggeststhatchildrenwhoparticipatedinnaturebasedactivitiesbefore theageof11aremuchmorelikelytoexpressproenvironmentattitudesandengageinpro environmentbehaviours(Figure23.3).Experienceduringchildhoodcan,therefore,haveasignificant impactuponanindividualsattitudetowardstheenvironment,afactorthatcouldpotentiallyimpact uponenvironmentalconservation(Wells&Lekies2006). Despitetheevidencethatadultswhohavehighlevelsofcontactwithnatureduringyouthhavean increasedlikelihoodofadoptingahealthylifepathwayandexhibitingenvironmentallyfriendly behaviours(Wells&Lekies2006;Prettyetal.2009),opportunitiesforthechildrenoftodaytoplay andengageingreensettingsarecontinuallydiminishing.Lessthan10%ofchildreneverplayin 18

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naturalareas,comparedtothe40%oftodaysadultswhodidsoaschildren.Childrenarespending lesstimeoutdoorsthantheyusedto,andhaveareducedunderstandingofthenaturalenvironment (Louv2005;Bird2007).Ifthechildrenoftodaycontinuetobedisconnectedfromnature,itis increasinglylikelythattheywillembarkonanunhealthylifepathwaythroughouttheirlivesand, hence,haveareducedqualityoflifeandlifeexpectancy(Prettyetal.2009). 23.4.6EpidemiologicalStudies Epidemiologicalstudiesoftenshowassociationsbetweentheproximityofgreenspacetothehome andpositivehealthoutcomes(Maasetal.2006;Mitchell&Popham2007,2008).Adirectlink betweentheamountofaccessiblelocalgreenspaceandhealthhasbeenevidencedusinglargescale epidemiologicalstudiesinJapan,NetherlandsandSweden,whichwehavereviewedhere(Takano etal.2002;DeVriesetal.2003;Grahn&Stigsdotter2003). InTokyo,Japan,treelinedstreets,parksandothergreenspacesplayakeyroleintheincreased longevityofresidents,anddecreasetheriskofmentalhealthissues(Takanoetal.2002).A longitudinalstudycomparedaccesstolocalgreenspaceswithinwalkingdistanceofhomeand mortalityratesinelderlypeopleoveraperiodoffiveyears.Aftercontrollingfordemographicand socioeconomicvariables,Takanoetal.(2002)foundthat,outof3,100Tokyocitizensbornbetween 1903and1918,71%werestillalivein1992,andthattheprobabilityoftheirlivingforanadditional fiveyearswaslinkedtotheirabilitytowalkinalocalparkortreelinedstreet(Takanoetal.2002). However,theissueofcausalityisnotclearasitispossiblethatthemoreaffluentindividuals,who oftenlivelongeranyway,representedthosewholivedinthegreenerneighbourhoods(Adams& White2003). IntheNetherlands,selfreportedhealthdatafromovertenthousandDutchurbanresidentswas correlatedwithnationalenvironmentaldatacharacterisingthetypeandquantityofblueandgreen spacespresentintheirneighbourhood.Socioeconomicanddemographiccharacteristicswere controlledforselectioneffectsandthestudyreportedthatpeoplelivingingreenerneighbourhoods enjoyedbettergeneralhealth(DeVriesetal.2003).Thetypeofgreenspacedidnotseemtoalter effectiveness;thetotalamountofgreenspaceinthelivingenvironmentseemedtobethemost relevantpredictor.However,environmentalcharacteristicswereseparatedintoneighbourhoods, andallindividualswithinthatparticularareawereclassedashavingequalaccesstogreenspaces. Thismeasuredoesnotacknowledgethatexposuretogreenspacemayvaryconsiderablybetween residentsofthesameneighbourhoodandthatdurationsofexposuremayalsodiffer. InaSwedishstudy,GrahnandStigsdotter(2003)examinedtherelationshipbetweentheuseof urbangreenspacesandhealth,andfoundthatthelevelofselfreportedstressshowedsignificant relationshipswiththeproximityofurbangreenspaces,thefrequencyofvisitstothosegreenspaces, andthedurationofthestay.Thefindingsimpliedthatthemorefrequentthevisits,thelowerthe incidenceofstressrelatedillnesses.Havingaccesstoapublicorprivatelyownedgardenadjacentto theirplaceofresidencewasanotherprincipalfactor,whichhasimplicationsforbothpolicyand urbanlandscapeplanning(Maasetal.2006;Mitchell&Popham2007,2008). Perceivedneighbourhoodgreennessisalsostronglyassociatedwithbettermentalandphysical health(Sugiyamaetal.2008).Respondentswhoperceivedtheirneighbourhoodashighlygreen were1.37and1.60timesmorelikelytohavebetterphysicalandmentalhealthrespectively,in comparisonwiththosewhoperceiveditaslowingreenery.Thedegreeofspeciesrichnessinurban greenspaceshasalsobeenpositivelyassociatedwiththepsychologicalwellbeingofvisitors(Fuller 19

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etal.2007),emphasisingtheimportanceoflocallymanagedbiodiversityinprovidingasenseof placeandanobjectforreflection. Despitethesefindings,itisalsoimportanttoacknowledgepotentialselectionorcausation mechanisms(DeVriesetal.2003).Selectionprocesseswouldsuggestthathealthypeoplemoveto greensurroundings(selectivemigration),whereascausationmechanismswouldimplythatlivingin greenenvironmentspromotesgoodhealthandwellbeing.Sodogreenenvironmentsmakepeople healthierandaffectindividualbehaviour,ordothoseparticularareasattracthealthypeople?Ifa personresidesinagreenarea,dotheyspendmoretimebeingphysicallyactiveoutdoors?Evenif thenaturalenvironmentdidnotaffectphysicalactivitypatterns,wouldthehealthofthoselivingin greenersurroundingsimprovesolelyfromtheincreasedexposuretonature?Althoughallofthese studieshaveattemptedtoaddressthepossibilityofselectivemigration,itcannotbecategorically ruledout.Thestudiesarealsocrosssectionalinnature,asopposedtolongitudinal.Crosssectional studiesarevaluableandprovideagoodstartingpoint(Wellsetal.2007)byestablishing relationshipsamongcorrelatesorcovariates(Baumanetal.2002).However,longitudinalstudiesare necessarytoestablishcausality,whichisanimportantoutcomeforinformingpolicyandpractical recommendations.Althoughlongitudinalstudiesaretimeintensive,theadvantageofexploring causalitymakesthemacreditablegoal. 23.5ReducingtheIncidenceofPollutionandDiseaseVectors Ecosystemsprovideimportantservicesbyreducingthreatstohealththroughpurification, dampeningandconsumptionfunctions.Processesincludelocalclimateregulation,noisereduction, scavengingofairpollutantsandthecontrolofvectorsofdisease. 23.5.1AirPurificationthroughtheReductionofPollution Ambientairpollutionhaslongbeenimplicatedasacontributortoadversehealtheffects.TheHouse ofCommonsEnvironmentAuditCommitteereportedthatupto50,000peopleayearintheUKmay bedyingprematurelybecauseofairpollution(Defra,2007).TheGovernments2007AirQuality StrategyestimatesthatthehealthimpactofparticulatematteralonecoststheUKbetween8.5 billionand20.2billionayear(Defra2007).Thisisverylikelytobeanunderestimateasitignores theimpactonmorbidity,costingonlymortality.Inaddition,airpollutionhaswideranging environmentalimpactsincludinglossofbiodiversity,reducedcropyieldsandcontributingtoclimate change. RehdanzandMaddison(2008)foundthatperceivedlevelsofairpollutionarenegativelyrelatedto wellbeinginGermany.Welsch(2006)examinedaveragewellbeinginrelationtoaverageair pollutionvalues,andfoundsignificantnegativeassociationsineachcase.Breretonetal.(2006)and Ferreira&Moro(2010)workingwithindividualleveldataonairpollutionandotherEnvironmental QualityparametersinIreland,alsofoundnegativeassociationsbetweenairpollutionandwellbeing; andMacKerron&Mourato(2010)arrivedatthesameconclusionusingairpollutiondataforLondon. Numerousstudieshaveshownhowecosystemscanplayasignificantroleinreducingairpollution. Rowe(2010)recentlyreviewedtheuseofgreenroofstoreducepollution.Heconcludedthatthey havesignificantpotentialtoreduceairpollutiondirectlyandemissionsindirectly.Themajorhurdle totheirwidespreadutilisationistheconsiderablecostbarrierbetweengreenandconventionalroofs (Rowe2010). 20

