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Heather: Hello, and welcome to this Lancet
Spotlight podcast on climate change and health, which is part of the Lancet's 200th anniversary celebrations. I'm Heather Brown, an editor at the Lancet Neurology.
Lauren: And I'm Lauren Southwell. I'm a senior assistant editor here at the Lancet. Our topic today is going to be urban green and blue spaces. We're very pleased to
Heather: be joined by Professor Rhys Hunter and Professor Thomas Astle Burt.
Welcome Rhys and Thomas. Would you like to introduce yourselves?
Ruth: Sure. Thanks. And great to be here. My name's Rhys Hunter. I'm a professor of public health and planetary health at the Centre for Public Health, Queen's University, Belfast.
Thomas: And my name is Thomas Astle Burt. I'm a professor of population health and environmental data science.
at the University of Wollongong and also an Australian Research Council Future Fellow in Nature Based Solutions for Social Health, such as loneliness. Great to be here. Thank you.
Heather: Thank you very much for joining us. So first of all, what are the urban green and blue spaces?
Ruth: So there's many different definitions of green and blue spaces.
I think for green spaces, we. Typically use the definition that they're, these are natural environments, typically covered in vegetation, so examples would include our parks, forests, woodlands, greenways, but also things like green roofs, street trees, green walls, and then if we think of our blue spaces, these are essentially like bodies of water, so things like rivers, canals, lakes, our ponds, seas and beaches.
And these are really important spaces for health, really important recreational spaces, but more and more, they're important places and spaces to help us with climate mitigation and adaptation.
Thomas: Roof, we really hit the nail on the head there. And I'd only really add that, in my opinion, some of the best urban green and blue spaces are actually the same place.
Down in my neck of the woods in the city of Sydney, you have beautiful The glorious Centennial Park, which is this huge oasis of green and blue vegetation, trees, lawns, bush, but also lots of lakes as well, which people in the city of Sydney can enjoy. And they do on a daily basis.
Heather: What attracted you both to urban green and blue spaces as a topic for research, and why are these spaces important, and what are their co benefits?
Thomas: I think in research, we often to study, or we often select into things that we have a bit of experience about a bit of lived experience. And for me, that's no different. I grew up with a, I think, a quite a privileged background. Now I look back, I was in the scouts. My dad took me to play rugby at the weekend.
We got involved in a lot of pro environmental behaviors outdoors. Basically, if it was a. An opportunity to be outdoors. I was out there. Also, during those times, there was something which really triggered me a little bit. When I was playing rugby. In the the rugby fields in the west of Yorkshire in the UK, there was woods nearby and there was people actually demonstrating and showing activism in those woods to make sure that those trees didn't get cut down because of the desire to build a freeway around the town that we were in.
And so that was not necessarily part of that, but that really resonated in a way that made me feel. We need to really try and protect these not only for current generations, but for future generations as well. And we can come to the benefits, I think, in a bit, but to give you a bit of a flavor for it, my research in the last 10 years or so, Has really shown, I think, in the Australian context that those of us who have more tree canopy nearby tend to have better mental health, but general health, we get better sleep.
We tend to be a bit slimmer. We tend to also be less lonely. And we're at reduced risks of getting hypertension, diabetes, heart disease, even dementia. So there's a really great impact Set of health benefits and also potential co benefits here as well from protecting and restoring those green, urban and blue spaces.
Ruth: That sounds great, Thomas. I think for me, I've been working in this area since 2010. So that takes me back to my first postdoctoral research fellow position. Which was working on this large natural experiment investigating the public health impact of the Conswater community greenway in Belfast. So at the time this was around 35 UK Big Lottery.
I really saw this development of a new urban greenway in a part of Belfast that really includes some of the most deprived areas in Northern Ireland. So the greenway, it was opened in 2017, and it essentially contains 16 kilometers of new and improved walkways, cycling infrastructure, remediated rivers, flood alleviation schemes, different social programs, and this development of the, this new civic square.
And over that kind of last 10, 12 years, I've really just saw firsthand what impact these types of investments can have on the lives of the local communities. And 12 years on, I'm still working with the team at the Conswater Community Greenway. I'm a member of their trust. And we're in the fade of the game, actually, just at the moment, conducting a five year follow up of its impact.
And this is mix up content. Probably one of the longest running natural experiments of green blue space interventions. So from that, I just really became interested in exploring how, where we live and how we live can have this huge impact, not only on our own health, but also
Lauren: the health of the planet as well.
