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Unverified information concerning COVID-19 can affect mental health. Understanding perceived trust in information sources and associated mental health outcomes during the COVID-19 pandemic is vital to ensure ongoing media coverage of the crisis does not exacerbate mental health impacts. A number of studies have been conducted in other parts of the world to determine associations between information exposure relating to COVID-19 and mental health. However, the mechanism by which trust in information sources may affect mental health is not fully explained in the developing country context. To address this issue, the present study examined associations between perceived trust in three sources of information concerning COVID-19 and anxiety/stress with the mediating effects of COVID-19 stress in Bangladesh. An online cross-sectional study was conducted with 744 Bangladeshi adults between 17 April and 1 May 2020. Perceived trust in traditional, social, and health media for COVID-19 information, demographics, frontline service status, COVID-19-related stressors, anxiety (GAD-7), and stress (PSS-4) were assessed via self-report. Linear regression tested for associations between perceived trust and mental health. Mediation analyses investigated whether COVID-19-related stressors affected perceived trust and mental health associations. In fully adjusted models, more trust in social media was associated with more anxiety (B = 0.03, CI = 0.27–0.97) and stress (B = 0.01, CI = −0.34–0.47), while more trust in traditional media was associated with more anxiety (B = 0.09, CI = 0.17–2.26) but less stress (B = −0.08, CI = −0.89–0.03). Mediation analyses showed that COVID-19-related stressors partially explained associations between perceived trust and anxiety. These findings suggest that trusting social media to provide accurate COVID-19 information may exacerbate poor mental health. These findings also indicate that trusting traditional media (i.e., television, radio, and the newspaper) may have stress-buffering effects. We recommend that responsible authorities call attention to concerns about the trustworthiness of social media as well as broadcast positive and authentic news in traditional media outcomes based on these results.

A novel coronavirus disease known as COVID-19 has spread globally and brought a public health emergency to all nations. To respond to the pandemic, the Bangladesh Government imposed a nationwide lockdown that may have degraded mental health among residents, in particular, university students and working professionals. We examined clinically significant anxiety levels with the Generalized Anxiety Disorder (GAD-7) scale and perceived stress levels with the Perceived Stress Scale (PSS-4) in an online cross-sectional study with 744 adults. Approximately 70% of respondents were afflicted with clinically significant anxiety levels, and more than 43.82% were afflicted with moderate or high perceived stress levels. Multivariate logistic regression models showed that postgraduates (OR = 2.78, 95% confidence interval [CI] = 1.03–8.75, p < 0.05) were more likely to experience anxiety than their student counterparts. No such differences emerged for working professionals, however. Living with family members compared to living alone was a risk factor for perceived stress among working professionals (OR = 4.05, 95% CI = 1.45–11.32, p < 0.05). COVID-19 stressors such as financial hardship (OR = 1.84, 95% CI = 1.11–3.05, p < 0.05) and worries of family members’ health (OR = 1.84, 95% CI = 1.12–2.99) were risk factors for anxiety among students. Questionable social media news exposure (OR = 2.99, 95% CI = 1.13–7.92, p < 0.05) contributed to the development of mental stress among working professionals. These findings confirm that effective initiatives and proactive efforts from concerned authorities are necessary to cope with the mental health correlates of the COVID-19 pandemic, including in developing contexts such as Bangladesh.

The COVID-19 pandemic affected every area of students' lives, especially their education. Limited research has explored students' experiences during the pandemic. This study documents how students across seven United States universities viewed the impact of the COVID-19 pandemic on their educational experiences and how these students reacted to these impacts. We present qualitative data from an online survey conducted between March and May 2020 that resulted in 1267 respondents with relevant data. Conventional content analysis with an inductive approach was used to analyze open-ended responses to the question, "We are interested in the ways that the coronavirus (COVID-19) pandemic has changed how you feel and behave. What are the first three ways that come to mind?" Six categories emerged from the data: changes in instruction delivery mode, changes in schedule and everyday life, increased technology use, decreased academic opportunities and resources, negative reaction to the changes in higher education, and positive reactions to changes in higher education. Among our recommendations for practice are personalized approaches to material delivery and evaluation, synchronous classes and opportunities to connect with professors and students, and convenient support services.