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Urbanforestscaneitherreduceairpollutionbyincreasingdrydeposition,orincreaseitthrough emissionsofenhancedbiogenicvolatileorganiccompound(BVOC),whichcanactasprecursorsof secondaryairpollutants.Manyreportshaveshownthattreesinurbanareasprovideasignificant contributiontothereductionofairpollutants(Yangetal.2005;Nowak2006;Escobedo&Nowak 2009).Escobedaetal.(2011)arguetheforestsshouldbemanagedwithintheparametersofurban sustainabilityand,atthesametime,promotedtopolicymakersandcitizensasameansof mitigatingpollution,sotheycanbeusedtoimprovehumanqualityoflifethroughoutthecitiesof theworld(Escobedoetal.2011). Thereislittleguidanceonoptimumlocationsinwhichtoplanttreesinurbanareas.InNewYork, locationsfortreeplantinghaveusedindicatorssuchashospitalisationandasthmarates(Groveet al.2006).Thisearlierworkhasnowbeendevelopedintoaplantingpriorityindexthatspatially considersairpollutionconcentrations,humanpopulationdensityandtreecover.Ontheotherhand, theplacementoftreesmayalsoincreasepollutionconcentrationsatstreetlevels,especiallyin valleyswheretheyimpactonthedispersionprocesses(Buccolierietal.2009). Onaglobalscale,BVOCsemittedfromvegetationaremorereactivethan,andexceed, anthropogenicVOCs.EmissionratesofBVOCsarestronglydependentupontemperature,soitis expectedthattheywillincreaseinthefutureasaresultofclimatechange.Emissionsalsovaryfrom speciestospecies,soselectiveplantingoflowemittingspeciesmaybebeneficial.Donovanetal. (2005)developedanurbantreeairqualityscorethatrankstreesinorderoftheirpotentialto improveairquality.Theyconcludedthatpine,larchandsilverbirchhadthegreatestpotentialto improveairquality.Incontrast,ifplantedinlargenumbers,oaks,willowsandpoplarshadthe potentialtodecreaseairqualitydownwind(Donovanetal.2005). 23.5.2InterceptionofNoiseandWater Inrecentyears,noisepollutionhasbecomeanincreasinglyimportantenvironmentalproblemwhich canhaveadverseeffectsonhumanhealth(Ozeretal.2008).Trafficgeneratednoiseisoneofthe mainsourcesofnoisepollution,withexcessivenoisefromroads,airtrafficandrailwaysinurban areascommonlyresultinginstress(denBoer&Schroten2007;Ozeretal.2008).Habitatscontaining treesandshrubvegetationhavebeendemonstratedtobeparticularlyeffectiveatprovidingbarriers tonoiseinurbansettings(Frumkinetal.2004;Ozeretal.2008;Ernstsonetal.2010;Fitteretal. 2010).Researchhasalsodemonstratedthatthepresenceofvegetationcansignificantlyreduce noiselevelsfromurbanmotorways(Ozeretal.2008).Furthermore,greenbeltshavebeen suggestedtobeeffectivetoolsforthemitigationoftrafficgeneratednoise(Pathaketal.2011). However,thespecificcharacteristicsofthevegetationshouldbeconsideredasthecrownwidth, heightanddensityofplants,andthepositionoftheirleavesagainstthedirectionofthenoise,may influencetheireffectiveness(Ozeretal.2008).Thevegetationmustalsobetoleranttoairpollutants frommotorisedtransport(Pathaketal.2011). VegetationisimportantfortheinterceptionofwaterinUrbanhabitats(CornellUniversity2009). Largecitiesandtownsareoftencoveredwithhardsurfacesthatdonotallowfortheabsorptionof water.Duringstormsortimesofhighrainfall,thiscanresultinhighlevelsofsurfacewater.This excesswateroftenrunsintosewersystemscausingthemtooverflowintoriversandlakes,washing pollutantsintothem.Thepresenceoftreesandothervegetationcanreducethisproblemby lesseningthesurfacewaterandenhancingwaterabsorptionviathesoil.Vegetationcanalso transpirewaterfromtheirleaves.Thepresenceofvegetationinurbanecosystemsis,therefore,of 21