So you both touched on some really important points there. Thomas, you mentioned that you had quite a privileged upbringing to be out in these green and blue spaces and Ruth as well, you mentioned deprivation in the area surrounding some of these green spaces. So I wanted to ask you. Are there inequalities in the coverage and access of green and blue spaces?
And if so, what are they?
Thomas: Yeah, this is really important that we acknowledge where we have privilege, and I certainly did. Growing up in the west of Yorkshire, there's a lot of greenery nearby, although I might add, not always accessible. So if you took like a satellite view of where I and many of my contemporaries grew up, you have Conurbations, you have towns, villages surrounded by farmland, which isn't always necessarily accessible to go run around and climb trees and feel great.
So more green does not necessarily always mean more accessible green for everyone, but in general, what 10 years have found. Is that if you look at, say, the five most populous cities in Australia, there is a clear gradient in that the more socio economically disadvantaged an area is in terms of its income, its employment levels, its educational levels, it tends to have lower levels of parkland in general.
And that also in more recent work translates into tree canopy levels as well. Less tree canopy in more socioeconomically disadvantaged neighborhoods, which are already Communities where there is a lack of resources for maintaining good health, keeping healthy and out of hospital, it's all double trouble, if you will.
And that's led, I think, through replication in many countries around the world, and it's been shown previously, too, to notions of things like tree equity, that we need to invest in not only more trees to combat things like climate change and to, make our cities cooler, but to also ensure that everyone has the opportunity to reap the rewards from those investments.
And that means investing specifically in those disadvantaged areas. I want to just leave you with this because I think this is something I think is very important for the current housing crisis in Australia. And I think in many other countries around the world, in the North Shore, Eastern Suburbs area of Sydney, you have a suburb called Mossman.
Very affluent area. The median cost to buy a house in Mossman is about five million Australian dollars. I can't remember what the conversion is for U. S. or pounds sterling. But five million, that's a chunk of money, right? In comparison, and that's Tree canopy levels, high. Beaches, aplenty. Bushland, fantastic.
And accessibility to everything. Diabetes levels, just over 2%. You move over to the west of Sydney, where I've spent a lot of time working with clinicians in the western Sydney, like Mount Druitt. The median cost of a house there is just over 800, 000. So you can see there's a massive difference. By the way, Mount Druitt, some of the lowest levels of tree canopy in the city and some of the highest levels of diabetes getting on for 10 to 15%.
So you can see just in this context, massive inequalities. And I think they are somewhat replicated in other contexts too, which Ruth will be very familiar with.
Ruth: Thanks, Thomas. And just to pick up on some of that. So we've We know there's substantial segments of the population, including those from some of our most deprived communities, but also from marginalised groups who've less access to green and blue spaces, and therefore they visit them fewer than those individuals from a high income background.
And this then has, as Thomas has just described, these consequences for health and wellbeing. And this kind of quality of green and blue space also has some distinct social pattern that's not only rooted in unequal access. So low disadvantage areas are not necessarily deprived in the quantity of green spaces compared with advantaged areas.
Green spaces in these disadvantage areas tend to be of poor quality. They have less facilities and there are safety concerns, which means people visit them less. So we're thinking about people with chronic diseases, those with socioeconomic disadvantages. And those of you feeling particularly excluded from local spaces, they're much less likely to visit green and blue spaces at all than those from more advantaged areas.
And the other thing I think is we know fairly little about non use of these spaces, but the scarce evidence that we do know suggests that things like culture, so personal values, capability, for example, not wanting to or not feeling able to visit these streets of things like time poverty. Quality of spaces.
These are great determinants of non-use of these spaces. And I think another area worth mentioning, and Thomas has done quite a lot of work in this area is around low and middle income settings. So we know research on green and blue spaces in low middle income settings is scant. These are areas facing rafford, urbanization.
And hypothetically, there's reason to assume that green and blue space research in low and middle income countries would confer similar health benefits and co benefits as high income countries, but context really matters. And there's a real dearth of research in low and middle income countries, and that presents real obstacles really to the adoption of green and blue space policies by different policymakers.
