August 24, 2016

Useable Green Spaces Can Affect Children’s Health-Related Quality of Life and BMI

Evidence supports the benefits of the great outdoors
Most parents intuitively recognize that spending time outside is good for their children, but objective evidence of the value of green space for health may push both parents and practitioners to be more proactive in getting children outdoors.

This paper is part of the September 2016 Pediatrics Special Issue. Read the entire issue or download it.


Kim JH, Lee C, Sohn W. Urban natural environments, obesity, and health-related quality of life among Hispanic children living in inner-city neighborhoods. Int J Envir Res Public Health. 2016;13(1):121-136.

Design and Participants

This cross-sectional study collected data from children (N=92, 9-11 years old) who attended elementary school in the East End district of Houston, Texas. This area was chosen because of racial/ethnic and socioeconomic demographics. All participants were of Hispanic background, could speak and read in either English or Spanish, and had no major medical conditions. The quality of their natural environment was assessed using landscape data generated by geographic information systems (GIS) and remote sensing. 

Outcome Measures

Participants were assessed for their health-related quality of life (HRQOL) using the Pediatric Quality of Life Inventory (PedsQL), a validated and reliable QOL instrument for children. This self-report measure is filled out simultaneously by both child and parent to assess the child’s subjective internal states (child) and their objective external behaviors (parents). Control variables collected included each child’s sociodemographic information (ie, parents’ income and education level), obesity status (BMI), physical activity level (PAQ-C), hours watching TV, and environmental perceptions of their neighborhood (ie, accessibility, safety, comfort, attractiveness, satisfaction).
The positive associations between activity level and quality of life and negative associations between hours of TV and quality of life demonstrate how vital it is to encourage movement and decrease sedentary behavior in children.
Landscape GIS information was obtained from the Texas Natural Resources Information System and organized based on 40 recognized spatial land-use patterns. Comparisons of this information to each participant’s data were made for quarter-mile airline (QA) and half-mile airline (HA) buffers surrounding each participant’s house. 

Key Findings

Multivariate regression analysis detected statistically significant associations between landscape spatial patterns and HRQOL, with landscape accounting for approximately 43% of the variance of HRQOL in both QA and HA radius buffer models. 
After controlling for sociodemographic, BMI, PAQ-C, and environmental perception variables, specific sub-analyses of the landscape patterns showed that green space percentage of buffer area (P=0.023/P=0.069), number of patches of trees (P=0.016/P=0.020), and mean distance between tree patches (P=0.001/P=0.004) were all significant predictors of HRQOL using both HA and QA models (respectively).  
Data analysis also found statistically significant predictive associations between children’s HRQOL and BMI (P=0.010/P=0.008), weekend PAQ-C (P=0.000/P=0.000), and hours of TV (P=0.015/P=0.005). 

Practice Implications

This is one of the first studies in the growing body of green space and health literature to use children as a population of interest.1,2 Children are a critical population to consider, and not only because of the epidemic of childhood obesity that is currently plaguing our healthcare system with physical and mental health effects.3,4 It is also vital that children be exposed to nature as early as possible to instill an ethic of environmental stewardship; studies have shown that children who don't get this exposure are less creative, less empathetic, and less likely to care about the environment as adults. In this era of “screen time vs green time,” there is growing concern that the next generation will not be able to provide enough capable, eco-minded leaders to solve the massive environment-related health problems that are coming our way.5-7 
In addition, this study is one of the first to use a broad measure of health rather than investigating a specific biomarker or pathologic condition.8 HRQOL is an important metric in healthcare because it focuses on qualitative aspects of well-being rather than traditional quantitative metrics like disease prevalence or mortality rates. It also assesses the holistic, “multidimensional” aspects of life and considers how health affects all aspects of life.9 It is useful to remember that “health” itself is a holistic condition as defined by the World Health Organization (WHO). According to WHO, health is “a state of physical, mental, and social well-being and not merely the absence of disease or infirmity...[Health is] a resource for everyday life, not the objective of living…[Health is] a positive concept emphasizing social and personal resources, as well as physical capacities.”10,11 In an era in which so much of the medical system takes a pathocentric (disease-focused) approach to healthcare, it is nice to know that some interventions do have a salutogenic (health-promoting) effect.12
For the practitioner, this study emphasizes that environmental factors may act as enhancers or barriers to achieving health. There are many things in a patient’s life that may influence health beyond what can be prescribed, or what may even come up, in a clinical visit. When a patient’s condition seems to be resistant to treatment, we must look past the condition itself and consider how the patient functions in the context of their greater life. 
These findings also suggest the value of taking a proactive approach to getting kids outside. The positive associations between activity level and quality of life and negative associations between hours of TV and quality of life demonstrate how vital it is to encourage movement and decrease sedentary behavior in children. Increasingly, more conventional physicians are organizing and creating standardized “Vitamin N” (for “nature”) prescription-writing programs. Under the umbrella program of ParkRx in conjunction with the National Park Service, the National Recreation and Park Association, and the Institute at the Golden Gate, doctors are learning their role in promoting children’s use of the “natural medicine” a nearby park can provide.

Categorized Under


  1. Hartig T, Mitchell R, de Vries S, Frumkin H. Nature and health. Annu Rev Public Health. 2014;35:207-208.
  2. Kuo FE. Parks and Other Green Environments: Essential Components of a Healthy Human Habitat. Ashburn, VA: National Recreation and Park Association; 2010.
  3. Williams J, Wake M, Hesketh K, Maher E, Waters E. Health-related quality of life of overweight and obese children. JAMA. 2005;293(1):70-76.
  4. Banis HT, Varni JW, Wallander JL, et al. Psychological and social adjustment of obese children and their families. Child Care Health Dev. 1988;14(3):157-173.
  5. Bragg R, Wood C, Barton J, Pretty J. Measuring connection to nature in children: a robust methodology for the RSPB. University of Essex: Essex Sustainability Institute and School of Biological Sciences; 2013.
  6. Pergams OR, Zaradic PA. Is love of nature in the US becoming love of electronic media? 16-year downtrend in national park visits explained by watching movies, playing video games, internet use, and oil prices. J Environ Manage. 2006;80(4):387-393.
  7. Zaradic PA, Pergams OR, Kareiva P. The impact of nature experience on willingness to support conservation. PLoS One. 2009;4(10):e7367. doi: 10.1371/journal.pone.0007367.
  8. van den Berg M, Wendel-Vos W, van Poppel M, Kemper H, van Mechelen W, Maas J. Health benefits of green spaces in the living environment: a systematic review of epidemiological studies. Urban For Urban Gree. 2015;14(4):806-816.
  9. US Department of Health and Human Services. Health-related quality of life and well-being. In Healthy People 2020. Washington, DC: US Dept of Health and Human Services. Office of Disease Prevention and Health Promotion. Updated June 10, 2016. Accessed June 13, 2016.
  10. World Health Organization. WHO Definition of Health. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, June 19-July 22, 1946; signed on July 22, 1946. 
  11. World Health Organization. Ottawa Charter for Health Promotion. Health Promot Int; 1986;1(4):405. doi:10.1093/heapro/1.4.405-a.
  12. Thompson CW, Aspinall P, Roe J. Access to green space in disadvantaged urban communities: evidence of salutogenic effects based on biomarker and self-report measures of wellbeing. Procedia Soc Behav Sci. 2014;153:10-22.