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Full-Text Screens Were Then Carried out Independently by Two Reviewers (MG, SC), While a Third Reviewer Was Used to Settle Conflicting Decisions International Journal of Environmental Research and Public Health Systematic Review Mechanisms of Impact of Blue Spaces on Human Health: A Systematic Literature Review and Meta-Analysis Michail Georgiou 1,* , Gordon Morison 2, Niamh Smith 1, Zoë Tieges 1,3 and Sebastien Chastin 1,4 1 School of Health and Life Sciences, Glasgow Caledonian University, 70 Cowcaddens Road, Glasgow G4 0BA, UK; [email protected] (N.S.); [email protected] (Z.T.); [email protected] (S.C.) 2 School of Engineering and Built Environment, Glasgow Caledonian University, 70 Cowcaddens Road, Glasgow G4 0BA, UK; [email protected] 3 Geriatric Medicine, Usher Institute, University of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK 4 Department of Movement and Sports, Ghent University, Watersportlaan 2, 9000 Ghent, Belgium * Correspondence: [email protected] Abstract: Blue spaces have been found to have significant salutogenic effects. However, little is known about the mechanisms and pathways that link blue spaces and health. The purpose of this systematic review and meta-analysis is to summarise the evidence and quantify the effect of blue spaces on four hypothesised mediating pathways: physical activity, restoration, social interaction and environmental factors. Following the PRISMA guidelines, a literature search was conducted using six databases (PubMed, Scopus, PsycInfo, Web of Science, Cochrane Library, EBSCOHOST/CINAHL). Fifty studies were included in our systematic review. The overall quality of the included articles, evaluated with Citation: Georgiou, M.; Morison, G.; the Qualsyst tool, was judged to be very good, as no mediating pathway had an average article quality Smith, N.; Tieges, Z.; Chastin, S. lower than 70%. Random-effects meta-analyses were conducted for physical activity, restoration and Mechanisms of Impact of Blue Spaces social interaction. Living closer to blue space was associated with statistically significantly higher on Human Health: A Systematic physical activity levels (Cohen’s d = 0.122, 95% CI: 0.065, 0.179). Shorter distance to blue space Literature Review and Meta-Analysis. was not associated with restoration (Cohen’s d = 0.123, 95% CI: −0.037, 0.284) or social interaction Int. J. Environ. Res. Public Health 2021, (Cohen’s d = −0.214, 95% CI: −0.55, 0.122). Larger amounts of blue space within a geographical area 18, 2486. https://doi.org/10.3390/ ijerph18052486 were significantly associated with higher physical activity levels (Cohen’s d = 0.144, 95% CI: 0.024, 0.264) and higher levels of restoration (Cohen’s d = 0.339, 95% CI: 0.072, 0.606). Being in more contact Academic Editors: Paul Tchounwou with blue space was significantly associated with higher levels of restoration (Cohen’s d = 0.191, and Simon Bell 95% CI: 0.084, 0.298). There is also evidence that blue spaces improve environmental factors, but more studies are necessary for meta-analyses to be conducted. Evidence is conflicting on the mediating Received: 22 December 2020 effects of social interaction and further research is required on this hypothesised pathway. Blue spaces Accepted: 27 February 2021 may offer part of a solution to public health concerns faced by growing global urban populations. Published: 3 March 2021 Keywords: physical activity; stress; social isolation; pollution; heat island; urban nature; park; lake; Publisher’s Note: MDPI stays neutral health; environment with regard to jurisdictional claims in published maps and institutional affil- iations. 1. Introduction The world’s urban population has grown by approximately 460% between 1950 and 2018, increasing the number of people living in urban areas from 751 million in 1950 to Copyright: © 2021 by the authors. 4.2 billion in 2018 [1]. This tremendous increase in the urban population has raised several Licensee MDPI, Basel, Switzerland. environmental, social and health concerns [2]. Urbanisation is linked to increased risk of This article is an open access article non-communicable diseases, premature mortality [3], as well as a higher risk of mental distributed under the terms and illnesses [4] and social isolation [5]. Urban growth is projected to continue and bring conditions of the Creative Commons an additional 2.5 billion people to urban areas by 2050 [1]. It is therefore of paramount Attribution (CC BY) license (https:// importance for city-planners to create sustainable and healthy urban environments, which creativecommons.org/licenses/by/ 4.0/). promote mental and physical wellbeing. Int. J. Environ. Res. Public Health 2021, 18, 2486. https://doi.org/10.3390/ijerph18052486 https://www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2021, 18, x 2 of 45 additional 2.5 billion