Thomas: Yeah, context really matters. And not just in the geographical sense, but the temporal sense as well. We all know about The challenges in the last few years due to, let's just say, one thing and another, and what Professor Xiaoqi Feng at the University of New South Wales and I found in Australian cities was that, and this is to pick up exactly on Ruth's point, that those people who had Good proximity and we're able to visit green spaces, blue spaces, natural spaces that they personally found to be high quality and whatever that may be high amenity, high aesthetic opportunities for restoration and relaxation, recuperation, whatever it might be that really makes those spaces special to people, those people who were able to visit were able to visit them, visited them four times more often than those who had less quality green spaces.
They also felt that those spaces were five times more likely to keep people connected during what was very troubling times, and nearly ten times, ten times more likely to feel a sense of respite and solace through that tricky period in everyone's life. So I think what that really shows is that the investments by local councils, by local community groups, by state and federal government, Even federal governments in Australia, and I think this is in the case in many other countries around the world in quality green spaces that people feel a sense of buy in that they resonate with in local communities really came to people's aid and helped people through extraordinary times, and they will do so in future too.
Lauren: Thank you both very much. Those are really interesting points. I think you've mentioned some quite pertinent things there, sort of investment, maybe a lack of research, things like this. So I wanted to ask what could, and I think should we, either the general public, governing bodies, health institutions, what should we be doing to help overcome these inequalities in access, in research, in the quality of green and blue spaces themselves?
Ruth: Two main pleas on that one. The first one is actually implementing policies that we already have. So putting what's written on paper into actual action. We have various political frameworks that underscore the need for green and blue spaces in cities. For example, we have the new urban agenda that states about green space can reduce urban poverty, including tackling urban regeneration, creating safe and social spaces for integration, interaction and access to quality services.
However, Some of the green space policies can also inadvertently expand the gap between advantaged and disadvantaged as a result of things like gentrification and unequitable distribution of this high quality green space that we've just discussed. So I think there's a need to implement policies that we have.
We need to implement those policies. Those policies also need to be evaluated and develop much more kind of effective participatory and equitable approaches. These policy evaluations are not easy to do, but we need to know which policies worked and which don't work. The other plea I would make is for just some genuine co creation.
I think that's really important. So this is some genuine co creation of approaches that involve researchers, policy makers or practitioners. working with our communities and ensuring that our community and voices are embedded so that we know what's needed in those particular areas. And these types of approaches can then provide much greater knowledge of an individual's connection with that public space and really aid and understand those kind of direct, active, and not always conflict free interactions of the population with their environment.
And part of that as well, I think, is In bearing citizen science approaches to environmental change that can also be applied to green and blue spaces and in particularly in low middle income settings,
Thomas: thinking about this question that it suddenly popped into my head, an amazing study, which was One of a number that really inspired me to pick up my academic career in what we might refer to as natural environments and population health.
And that was a study by Professor Sally McIntyre, who used to run the Medical Research Council's Social and Public Health Sciences Unit. Up in Glasgow, where I did my postdoc, great times, and she was able to show with her team that in Glasgow, if you looked at the amount and the access to different parks that were available, and then you actually Looked at what people said about their access to the parks.
They weren't necessarily corresponding very well. A person may have physically a park nearby or some form of green space, but that doesn't necessarily mean that one recognizes it as within their neighborhood toolkit of things which they can go and visit and have a good time and feel a sense of belonging and community and restoration.
I think that Roof's point, especially around citizen science and I think co design, co production, hugely important here. It would be remiss of me not to bring up one of our neighbours in Australia, Singapore, which is done very well in greening within the context of an extraordinary high dense setting.
You can pretty much drive from one side of Singapore to the other within an hour, and it's a city of five million people, which gives you a sense, if you, for any listeners who haven't been to Singapore the, this, Sheer density of this amazing connected city, which is abundantly green as well. And that's because over time, green walls have come up across large buildings.
They've put in parks halfway up the buildings with bridges between the buildings to make sure people can get access to them in addition to the parks that are along the floor. One of my PhD students, Dr. Faisal Shuval. He did some fieldwork there, as well as in some other countries, and found that consistently, regardless of whether one is in one of the more affluent neighborhoods in Singapore, or one of the more socioeconomically disadvantaged areas, there's consistently high quality green space.
As shown by lots of people getting outdoors and being active and social, which is fantastic. Not the case in all places. In my neck of the woods in Australia, we have far to go. But places like Sydney, the city of Sydney, have taken up work that I am my lab have done over the last 10 years, showing that more parkland and more tree canopy in particular.