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greatimportanceasitcanhelptoreducefloodingandpreventthepollutionofriversandlakes (CornellUniversity2009). 23.5.3MitigationoftheHeatIslandEffect TheHeatIslandeffectisawellestablishedphenomenonoflargeurbansettlements;the temperaturedifferencebetweenLondonandthesurroundingsuburbs,forexample,canbeaslarge as9oC(Kolokotroni&Giridharan2008).Itisknownthaturbangreenspacemitigatesthiseffect(Gill etal.2007).Treesalsofilterandtakeupairpollutants,includingoxidesofnitrogenandsulphurand particulates(Beckettetal.1998;Tiwaryetal.2009).Thecurrent7%treecoverintheWestMidlands reducesairconcentrationsofPM10(particulates>10micrometres)by4%(McDonaldetal.2007). Treesandothervegetationalsointerceptnoisebyabsorbingreflectedandlaterallytransmitted noise. 23.6DirectThreatstoHumanHealth Thissectiondoesnotconsiderthetoxicants,pollutantsorcontaminantsintroducedintothe environmentasaresultofhumanactivityormanagement.Thoseclassesofcompoundswithknown effectsonhumanhealthincludesomepesticides,airpollutants,endocrinedisruptors,PCBs,heavy metals,radionuclides,asbestos,aliphatics(e.g.vinylchloride,formaldehyde),andoils(Conway& Pretty1991;Frumkin2005;Pretty2005).Theeffectsofsomeofthesethreatstohealthare dampenedormitigatedbyspecificecosystems. Ecosystemsthemselves,however,canbeadirectproviderofthreatstohumanhealth,anditisthese threatsthatwearereviewinghere.Theyincludeinfectiousagents(e.g.Lymeborreliosis, Cryptosporidiumspecies,malaria,cholera,cyclosporacayetanensis,campylobacterspeciesand leptospirosisspecies);physicalthreatsfromwildanimals(thoughnotgenerallyafactorinUK), domesticlivestockanddogs;pollutantsorcontaminantsfromplants(e.g.brackenspores,VOCs, pollen);elementalthreatsthroughextremesoftemperatureorUVradiation;andaccidents(Frumkin etal.2004). ThereareawidevarietyofpathogensinwaterthatcomprisethreatstohealthincludingEscherichia coliandSalmonella,Campylobacter,GiardiaandCryptosporidiumspecies.Someofthesecomefrom naturalsources,suchas(waterbirdsandwildanimals,andsomecomefromhumansources.Vector bornediseasesinvolvethetransmissionofinfectiousagents(viruses,bacteriaandparasites)by bloodsuckingarthropodssuchasmosquitoes.Anumberofsuchdiseaseshaveemergedforthefirst time,orresurged,assignificantpublichealththreatsduringthepast25years.TheseincludeLyme Disease,DengueFeverandthemoreseriousDengueHaemorrhagicFever,YellowFever,Japanese Encephalitis,WestNileVirus,AlkhurmaVirus,asubtypeofKyasanurForestDisease,Venezuelan EquineEncephalitis,EpidemicPolyarthritis(RossRiverVirus),BarmahForestVirus,RiftValleyFever, OropoucheFever,CaliforniaEncephalitisandCrimeanCongoHaemorrhagicFever(Watsonetal. 2005). LymeDisease,involvingtheinfectionofhumansfollowingatickbite,hasbecomeasignificantpublic healthproblemintheUSA,andhasrecentlyincreasedwithintheUK.TheHealthProtectionAgency nowestimatesthatthereare1,0002,000casesofLymeDiseaseintheUKeachyear.Theticksthat causeLymeDiseasearecommonlyfoundinwoodlandandheathlandareasbecausethesetypesof habitatshaveahighnumberoftickcarryinganimalssuchasdeerandmice.PartsoftheUKthatare knowntohaveaparticularlyhighpopulationofticksincludeExmoor,theNewForest,theSouth 22

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Downs,partsofWiltshireandBerkshire,ThetfordForestinNorfolk,theLakeDistrict,theYorkshire MoorsandtheScottishHighlands(NHS2011b).Thetickpopulationishighestinlatespringandearly summer. AfurtherthreattohumanhealtharisesfromnaturalVOCs.Theseairpollutantsoriginatefrom vegetation,suchasoakandmaple,butcanalsobeanthropogenicinorigin(Steinbrecheretal. 2008).ThemainnaturalVOCsareisopreneandterpene,andlargeforestscanemit50kg/km2daily attheheightofthegrowingseason(Behr&Johnen2008).NaturalVOCsemittedbysuchhabitats cancontributesignificantlytotheformationoftroposphericozone,whichhasnegativehealth consequences(AQEG2009). Anotherthreattohumanhealtharisesfromnoiseintrudingonecosystemsandconsequently affectingwellbeing.Thesourcesofnoisepollutionaremainlyfromtransport.VanPragg&Baarsma (2005)investigatedaircraftnoisearoundAmsterdamSchipholairportandfoundthatexperienced noisenuisancewasnegativelyrelatedtowellbeing,althoughdirectnoisemeasureswerenot significant. Climatealsohasaneffectonhumanhealth.Redhanz&Maddison(2005)assessedclimate parametersacross67countriesandfoundthatgreaterwellbeingwasassociatedwithahigher meantemperatureduringcoldmonthsandalowermeantemperatureduringhotmonths.In addition,Breretonetal.(2006)foundthathigherwellbeinginIrelandwasrelatedtolowerwind speeds,buthigherrainfall. Inadditiontothedirecteffectsofclimateonwellbeing,climatechangeispredictedtohavea substantialfutureimpactasalteredconditionsallowthespreadanddevelopmentofnewvector borneandwaterbornediseases(Watsonetal.2005).Itisnotclearwhetherthiswillbringvectors thataffecthumanhealth,butthelivestockdisease,BluetongueVirus,hasnowbecomeestablished intheUKsinceitsarrivalfromthecontinentviamigratingadultmidgestakingadvantageofwarmer conditions.Airborneallergensmayalsobesignificantlyinfluencedbyclimatechange.Ithasbeen shownthatpollencountsrisewithincreasingtemperatures(Tamuraetal.1997;Anhlholmetal. 1998).Inaddition,increasedatmosphericcarbondioxideresultsinenhancedproductionofpollens fromspeciessuchasragwort(Seneciojacobea)(Ziska&Caulfield2000).Therecentcomprehensive assessmentbytheHealthProtectionAgency(DepartmentofHealth/HealthProtectionAgency2008) hasconcludedthatoutbreaksofmalariaintheUKarelikelytoremainrare,butthatthereisstillthe possibilitythatmoreeffectivevectors(differentspeciesofmosquito)mayarriveintheUKasthe climatebecomesmoresuitableforthem.Tickbornediseasesareexpectedtobecomemore common,butthisismorelikelytobeduetochangesinlanduseandleisureactivitiesthantoclimate change.ThelikelihoodthattickborneencephalitiswillbecomeestablishedintheUKisverylow. Finally,therearesomenaturalsourcesofradiationintheUK(e.g.radonfromgraniterocksinsouth westEnglandandScotland)thatconstitutesignificantnaturalthreatstohealth. 23.7MethodsforEstablishingHealthValues 23.7.1QuestionnairebasedMeasuresforMentalHealth Table23.4summarisesthemaininstrumentsinuseformeasuringmentalhealtharisingfrom exposuretonature.Manydifferentmethodsareavailable,butTable23.4comprisesalistofthe 23