Studies have investigated various aspects of how the COVID-19 pandemic has impacted college students’ well-being. However, the complex relationships between stress and its correlates have received limited attention. Thus, the main objective of this study is to evaluate multiplicative associations between stress and demographic, lifestyle, and other negative emotion factors during the pandemic. We used data from a survey with 2,534 students enrolled in seven U.S. universities and analyzed such data with generalized additive Tobit models and pairwise interaction terms. The results highlighted associations and interactions between myriad factors such as students’ social class, income, parental education, body mass index (BMI), amount of exercise, and knowing infected people in the student’s communities. For instance, we found that the associations between feeling irritable and sad due to the pandemic were interactive, resulting in higher associated stress for students with higher levels of parents’ education. Furthermore, associations between taking precautionary actions (i.e., avoiding travel and large gatherings) and stress varied with the intensity of negative feelings (i.e., sadness and irritability). Considering these interaction terms, the results highlighted a great inequality in pandemic-related stress within low income, lower social class, and higher BMI students. This study is among the earliest that employed a stratified approach with numerous interaction terms to better understand the multiplicative associations between different factors during the COVID-19 pandemic.

Teachers wishing to offer lessons in nature may hold back for fear of leaving students keyed up and unable to concentrate in subsequent, indoor lessons. This study tested the hypothesis that lessons in nature have positive—not negative—aftereffects on subsequent classroom engagement. Using carefully matched pairs of lessons (one in a relatively natural outdoor setting and one indoors), we observed subsequent classroom engagement during an indoor instructional period, replicating these comparisons over 10 different topics and weeks in the school year, in each of two third grade classrooms. Pairs were roughly balanced in how often the outdoor lesson preceded or followed the classroom lesson. Classroom engagement was significantly better after lessons in nature than after their matched counterparts for four of the five measures developed for this study. This nature advantage held for teacher ratings; third-party tallies of ‘redirects’ (the number of times the teacher stopped instruction to direct student attention back to the task at hand); independent, photo-based ratings made blind to condition; and a composite index of classroom engagement, but not for student ratings. The nature advantage held across different teachers and held equally over the initial and final five weeks of lessons. The nature advantage was large: after a lesson in nature, ‘redirects’ were roughly half as frequent, allowing teachers to teach for longer periods uninterrupted. In 48 out of 100 paired comparisons, the nature lesson was a full standard deviation better than its classroom counterpart; in 20 of the 48, the nature lesson was over two standard deviations better. Because the pairs of lessons were matched on teacher, class (students and classroom), topic, teaching style, week of the semester, and time of day, the advantage of the nature-based lessons could not be attributed to any of these factors. It appears that, far from leaving students too keyed up to concentrate afterward, lessons in nature may leave students more able to engage in the next lesson. Such “refueling in flight” argues for including more lessons in nature in formal education.

PURPOSE The purpose of this integrative review was to explore how adolescents and young adults used the social determinant of the built environment, specifically greenspace, as a potential point of intervention to address overall well-being, specifically mental health symptoms. METHOD The approach used strategies described by Whittemore and Knafl. Peer-reviewed, published research articles in English were identified using electronic databases CINAHL, PubMed, and EMBASE. Seventeen research reports using qualitative or quantitative methods with adolescents and young adults. Each article was evaluated for quality using a critical appraisal tool by Hawker et al. Data were analyzed and then synthesized using the Matrix Method. FINDINGS Three themes related to the purpose and aims were extracted: elements of greenspace, activity variation, and amenities. All themes shared a common element of quality, which influenced the perception of safety and greenspace use. DISCUSSION The science of urban greenspace and adolescent-young adult well-being is still relatively new. Public health nurses can incorporate social determinants of health, such as the built environment in research, to understand how greenspace is to be used as an alternative health strategy to possibly reduce mental health symptoms and improve well-being.

We review the methods and findings of experiments that have examined the effects of exposure to simulated natural landscapes on human health and cognitive performance. Keyword searches of PubMed, Scopus, and Web of Science resulted in the inclusion of 175 experiments in 148 research articles. that were published/in press by December 31, 2018. We report how often landscape features and human factors are controlled for within these experiments, thereby—for the first time—recording specifically what elements of “nature” and the built/social environment are used when testing the benefits of green space and blue space exposure. We also document all the simulation methods that are used (e.g., duration, number of exposures, senses engaged, and devices used). Next, to determine what methodological decisions influence study findings, we compare positive versus mixed/null or negative findings across 14 potential moderators. Only study quality and outcome measure influence findings; experiments without control groups or randomized treatments reported more positive findings than expected. Experiments studying perceived restoration also reported more positive findings than expected—remarkably, 95% of such experiments reported simulated nature was indeed restorative. We discuss the possibility that these findings may indicate publication bias in favor of overreporting the salutory impacts of natural landscapes. We conclude our review with a synthesis of best practices for future research studies.