And if you hit about 30%, you start to see meaningful returns on investment. They've introduced that work into their own near 400 million greening strategy. In downtown Sydney and the neighboring suburbs, and they're aiming for 40 percent green can green cover 20 percent 27 percent tree canopy cover along residential streets, and they have an explicit focus on.
Leveling up the playing field so everyone has an opportunity to benefit. Wollongong, where is, where the location of my university, we have a tree canopy target of 34%, and I believe in places like Seattle and Vancouver and Barcelona and Canberra, not too far away from where I am now, there's also 30 percent tree canopy cover targets too.
The message is getting around, and People in councils are listening to the evidence and saying that we need to establish these sorts of tree canopy targets to ensure that everyone has an opportunity for a good, healthy and flourishing life. Just one final point on this. My colleague, Dr. Cecil Konenendijk, is an urban forester and has introduced something in the last couple of years called the three 30 300 rule.
Every house should be able to see three trees from a window, have 30 percent tree canopy in the neighborhood, reflecting the evidence that my lab and others have shown over the years, and also be within 300 meters of a decent quality green space. There is a roadmap for many places to also follow, not just ensuring that there's good tree canopy cover for everyone, but also.
Good quality green space nearby and also a visual of that space too, especially important for folks who find it difficult to get out of the home.
Lauren: It sounds like there's some really important research going on and some really important work going on at more localized levels, but at a higher sort of more institutional global level, did the UN sustainable development goals say anything about green and blue spaces?
What sort of progress is being made at that level?
Thomas: I can come in on that briefly. So yeah, the UN does have a range of goals which are pertinent to this. The one which I think is most directly relevant is, and I forget the number, but it's to improve access to safe and inclusive green spaces. And this is especially for women and children and older persons and individuals living with disability too.
I think our conversation so far, between Ruth and I, shows that we've still got a long way to go. I'm aware of some really interesting qualitative research being done in a variety of countries, which is showing that, yeah, more green is good often, but for individuals who are living with disability, there is a recognition that.
If they were able to spend more time in parks and botanic gardens and reserves and all the rest of it, that would be probably fabulous and be a catalyst for maintaining connectedness among a group who we already know are at increased risks of psychological distress and loneliness. The access isn't always there.
And I can't help, but feel that may make sometimes for some people When you know that something's there and you know it would be good for you and you know that other people in the community are there having a great time and you really want to be part of that, but you can't because the access arrangements aren't there or there's a really massive road with lorries thudding by and it makes it difficult to get across the road, then these spaces may often be symbolic of lost opportunities.
And for some, they may be great, but for others, they may be symbolic. And of a missed opportunity, a source of actual distress. But maybe Ruth has, I think, more on that, particularly with your awesome natural experiment where you've been doing great work over the last few years.
Ruth: Yeah, thanks, Thomas. I think green and blue spaces have, and we're talking about high quality, equitable green and blue spaces have the potential to make a real significant contribution to the sustainable development goals.
So I think things like SDG 11. States like By 2030, the goal is to provide universal access to safe, inclusive and accessible green and blue spaces. We've been doing some work looking at the evidence around green and blue spaces and each of the sustainable development goals. The majority of the work as we've discussed so far in this podcast has really been concentrated around health and being and some other work around some of the planetary health outcomes, particularly things like the Urban heat islands and air pollution.
But I think there's other areas such as tackling poverty through the provision of new job opportunities, things like reducing inequalities by providing access to good quality spaces that we've talked a lot about. But other things like supporting new sources of sustainable energy through wind and water, reducing hunger through things like urban farming approaches have largely really been neglected in the research to date.
So theoretically, I think green and blue spaces can contribute significantly to many of the sustainable development goals, and I think what it does is really reaffirm the importance of these types of spaces to mitigate health, social, economic, and environmental degradation, which is caused by rapid urbanization that we see, which threatens the ecological stability of our countries and our cities, but also the population health and the planetary health of cities.
So I think In summary here, I think green and blue spaces have a significant contribution to make across many areas. of the sustainable development goals.
Thomas: Yeah. And just to add a little cherry on the cake there, in New South Wales, which is the most populous state in Australia, for the last five years or maybe more, the Premier has had a priority for investing in higher quality green and open spaces Trying to level up the playing field so everyone has the opportunity and so far among various major investments, I'd like to highlight that they've also invested 150 million Australian dollars in creating, regenerating nine new parks in some of the most disadvantaged neighborhoods across the city.
