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Prior reviews have highlighted that nature exposure was a valuable coping strategy enhancing mental health during the COVID-19 pandemic. However, no existing reviews have determined the quality of evidence and risk of bias of the empirical studies supporting this claim. To address this gap, we employed a Navigation Guide systematic review and meta-analysis approach to investigate associations between nature exposure and mental health during the pandemic. Searches in PubMed, Web of Science, Scopus, CINAHL, and PsycInfo retrieved relevant articles published between January 1, 2020, and March 4, 2024. We used the Navigation Guide methodology to assess the risk of bias and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) assessments to evaluate the overall quality of evidence. Our search retrieved 113 studies that met the inclusion criteria and reported diverse types of exposure, including nature availability, nature visit frequency, green space accessibility, and green space type, alongside associations with 12 mental health outcomes. Meta-analyses found access to gardens was associated with lower odds of depression [(Pooled odds ratio [OR] = 0.71, 95%CI = 0.61, 0.82), I 2  = 0%, n = 3] and anxiety [(Pooled OR = 0.73, 95%CI = 0.63, 0.84), I 2  = 0%, n = 3]. Increased time in green spaces was associated with lower level of stress [(Pooled Corr = -0.11, 95%CI = -0.17, -0.05), I 2  = 0%, n = 2]. Higher frequency of visits to nature was associated with improved mental well-being [(Pooled standardized beta = 0.10, 95%CI = 0.07, 0.14), I 2  = 0%, n = 2] and general mental health [(Pooled standardized beta = 0.11, 95%CI = 0.03-0.38), I 2  = 82%, n = 2]. However, the number of pooled studies was small and the overall quality of evidence was "very low" for all outcomes, and high levels of bias were observed (26% of studies had high, 71% probably high). Nonetheless, given the trends in the results, nature-based solutions emphasizing exposure to gardens and green spaces near the home may have promoted psychological resilience during this public health crisis., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Introduction: The COVID-19 pandemic has had a significant impact on mental health globally, with limited access to mental health care affecting low- and middle-income countries (LMICs) the most. In response, alternative strategies to support mental health have been necessary, with access to green spaces being a potential solution. While studies have highlighted the role of green spaces in promoting mental health during pandemic lockdowns, few studies have focused on the role of green spaces in mental health recovery after lockdowns. This study investigated changes in green space access and associations with mental health recovery in Bangladesh and Egypt across the pandemic., Methods: An online survey was conducted between January and April 2021 after the first lockdown was lifted in Bangladesh (n = 556) and Egypt (n = 660). We evaluated indoor and outdoor greenery, including the number of household plants, window views, and duration of outdoor visits. The quantity of greenness was estimated using the normalized difference vegetation index (NDVI). This index was estimated using satellite images with a resolution of 10x10m during the survey period (January-April 2021) with Sentinel-2 satellite in the Google Earth Engine platform. We calculated averages within 250m, 300m, 500m and 1000m buffers of the survey check-in locations using ArcGIS 10.3. Multiple linear regression models were used to evaluate relationships between changes in natural exposure and changes in mental health., Results: The results showed that mental health improved in both countries after the lockdown period. People in both countries increased their time spent outdoors in green spaces after the lockdown period, and these increases in time outdoors were associated with improved mental health. Unexpectedly, changes in the number of indoor plants after the lockdown period were associated with contrasting mental health outcomes; more plants translated to increased anxiety and decreased depression. Refocusing lives after the pandemic on areas other than maintaining indoor plants may assist with worrying and feeling panicked. Still, indoor plants may assist with depressive symptoms for people remaining isolated., Conclusion: These findings have important implications for policymakers and urban planners in LMICs, highlighting the need to increase access to natural environments in urban areas to improve mental health and well-being in public health emergencies., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2024 Patwary, Bardhan, İnan, Browning, Disha, Haque, Helmy, Ashraf, Dzhambov, Shuvo, Alam, Billah, Kabir, Hossain, Azam, Rahman, Swed, Sah, Montenegro-Idrogo, Bonilla-Aldana and Rodriguez-Morales.)