Green land covers (e.g., forests and parks) are associated with better human health. Better health, in turn, may lead to lower spending on healthcare, an increasingly large portion of the budget of both American citizens and the government. There is a significant gap in our knowledge on the direct association between green covers and health care costs. We estimated associations between the percentage of green land cover in a county and its age- and risk-adjusted Medicare fee-for-service expenditures for each of five types of green land cover (forest, shrub, grass, agriculture, and urban vegetation) drawn from the 2011 National Land Cover Database. Generalized linear mixed models were used to predict median regionally standardized per-capita Medicare expenditures for 2010–2014 for 3,086 counties (comprising over 30 million Medicare fee-for-service users), with state as a random effect and controls for environmental, behavioral, and healthcare access covariates. We found associations between two types of green land cover and healthcare spending. Forest and shrub covers were significantly and inversely associated with median Medicare fee-for-service spending with small effect sizes. Grass land cover did not have a statistically significant association with expenditures. For agriculture and urban vegetation land covers, the results were unclear. Counties with more forest and shrub land cover may hold both health and economic benefits for the elderly and disabled. This study demonstrates that exposure to green land cover may be linked to lower healthcare spending. However, more definitive studies, particularly those that use individual-level data, are needed.

People who live near more greenspace report less anxiety and depression. Do these findings hold for elderly populations living in care facilities, such as nursing homes? The answer to this question has not been directly examined. Studies on the relationship between greenspace and mental health in this population have focused on nature-based therapy programs rather than on greenspace coverage. Research on outdoor greenspace coverage is important for facility design. Facilities should know whether to prioritize greening investments in indoor atriums where programming can be provided year-round or in outdoor greenspace, which can also promote health by providing restorative views and reducing harmful exposures (e.g., noise and air pollution). To investigate whether nursing homes residents benefit from outdoor greenspace cover, we examined the relationship between tree canopy cover around 9186 U.S. nursing homes and the percentage of residents suffering from depressive symptoms. Depressive symptoms data were obtained from the 2011 Minimum Data Set, and canopy data were obtained from the 2011 National Land Cover Database. Because facilities with more resources and higher qualities of care might also have more trees, we gathered 2011 data on occupancy rates, staffing ratios, age, sex, percent Medicaid eligibility, care needs, for-profit status, presence of special care units from the Long Term Care Focus dataset as well as air quality and population density and used these potential covariates in adjusted generalized linear mixed models and spatial lag models. We observed an inverse relationship between depressive symptoms and tree cover surrounding facilities. Associations did not vary by aggregated racial or socioeconomic characteristics of residents but did became weaker at greater distances from facilities. These findings provide hypotheses for future testing regarding whether nursing homes should incorporate outdoor greening in addition to nature-based therapy programs for residents’ mental health.

As evidence continues to mount that areas with more natural spaces also have healthier residents, researchers are beginning to suspect that these benefits extend beyond health to other related factors, such as healthcare spending. If more nature translates to better health, does more nature ultimately reduce the need for and spending on healthcare, and is this especially true for the elderly and disabled, who benefit differently from nature? This study aims to answer that question, employing a cross-sectional, ecological study design on county-level, annual per-capita Medicare spending in the United States. We examine the association between Medicare spending and the amount of total greenness in a county as well as the amount of blue space, or open water, in a county while controlling for demographic, socioeconomic, and healthcare access confounders. Our results show a significant and inverse association between greenness and spending and mixed results in regard to blue spaces and spending. The greenness-spending association persists in varying levels of the urban–rural spectrum, including both the most and least urban counties.