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mostcommonlyappliedtoolsfromkeystudiesidentifiedinearliersections.Thislistisindicative ratherthanexhaustive. Inserttable23.4here 23.7.1.1Selfesteem Selfesteemiscommonlyacceptedasakeyindicatorofemotionalstabilityand,therefore,isa contributortomentalwellbeing,qualityoflifeandsurvival(Huppert&Whittington2003).An individualslevelofselfesteemhasimplicationsforhealthbehaviours,motivationsandlifestyle choices.Highlevelsofselfesteemareassociatedwithhealthybehaviours,suchashealthyeating andphysicalactivity,andalsostressresilienceandlifesatisfaction(Torres&Fernandez1995;Fox 2000).Lowselfesteemiscloselylinkedtomentalillnessandtheabsenceofpsychologicalwell being,withsymptomsincludingdepression,traitanxiety,suicidalideationandasenseof hopelessness(Fox2000). RosenbergsSelfEsteemScale(RSE)isthemostwidelyusedandpopularselfesteemmeasure (Rosenberg1965).Itisastandardisedtoolusedinhealthpsychologyandisregardedasthestandard againstwhichothermeasuresofselfesteemshouldbecompared(Rosenberg1965).TheRSEscale consistsoftenstatementsconcerninghowanindividualviewsthemselves,andrequiresaresponse ofstronglyagree,agree,disagreeorstronglydisagreeforeach(Rosenberg1965).Thescales conservativemeasure,superiorreliabilityandvalidityiswidelyacknowledge,andthesequalities havebeendemonstratedwithmanydifferentsamplegroups(Fox2000):itsusehasbeenvalidated foradolescent,adultandelderlypopulations.TheRSEhasbeenusedinawiderangeofgreen exercisestudies,predominantlyintheUK(Prettyetal.2005;Peacocketal.2007;Prettyetal.2007; Peacocketal.2008;Bartonetal.2009;Barton&Pretty2010;Bartonetal.2011). 23.7.1.2Moodstatesand/oremotion Moodisdefinedasthesubtlesubjectivestateorfeelingsofapersonatanygivenmoment(Hull 1991).Itisanintegralcomponentofdailylifeandhasastronginfluenceonfeelingsofhappiness, beingabletoappreciatethemoment,copingwithstressfulsituationsandgeneralqualityoflife (Bergeretal.2002).Moodstatesareknowntoinfluencelongtermhealthbybothdirect(immune system)andsecondary(lifestylechoices)pathways. TheProfileofMoodState(POMS)standardisedshortformquestionnaireistheprimaryinstrument formeasuringmoodduetoitssensitivitytomoodchangesinmanysettings(McNairetal.1971; Biddle2000;Biddleetal.2000).ThePOMSquestionnairecomprisessixsubscalemoodcomponents: fivenegativeandonepositive.Theseareangerhostility,confusionbewilderment,depression dejection,fatigueinertia,tensionanxietyandvigouractivity(McNairetal.1971).Therearefive wordstorepresenteachofthesixsubscalesandrespondentsarerequestedtoindicatethedegree towhichtheyareexperiencingtheparticularmoodstatebyselectingnotatall,alittle, moderately,quiteabitorextremely(McNairetal.1971).ThePOMSquestionnairehasbeen regularlyusedtoassessshortterm,acutemoodchangesinindividualsaftertheyhaveparticipated innaturebasedactivitiesintheUK(Prettyetal.2005;Peacocketal.2007;Prettyetal.2007; Peacocketal.2008;Bartonetal.2009;Barton&Pretty2010;Bartonetal.2011). TheZuckermanInventoryofPersonalReactions(ZIPERS)isabroadstateaffecttestthatassesses feelingsonfivefactors:feararousal,positiveaffect,anger/aggression,attentivenessand sadness(Zuckerman1977;Ulrich1981;Hartig2003).Therespondentsindicatetheextenttowhich thestatementsdescribehowtheyfeelatthatprecisemomentusingafivepointscale(1=notatall 24

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to5=verymuch)(Zuckerman1977;Hartig2003).TheZIPERShasbeenusedinalargenumberof studiesexaminingtheeffectofrestorativeenvironments,mainlyintheUSA(Ulrich2002;Hartig 2003). Anxietyisamoodoremotionalstatethatincludesfeelingsofapprehension,tensionand nervousness(Spielberger1970).TheSpielbergerstatetraitanxietyinventory(SSTAI)andtheS STAIsixitemshortversionareusedtoassessanxiety(Spielberger1970;Dietteetal.2003).TheS STAIisaselfreportquestionnairewhichrequiresparticipantstoindicatewhethertheyarefeeling calm,tense,upset,relaxed,etc.Participantsrespondonafourpointscaleusingeithernotatall, somewhat,moderatelyorverymuchso(Spielberger1970;Dietteetal.2003).Thescoresare summedandnormalisedtoascalewithscoresrangingfrom20to80:20representsalowlevelof anxietyand80representsahighlevel(Dietteetal.2003). TheLewisStressfulLifeEventsScaleisusedtoassessthefrequencyofstressfullifeevents(Lewiset al.1984)andwasoriginallytestedanddevelopedonchildrenintheUSA(Wells&Evans2003).The scaleconsistsof20itemseachconcerningastressfullifeevent.Therespondentisaskedtoindicate thedegreetowhichtheyexperiencethisstressfullifeeventusingalot,sometimesornever (Lewisetal.1984;Wells&Evans2003).Examplesofitemsonthescaleincludehowoftenwereyou pickedonormadefunofbyotherkids?andHowoftendidyoufightorarguewithyourparents?. Themethodhasbeenusedtoexplorerelationshipsbetweenaccesstonatureandtheabilitytocope withstressfullifeevents(Wells&Evans2003). 23.7.1.3Overallmentalwellbeing TheGeneralHealthQuestionnaire(GHQ)istheindustrystandardformeasuringpsychological healthandprovidesanoverallindicationofpsychologicalstate(Chisholmetal.1975;Goldberg 1978).ThereareseveralversionsoftheGHQincludinga28itemand12itemversion(Goldberget al.1997).QuestionsarescoredusingathreepointLikertscale,withvariationintheirmeaning accordingtothequestionitself(Goldberg1978;Goldbergetal.1997).The12itemversionhasbeen demonstratedtoberobustandtoworkaswellasthelonger,28itemversion(Goldbergetal.1997). Onthe12itemversion,thequestionnairescoresrangefromaminimumof0toamaximumof36.A scoreof0representsanexcellentstateofmentalhealth,whileascoreof36representsapoorstate ofmentalhealth(Prettyetal.2005).Althoughthistooliscommonlyusedinmentalhealthresearch, ithasonlybeenusedsparinglytoassessthehealthvaluesofcontactwithnature. TheRutterChildBehaviourQuestionnaireisusedtoassesspsychologicaldistress,including symptomsofbehaviouraldisorders,anxietyanddepression(Rutteretal.1970;Boyle&Jones1985; Wells&Evans2003).Thequestionnaireisastandardised,widelyusedinstrumentthatiscommonly usedinnonclinicalpopulations.Thequestionnaireconsistsof26itemsthatarerespondedtoona threepointscalebythechildsmother(0=doesnotapply,1=appliessomewhat,2=certainlyapplies) (Wells&Evans2003).Itemsonthescaleincludephrasessuchasmychildoftenappearsunhappy andbulliesotherchildren.Thisinstrumenthasbeenusedtoexplorerelationshipsbetweenaccess tonatureandtheabilitytocopewithstressfullifeevents(Rutteretal.1970;Boyle&Jones1985; Wells&Evans2003). TheGlobalSelfWorthScaleisusedtoassesschildrensperceptionofmentalwellbeing(Harter 1982).Thescaleassessesthreedomainsofselfcompetence,includingsocial,cognitiveandphysical domains,andalsoassessesgeneralselfworth(Harter1982).Thescaleincludessixitemswith statementssuchassomekidslikethekindofpersonthattheyarebutotherkidsoftenwishthey 25