Background The exposome approach can be a powerful tool for understanding the intertwining of social, physical, and internal influences that shape mental health and cognitive development throughout childhood. To distil conceptual models for subsequent analyses, the EU-funded project Early Environmental quality and Life-course mental health effects (Equal-Life) has conducted literature reviews on potential mediators linking the exposome to these outcomes. We report on a scoping review and a conceptual model of the role of restorative possibilities and physical activity. Methods Peer-reviewed studies published since the year 2000 in English, on the association between the exposome and mental health/cognition in children/adolescents, and quantitatively investigating restoration/restorative quality as a mediating variable were considered. Database searches were last updated in December 2022. We used an unstructured expert-driven approach to fill in gaps in the reviewed literature. Results Five records of three distinct studies were identified, indicating a scarcity of empirical evidence in this newly developing research area. Not only were these studies few in numbers, but also cross-sectional, lending only tentative support to the idea that perceived restorative quality of adolescent's living environment might mediate the association between greenspace and mental health. Physical activity emerged as a mediator leading to better psychological outcomes in restorative environments. We provide a critical discussion of potential caveats when investigating the restoration mechanism in children and propose a hierarchical model including restoration, physical activity, and relational dynamics between children and their environment, including social context, as well as restorative environments other than nature. Conclusions It is justified to further explore the role of restoration and physical activity as mediators in the association between early-life exposome and mental health/cognitive development. It is important to consider the child perspective and specific methodological caveats. Given the evolving conceptual definitions/operationalizations, Equal-Life will attempt to fill in a critical gap in the literature., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Inadequate translation from theoretical to statistical models of the greenspace - health relationship may lead to incorrect conclusions about the importance of some pathways, which in turn may reduce the effectiveness of public health interventions involving urban greening. In this scoping review we aimed to: (1) summarize the general characteristics of approaches to intervening variable inference (mediation analysis) employed in epidemiological research in the field; (2) identify potential threats to the validity of findings; and (3) propose recommendations for planning, conducting, and reporting mediation analyses., Methods: We conducted a scoping review, searching PubMed, Scopus, and Web of Science for peer-reviewed epidemiological studies published by December 31, 2019. The list of potential studies was continuously updated through other sources until March 2020. Narrative presentation of the results was coupled with descriptive summary of study characteristics., Results: We found 106 studies, most of which were cross-sectional in design. Most studies only had a spatial measure of greenspace. Mental health/well-being was the most commonly studied outcome, and physical activity and air pollution were the most commonly tested intervening variables. Most studies only conducted single mediation analysis, even when multiple potentially intertwined mediators were measured. The analytical approaches used were causal steps, difference-of-coefficients, product-of-coefficients, counterfactual framework, and structural equation modelling (SEM). Bootstrapping was the most commonly used method to construct the 95% CI of the indirect effect. The product-of-coefficients method and SEM as used to investigate serial mediation components were more likely to yield findings of indirect effect. In some cases, the causal steps approach thwarted tests of indirect effect, even though both links in an indirect effect were supported. In most studies, sensitivity analyses and proper methodological discussion of the modelling approach were missing., Conclusions: We found a persistent pattern of suboptimal conduct and reporting of mediation analysis in epidemiological studies investigating pathways linking greenspace to health; however, recent years have seen improvements in these respects. Better planning, conduct, and reporting of mediation analyses are warranted., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The Ruminative Thought Style Questionnaire (RTSQ) is a multifaceted measure of general trait rumination. However, there is no instrument for measuring rumination in Bulgarian, which limits progress in the field., Aim: We aimed to validate the RTSQ in Bulgarian and examine its psychometric properties and contribution to several mental health outcomes., Materials and Methods: We sampled 529 undergraduate students (18 – 35 