While many studies suggest evidence for the health benefits of nature, there is currently no standardized method to measure time spent in nature or nature contact, nor agreement on how best to define nature contact in research. The purpose of this review is to summarize how nature contact has been measured in recent health research and provide insight into current metrics of exposure to nature at individual and population scales. The most common methods include surrounding greenness, questionnaires, and global positioning systems (GPS) tracking. Several national-level surveys exist, though these are limited by their cross-sectional design, often measuring only a single component of time spent in nature, and poor links to measures of health. In future research, exposure assessment combining the quantifying (e.g., time spent in nature and frequency of visits to nature) and qualifying (e.g., greenness by the normalized difference of vegetation index (NDVI) and ratings on perception by individuals) aspects of current methods and leveraging innovative methods (e.g., experience sampling methods, ecological momentary assessment) will provide a more comprehensive understanding of the health effects of nature exposure and inform health policy and urban planning.

Disadvantaged groups worldwide, such as low-income and racially/ethnically minoritized people, experience worse health outcomes than more privileged groups, including wealthier and white people. Such health disparities are a major public health issue in several countries around the world. In this systematic review, we examine whether green space shows stronger associations with physical health for disadvantaged groups than for privileged groups. We hypothesize that disadvantaged groups have stronger protective effects from green space because of their greater dependency on proximate green space, as they tend to lack access to other health-promoting resources. We use the preferred reporting items for systematic reviews and meta-analyses (PRISMA) method and search five databases (CINAHL, Cochrane, PubMed, Scopus, and Web of Science) to look for articles that examine whether socioeconomic status (SES) or race/ethnicity modify the green space-health associations. Based on this search, we identify 90 articles meeting our inclusion criteria. We find lower-SES people show more beneficial effects than affluent people, particularly when concerning public green spaces/parks rather than green land covers/greenness. Studies in Europe show stronger protective effects for lower-SES people versus higher-SES people than do studies in North America. We find no notable differences in the protective effects of green space between racial/ethnic groups. Collectively, these results suggest green space might be a tool to advance health equity and provide ways forward for urban planners, parks managers, and public health professionals to address health disparities.

Background Virtual reality (VR) is an evolving technology that is becoming a common treatment for pain management and psychologic phobias. Although nonimmersive devices (e.g., the Nintendo Wii) have been previously tested with patients on hemodialysis, no studies to date have used fully immersive VR as a tool for intervention delivery. This pilot trial tests the initial safety, acceptability, and utility of VR during maintenance hemodialysis treatment sessions—particularly, whether VR triggers motion sickness that mimics or negatively effects treatment-related symptoms (e.g., nausea). Methods Patients on hemodialysis (n=20) were enrolled in a phase 1 single-arm proof-of-concept trial. While undergoing hemodialysis, participants were exposed to our new Joviality VR program. This 25-minute program delivers mindfulness training and guided meditation using the Oculus Rift head-mounted display. Participants experienced the program on two separate occasions. Before and immediately after exposure, participants recorded motion-related symptoms and related discomfort on the Simulator Sickness Questionnaire. Utility measures included the end-user’s ability to be fully immersed in the virtual space, interact with virtual objects, find hardware user friendly, and easily navigate the Joviality program with the System Usability Scale. Results Mean age was 55.3 (±13.1) years; 80% male; 60% Black; and mean dialysis vintage was 3.56 (±3.75) years. At the first session, there were significant decreases in treatment and/or motion-related symptoms after VR exposure (22.6 versus 11.2; P=0.03); scores >20 indicate problematic immersion. Hemodialysis end-users reported high levels of immersion in the VR environment and rated the software easy to operate, with average System Usability Scale scores of 82.8 out of 100. Conclusions Patients on hemodialysis routinely suffer from fatigue, nausea, lightheadedness, and headaches that often manifest during their dialysis sessions. Our Joviality VR program decreased symptom severity without adverse effects. VR programs may be a safe platform to improve the experience of patients on dialysis.

