Question:
How do natural Spaces sustain the health and wellbeing of elderly Australians?
Australia has been regarded as one of the country with increased number of ageing population. Presence of large number of older people means that adverse health condition and associated disability will increase. This will eventually put extra pressure on the health care system and increase the overall health cost and expenditure (Prince et al. 2015). Apart from transforming the current workforce and health care system, there is also a need for providing a safe environment to people. It has been recognized that chronic health conditions like diabetes and heart disease are the consequence of poor lifestyle and little physical activity (Kyu et al. 2016). In an effort to promote health and well-being of the elderly population, green/ natural space has been gaining attention of the government. However, the main concern is that it is not understood how far green space can be regarded as reliable source to improve and sustain health of elderly people. As there is lack of knowledge regarding the benefits of green space in reducing illness and suffering in people, the main purpose of this literature review is to gain greater insight regarding benefits of green space.
To advocate for the widespread introduction of green/natural space for Australians, this literature review firstly explores the research question of ‘How do natural/green spaces sustain or improve health and well-being of elderly Australian?’. The main purpose of investigating this research question is to address the following objectives in literature review-
The main focus of this literature review is to address the issue related to ageing population by providing such community environment that supports physical activity and social well-being. In this sense, green space or natural space around people has been regarded as a positive stimulant to promote health and well-being. But, there is doubt regarding how far green space can reduce overall health care burden and cost associated with illness in ageing population. (Pleson et al., 2014) is of the view that ageing restricts people to limited space due to changing social and economic roles. On the contrary, if natural space is provided to people from young age, it will allow them to engage in physical activity, live independently, reduce risk of social isolation and facilitate a sense of equity, dignity, empowerment and participation too. On the whole, green space has been regarded as a factor that promotes social engagement physical activity and relaxation. To analyze how far green space can be safe for health and well-being of elderly population, peer-review journals and other research work will be analyzed.
Research methods and Search strategy:
To gain insight into the research question of role of green space on sustaining health and well-being of ageing Australians, a comprehensive and systematic literature review was conducted. As the aim was to get enough evidence related to the topic study, databases like CINAHL, Global Health, Medline, PubMed and Cochrane library was searched. These database were searched to gain access to grey literature, peer reviewed journals, e-journals, periodic journals and other reports. The above mentioned databases guarantees credibility of information and coverage of wide range of perspective to analyze any topic. There are more chances to get relevant papers and excellent health related information.
The key search term for finding articles to address the research question was ‘Green space and elderly health’, ‘impact of green space on health and well-being of elderly Australians’, ‘Advantage of green space for mental health’, ‘benefits of green space in promoting social inclusion’ and many other terms. If no results were obtained by entering key research term, smart text searching was also done. In some case, keywords were modified also to obtain relevant articles.
Two stages of eligibility screening was done for the literature review. Firstly, abstract of the article was reviewed for inclusion into the study. Secondly, all the inclusion criteria was independently reviewed in the full text of the selected articles. After being checked for inclusion criteria, the reference list was also checked to get access multi-dimensional benefits of green space for ageing population. The following figure is the result of search strategy:
Figure 1: Results of the literature search
The key inclusion criteria for the systematic review include:
The exclusion criteria for searching research article included:
After the final selection of 18 articles, all the articles were analyzed by means of an evidence based research tool called CASP (Critical Appraisal Skills Programme) tool. This tool was selected because it is an evidence based tool that easily evaluate quality of different research articles like qualitative study, systematic review or cohort studies (Nadelson et al., 2014). The CASP tool had 10 questions to judge the quality of the research work. If any article met all the 10 criteria, it was given a five star grade. The grading of the article was done by evaluating by CASP tool. The three grading term was high quality evidence, intermediate quality evidence and low quality evidence. If the articles met 1-4 criteria of CASP tool, it was low quality evidence. When an article met 5-7 criteria of the CASP tool, it was regarded as moderated piece of evidence. A high quality paper was done that met 8-10 criteria specified in the CASP tool. The following are the list of questions on the basis of which each article was evaluated:
Figure 2: CASP tool review questions
After evaluating the quality of each article by means of the CASP tool, all the articles were synthesized into different themes after review of the whole literature. On this basis, the findings of the literature review was classified into different themes. The final theme came after the literature review process as well as the brainstorming process. All the themes were reported according to narrative style.