years; 33.6% male; 80.9% Bulgarian) from the Medical University in Plovdiv, Bulgaria. They completed a questionnaire asking about rumination (RTSQ), mental health, and sociodemographic information. The RTSQ was first translated to Bulgarian. Its internal consistency was assessed with Cronbach’s alpha. Confirmatory factor analysis was performed on the 4-factor RTSQ, and multi-group CFA examined its measurement invariance. Structural equation modelling was used to test the relations between the RTSQ factors, depression, anxiety, and resilience to stress., Results: The RTSQ had acceptable internal consistency (α ≥ 0.8) and its 4-factor model had good fit to the data. In addition, its measurement invariance was supported across languages and cultures of administration. We observed differential associations with depression, anxiety, and resilience, with some of the RTSQ factors emerging as maladaptive (problem-focused thoughts and repetitive thoughts), while others as neutral (anticipatory thoughts) or potentially supportive of resilience (counterfactual thinking)., Conclusion: The RTSQ was successfully validated in Bulgarian and represents a reliable measure of trait rumination. It could be useful in gaining further insight into strategies adopted by individuals to cope with stressors and could help develop interventions supporting healthy coping styles. These findings should be replicated in other non-clinical/clinical populations., (This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Experiences afforded by natural settings promote health by helping people to build new adaptive capacities and to restore existing capacities. The aim of this study was to examine relations among restorative experience, mindfulness, rumination and psychological resilience in pathways linking residential greenspace to anxiety and depression symptoms., Methods: We sampled 529 university students residing in Plovdiv, Bulgaria. Residential greenspace was measured in terms of the Normalized Difference Vegetation Index (NDVI) and tree cover density for different buffer sizes. Symptoms of anxiety and depression were measured with the Generalized Anxiety Disorder scale (7-item) and Patient Health Questionnaire (9-item), respectively. The following mediators were assessed by self-report: perceived greenspace, restorative quality of the neighborhood, dispositional mindfulness, rumination, and psychological resilience. Structural equation modelling techniques were used to test the theoretically-indicated relations among the variables., Results: Across different buffer sizes, higher greenspace was consistently associated with reduced scores on the anxiety and depression scales. This effect was partially mediated via several pathways. Specifically, higher NDVI 500-m was associated with higher perceived greenspace, and in turn, with higher restorative quality, and then with higher mindfulness, lower rumination, and greater resilience to stress, and consequently, with better mental health., Conclusions: Our findings affirm the potential of greenspace for building psychological resilience and promoting health by offsetting dysfunctional rumination and facilitating mindfulness as components of intertwined capacity-building and capacity-restoring pathways., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Previous research has suggested that natural urban environment (green space and blue space) benefit mental health, but only a few longitudinal studies have explored the underlying mechanisms. In this pilot study we aimed to examine mechanisms/variables mediating associations between residential green/blue space and symptoms of anxiety/depression in 109 Bulgarian students from Plovdiv university. The students were followed from the beginning to the end of the school year (October 2017 to May 2018). Residential green space was defined as the mean of the normalised difference vegetation index (NDVI) in circular buffers of 100, 300, and 500 m around their residences. Blue space was assessed based on its presence in the same buffers. Levels of anxiety/depression were assessed using the 12-item General Health Questionnaire. The investigated mediator variables included residential noise (LAeq) and air pollution (NO2), environmental annoyance, perceived restorative quality of the neighbourhood, neighbourhood social cohesion, physical activity, and sleep disturbance. Cross-sectional data (obtained at baseline) showed that higher NDVI correlated with better mental health only indirectly through higher physical activity and restorative quality. Longitudinal (follow-up) data showed improved mental health but no significant effect of mediator variables. Similarly, blue space correlated with better mental health in all models, but physical activity and restorative quality were significant mediator variables only in the cross-sectional analysis. Our findings support that green space and blue space are psychologically restorative features in urban environment. Future research should replicate these findings in the general population and employ longitudinal modelling tailored to the specific mechanisms under study.