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weresomeoneelse(Wells&Evans2003).Therespondentrespondstoeachstatementusingeither reallytrueorsortoftrue(Wells&Evans2003). 23.7.1.4Mappinessmethods AcustomiPhoneapplication(app)andaccompanyingbackenddataserverhavebeendeveloped by(Mourato&MacKerron2010).Recruitmentofparticipantsisopportunistic,relyingmainlyon mediacoverageandsnowballingviaTwitter.Afterdownloadingtheapptotheirdevices,participants providebasicdemographicandhealthrelatedinformation,confirmsettings,andgivetheirinformed consentinordertoregister.Participationisanonymous:noname,address,orothercontact informationisrequested.Participantsreceivesimplefeedback,chartingtheirhappinessindifferent contexts,andcantakepartinthestudyforaslong(orshort)aperiodastheywish.Following registration,participantsreceiveanotification(beep)ontheirdevicebetweenoneandfivetimesa day,attheirownchoice.Thenotificationscomeatarandommomentduringhoursagreedbythe participant.Thedefaultfrequencyistwiceaday,andthedefaulthoursare8am10pm.Each notificationpromptstheparticipanttoopentheappandtobrieflyreporthowtheyarefeelingand, inbroadterms,whomtheyarewith,wheretheyareandwhattheyaredoing.Respondentsreport theextenttowhichtheyfeelHappy,RelaxedandAwakeonaslidingvisualanaloguescale. 23.7.2 PhysiologicalandQuestionnairebasedMethodsforAssessingPhysicalHealth Themajorityoftheresearchassessingthehealthbenefitsofexposuretonaturehaspredominantly usedmentalhealthmeasures.However,toestablishanoverallhealthvaluewealsoneedtoaddress theimpactuponphysicalhealthindicessuchasheartrate,bloodpressure,skinconductanceand/or cortisol(stresshormone).SomeauthorshavestartedexploringtheimpactonnaturalkillerTcell activityandotherkeyhormonestoprogresstheresearchtoacellularlevel(Lietal.2007). 23.7.2.1BodyMassIndexandWaisttohipratio BodyMassIndex(BMI)isasimpleindexofweight:heightthathasbeenwidelyusedtoestimate bodyfatandtoclassifyadultsasunderweight,overweightandobeseforseveraldecades(Keysetal. 1972;WHO2011;NHS2011a;NIH2011).Itisdefinedastheweightinkilogramsdividedbythe squareoftheheightinmetres(kg/m2).IthasbeenusedbytheWorldHealthOrganizationasthe standardforrecordingobesitystatisticssincetheearly1980sandisseenasausefulestimationof riskfordiseasesthatcanoccurwithmorebodyfat.ThehighertheBMIcalculation,thegreaterthe riskforcertainhealthissuessuchasCardiovascularDisease,highbloodpressure,Type2Diabetes, gallstones,breathingproblemsandcertaincancers(NIH2011).Althoughcontroversiesovertheuse ofBMIformedicaldiagnosisremain,itisgenerallyacceptedforindividualswithanaveragebody composition(WHO1995).ClassificationofBMIscoresare:<18.5=underweight;18.524.99= normal;2529.99=overweightand>30=obese.SomestudieshavemonitoredchangesinBMIover timeasaresultofparticipationingreenexerciseactivities(Hineetal.2011).Othershaveexplored therelationshipbetweenBMIandthementalhealthbenefitsexperiencedthroughnaturebased activity(Prettyetal.2005). Waisttohipratio(WHR)isasimpleandusefulmeasureoffatdistributionandisatoolthathelps determineoverallhealthrisk(NHS2011a).Peoplewithmoreweightaroundtheirwaistareat greaterriskoflifestylerelateddiseases,suchasCardiovascularDiseaseanddiabetes,thanthose withweightaroundtheirhips.Theclassificationofriskasdefinedbywaisttohipratiosisasfollows: formen:<0.95=lowrisk;0.961.00=moderaterisk;>1=highrisk;andforwomen:<0.80=lowrisk; 0.810.85=moderaterisk;>0.85=highrisk.Thenormsforadultsare0.84formalesand0.72for females.Waistcircumferenceismeasuredwithameasuringtapearoundthenarrowest 26

