Until recently, recognition of the value of the natural environment as a health asset was lacking in health and environmental policy. Interdisciplinary research at Exeter’s European Centre for Environment and Human Health led to a paradigm shift in how health policy, environmental planning and public heath practice harness the potential of natural environments for supporting health.

International impact

Research has influenced the work of the World Health Organisation (WHO). For example WHO urging 53 member states for action on urban green space for health.

National impact

Policy decisions have been informed by our research evidence. For example the UK Government invested more than £15 million in natural environment-based population health promotion programmes and environmental social prescribing scheme.

Local impact

Our work has changed public health practice in Dorset, Cornwall and the third sector, and stimulated foreign direct investment.  This includes EU investment of £3.5m in urban Public Open Space in Cornwall for health and biodiversity gain.

Creating a coherent body of evidence

Across a decade of work,  a targeted combination of approaches including observational epidemiological studies, lab-based experimental studies, field experiments, qualitative research, evidence synthesis (including systematic reviews), and policy and practice analyses have been used to build a coherent body of evidence.

This research has demonstrated, quantified and transformed understanding of the contribution of natural environments to human population health and well-being.

How natural environments can promote health

As core members of the UK Centre of the Collaboration for Environmental Evidence, the European Centre for Environment and Human Health team have pioneered the application of systematic review methodologies to environment and health issues. Our systematic review of the potential health impacts of environmental volunteering, the first ever mixed-methods Cochrane systematic review, clarified the key mechanisms for successful interventions and activities using natural environments for health and wellbeing. It found that environment-based interventions could result in health impacts through mechanisms including physical activity, social contact and personal achievement.

Our systematic review of the health and well-being benefits of biodiverse environments flagged the potential of thinking beyond ‘green space vs grey space’ for health and environment. It showed the mutual benefit of each and demonstrated significant inconsistencies and weaknesses in the evidence base, and the need for high quality, interdisciplinary research to better inform decision-making.

The scale of health economic values and wellbeing benefit of natural environments

In collaboration with Public Health England (PHE) and Natural England (NE), our research has shown that outdoor physical activity delivers an estimated £2.2bn worth of health benefits to adults in England each year. This study used NE’s unique Monitor of Engagement with the Natural Environment data to estimate physical activity associated with 1.13bn active visits per year to natural environments in England.

Further analysis identified a potential 120-minute/week threshold for outdoor activity to achieve health gains.

These studies established a more comprehensive set of health-related economic values of natural environments than was previously available, which led to the development of the Greenkeeper tool.

Moving to greener neighbourhoods improves health

Our studies using the 18-year British Household Panel Survey were among the first to use robust longitudinal approaches to demonstrate that people moving to greener urban neighbourhoods have subsequent better mental health outcomes, and that positive effects last for at least three years following a move.

Identification of opportunities and strategies for cross-sectoral policy and service delivery

Collaborative synthesis and policy-focussed research with Defra, Natural England and other Governmental partners identified opportunities to transform Defra’s role in promoting public health and the integration of health into the new Green Infrastructure Standards for England. Similarly, collaborative research with PHE and Local Authorities in the South West has informed how PHE works with local authorities to deliver health improvement through local government planning, environment and land use policy and delivery.

Supporting the linkage of environmental policy and social care practice, our systematic review on the value of natural environment engagement in care home settings demonstrated promising evidence of reduced agitation in care home residents with dementia who spend time in a garden.

This large interdisciplinary body of research has shown that the natural environment plays a critical role in delivering health and wellbeing benefits. We have also shown that the scale and likely causal pathways of these benefits have previously been underestimated and undefined.

Shaping policy

Research from the Centre has changed policy mind-sets, strategies and practice. Evidence has strengthened conservation, environmental management and investment policy at scales from local to international by clarifying the role of ‘natural capital’ in supporting human health and wellbeing.

Traditionally, environmental policies relating to human health have been dominated by hazards; our evidence means these are now balanced by the recognition of the health and wellbeing benefits of good quality natural environments. This research impact has been amplified through active engagement and close collaborations with policy bodies who have recognised our expertise and invited participation in a range of expert advisory roles and joint projects.

Influencing international policy on natural environment and health

Our research has led to changes in international policy and strategy in both the health and environment sectors. Since 2015, we have worked with the WHO Regional Office for Europe and the Convention on Biological Diversity (CBD) on urban greenspace, biodiversity and health. Our 2014 systematic review of links between biodiverse environments and ‘good’ health was used to inform the ratification of two key CBD decisions on biodiversity and human health, with a joint CBD/WHO report co-authored by Dr Rebecca Lovell. These decisions invite the 195 nation state signatories, and the European Union, to act on the linkages in developing health and environmental strategies (COP12 decision XII/21; COP13 decision XIII/6).