Multiple systematic reviews on greenspace and health outcomes exist, but the overall evidence base remains unclear. Therefore, we performed an umbrella review to collect and appraise all relevant systematic reviews of epidemiological studies on greenness exposure and health. We searched PubMed, Embase, and Web of Science from inception to June 28, 2021, and screened references of relevant articles. Systematic reviews with or without meta-analyses of epidemiological studies that examined the associations of greenness with any health outcome were included. Two independent investigators performed study selection and data extraction. We also evaluated the methodological quality of the included systematic reviews using the “Assessing the Methodological Quality of Systematic Reviews 2” checklist. A total of 40 systematic reviews and meta-analyses were included, of which most were cross-sectional studies conducted in high-income countries. Greenspace exposure was estimated with various objective and subjective parameters. Beneficial associations of greenspace with all-cause and stroke-specific mortality, CVD morbidity, cardiometabolic factors, mental health, low birth weight, physical activity, sleep quality, and urban crime were observed. No consistent associations between greenspace and other health outcomes (e.g., cancers) were observed. Most of the included systematic reviews and meta-analyses had one or more limitations in methodology. Our findings provide supportive evidence regarding the beneficial effects of greenspace exposure on some aspects of human health. However, the credibility of such evidence was compromised by methodological limitations. Better performed systematic reviews and meta-analyses as well as longitudinal designed primary studies are needed to validate this conclusion., Graphical abstract, Public summary • The evidence concerning greenspace and health outcomes remains unclear • We performed an umbrella review of 40 systematic reviews on greenspace and health • Greenspace exposure was estimated with various objective and subjective parameters • Greenspace was beneficially associated with several aspects of human health

Background: Exposure to greenspace has been proposed to be beneficially associated with cardiovascular morbidity and mortality. Many studies have explored this topic, but the results remain conflicting. We aimed to evaluate the epidemiological evidence on this topic by performing a systematic review with meta-analysis. Methods: We searched PubMed, Web of Science and Embase for studies on the green space-cardiovascular disease (CVD) relationship that were published till May 12th, 2021. Two authors independently performed study selection, data extraction, quality assessment, and risk of bias assessment. For studies providing detailed numeric data, we conducted quantitative meta-analyses and calculated the pooled odd ratios (ORs) for associations between the most commonly used greenspace exposure (normalized difference vegetative index [NDVI]) and six CVD events: CVD mortality, ischemic heart disease (IHD) mortality, stroke incidence/prevalence, and coronary heart disease (CHD) incidence/prevalence. Sensitivity analyses and publication bias tests were also conducted. Findings: Of the 6229 records identified, 48 studies were eligible for inclusion. These studies covered 18 countries and included data from more than 100 million persons. Meta-analyses showed that a 0∙1 increase in NDVI was associated with 2-13% lower odds of CVD mortality (OR 0∙97, 95% CI 0∙96-0∙99, I2 95∙8%), IHD mortality (OR 0∙98, 95% CI 0∙96-1∙00, I2 90∙7%), stroke incidence/prevalence (OR 0∙97, 95% CI 0∙96-0∙99, I2 29∙6%), and CHD incidence/prevalence (OR 0∙87, 95% CI 0∙83-0∙91, I2 0∙0%). The pooled estimates were not substantially different in sensitive analyses. No evidence of publication bias was detected. Interpretation: We provide strong and robust evidence for beneficial effects of greenspace exposure on cardiovascular health. More prospective studies and mechanistic studies are needed. Funding: The Natural Science Foundation of the Xinjiang Uyghur Autonomous Region, China; the National Natural Science Foundation of China. Declaration of Interests: We declare no competing interests.

Background: While greenness has been associated with lower depression, the generalizability of this association in arid landscapes remains undetermined. We assessed the association between depression and residential greenness, but also brownness and grayness among nursing students living in El Paso, Texas (the Chihuahuan desert). Methods: Depression was measured with the Patient Health Questionnaire-9 scale and greenness with the normalized difference vegetation index across three buffer sizes (i.e., 250, 500, and 1000 m). Using data from the National Land Cover Database, two additional measures of land patterns were analyzed: grayness and brownness. Structural equation models were used to assess the relationships of these land patterns to depression and quantify the indirect effects of peer alienation. Results: After adjusting for individual characteristics, at buffers 250 m, greenness was not associated with a decrease in the Incidence Rate Ratios (IRR) of depression (IRR, 0.51, 95% CI, 0.12&ndash, 2.10), however, grayness and brownness were respectively associated with increases by 64% (IRR, 1.64, 95% CI, 1.07&ndash, 2.52) and decreases by 35% (IRR, 0.65, 95% CI, 0.42&ndash, 0.99). At buffer 250 m, peer alienation explained 17.43% (95% CI, &minus, 1.79&ndash, 36.66) of the association between depression and brownness, suggesting a pathway to depression. Conclusions: We did not observe an association between depression and residential greenness in El Paso, Texas. However, we did observe a protective association between brownness and depression and an adverse association with grayness. These results have theoretical implications as they were based on commonly used frameworks in this literature, and adverse association of brownness (and the lack of greenness) and depression was expected.