Study design and quality scores:
Table 1: Grade and quality of papers
|
Serial No. |
Author |
Type of study |
Type of CASP tool used |
Quality of article |
|
1 |
Reklaitiene et al. (2014) |
Cross-sectional study of population based sample |
Qualitative |
High |
|
2 |
Van den Berg et al. (2010) |
Quantitative |
No (Manual) |
Poor |
|
3 |
Maas et al. (2008) |
Quantitative |
No |
Poor |
|
4 |
Thompson Coon et al. (2011) |
Systematic review |
Yes |
Moderate |
|
5 |
Astell-Burt, T., Feng, X. and Kolt, G.S., 2013. |
Quantitative |
no |
High |
|
6 |
Nielsen and Hansen, (2007) |
Quantitative |
no |
Moderate |
|
7 |
Gong et al. (2014 |
Cohort based study |
Yes |
High |
|
8 |
Tamosiunas et al. (2014) |
Cohort study |
Yes |
High |
|
9 |
Parkinson et al. (2011) |
Mixed method |
Yes |
Moderate |
|
10 |
Wang and MacMillan, (2013) |
Systematic review |
Yes |
Poor |
|
11 |
Detweiler et al. (2012) |
Literature review |
No |
Moderate |
|
12 |
Park et al. (2009) |
Quantitative |
No |
Moderate |
|
13 |
Chen and Janke (2012) |
Qualitative |
No |
High |
|
14 |
Währborg et al. (2014) |
Cohort study |
Yes |
Moderate |
|
15 |
Hawkins et al. (2011) |
Cross sectional qualitative study |
Yes |
High |
|
16 |
(Pretty et al. 2007) |
Qualitative |
Yes |
Moderate |
|
17 |
Lee and Maheswaran (2011) |
Review |
Yes |
High |
|
18 |
Wolch et al. (2014) |
Review paper |
No |
High |
Table 2: Critical appraisal of articles by use of CASP tool for qualitative research:
|
Author and year |
Clear statement of the aim of research |
Appropriateness of methodology |
Research design aligned to aim of research |
Recruitment strategy |
Data collection to address research issue |
Consideration of relation between researcher and participants |
Consideration of ethical issues |
Data analysis sufficient |
Clear statement of findings |
Value of research |
|
Reklaitiene et al. (2014) |
Yes |
Yes |
Yes, to some extent |
Yes |
yes |
No |
Yes |
Yes |
Yes |
High |
|
Parkinson et al. (2011) |
Yes |
Yes |
Yes |
yes |
Yes |
No |
Yes |
No |
Yes |
Moderate |
|
Hawkins et al. (2011) |
Yes |
Yes |
yes |
yes |
yes |
yes |
yes |
No |
Yes |
High |
|
(Pretty et al. 2007) |
yes |
Yes |
yes |
no |
Yes |
no |
yes |
yes |
no |
yes |
Table 3: Critical appraisal of articles by use of CASP tool for systematic review:
|
Author and title |
Clear focused question addressed |
Analysis of right papers |
Important studies included |
Assessment of quality |
Results of the review combined |
Application to local population |
Consideration of important outcomes |
Benefits worth the harm and cost |
|
Thompson Coon et al. (2011) |
Yes |
Yes (Randomized and non-randomized study included) |
Yes |
Yes |
No |
No |
Little |
Moderate |
|
Wang and MacMillan, (2013) |
Yes |
No |
No |
Yes |
No |
NO |
Yes |
Poor |
|
Lee and Maheswaran (2011) |
Yes |
Yes |
Yes |
Yes |
no |
yes |
Yes |
High |
|
Author and Date |
Clear focused issue |
Cohort recruitment in appropriate way |
Exposure measured to minimum biasness |
Identification of all confounding factors |
Complete follow up |
Belief in result |
Application to local population |
Suitability with other evidence |
|
Gong et al. (2014 |
Yes |
No |
Yes |
No |
yes |
yes |
yes |
Yes |
|
Tamosiunas et al. (2014) |
Yes |
Yes |
Yes |
No |
Yes |
Yes |
Yes |
No |
|
Währborg et al. (2014) |
Yes |
yes |
No |
Yes |
No |
Yes |
Yes |
Yes |
Positive assciation between green space and health:
The most common theme from review of literature is that green space and health had a positive relation. This was demonstrated by 4-5 publications. The subthemes arising under these themes are:
Green space has positive association with general health:
Reklaitiene et al. (2014) examined the relation between green space, general health and depressive symptoms. This study was includes as the sample population in this group consisted of men and women between the age of 45-72 years. The cross sectional study used self-reported questionnaires to assess the proximity to green space, use of green space per week, presence of depressive symptoms and general health. The result of the study showed that prevalence of depressive symptoms was higher in women and those who used the park (green space) less than 4 hours a week. This finding indicates that green space improves mental health of individual and this is also in concurrence with the study by Irvine et al. (2013) which proved that green space relieves stress and improves mental well-being. It can be said that greater the proximity of green space, greater is the determinant of health and well-being in a population. The study by Reklaitiene et al. (2014) provides ample evidence that if green space is used appropriately, it would play a great role in improving health of the population.