So I think that. As we've mentioned already, progress towards this goal is moving in the right direction. And I think in some contests, like in Sydney, we can see that there is really great positive steps towards improving equity of access to high quality green spaces, but that doesn't mean we can rest on our laurels and.
Stop right there. It requires continued investment to make sure that those spaces continue to be seen as great places, because there is some really interesting research out there, which shows that if you are walking through a space, a green space, which is all run down and it's not seen any investment and the playground has seen.
Better days, it's all smashed up and all the rest of it. Then this can actually be a source of misery more than the feelings of restoration and health. So clearly continued investments very important, not just the one-off, just to ensure we meet a target initially.
Lauren: So I just wanted to touch on something, Ruth, that you mentioned.
You mentioned the ecological stability and the planetary health and its relation to, and their relation to. urban green and blue spaces. So what are the effects of these spaces on climate effects and climate damage? And what are the effects of climate change, climate effects, climate damage on these spaces?
What is the interplay between the two?
Ruth: Yeah. So I think this is an area of research that I think is only set to grow over the coming years. And I think these green and blue spaces have important contributions to make in terms of climate mitigation and also climate change. adaptation. So I mentioned previously about urban heat island effect.
So this really refers to an increase in our air and surface temperature of cities compared, essentially compared to their rural kind of surroundings. And it's a result of the spatial and physical characteristics of our cities. So things like there's a higher proportion of impervious surfaces, there's lower levels of vegetation cover, and we get this presence really of heat trapping streets.
So our green and blue spaces can really be important to create this coolant effect. Essentially by intercepting the rays from the sun and providing shade, really, that can further reduce the temperatures. There's also added benefits in things such as reducing energy consumption, particularly during warmer periods.
This stabilizes these kind of fluctuation. in temperatures and also environmental benefits of things around reducing the risk of flooding, which again, we're expected to see more and more flooding events over the coming years with our changing climate, but other things that it can do. We talk about a climate crisis.
We also have a biodiversity and nature crisis. So these can be important sources for improving our biodiversity and really providing these habitats. These are really important spaces for us. in, in our kind of changing climate context, and we do, we need much more research. There's a need to protect these spaces as well, particularly where we're seeing, we've seen over the summertime.
Much more increased incidents of, or wildfires and forest fires that are destroying these spaces. And particularly when we see our forests destroyed that have taken decades to grow, we really need to protect these spaces for the long term.
Thomas: One does not need to run a randomised control trial to know that if you stand under a tree you're going to be a bit cooler on a hot day.
In fact, I think that the temperature difference can be as much as 10 degrees in the summer. Some context and depending upon how hot it happens to be in my goodness. It's been very hot this last month. I think in Sydney. It's been the warmest August and September since records began, which gives you an idea of where we were at.
thing which should be obvious to the listeners is that trees are living beings as well, revered by many communities which have a great sense of connectedness to them as I count myself a month. Trees also do not necessarily always fare well in extreme temperatures, particularly if they are protractedly high temperatures and there's also drought.
There can be unfortunate Dieback and eventual tree death. So clearly Investing in millions of trees trillions of trees in by some organizations, I understand Also requires investments in good access to water So those trees are nourished just in the same way as we human beings also need our nourishment every day as well If we don't do that Then we are not going to have green cities for very long.
Lauren: Thank you both for such thoughtful answers. I think it's a really important topic and thank you very much for that. So just going back to the more institutional side of things, is WHO doing anything about urban green and blue spaces?
Ruth: The WHO have been working in this area for quite a while and they really recognise the capacity for green and blue spaces, not only to reduce the kind of environmental health risks, particularly of living in urban settings, but also to provide diverse, long term, both public health and planetary health benefits.
Think of back to 2016, the WHO published a review on urban green space and health, which really summarised the evidence. to date, but also exploring those core mechanistic pathways by exactly how green spaces had these different health outcomes. And I was then part of a follow up series that they did, which, where we reviewed the evidence then for green space intervention.
So they were really acknowledging the fact There was lots of cross sectional evidence, but what do we actually know about interventions? How do we actually do this? How do we introduce more green spaces or make better use of what we have, particularly for health benefits? And that really looked at green space interventions, not just for health, but also the socio economic and environmental outcomes to really see in these spaces as these kind of multi solvers, not just with health, but these, all these other.
co benefits, which I think is something really unique about these types of interventions and policies. And that piece was then accompanied by an action brief that really set out different recommendations for policy makers and practitioners to take action. So it covered things like what's the benefits, but also general considerations around planning and design.