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circumferencebetweenpelvisandthorax(ortwofingerwidthabovenavel)andhipsaremeasured fromthesideatthelevelofthemaximalprotuberanceofbuttocks. 23.7.2.2Bloodpressure Bloodpressureisanimportantmarkerofcardiovascularhealth:particularlyhighlevelsare associatedwithCardiovascularDiseaseandcerebrovascularevents(DepartmentofHealthEducation andWelfare2004).Manualanddigitalsphygmomanometersaremostcommonlyutilisedtoassess bloodpressureandareapplicableinavarietyofsettings(O'Brienetal.2001).Theyaresimpletouse andprovideaquickassessmentofbloodpressure.However,theaccuracyofthemanualmonitoris largelyinfluencedbytheassessoritselfandshouldonlybeusedbyexperiencedindividuals(O'Brien etal.2001).Assessingbloodpressurechangepreandpostnaturebasedinterventionsprovidesan indicationofrecovery,andmanystudieshaveusedthisapproachtocompareexposuretonatural environmentsandurbanareaslackingnature(Ulrich1981;Ulrichetal.1991;Parsonsetal.1998; Prettyetal.2005).Aportapresisusedtomeasurebloodpressureandcanprovideabeatbybeat assessmentforupto24hours(O'Brienetal.2001).Thiswouldallowresearcherstoexplorethe longertermimpactofexposuretonatureonbloodpressureovera24hourperiodandintroduce ambulatorymonitoringratherthanoneoffmeasures.Theportapresgiveswaveformmeasurements similartointraarterialrecordings.However,thismethodcanleadtovariousinaccuracieswhichmay onlybefixedbycorrectionfactorsanddigitalmonitors(O'Brienetal.2001). 23.7.2.3HeartrateandHeartRateVariability(HRV) Heartrateandheartratevariability(HRV)areimportantmarkersofautonomicnervoussystem activityandarecontributorstocardiovascularhealth,especiallyasthereisasignificantrelationship betweentheautonomicnervoussystemandcardiovascularmortality(Treiberetal.1989;TaskForce 1996).HeartRatemonitorsarecommonlyutilisedtoassessheartrateastheyareapplicableinboth laboratoryandfieldsettings(Treiberetal.1989).Heartratemonitorsconsistofacheststrapanda wristwatch.Thecheststrapisfittedaroundthesubjectschesttodetectaheartratereading;this readingistransmittedtothewristwatchwhichstoresandmonitorsheartrateforaselectedtime period(Treiberetal.1989).Whileheartratemonitorsareeasytouseinbothlaboratoryandfield settings,thereissomeconcernwithregardstotheiraccuracy(Treiberetal.1989).Heartrate monitorshavebeenusedtoassessexperiencesbothingreenspacesandinurbanareaslacking natureinafewstudies(Ulrichetal.1991;Parsonsetal.1998;Prettyetal.2005). Electrocardiograms(ECGs)arealsousedtoassessheartrateandareconsideredtoprovidemuch morereliableresultsthanheartratemonitors(Treiberetal.1989).NotonlydoECGsprovidean overallmeasureofheartrate,buttheyalsoprovideameasureofheartratevariability:beatbybeat variationinheartrate(TaskForce1996;Martini2006).Threeelectrodesareplacedatdifferent pointsonthebodyssurfaceandconnectedtoacomputer(Martini2006).Thecomputergeneratesa graphofeachheartbeatcycle,whichismadeupofseveraldifferentfeaturesincludingaPwave, QRScomplexandTwave.Ifaportionofthehearthasbeendamaged,forexamplebyaheartattack, theECGwilldetectabnormalitiesinthenormalheartbeatcycle(TaskForce1996;Martini2006). Althoughusefulinlaboratorystudiesusingpicturesofnaturalscenesandurbansceneslacking natureorgreenspace(Ulrichetal.1991),thismethodwouldhavelimitedapplicabilityinfield settings. 23.7.2.4Cortisol Cortisolisabiomarkerofpsychosocialstress.Cortisollevelsgraduallyincreasewithinafewminutes ofstressstimulationandreachpeakconcentrations1030minutesafterstresscessation(Foley& Kirschbaum2010).Cortisollevelsarecommonlymeasuredthroughsaliva.Apieceofabsorbent 27

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cottonisplacedinthemouthforapproximately12minutesandplacedinatesttube.Thesaliva samplecanthenbefrozenandstoredforlateranalysisofcortisolconcentration(Foley& Kirschbaum2010;Parketal.2010).However,whencortisolismeasuredviasamplesofsaliva,itis onlypossibletodeterminefreecortisollevels(theconcentrationofthosecortisolparticlesnot boundtoprotein)(Foley&Kirschbaum2010). Bloodsamplescanalsobetakentomeasurecortisollevels.Unlikesalivarysamples,bloodserum samplescanprovidebothameasureoffreecortisollevelsandtotalcortisol(Foley&Kirschbaum 2010).However,bloodsamplingisamoreintrusivemethod.Exploringchangesincortisolprofiles followingparticipationinlongertermnaturebasedinterventionsiscurrentlybeingconsideredfor futureresearch.Veryfewstudieshaveanalysedcortisollevels(Hartigetal.1996)ininrelationto contactwithnature,butinvestigatingthisstresshormonecouldpotentiallyinformfuturecalculated healthvalues. 23.7.3 QuestionnairebasedMethodsforEstablishingConnectednesstoNature 23.7.3.1Connectednesstonature Connectednesstonatureisanimportantpredictorofecologicalbehaviourandsubjectivewellbeing andhasbeendemonstratedtoberelatedtoanincreaseinawarenessofenvironmentalissuesand environmentallyfriendlybehaviour(Hineetal.2008b).TheConnectednesstoNatureScale(CNS)is astandardisedandvalidatedquestionnairewhichisanewmeasureofindividualstraitfeelingsof beingemotionallyconnectedtothenaturalworld(Mayer&McPhersonFrantz2004).Thirteen questionsarescoredonascalerangingfromonetofive,withfiveindicatingthemaximumlevelof connectednesstonature.TheCNSscoreiscalculatedbyaddingthescoresforeachquestionand dividingbythirteentogiveanoverallscorebetweenoneandfive(Mayer&McPhersonFrantz 2004).TheCNShasbeenutilisedtoassessshorttermchangesinconnectivityfollowinggreen exerciseactivities(Peacocketal.2008;Hineetal.2011). 23.7.3.2Naturerelatedness Naturerelatednessdescribesanindividualslevelsofconnectednesswiththenaturalworldand comprisesthecognitive,affectiveandphysicalconnectionwehavewithnature(Nisbetetal.2009; Nisbet2011).TheNatureRelatednessScaleisarelativelyrecentscale(2008)designedtomeasure anindividualslevelofconnectednesswiththenaturalworld.Thescaleconsistsof21itemsratedon afivepointLikertscale,from1(disagreestrongly)to5(agreestrongly).Items2,3,10,11,13,14,15 and18arereversescored.Atotalnaturerelatednessscalescoreiscreatedbyaddingthetotalscore anddividingby21.Scoresrangefromonetofive,withahighscoreendorsingacognitive,affective andphysicalconnectionwithnature(Nisbetetal.2009). TheNatureRelatednessScalealsohasthreesubscales:self,perspectiveandexperience.Ascore canbecreatedforeachsubscalebyaveragingtheitemswithinthatsubscale.Again,scoresagain rangefromonetofive,withhighscoresendorsingthesubscale.Theselfsubscalemeasuresan internalizedidentificationwithnature,reflectingfeelingsandthoughtsaboutonespersonal connectiontonature;theperspectivesubscalemeasuresanexternal,naturerelatedworldview,a senseofagencyconcerningindividualhumanactionsandtheirimpactonalllivingthings;andthe experiencesubscalemeasuresaphysicalfamiliaritywiththenaturalworldandthelevelofcomfort withanddesiretobeoutinnature(Nisbetetal.2009).Thismeasureisnowstartingtobeusedin ecosystemandhealthresearch. 23.8Conclusions 28