Green space moderates stressful life events and health:
Through a national level survey data, Van den Berg et al. (2010) evaluated the role of green space in reducing stressful live events and improving health. The health status of participants were evaluated by means of number of health complaints within two weeks, perceived mental health and perceived general health. The research hypothesis was that likelihood of experiencing extreme life events related to physical and mental health is low if people have access to more green space in their surroundings. The researcher further stressed that positive effects of green space will be stronger if it is located within 3 km radius than 1 km radius. The findings of the research proved the research hypothesis and people having access to green space within 3km radius of their home were found to have little stressful life events as well as health complaints. However, this study did not give any insight into the how coping strategies of individuals affects individuals with crisis to use green space. Hence, the health impact of green space in this study was not of great clinical significance. This may be explained by the vagueness in the extent which people are affected by stressful life events.
Mental health benefits of green space
Although many studies report about the role of green space on mental health, Astell-Burt et al. (2013) tried to identify the association between green space and psychological distress. In this study, middle to old age Australians above 45 years of age were taken and their physical activity was measured through a survey. One unique factor of this study was that green space within 1 km of residence was taken. The survey enquired about the symptoms of psychological distress over the four week and number of times particular physical activity was done last week. The researcher also measured social interaction of participants to see the presence of mental health. The finding of the research showed that all the variable such as physical activity, psychological distress, social interaction and fall experience has relation with level of green space. The greater the green space, the lesser was physical inactivity and psychological distress symptoms among people. On the whole, this literature encourages other studies that favors green space for mental health and well-being. Mytton et al. (2012) has emphasized that physical activity among people living in greener areas automatically increases as they engage in maintenance and gardening work. Garden itself is found to have therapeutic effect. Going by the findings of this study, the main action that would be required in the future is that Australian Government will have to engage in green space planning and investment in resources so that maximum green space is available to all members of the community.
Relation between green space and obesity
Previous studies mentioned above evaluated green space on health on the basis of proximity to resident and more area of green space. Nielsen and Hansen, (2007) gave the indication regarding the relation between green areas and obesity and stress. It was based on the assumption that access and use of green space is dependent on distance to green area, characteristics of neighbor and conduciveness to outdoor activities. The participants of the study included Danish people between the age of 18-80 years. The questionnaire based study inquired about the type of physical activity, frequency of visits, health indicators and preference towards green space in participants. The distance of green space from home and type of recreational areas was also part of the questionnaire. Obesity was evaluated by assessing whether participants were above or below threshold BMI. The result of the study showed that access to green space is associated with less stress. Obesity was dependent on pedestrian environment factors and characteristics of neighbourhood. The level of physical activity by this factor finally decided the likelihood of obesity. One limitation of this study is that lifestyle variable is also a factor contributing to obesity. However, this was ignored in this study, hence future studies must evaluate lifestyle factors to evaluate the true effect of greenery on physical activity and obesity. Exploitation of the beneficial effects of green space is at a larger level is needed to adequately plan health care reform and public health policies.
Due the burden associated with managing health of elderly population, analyzing the impact of green space and physical activity on health was necessary. Maas et al. (2008) investigated whether physical activity is dependent on the relation between green space and self-perceived health. The first important consideration for this study was to evaluate whether amount of green space around a person affects physical activity and then it was evaluated if green space and physical activity promotes health. The interview with Dutch participants revealed that there is no relation between amount of green space and physical activity. This eventually meant that relationship between green space and health could not be confirmed. This finding challenges the strategy to introduce more green space for Australia’s ageing population. This result might be further reviewed by analyzing density of sports facility on physical activity.