It really emphasized involvement of the community and stakeholders. And also these lessons learned. So looking at these different case studies. across the world and what can different policy makers and practitioners learn from each other? And then more recently, they've had a really important piece published around assessing the value of green and blue spaces for health and being, not just a kind of monetary value, but also looking at these non monetary benefits in the kind of social, environmental, and climate realms as well.
And other important reports coming out around human health and biodiversity. And really trying to integrate climate, One Health, biodiversity and nature based solutions. So I think they're really trying to push things forward.
Thomas: Yeah. And those reports can be really powerful. The one in 2015, 16 I used that at the time I was, applying for a major flagship grant at the University of Wollongong with professor Xiaoqi Feng and I think nearly in the region of about 20 other staff members across all faculties and we were going for a big Co investment partnership grant with one of the major R and D organizations for the horticultural sector in Australia.
And we're basically saying this document from the WHO, from WHO, from World Health Organization, plus our local evidence really shows that. More green is good, but what we really need to now know is how much green space do we need in each and every neighborhood to give everyone a fighting chance of staying healthy and keeping outta hospital?
And that is exactly what we did over the next five years, and I have no doubt that it was partly due to us. They working really hard to get local evidence because without that you can't get local decision making made. But also with that recognition. from peak bodies around the world to say, this is really important for population health and improving health equity.
And we all need to invest in more research. So we keep on pushing the frontiers of knowledge and making progressive and effective policies that benefit everyone.
Heather: Thank you very much. I was going to shift the topic slightly now to ask, what are nature prescriptions and what do we know about their benefits?
Thomas: A nature prescription can take many forms, but I would say that it's often a verbal or written recommendation from an authoritative source, such as a general practitioner or a social worker or another health professional, which basically says, we recommend that it would be potentially good for you, for your health, to spend more time in a preferential setting.
natural setting, whichever you feel is comfortable and safe and inclusive and fun for you to be in. We can see that this idea has really taken off in many countries around the world, and it's not necessarily even a new idea. Back in 2013, The Park Rx was launched in the United States of America in the midst of the global pandemic, 2020, and my colleague, Dr.
Melissa Lem, spearheaded the launch of the P A R X program, which is national across Canada now and has over 10, 000 health professionals registered to it. To give nature prescriptions, we can see that this is also done on a more anecdotal basis in places like in Australia. And I think that also in the UK context, there's a big focus on nature as part of the social prescribing programs in the National Health Service, which I think maybe Ruth can maybe speak a little bit more about.
Ruth: Yeah, just to pick up on some of that. So you say, Thomas, in in the UK, they're known as social prescribing. And we're seeing a real shift away from what would have traditionally been prescriptions for gym programs. We're now seeing these prescriptions for people to spend time in nature, time outdoors, join walking groups.
And the Coldwater Community Greenway is a kind of popular venue where our GPs and local practitioners are prescribing patients to spend time outdoors and time in nature. And what we can see there, we can see improvements in mental being, improvements in quality of life, increase in physical activity levels.
But also other benefits, particularly around increased social interactions, for example. So again, I think this is another area where we're going to see more and more research in the future. And what
Heather: barriers are there to widespread implementation of nature prescriptions and how can those be overcome?
Thomas: This is actually a major focus of my new research program in Australia.
I'm leading the PANDA trial. This is the physical activity in nature for people with cardiometabolic diseases aged 45 and over. And we're recognizing that for a lot of people, there is a desire to get out into nature, but Or green and blue spaces more generally, but there are significant barriers along the way and we've touched them already in our conversation around physical access.
If there's difficulty getting across a major road from where one lives and the salubrious green surroundings just on the other side, that can be a big challenge, the physical barriers. For some people. Access in terms of getting into a car, which they do not own. So therefore that's rather tricky, but also getting onto public transport as well, which is not always available or frequent, or just coming at the time of day that people are actually able to get to those natural landscapes.
I'm thinking of people who do shift work, for example, and even if they could get to the natural space, it's not lit in the evenings, which would make it feel Because it's dark, it wouldn't necessarily feel a particularly safe place to be. So there are these access issues, of which there are many. We've also touched on heat.
In this neck of the woods, it can get very hot, especially in December, January, and February, which may make it even a short walk outside rather uncomfortable for a person. A lot of people. So that clearly has into play with the climate crisis here and, um, our the heat in our cities. But then there's another thing which I think is really important here, and that not everybody necessarily recognizes the health benefits that may come from getting into nature, and not every health professional necessarily sees this as a credible thing to be prescribing, either to the patient sat in front of them, whom they may only have maybe five, six minutes with, and they want to maximize their effectiveness in that encounter.