Background: Evidence suggests that green environments are protective of health and wellbeing. Many of these studies evoke prospect-refuge theory that poses that savanna-like landscapes offer opport...

Background: While greenness has been associated with lower depression, the generalizability of this association in arid landscapes remains undetermined. We assessed the association between depression and greenness among nursing students living in El Paso, Texas (the Chihuahuan desert). Methods: Depression was measured with the Patient Health Questionnaire-9 scale, and greenness with the normalized difference vegetation index (at buffer sizes =250m, 500m, 1000m). Using data from the National Land Cover Database two additional measures of land patterns were analyzed: grayness and brownness. Structural equation models were used to assess the relationships of these land patterns to depression and quantify the indirect effects of peer alienation. Results: After adjusting for individual characteristics, at buffers 250 m greenness was associated with a decrease in the Incidence Rate Ratios (IRR) of depression by 49% (IRR, 0.51; 95%CI, 0.12-2.10), greyness with increases by 64% (IRR, 1.64; 95%CI, 1.07-2.52) and brownness with decreases by 35% (IRR, 0.65; 95%CI, 0.42-0.99). At buffer 250 m peer alienation explained 17.43% (95% CI, -1.79-36.66) of the association between depression and brownness, suggesting a pathway to depression. Conclusions: We did not observe an association between depression and residential greenness in El Paso, Texas. However, we did observe a protective association between brownness and depression as well as an adverse association with grayness. These results have theoretical implications as based on commonly used frameworks in this literature and adverse association of brownness (and the lack of greenness) and depression was expected.

Urban green space use is often associated with improved physical and mental health and lower noncommunicable disease (NCDs) burdens. Factors that influence green space visits have been documented in cities of the Global North, but evidence of urban green space use patterns for cities in the Global South is scarce. The aim of this study is to investigate factors influencing urban green space use patterns in Dhaka, Bangladesh, a megacity of the Global South, with a particular focus on how poor health condition and healthcare professionals&rsquo, prescriptions to exercise outdoors (park prescriptions&mdash, ParkRx) impact the green space use of middle-aged adults. We collected green space characteristics and use factors (i.e., availability, accessibility, attractiveness, and attachment), health condition, ParkRx, and urban green space use intensity (i.e., frequency and duration) via a self-reported questionnaire from 169 middle-aged residents of Dhaka. We used multivariate modeling to estimate the association of green space characteristics, health condition, and ParkRx with use intensity. We further applied a mediation analysis to determine the influence of ParkRx on the relationship between residents&rsquo, poor health conditions and use intensity. We found that green space availability and accessibility did not significantly influence use intensity, but attractiveness was negatively associated with use intensity. Green space use intensity was significantly and positively associated with attachment to the green space, poor health condition (i.e., having noncommunicable diseases), and ParkRx. ParkRx significantly mediated the relationship between health condition and use intensity. We observed limited supply, poor access, and low attractiveness when studying the urban green spaces in Dhaka, but these qualities did not affect use intensity, as found in many case studies in the Global North. In contrast, urban green space use intensity in our case study is mostly dependent on poor health condition and park prescriptions.

Purpose: We propose a methodological framework to use immersive virtual environments (IVEs) in head-mounted displays for environmental design research. Background: IVEs offer researchers with experimental control and realistic representations of environments with high levels of ecological validity. IVEs are also increasingly being used to visualize proposed designs. Despite these tremendous benefits, IVEs are underutilized in environmental design research. We are unaware of preexisting frameworks that synthesize the methodological decisions related to the use of IVEs to conduct environmental design research. Methods/Results: We define the concepts necessary to conduct IVE research (virtual reality [VR], IVEs, ecological validity, visual realism, behavioral realism, and contextual realism). We also summarize the available study designs (correlational studies, experimental studies, and performance evaluations) and software systems used to create IVEs. We conclude with a conceptual framework that describes how research questions and study designs inform IVE selection and ecological validity. This framework is accompanied by a workflow that operationalizes the creation and use of IVEs in research. Conclusions: VR provides a robust and innovative research strategy for environmental design research because of its high degree of experimental control, rich data collection options, and opportunities for systematic evaluation of alternative design configurations.

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.