Another study gave insight into the benefits of physical activity in outdoor natural space on health and well-being. The systematic review done by Thompson Coon et al. (2011) compared the effect of mental and physical being on physical activity outdoor and indoor. It includes many randomized and non-randomized trials done with young students. They were engaged in walking and running activity outdoors and indoors. It assessed the effect of exercise on mental well-being and attitude towards exercise. The overall analysis of different research study showed that the results are in favour of the positive effects of outdoor activity in the natural environment compared to the outdoor environment. Engaging in exercise and physical activity in natural space increased feelings of revitalization, social inclusion and decreased anger and depression. If students actively engage in outdoor physical activity, they were found to get more enjoyment and satisfaction. The significance of this research study is that it gives insight into the positive effects of natural environment on mental well-being of people. However, there were very few high quality evidence to prove the positive effects of green space on mental and physical health. Large and well-designed long term study is needed to fully evaluate the positive effects of natural space on health.
As the ageing population is a major public health burden. To make plans for improving health of elderly people, the study by Gong et al. (2014) tried to evaluate the role of green space on level of physical activity particularly in elderly men with different lower extremity physical function. The quantity of green space was evaluated by aerial photography and men above the age of 66 years were include in the study. This study is considered important because past studies did not focused on limitations in elderly particularly in terms of mobility. It was done mainly on physical health, mental health and obesity. Hence, this study contributes to real interpretation of green space in elderly people with different physical functions. The main purpose of investigation was whether walkable neighbourhood increase physical activity among elderly people with poor physical function. The lower extremity physical function was assessed by means of nine-item questionnaire. Participants were regarded as active in participating in physical activity if they did gardening, or visited the coast, parks or did physical exercise at least 3 times a week. The result of the study showed that higher amount of green space was associated with increased frequency of participation in physical activity regardless of lower extremity physical function. However, regular physical activity was higher for those who has good lower extremity physical function compared to those who had poor lower extremity physical function. The main implication of this study is that active ageing can be facilitated in elderly people with limited physical function if they have access to greener environment. Hence, this study gives the direction for future action, which is to increase the provisions of green space by green space policy that preserve green space in residential area. One limitation is that three activities were treated equally and not differentiated on the basis of high or low intensity. Hence, in the future novel interventions and policy making related to green space is needed to support active ageing and health of elderly Australians.
Cardiovascular disease (CVD) is also the leading cause of mobility and mortality in western countries. To enhance the health and well-being of the elderly population, green space is also regarded as a healing factor apart from lifestyle related changes. The above mentioned evidence provides ample evidence regarding the psychologically and physiologically restorative effects of contact with natural environment. As Lithuania is a region with high mortality rates, Tamosiunas et al. (2014) explored the effect of green space on incidence of CVD in middle age to elderly population between the age of 45-72 years through a baseline survey. The survey questionnaire mainly included age of participants, education, smoking status, use of green space, time spent in parks per week, self-rated health and quality of life. Unlike the study by Gong et al. (2014), Tamosiunas et al. (2014) categorize physical activity levels on the basis of number of hours per week. The result shows that rate of hypertension, obesity and hypercholesterolemia was high among participants and prevalence of CVD was not related to use of green space. Hence, the association between access to green space and cardiovascular risk factor was absent, but some association between use of green space and cardiovascular risk factor. Therefore, this study had little clinical significance and this may be explained by different socioeconomic position of participants. Further studies are needed to identify full benefits of green space for cardiovascular health. More attention to the density of population, transportation infrastructure and land use is need to promote good health of the community.
Large number of literature support the effectiveness of horticulture in mental health setting. Parkinson et al. (2011) tried to evaluate the elements of the horticulture projects that provided the maximum therapeutic benefit to client. The therapeutic benefits were evaluated on the basis of following factor:
Figure 2: Parameters on the basis of which therapeutic benefits of horticulture were analysed (Parkinson et al. 2011)
Client between the age of 18-65 years participated in the horticulture project. Many of them regarded gardening as a meaningful activity that promoted mental health. It also increased feelings of social inclusiveness among participants. Hence, horticulture was found to have intrinsic benefits where individuals got the chance of engaging in physical activity and enhancing sensory experience. However, involvement in such activity dependent on gender and personal factor of participants.