What we are going to do in the Panda trial is work with patient and consumer groups, work with health professionals, and also the folks who Their daily bread and butter is to enable and empower people to get out into nature, to customise and co design a nature prescription that we will go and then test with a randomised trial over the next few years.
The final cherry on the cake here really is that a lot of people may say, you know what, we need an app for this. And indeed there is an app for pretty much everything I see nowadays, but that may not always be a solution. And One of my PhD students, Gideon Merowitz Katz, over in Western Sydney, he found that after a couple of months, about 43 percent of users of apps for chronic disease management just stop using them for whatever reason, and then a large proportion of the remainder only use them maybe once or twice a year.
So clearly, investing in the great outdoors and investing in ways in which we can enable and empower people to have meaningful contact with those natural spaces is a big part of the solution. And the apps may also play a role, but we shouldn't rely entirely on those because clearly there's a stickiness issue that we haven't quite solved yet.
Lauren: Throughout this podcast, you've both mentioned some really important research that you and your colleagues are doing around urban green and blue spaces. But are there any limitations of current research and can these be overcome?
Ruth: I'm a director of the Groundswell Consortium. That's a five year research project in the UK, which is very specifically about green blue spaces, particularly for chronic disease prevention, but also around reducing inequalities.
And we've set out these kind of six different challenges that we're addressing in our research. So the first one is around research design. So as we mentioned before, a lot of the research that we have on green and blue spaces is particularly from cross sectional studies and to a much lesser extent from longitudinal observational studies and very sparse evidence really from intervention or natural experiment approaches.
We need to see more of these kind of natural experiment intervention studies. And I think we also need more research, particularly to help us better understand the ecological aspects of green and blue spaces. So particularly around biodiversity can benefit human health. The other challenge that we've talked about in this podcast is around diverse populations or marginalized groups and equity.
So we know, and we've seen this, the different segments of the population, particularly those from deprived and marginalized groups, have less access, fewer visits, and then these consequences for health and being. So we really need to understand more around what those barriers are and how we design and develop these spaces and programs that encourage those from marginalized groups.
to use these spaces and have those benefits. There's another around, particularly around measurement and data. Research is often really criticized for being slow and sometimes of little relevance to policy and practice. And I think there's things we can do here, particularly around using administrative data and also innovative ways to co develop approaches and methods involving our local communities.
particularly working alongside researchers, policy makers, practitioners, that helps us explore that real time, community rich data sources. I think there's other challenges we have around understanding some of the mechanisms, particularly around interventions and how they really work. And two final points around, one around blue space.
So we really need to accelerate our research on blue space. Many years behind, where the green space evidence base is. By its nature, blue space is unequally distributed. They're fairly fixed spaces, albeit we can enhance access through paths, provision of artificial ponds. But blue spaces do present some unique challenges, particularly in terms of equity and access.
And the last thing I think where we've had a limitation and a gap is particularly around economic assessment. So few of our intervention studies have actually assessed their value for money and most existing valuations fail to capture the health and social effects. We've done some work recently with our Cold War Community Greenway work looking at social return on investment and we see from that for every One pound investment, we expect to see between a four pounds and six pounds return on that investment.
So I think we need to really move beyond these kind of business cases and start thinking about developing social cases that take account for many of these non monetary benefits. And also climate impact, so things around tourism, job creation, productivity, biodiversity, house prices. So those where I see the kind of key limitations and where we can start to take some of those things forward.
Lauren: So I think we've quite comprehensively covered a lot of the areas that you think maybe future research could work on. For you personally, what would the priorities be for future research and for future action?
Ruth: We recently published a viewpoint in the Lancet Public Health that was really, spoke to this around how do we advance our green blue space research policy and practice.
So some of the. Key highlights and recommendations coming out from that piece where, you know, what we've just mentioned, that real need to move longitudinal studies, natural experiments, intervention based research, this focus on really understanding diverse population groups and communities, a real need to accelerate research that addresses environmental and health issues.
inequities. As I mentioned before, a focus on blue space. And as Thomas mentioned earlier, many of the areas are green and blue spaces. When we do our research, we tend to look at them through one lens or the other, but quite often they're integrated spaces. And I think we need to get better at addressing that and measuring and doing research with that lens and other things around really incorporating these principles of what we call things like co design, co implementation, co evaluation, and really co translation.
