Health impacts of environmental and social interventions designed to increase deprived communities’ access to urban woodlands: a mixed methods study

Background: Contact with natural environments can bringhealth benefits but research is lacking on how changes in access to naturalenvironments might improve health, especially for deprived populations.

Objective: To evaluate the health impacts of woodlandenvironment interventions intended to increase communities’ engagement with thesewoodlands.

Design: A prospective study of Forestry CommissionScotland’s Woods In and Around Town (WIAT) programme in deprived communities toenhance public access to natural environments. The study investigated WIAT impactson community level mental health over time.

Setting: Three intervention and three control woodlandsites, and associated communities within 1.5km of the woodlands, located incentral Scotland and eligible for WIAT support.

Participants: A core community survey was administered ateach site in three waves, at baseline and after each phase of intervention(n=5,460, Panel A). The completed survey contained a nested longitudinal cohort(n=609, Panel B). Community members also undertook 6-monthly environmentalaudits at all sites (n=256) and participated in post-intervention focus groups(n=34).

Interventions: Phase 1 involved physical changes to thewoodlands, including footpaths, entrances and vegetation. Phase 2 involvedcommunity engagement events promoting woodland use.

Main outcome measures: The primary outcome was the PerceivedStress Scale (PSS). Other health measures included Health-Related Qualityof Life (HRQoL) (EQ5D), physical activity (PA) (IPAQ), connectedness to nature(INS) and social cohesion. iv

Results: PSS increased significantly in the interventiongroup and marginally decreased in the control. Multilevel regression modelsshowed a differential impact between intervention and control at survey Wave 3 in Panel A[B 3.58, 95% confidence interval (CI) 2.85 to 4.31, p<.001] and inPanel B [B 3.03, CI 1.54 to 4.52, p<.001]. Using the same analytical approach, nosignificant change in HRQoL was associated with the intervention. Economic assessmentincluded an illustrative costutility analysis and a cost-consequence analysis.The differential in stress between intervention and control was lower or non-significant inthose who visited ‘nature’ in the previous year [Panel A, B 1.9, CI 0.8 to 3, p<.001;Panel B, B 0.64, CI -1.6 to 2.88, p=0.57]. IPAQ showed positive association with theintervention for moderate levels of PA [Panel B, B 559.3, CI 211.3 to 907.2, p=0.002]and overall PA [Panel B, B 861.5, CI 106.5 to 1616.4, p=0.025]. The intervention wasalso associated with increased nature connectedness and social cohesion by Wave 3- significant for Panel A only. Qualitative and quantitative evidence showedinterventions increased the perceived quality of the woodland environment andenhanced its enjoyment for different activities but the increase in use of natural environmentspost-intervention was only 6% (Panel B).

Limitations: Our study was limited to three interventionsites. External factors may be the primary influence on health outcomes.

Conclusions: The WIAT interventions did not improvecommunity-level health within six months of completion, hence no basis for demonstratingcost-effectiveness. However, they are low cost (average £11.80 per person in theeligible population) and have potential for cost-effectiveness, if healthbenefits were found longer-term.

Future work: Using routinely collected data to consider awhole programme evaluation is recommended.

Funding details: The National Institute for Health Research,Public Health Research programme.