As older population continues to increase, there is a need to adopt strategies to promote wellness of students. As gardening is regarded as a therapeutic activity, Wang and MacMillan, (2013) conducted a systematic review to determine the benefits of gardening for community dwelling and institutionalized older adults. Different studies showed participants engaged in different types of gardening activities like planting herbs, seeding, cutting and rooting herbs, sowing seeds and watering plants. Majority of studies showed that gardening enhances the overall quality of life, activeness and physical activity levels of older adults. Older adults who lived in community were found to have greater overall health and well-being. It enhances their physical functioning, improved body flexibility and decreased bodily pain. The motivation behind gardening was the past family experience and love of nature. It increased levels of social connectedness too. The evidence however lacks generalizability and more research is needed with different population size.
Past studies have proved the beneficial effect of horticulture therapy and gardening on reducing pain, reducing stress, lowering need for medications and antipsychotics and falls. However, there is lack of studies with therapeutic gardens and rehabilitation greenhouses. Very few controlled trial used garden setting as rehabilitation for elderly people. Therefore, the study by Detweiler et al. (2012) evaluated the effects of natural setting for care of older adults having mental and physical health problems. Horticulture therapy has been found to reduce stress, increase concentration and improve cognition in dementia patients. In case of elderly people, dementia is regarded as a high risk factor for fall. The risk of fall also increased due to the side effect of medications and use of antipsychotics and antidepressant to control behavioral problems in dementia patient. It was found that that those who engaged in gardening did not had to use high dose of antipsychotics, but it did not reduced the use of primary antidepressant and anxiolytics. The limitation of the study is that quantitative analysis of gardening benefits for elderly has not been analysed yet. There is need for extensive study of gardening on ageing population.
The study by Park et al. (2009) is an important literature as it evaluated the physical and psychological health of older gardeners and non-gardeners. Gardening has been found to improve physical and psychological heath by reducing cholesterol level, blood pressure and improving social integration in people. The study was done with older adults living in Manhattan aged between 58 to 86 years. The survey included demographic questionnaire and health assessment and measurement of leisure time activities of older adults. The study findings revealed that gardening activity explained difference in health outcome of participants. Older gardeners were found to have high hand functions. Those who engaged in physical activity more than 5 days a week were found to have good physical function and reduced bodily pain. Despite this finding, the generalisability of the result is low because it was done only 52 subjects. More extensive research is needed with larger sample size.
As this literature review is aimed to find the benefits of green space on improving health of elderly, it is necessary to analye its effects on reducing galls too. This is because risk of fall in older adults is a major public health concern. The likelihood of fatal and non-fatal falls among adults above 65 years age place great burden on the health care system. As poor gait, balance and functional limitations increase the risk of fall, Ambrose et al. (2013) affirms that exercise and physical activity might help reduce the incidence of falls. Gardening is regarded as a preferred moderate level exercise for older adults. Gardening activities increased health benefits because it requires a person to use their motor skills and muscle coordinaton skills. As majority of studies have studies about the effect of gardening on mental health and social health, there is lack of study examining the relation between gardening and physical health. Chen and Janke (2012) examined whether gardening activities improved physical health and reduced risk of fall and performance related to balance and gait speed in elderly people or not. Firstly, level of gait, functional limitations and gardening was assessed in elderly participant. The result of the study showed that there was no relationship between gardening and educational attainments, however gardeners were mostly younger than non-gardeners. Gardening was also found to decrease the risk of fall. Gardening indirectly reduced fall risk due to its relations with fall risk factors of gait, balance, chronic disease and functional limitations.
The study by Chen and Janke (2012) is important for this review for several reasons. Firstly, this was the first study that investigated about the link between gardening and falls in elderly. People who engaged in gardening were found to have better health status and physical functions. Though gardening did not reduced the incidence of falls, however it was found to influence the fall risk in adults. Another advantage of using gardening as a therapeutic intervention for participants was that unlike other interventions, it can be tailored according to people’s need. People who have physical disabilitys and poor gait can start with easier task and proceed to harder task once they are more competent with simpler task. This can ultimately improve physical challenges in older adults and improve their health and functioning. Despite the strength, the study has some limitations too. Firstly, type of gardening activities is not specified by the researcher. Secondly, effect of gardening on dynamic balance was also not evaluated.