We can't do this on our own. We can't do this as just a set of researchers. We really need to be working with policymakers, practitioners, and local communities. And I think one of the other things that we touched on earlier, but it is worth emphasizing, is really how little we know about green blue spaces in low and middle income countries.
So we make some specific recommendations in that area around things like modification of data collection tools to facilitate low cost research in these types of contexts. Things about understanding unintended consequences and kind of potential negative effects of green blue spaces. Particularly things such as increased prevalence of asthma and pollen allergy.
vector borne diseases, social nuisances, for example, also better understanding of different moderating factors. So things like crime, inequalities, environmental pollution, litter, accumulation of human waste, and then also understanding the relationship between green blue spaces and health and particularly for mental health and also in terms of informal settlements and slums.
So I think there's a huge research area in low and middle income set and we really need to accelerate.
Thomas: My colleague over in the University of Uppsala, Professor Terry Hartig, has been a real stalwart, a driving force. for theoretical development in helping to explain why it is that contact with natural environments can be health promoting.
And there, there's still more work to be done in that regard. We, we often talk about attentional restoration theory, helping get people up off the mat after a very stressful day or stress reduction theory, literally keeping people away from sources of stress. And these are some of the very common now ways of understanding why contact with green and blue spaces are important.
But this is expanding to things like collective restoration theory, which Talks to the points that I've made around loneliness and green spaces as catalysts for bringing people together on shared ground, where people coming together for similar reasons, not for profit related reasons, but for things which enhance a sense of attachment and community and compassion and belonging and sensitivity to the fragile nature of the world around us, and then inspiration for pro environmental behavior.
Quite a lot of theoretical development to be made, and that will directly inform the testing of those theories through not only the standard skill set in the epidemiological toolkit, but also through those randomized trials and implementation science studies, which we've mentioned already. I want to mention And one of my PhD students, Dr Selene Akarachi, who I think is also in Ruth's team now doing postdoc, which is fabulous.
Another connection between us. Ruth and I also published a paper a few years ago on what makes green spaces great places to be physically active. And what Selene was able to show in her PhD was that on average across the world for all the studies that have been done, more green also tends to be greener.
Relate to a healthier birth weight, setting people up for a healthy life right from the very beginning. There are things therefore which perhaps aren't necessarily well researched or perhaps are but just aren't well known and are therefore reasons why we should try and increase investments in these spaces.
People may often think that green spaces are great to be physically active in Or to go for a picnic in, but the co benefits are so much wider across the whole life course than that. And I think, therefore, we need to do this. We need to be bold. We need to focus on big things like depression, diabetes, and dementia, but also be big in communicating that to the people who really have the car, their hand on the ignition to make real change on the ground.
for the population. That's B for bold. B also open. O for open to different ways of understanding the world around us and our interdependencies with the natural environment. I think there's a whole heap we can learn from various different cultures around the world. Ruth's already mentioned lower middle income countries in my neck of the woods as well.
Aboriginal and Torres Strait Islander groups with their very strong connectedness and reverence for the natural world. I think by working side by side, arm in arm, hand in hand with all communities, we're able to actually provide a more comprehensive understanding of these environments and not leave anyone behind.
Behind L lead, we need to lead more innovative research as basically following the roadmap, which Ruth and I have laid out. And many others will point out that there are other things that we can do to really push the boundaries of what it is that we know and therefore take into account that sure, more studies, which show more green is good, is Fantastic.
And add them to the pile, but that's to some extent, the easy approach. We need to focus on the D, the difficult, what is the new and expanding and emerging horizons for us to really tackle? Loneliness is a big problem without any clear, sustainable, effective, equitable solutions. And that's one, which I am certainly suiting up for the next decade to try and solve.
through nature based solutions. And I welcome any of the listeners to this podcast to get in contact and join me so we can do some research together.
Heather: Thank you both very much for your time today. That's been absolutely fascinating. And thank you for listening to this Lancet Spotlight podcast on climate change and health.
Gavin: Thanks so much for joining us for this episode of the Lancet voice. This podcast will be marking the Lancet's 200th anniversary throughout 2023 by focusing on the spotlights with lots of different guest hosts from across the Lancet group. Remember to subscribe if you haven't already and we'll see you back here soon.
Thanks so much for listening.