These international decisions set the context for national policymaking, including the UK Government 25 Year Plan for the Environment. The CBD/WHO report was also used to inform the implementation of the relevant 2030 UN Sustainable Development Goals adopted in 2015 by all UN member states (especially SDG3 (health), but also SDGs 7 (water quality) and 11 (nature-based solutions to challenges related to urban well-being).

Recognition of our research outputs and expertise led to Professor Michael Depledge and Dr Benedict Wheeler contributing one of three chapters of the key 2016 WHO evidence review, on Urban green spaces and health, underpinning WHO urban greenspace action.

Professor Wheeler was subsequently a member of an Expert Group advising WHO, ultimately resulting in WHO’s Urban green spaces: a brief for action for authorities promoting and supporting action for urban greenspaces.

At the national scale, the Centre’s research resulted in a joint report and Departmental briefing that informed the Government’s position on natural environment and health. The report was produced by a collaboration between the Centre, Defra, PHE and related stakeholders, who synthesised existing evidence (including from Centre researchers) and conducted primary research.

This report, along with the key WHO report, were the key sources underpinning the health aspects of the UK Government 25 Year Plan for the Environment. Consequently, Defra has established policy commitments including the creation of national standards for Green Infrastructure, the transformation of agricultural subsidies to a focus on public goods (including health), environmental investments such as planting 11m trees by 2022, and large-scale initiatives.

Approximately £10 million has been committed to these health and nature programmes, reaching significant populations including over 500 schools.

Our evidence is influencing public health processes at the national scale, in part through our collaboration with PHE and the Health Protection Research Unit in Environmental Change and Health. Our research findings were used to establish the basis for the value of investing in urban green spaces for population mental health in PHE guidance to local authority planners Spatial Planning for Health; and in PHE guidance (co-authored by Lovell) on accessible greenspace, leading to the prominence of health in the new Green Infrastructure standards for England associated with the 25 Year Plan. Our work with Defra, PHE and the NHS, and evidence reviews of the impacts of nature-based health interventions have contributed to additional Government investment of £5m in social prescribing.

The Centre’s research directly led to the creation of a commercial tool, Greenkeeper, to evaluate the multiple economic values of urban green infrastructure. Prior to our longitudinal studies, there was no robust estimation of the magnitude of the positive impact of urban greenspace on population mental health, contributing to the under-valuing of urban nature. This work led to our collaboration with Vivid Economics and Barton Willmore on the Innovate UK-funded Greenkeeper project. This involved the development and application of our studies of mental health and physical activity values to incorporate health-related values in the tool. Greenkeeper has already been used for a range of purposes, including to support a 2020 call from National Trust and Heritage Lottery Fund to press the Government for £5.5bn green infrastructure funding as part of a ‘green recovery’ to address inequalities in access to nature highlighted by the Covid-19 pandemic.

At the local scale, our research has also been used to inform decision making and investment to promote the health and well-being of Dorset’s population, and reduce pressure on its health and care services. Our existing research and green space access mapping, carried out in collaboration with Public Health (PH) Dorset, underpinned the Healthy Places Strategy applied within PH Dorset’s Sustainability and Transformation Partnership and Integrated Care System.

Cornwall Council, under significant financial pressure due to austerity, identified a need to recognise the health value as well as biodiversity benefits of the almost 2000 parks, amenity and natural open spaces managed by the Council. Collaborative work resulting from the ESRC-funded Beyond Greenspace project led to co-produced outputs appended to the Council’s Open Space Strategy and has supported investment in and sustainable management of public open spaces for community health benefit in the future.

Health evidence input from the Centre contributed to a successful bid led by the Council (with Exeter as a Knowledge Exchange partner) to the European Structural and Investment Fund resulting in a £3.5m green space development project (with an additional £2.9m follow-on project), currently delivering  more than 60 hectares of improved urban green space quality and accessibility in Cornish towns.

Our evidence has also directly supported improvements in care settings and built confidence in staff to support residents to make use of their outdoor spaces. Our evidence synthesis of the beneficial impacts of gardens in care homes for people with dementia, together with a co-produced systematic review with the Sensory Trust, about older people’s sensory engagement with nature, has informed practice in care homes in the South West.

The Sensory Trust is a nationally leading authority on inclusive and sensory design, which works on delivery of large-scale UK government programmes. Our collaboration produced an evidence-based information and activity kit, My Nature.

In summary, our research outputs have directly informed policy and practice at international, national and local scales, and have led to substantive collaborations embedding Exeter researchers within decision making. This was recognised in November 2019, with the designation of the Centre as a WHO Collaborating Centre on Natural Environments and Health.