Depression is also a common issue for older adults because of poor physical health and social inclusion in life. Neuropsychiatric disorder is a global disease burden and to solve the problem among students, Währborg et al. (2014) evaluated the effect of nature related rehabilitation program in patients with mild to moderate depression. A retrospective cohort study was done with 118 participants and they were part of interventional rehabilitation programme consisting of specially designed rehabilitation garden. After this intervention program, the main change that was seen was that no reduction of sickness benefit was seen in participants. However, one positive result of this study was that for people who took part in the program, the health care consumption rate reduced after a year. This was seen both for primary health care and number of days spent in psychiatric health care. This indicated favorable improvement in general health of participants. In terms of assessing long term benefits, low health care consumption would translate to decreased cost of primary health care. Gardening can also increase the ability of people to cope with long term illness. However, some limitation of this program is that it was a newly developed program and this might have an impact on result. More studies is needed to overcome this limitation.
Another literature is of considerable importance for this literature review as it explains how gardening relieves people from stress and facilitates healthy ageing. The study by Hawkins et al. (2011) explored the benefits of allotment gardening in 94 participants aged between 50 and 88 years. They were divided into four groups who engaged in different activities like allotment gardening, home gardening, outdoor activities and indoor exercise groups. All these activities provide varying level of engagement with nature. The physiological health of participants was measured and questionnaire collected demographic details. The result of the study showed that there was significant difference in perceived stress level between allotment gardeners and indoor activity group. However, one negative point was that no benefit in social support was seen for gardening activities. Participating in gardening activities might help to overcome this limitation. Hence, the study by Hawkins et al. (2011) supports the fact that green spaces like gardening provide ideal opportunity for psychological restoration and stress reduction. This study reported difference in stress level of different groups but the mechanism behind this was not explained. So, future studies need to investigate these mechanisms. Different components of gardening can be used as health promoting activity to empower older adults and facilitate healthy ageing.
Government of developed countries plays a major role in making cities green. Urban green space eventually promotes physical activity and public health. As cities are getting more populated and congested, green space might help to improve lives of city dwellers. Green space has always been favoured for public health because green space improves health, removes pollution, filters air and cools the temperature. However, one of the greatest problem in cities is that green space is not equitably distributed. The study by Wolch et al. (2014) review Anglo-American literature to explain how US and Chinese governments put efforts to go green. For example, in Hangzhou, the most polluted city of China, the government has tried to restore lost green space by demolition of factories for more parks and engaging in mass tree planting along the streets of the city. Now, the city is known for its tree-lined streets. However, still the city may face environmental justice issues because older areas stills lacks green space. Therefore, this study indicated that being just green enough is not the solution to the problem. It demands careful balancing act and active involvement of urban planners and ecologist to advance public health and promote social justice in community.
Every year, the Government’s expenditure on health care increases due to great demand of mental health care. Mood disorders and stress is common among middle age to old age people. Considering the benefit of green space on promoting physical and psychological health of people, Pretty et al. (2007) measured the effect of different green exercise like fishing, boating, woodland activities, walking, conservation, cycling and fishing on participants aged between 13-84 years. The quantification of the data revealed that green exercise had an impact on mental health of participants and self-esteem score improved for the study group. The mood factors of anger, confusion, depression and tension improved after the activities. This is a significant results which indicates that any type of green exercise is associated with associated with mental health benefits. Despite this findings, the generalizability of the study is difficult because the study was done with participants who were already healthy and active and inactive people were not include in the study. However, the study gave many implications for policy making such as planning green space and its exposure for population groups.
The main limitations seen in most literature was that there was lack of planning regarding appropriate green space. As the main purpose of this literature review is to analyze the true benefits of green space for health and well-being, it is necessary to have an evidence based approach to urban development planning. As there is lack of evidence regarding the physical and non-physical health benefits of urban green space, Lee and Maheswaran (2011) investigated about the health benefits of green space by literature search of academic and grey literatures. One mechanism by which green space influence physical health was that green space promoted physical activity levels. However, there is lack of strong evidence for the link between physical activity and green space availability. Environmental determinants like accessibility, quality and availability of space influence use of green space as leisure time physical activity. On the other hand, physical activity determinants in green space included age, gender, disability, psychological factors like motivation, attitude towards physical activities and safety. Although this study gave ample evidence regarding the benefits of green space for health, however there is a need to study causal relationship between green space and health.