Background: Recent years have seen growing, but still tentative, evidence of the potential associations of environmental noise and air pollution with mental disorders. In the present study, we aimed to examine the associations between residential noise and air pollution exposures and general mental health in young adults with a focus on underlying processes METHODS: We sampled 720 students (18-35 years) from one university in the city of Plovdiv, Bulgaria. Residential noise (L Aeq ; day equivalent noise level) and air pollution (NO 2 ) were assessed at participant's residential address by land use regression models. General mental health was measured with a short form of the General Health Questionnaire (GHQ). The following putative mediators were considered: annoyance from environmental pollution, sleep disturbance, restorative quality of the neighborhood, neighborhood social cohesion, and commuting/leisure time physical activity. Structural equation modeling was used to analyze the theoretically-indicated interplay between exposures, mediators, and GHQ., Results: We observed an association between higher L Aeq and GHQ, in which environmental annoyance and neighborhood restorative quality emerged as key mediators. First, L Aeq was associated with higher annoyance, and through it with lower restorative quality, and then in turn with lower physical activity, and thus with higher GHQ. Simultaneously, higher annoyance was associated with higher sleep disturbance, and thereby with higher GHQ. NO 2 had no overall association with GHQ, but it was indirectly associated with it through higher annoyance, lower restorative quality, and lower physical activity working in serial., Conclusion: We found evidence that increased residential noise was related to mental ill-health through several indirect pathways. Air pollution was associated with mental health only indirectly., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: A growing body of scientific literature indicates that urban green- and bluespace support mental health; however, little research has attempted to address the complexities in likely interrelations among the pathways through which benefits plausibly are realized., Objectives: The present study examines how different plausible pathways between green/bluespace and mental health can work together. Both objective and perceived measures of green- and bluespace are used in these models., Methods: We sampled 720 students from the city of Plovdiv, Bulgaria. Residential greenspace was measured in terms of the Normalized Difference Vegetation Index (NDVI), tree cover density, percentage of green areas, and Euclidean distance to the nearest green space. Bluespace was measured in terms of its presence in the neighborhood and the Euclidean distance to the nearest bluespace. Mental health was measured with the 12-item form of the General Health Questionnaire (GHQ-12). The following mediators were considered: perceived neighborhood green/bluespace, restorative quality of the neighborhood, social cohesion, physical activity, noise and air pollution, and environmental annoyance. Structural equation modelling techniques were used to analyze the data., Results: Higher NDVI within a 300 m buffer around the residence was associated with better mental health through higher perceived greenspace; through higher perceived greenspace, leading to increased restorative quality, and subsequently to increased physical activity (i.e., serial mediation); through lower noise exposure, which in turn was associated with lower annoyance; and through higher perceived greenspace, which was associated with lower annoyance. Presence of bluespace within a 300 m buffer did not have a straightforward association with mental health owing to competitive indirect paths: one supporting mental health through higher perceived bluespace, restorative quality, and physical activity; and another engendering mental ill-health through higher noise exposure and annoyance., Conclusions: We found evidence that having more greenspace near the residence supported mental health through several indirect pathways with serial components. Conversely, bluespace was not clearly associated with mental health., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose of Review: We systematically summarized and evaluated evidence on association between traffic noise exposure and indicators of neurodevelopmental and mental health problems., Recent Findings: Twelve studies on 10 unique populations were reviewed. Different outcomes, mostly measured by the Strength and Difficulties Questionnaire (SDQ) and its subscales, were reported. Overall bias in each study was acceptable, but the quality of evidence for specific outcomes was "low" to "very low," according to the Grading of Recommendations Assessment, Development and Evaluation system. Data supporting the harmful effect of noise on neurodevelopmental and mental health in children are heterogeneous and limited. Direction of potentially harmful effect was most consistent for road traffic noise and total SDQ score and hyperactivity/inattention. At this point, there is only suggestive evidence that road traffic noise might lead to neurodevelopmental problems in children.