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Thefindingsofthischaptersuggestthatattentioncouldbegiventodevelopingtheuseofgreen exerciseasatherapeuticintervention(Hineetal.2009;Haubenhoferetal.2010);thatplannersand architectsshouldimproveaccesstogreenspace(greendesign);andthatchildrenshouldbe encouragedtospendmoretimeengagingwithnatureandbegivenopportunitiestolearninoutdoor settings(greeneducation).Someofthesubstantialmentalhealthchallengesfacingsociety (Foresight2008;HSE2008),andphysicalchallengesarisingfrommoderndietsandsedentary lifestyles(Wanless2002;Wanless2004;DepartmentofHealth2005a;SportEngland2006;Wellset al.2007;NICE2008;DH&DCSF2009;NICE2009),couldbeaddressedbyincreasingphysicalactivity ingreensettings.Ifchildrenareencouragedandenabledtoundertakemoregreenexercise,then theyaremorelikelytohaveactiveexposuretonatureembeddedintheirlifestyleasadultsandthey willreaptheassociatedhealthbenefits. Futureresearchneedstoaddresstheissueofcausalitytoconvincepolicymakersofthehealth benefitsderivedfromexposuretonature.Therefore,existingmeasuresneedtobeintegratedwithin longitudinalpopulationstudiessuchastheBritishHouseholdPanelSurvey.Thereremainsalackof longitudinalstudieswithintheexistingliterature,especiallyexploringchangesfromchildhoodto adulthood.Introducingthistypeoftimeseriesresearchwouldalsoallowacomparisonwith financialcostingstoinfervalueformoneyandidentifycausaleffectsoftheenvironmental intervention.Althoughtheexistingevidencebaseconcerningtherestorativepropertiesofnature anditsroleinreducingstressandreplenishingattentionfatigueisstrong,thedurationand frequencyofexposurerequiredtopreventstressrelatedillnessinthelongtermisnotfully understood.Thus,longitudinalstudieswouldensurethekeyquestionconcerninglongterm motivationandsustainedbehaviourchangewasaddressed,whichhasimportantconsequencesfor publichealth. References Adams,J.&White,M.(2003)Healthbenefitsofgreenspacesnotconfirmed.JournalofEpidmiology andCommunityHealth,57,312. Anhlholm,J.U.,Helander,M.L.&Savolainen,J.(1998)Geneticandenvironmentalfactorsaffecting theallergenicityofbirch(Betulapubescensssp.czerepanovii[Orl.]Hmetahti)pollen ClinicalandExperimentalAllergy,28,13841388. AQEG(AirQualityExpertGroup)(2009)OzoneintheUnitedKingdom.Defra,London. Barton,J.,Hine,R.&Pretty,J.(2009)Thehealthbenefitsofwalkingingreenspacesofhighnatural andheritagevalue.JournalofIntegrativeEnvironmentalSciences,6,261278. Barton,J.&Pretty,J.(2010)Whatisthebestdoseofnatureandgreenexerciseforimproving mentalhealth?Amultistudyanalysis.EnvironmentalScienceandTechnology,44,3947 3955. Barton,J.,Griffin,M.&Pretty,J.(2011)Exercise,natureandsociallyinteractivebasedinitiatives improvemoodandselfesteemintheclinicalpopulation.PerspectivesinPublicHealth,In press.DOI:10.1177/1757913910393862 Bauman,A.E.,Sallis,J.,Dzewaltowski,D.&Owen,N.(2002)Towardabetterunderstandingofthe influencesonphysicalactivity:Theroleofdeterminants,correlates,causalvariables, mediators,moderatorsandconfounders.AmericanJournalofPreventiveMedicine,23,514. Beckett,K.P.,FreerSmith,P.H.&Taylor,G.(1998)Urbanwoodlands:theirroleinreducingthe effectsofparticulatepollen.EnvironmentalPollution,99,347360. Behr,A.&Johnen,L.(2008)Myrceneasanaturalbasechemicalinsustainablechemistry:Acritical review.ChemSusChem,2,10721095. 29

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x23.1Approa achusedtoassigncertaint tytermstochapterKeyFindings Appendix Thischapt terbeganwit thasetofKey yFindings.Ad doptingtheapproachandterminologyusedbythe Intergove ernmentalPan nelonClimateChange(IPC CC)andtheM MillenniumAs ssessment(M MA),theseKey y Findingsa alsoincludeanindicationo ofthelevelof fscientificcertainty.Theuncertaintya approachof theUKNE EAconsistsof fasetofqual litativeuncer rtaintytermsderivedfrom ma4boxmod deland compleme ented,where epossible,wit thalikelihoodscale(seeb below).Estimatesofcertai intyare derivedfr romthecollec ctivejudgementofauthor rs,observatio onalevidence,modellingre esultsand/or r theoryexaminedforth hisassessmen nt. Througho outtheKeyFindingspresen ntedatthest tartofthischapter,supers scriptnumbersandletters s indicatetheestimated dlevelofcerta aintyforapa articularkeyfinding: 1. W Wellestablishe ed:highagree ementbasedonsignifican ntevidence 2. Es stablishedbu utincompleteevidence:hig ghagreement tbasedonlim mitedevidenc ce 3. Co ompetingexp planations:lo owagreement t,albeitwithsignificantev vidence 4. Sp peculative:lo owagreement tbasedonlim mitedevidenc ce

a. . b. c. . d. . e. f. g. . Virtuallyce ertain:>99%probabilityofoccurrence Verylikely:>90%proba ability Likely:>66 6%probability y Aboutasli ikelyasnot:> >3366%prob bability Unlikely:< <33%probability Veryunlike ely:<10%pro obability Exceptiona allyunlikely:< <1%probability

41 4

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Certaintyterms1to4constitutethe4boxmodel,whileatogconstitutethelikelihoodscale..

42

UKNation nalEcosystem mAssessment t:TechnicalReport Graphics FIGURES Figure23.1Healthben nefitsandthr reatsfromec cosystems.
Directpositivee effects (improvementsin mentalandphy ysical health)physical lactivity Indirectpositive eeffects (facilitatingactiv vity, socialengageme entand behaviourchange)

Heath hValues:Ch2 23

+v ve

Ecosyste emsand habitats s

+ve

Men ntalandphysical health

Reductionofth hreats (e.g.fromvecto ors, pollutants,noise(by d purificationand interception) Directthreats(e e.g.from infectiousagent ts, animals,polluta ants, extremesoftem mperature andUV,acciden nts, poisonousplant ts,pollen)

+ve

ve

Figure23.2Thegreencareumbrell la.Source:ad daptedfromH Hineetal.(20 008a)

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Figure23.3Dichotomousmodeloflifecourses.Source:reproducedfromPrettyetal.(2009)

Pathway A people tend to: Brain development a function of enriched environment Be active Be connected to people and society Engage with natural places Eat healthy foods Live longer Lower blood CRP and cortisol

Children freerange outdoors

A Can shift to other pathway range outdoors

Three ages of childhood In utero Attachment Secure Exploration Engagement Independence Inclusion Adulthood Elderly

-9 months

5-6 years

11-12 years

18 years Can shift to other pathway range outdoors B

60-65 years

Brain underdevelopment (atrophied hippocampus)

Children stay indoors

Pathway B people tend to: Be inactive/sedentary Be disconnected from society Not engage with natural places Eat energy-dense and unhealthy foods