This literature review was an in-depth exploration of research articles and grey literatures related to role of green space in improving health of elderly people. The main area of attention for this study was exclusively green space and older adults. This is because Australia is struggling with the burden of health issues in ageing population and greater clarifications regarding the availability of green space for promoting health and well-being might directs Government’s actions towards green space planning and implementation. The main strength of this review is that it evaluated both the quality as well as the content of the paper. The utilization of the CASP tool helped to explore the quality of the paper whereas the thematic analysis helped to get answer to the research question. Out of the 18 research articles, 8 articles gave solid evidence regarding the positive benefits of green space for health and well-being [(Reklaitiene et al. (2014), Astell-Burt et al. (2013), Gong et al. (2014), Tamosiunas et al. (2014) , Chen and Janke (2012), Hawkins et al. (2011), Wolch et al. (2014) and Lee and Maheswaran (2011)}].
For instance, one of the important contribution of Reklaitiene et al. (2014) was that it gave the indication that to improve the health of the population, appropriate use of green space is important. The study explained that more green space will contribute to better health and well-being. It also promoted the idea that green space needs to be near to home to ensure better usage. This point needs to be noted for policy planning and government’s action too. Study by Astell-Burt et al. (2013) was also a useful piece of literature as it studies the role of green space located within 1 km of the health of participants. Critical review of the findings of this study might help to invest in preventive health policy and promoting green space for all. While we were proceeding with the literature review, one literature was overcoming the limitations of previous literature. For instance, research by Astell-Burt et al. (2013) did no considered the benefits of green space for elder people who had poor lower extremity functioning and mobility problems. This limitation was addressed by Gong et al. (2014) who included this population group in the study and this study also indicated that physical activity can be increased only for those with good lower extremity function. The researcher also explained the mechanism behind the role of green space in encouraging physical activity among elderly people. This was explained by the fact that green space provided the opportunity walk and exercise in a greener environment. A well-characterized cohort was used in this study that truly answered the research question in relation to health of ageing population.
Considering the limitations of this review, time spent on reviewing the articles was short. More time would have lead to in-depth exploration of study. The number of moderate to week quality of articles was higher than high quality evidence. Secondly, all articles could not be evaluated by CASP tool because some were mixed method study or general published articles. Hence, those studies were evaluated on the basis of relatedness with research question and any biasness in the study. The determination of the causal mechanism of green space for health benefits was also a complex process and this was rarely identified in research articles. Although some literature barely discussed about providing green space to people with poor socioeconomic groups, however there is lack of information regarding ways to motivated people from poor socioeconomic group to use green space. There was also lack of studies, which could specify a universal standard that could be followed to characterize green space and facilitate optimal use of that green space. Therefore, the overall conclusion is that promoting healthy ageing through green space cannot be successful without meticulous planning process. Health planners need to address motivating factors as well as confounding factors to turn green space into a remedy for healthy living.
Conclusion:
Considering the rise in ageing population in Australia and increased burden for the health care system, the main objective of this literature review was to evaluate whether green space can sustain health and well-being for elderly population. This analysis was considered importance because this could remove mental health isssues in people and reduce the need for dependency on medicines. Many literature refer to the therapeutic effect of horticulture for a long time. Chen and Ji, (2015) showed that it can be useful particularly for vulnerable group suffering from health related problems, psychological difficulties and physical disabilities. However, its true benefit for the healthy aging has not been evaluated. Hence, this literature review sought to review the holistic benefit of green space for health and well-being of elderly population and analyze the impact of green space in all dimensions such as physical health, mental health, social well-being and economic benefits for Government. The critical appraisal of articles through CASP tool and the thematic analysis after taking final 18 articles for the review gave rise to five themes. This included positive association between green space and health, promotion of physical activity through green space use, use of green space for cardiovascular health and benefits of horticulture for health and well-being and benefits of green space for Government.