people to urban areas by 2050 [1]. It is therefore of paramount im- portance for city-planners to create sustainable and healthy urban environments, which promote mental and physical wellbeing. Int. J. Environ. Res. Public Health 2021, 18, 2486Natural environments bring several benefits to public health and social wellbeing2 of 41in urban settings. Studies have shown that exposure to natural environments contributes to reduced mortality rates and increased wellbeing among urban dwellers [6]. Most of the research has concentrated on the impact of green spaces (e.g., parks), but in recent years it hasNatural emerged environments that blue spaces bring such several as coasts, benefits lakes, to public rivers health and canals and social can wellbeingbring similar in urbanbenefits settings. [7–9]. To Studies date, havefew studies shown thatdifferen exposuretiate between to natural green environments and blue spaces, contributes as blue to reducedspace is mortalityoften treated rates as and an inherent increased compon wellbeingent amongof parks urban and natural dwellers environments [6]. Most of the[9]. researchHowever, has blue concentrated spaces are onindependent the impact entities of green and spaces there (e.g., is a parks),need to but be inconsidered recent years sepa- it hasrately emerged and not that solely blue as spaces a subcategory such as coasts, of green lakes, spaces rivers [10]. and Over canals the can years, bring research similar ben- has efitsfocused [7–9 on]. To the date, negative few studies effects differentiateof blue spaces between and the greenunderstanding and blue spaces,of such aseffects blue is space well is often treated as an inherent component of parks and natural environments [9]. However, developed [11]. Health hazards, such as an increased risk of flooding and higher levels of blue spaces are independent entities and there is a need to be considered separately and disease transmission, through exposure to several microbes and contact of humans with not solely as a subcategory of green spaces [10]. Over the years, research has focused on a wide range of hazardous chemicals, have often been linked to blue spaces [11]. However, the negative effects of blue spaces and the understanding of such effects is well devel- recent epidemiological studies have shown that blue spaces also have a positive effect on oped [11]. Health hazards, such as an increased risk of flooding and higher levels of disease public health [9], including the reduction of mortality rate with the greatest rate of decline transmission, through exposure to several microbes and contact of humans with a wide seen in areas closest to blue space [12], better physical health [7], and better mental health range of hazardous chemicals, have often been linked to blue spaces [11]. However, recent [8]. In fact, a recent meta-analysis quantified the health impact of blue spaces and con- epidemiological studies have shown that blue spaces also have a positive effect on public cluded that it is as strong as that of green spaces [9]. Therefore, it logically derives that the health [9], including the reduction of mortality rate with the greatest rate of decline seen in existence of such benefits from blue spaces also enables discussion of environmental jus- areas closest to blue space [12], better physical health [7], and better mental health [8]. In tice around their accessibility and availability to some groups of the population. Simulta- fact, a recent meta-analysis quantified the health impact of blue spaces and concluded that itneously, is as strong blue asspaces that ofare green considered spaces [valuable9]. Therefore, ecosystem it logically services, derives have that both the an existence aesthetic ofand such ecological benefits role from in blue urban spaces environments also enables and discussion can be used of environmental for urban microclimate justice around regu- theirlation accessibility [10,13]. and availability to some groups of the population. Simultaneously, blue spacesIn are order considered to leverage valuable these ecosystemsalutogenic services, effects haveand improve both an aestheticthe health and of ecologicalthe urban rolepopulation, in urban it environments is important andto understand can be used the for linking urban microclimatemechanisms regulationbetween exposure [10,13]. to blue Inspace order and to health. leverage Four these mechanisms salutogenic have effects been and proposed improve to mediate the health the of relationship the urban population,between blue it spaces is important and health to understand (Figure 1): the(1) Access linking to mechanisms blue spaces may between promote exposure physical to blueactivity space which and health.is the fourth Four mechanismsmost important have risk been factor proposed for poor to mediatehealth [14];
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