Higher blood CRP and cortisol

Die earlier

Live years with lower quality of life

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TABLES

Table23.1Thehealthandwellbeingbenefitsofcontactwithnature. Healthandwellbeingbenefit Evidence Providesopportunitiesforgreen Hartigetal.(1991),Ulrichetal.(1991),Hartigetal. exerciseandassociated (1996),Hartigetal.(2003),VandenBergetal.(2003), improvementsinselfesteemand/or Moritaetal.(2006),Prettyetal.(2005),Hineetal. mood (2007),Prettyetal.(2007),Bartonetal.(2009),Barton &Pretty(2010),Bowleretal.(2010). Reducesstress Parsons(1991),Ulrichetal. (1991),Lohretal.(1996), Rubinstein(1997),Parsonsetal.(1998),Hartigetal. (2003),Laumannetal.(2003),Fredrickson&Branigan (2005). Promotesecologicalknowledge Pilgrimetal.(2007),Pilgrimetal.(2008),Pretty(2011) Fosterssocialbonds Kawachietal.(1997),Takanoetal.(2002),Ward& Thompson(2002),Brughaetal.(2003);Bartonetal. (2011),Pretty(2011). Reduceslevelsofcrimeandviolence Kuo&Sullivan(2001a),Kuo&Sullivan(2001b) Providesoutdoorclassrooms Kaplan&Kaplan(1989),Kahn&Kellert(2002) Deliverscognitivebenefits Bermanetal. (2008),HansenKetchumetal.(2009) Influencesbehaviouralchoices Kuoetal.(1998a),Maasetal.(2006),Mitchell& Popham(2008),Bartonetal.(2011)

45

 Table23.2Healthrelatedecosystemservices(positiveandnegative)fromtheeightUKNEABroad Habitats. UKNEABroad Healthrelatedecosystemservices Habitats Directpositive Reducethreats Directthreatsto Provideplaces effectson fromdisease health forphysical health vectors, activityand pollutants,noise social engagement Mountains, Considerable Considerable Purificationof Bracken, Moorlandsand provision;access provision;wild waterandair accidents, Heaths generallygood foods temperature extremes Seminatural Considerable Considerable Purificationof Zoonosesand Grasslands provision;access provision;wild waterandair, vectors, oftenlimited foods floodregulation livestock accidents EnclosedFarmland Limitedaccess Considerable Purificationof Zoonosesand waterandair, vectors, exceptby provision;wild floodregulation livestock footpathsand foodsfrom bridleways hedgerows accidents Pollencausing Woodlands Considerable Considerable Purificationof asthma,VOCs, provision;access provision;wild waterandair, Lymedisease generallygood foods floodregulation, climate regulation (shadingand cooling) Purificationof Waterborne Considerable Considerable Freshwaters waterandair diseases provision;access provision;wild Openwaters, (Cryptosporidiu generallygood foodsfrom Wetlandsand m,Weils fishing Floodplains disease),red tidesfrom eutrophication, accidents Accidents Purificationof Urban* Considerable Provisionwhere waterandair, provision;access accessis interceptionof limited availablefrom noiseandwater, homesand reductionof workplaces; heatisland foodsfrom effect domestic gardensand allotments CoastalMargins Considerable Considerable Seadefences Redtides, provision;access provision;wild accidents generallygood foods(birds, shellfish,
46

 samphire) Limited Limited Accidents provision(as limitedaccess) *Urbangreenspaceincludes,forexample,parks,gardens,allotments,streettrees;doesnotinclude thebuiltenvironment. Table 23.3Summary findingsfromananalysisofsubjectivewellbeing(Mappiness). Significance: ***p<0.001,**p<0.01,*p<0.05,+p<0.1.Source:Mourato(xxxx). Explanatoryvariable Differenceinexplanatory Associateddifferencein variable happinessresponse Walking,hiking +2.6%*** Sports,running,exercise +6.1%*** Notdoingcomparedwith doingthisactivity Gardening,allotment +2.5%*** Birdwatching,naturewatching +2.9%** Outdoors Beingindoorscompared +1.4%*** withbeingoutdoors +5.2%*** MarineandCoastalMargins FreshwaterOpenwaters, +1.7%+ WetlandsandFloodplains Beingoutdoorsin Mountains,Moorlandsand +4.0%** continuousurbanland Heaths covercomparedwithbeing SeminaturalGrasslands +1.2%** outdoorsinthelistedland EnclosedFarmland +2.1%*** covertype ConiferousWoodland +4.5%*** Broadleaved/MixedWoodland +2.3%*** Suburban/ruraldeveloped +1.0%*** Marine Limitedaccess
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 Table23.4Summaryofmentalhealthmeasures.
Questionnairetitle 1. Rosenberg'sSelfEsteem Scale Mentalhealth measure Selfesteem Numberof items/Factorson questionnaire 10items Examplesofecosystem studiesinwhichtheyhave beenutilised Prettyetal.(2005),Peacock etal.(2007),Prettyetal. (2007),Bartonetal.(2009), Barton&Pretty(2010), Bartonetal.(2011). VandenBergetal.(2003), Prettyetal.(2005),Peacock etal.(2007),Prettyetal. (2007),Peacocketal.(2008), Bartonetal.(2009),Barton& Pretty(2010),Bartonetal. (2011). Ulrich(1981),Ulirichetal. (1991),Honeyman(1992), Hartigetal.(1996),Ulrich (2002),Hartigetal.(2003). Diette etal.(2003) Wells&Evans(2003)

2.

ProfileofMoodState Questionnaire

Mood

6factors(30items)

3.

TheZuckermanInventoryof PersonalReactions

Emotionand mood

5factors

4. 5. 6. 7.

SpielbergerStateTrait AnxietyInventory TheLewisStressfulLife EventsScale TheGeneralHealth Questionnaire TheRutterChildBehaviour Questionnaire

Anxiety Stress Mentalwellbeing Psychological distress, behavioural problems,anxiety anddepression Perceptionof mentalwellbeing

20items 20itemscale

28itemand12 Prettyetal.(2005) itemquestionnaires 26items Wells&Evans(2003)

8.

TheGlobalSelfworthscale

6items

Wells&Evans(2003)

BOXES Box23.1Sharedunderstandingofwellbeing.Source:Defra(2007). Wellbeingisapositivephysical,socialandmentalstate;itisnotjusttheabsenceofpain, discomfortandincapacity.Itrequiresthatbasicneedsaremet,thatindividualshaveasenseof purpose,thattheyfeelabletoachieveimportantpersonalgoalsandparticipateinsociety.Itis enhancedbyconditionsthatincludesupportivepersonalrelationships,strongandinclusive communities,goodhealth,financialandpersonalsecurity,rewardingemployment,andahealthy andattractiveenvironment.Governmentsroleistoenablepeopletohaveafairaccessnowandin thefuturetothesocial,economicandenvironmentalresourcesneededtoachievewellbeing.An understandingoftheeffectofpoliciesonthewaypeopleexperiencetheirlivesisimportantfor designingandprioritisingthem.
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