From the literature review, many useful insights into the role of green space for improving health and being has been found. For instance, while talking of high quality evidence, Reklaitiene et al. (2014) gave the idea that proximity of green space is a major determinant of health and well-being. Astell-Burt et al. (2013) contributed to the research question by stating that physical activity, stress level and social interactions can be enhanced by area of green space. Majority of studies gave the insight that allocation of more resource is needed to build more green space in community and encourage more people to spend time in green exercise. The study by Gong et al. (2014) was a siginificant study as it particularly focused on impact of green space with people having mobility problems. The only limitation in this study was that the researcher regarded all activities done by participants equally which might not be true. Tamosiunas et al. (2014) mitigated this limitation by focusing on physical activity levels done in number of hours per week. It evaluated green space particularly for cardiovascular health and found association of cardiovascular risk factors with green space. This literature review also gave rise to one very important piece of research that focused on comparing allotment gardening and home gardening for stress reduction and healthy ageing. It gave the indication that allotment gardening is most effective than home gardening in reducing stress and promoting health (Hawkins et al. 2011)
Apart from high quality evidence, there were also many articles which had limitations in terms of research design and planning of physical activity for participants. Although green space cannot totally replace health care burden, however it can play an important role in reducing health care cost and promoting health aging among people. From the analysis of different literatures, the main benefits of garden that can be extracted particularly for the elderly people are as follows:
The literature review gave the indication that green space is of immense benefits for health. However, to fully utilize them for the benefit of public and promoting health of elderly population is dependent on careful planning and implantation process. Before the Government sets out to achieve this, they need to first identify the barriers that prevents people from participating in activities in local parts nearby. Physical constraints for participants might include distance of the green space from home, presence of obstacle between green space and physical disability in older adults (Pretty et al. 2007). Lee and Maheswaran (2011) also mentioned about barriers such as presence of heavily trafficked road, lack of pedestrian croosing and poor quality of payments between home and green space. On the contrary, the social and cultural factors that prevent people from going to park include fear of crime and lack of motivation to engage in physical activity (Pretty et al. 2007). Despite these barriers, Governments need to prioritize healthy ageing particularly in the following areas:
As many people do not use green space because they do not have proper access to it, the policy makers and sectors like health, social and mental health service and sports and leisure industry needs to sit together and plan together. Lack of physical activity and prevalence of obesity increases the cost of public health (Malik et al. 2013). Hence, innovative solution is needed to address to increase access to green exercise activities and provide economic and public health benefits to Australian population.
To increase Government’s actions towards introducing more green space, there is need for identify the range of benefits of introducing green space in the community. Different types of benefits of green space for the community are as follows:
Environment benefits- Urban green space modifies extreme climate condition by modifying temperatures, improving the quality of air and has a positive impact on the hydrological cycle.
Social benefits- Australia spend lot of money on health and other activities. Planning more green space will be important to improve physical and mental health of public. Participation in recreational activities outdoor promote social inclusion as well as health and well-being. Investigation of the nature and characteristics of parks that can enhance health might help to prevent physical and psychological health need. Green space is particularly beneficial for child development, preventing obesity and physical activity. Green space also promote social equality by providing recreational opportunities to low income groups too (Fam et al., 2008).
Economic benefits- The economic implications of having more green space is that economic activity related to green space increase. Green space also increased property value because a land located near parks and greenery are preferred by most people (Fam et al., 2008).
After the realization of the above mentioned benefits of green space for health and well-being, the main action would be to analyze the characteristics of green space that would encourage more and more people to engage in activity in natural environment (Astell-Burt et al. 2013). However, the benefits will be more for people who are physically active and do not have mobility related issues. Hence. while planning green areas, it will be necessary to engage to includes those characteristics in garden or parks that facilitate physical activity for older adults. Secondly, health promotional acttivoties is also needed to motivate people to visit parks and engage in some form of activities at the park (Gong et al. 2014). For this, large scale promotional activities will be needed to make people understand the benefit of green space for mental well-being and motivating them to use green space regularly. Inclusion of eco-therapeutic approaches in health promotion will help Government to achieve both individual health as well as public health and environmental outcomes. Stewardship of green spaces will help in fulfillment of the dimension of social value in well-being and recovery from ill health and social exclusion. The following steps can be adapted by government to encourage more use of green space:
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