Protective effect of restorative possibilities on cognitive function and mental health in children and adolescents: A scoping review including the role of physical activity

Environmental Research 233 (2023) 116452 Available online 18 June 2023 0013-9351/© 2023 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/bync-nd/4.0/). Protective effect of restorative possibilities on cognitive function and mental health in children and adolescents: A scoping review including the role of physical activity Angel M. Dzhambov a , b , c , 1 , * , Peter Lercher b , 1 , Natalia Vincens d , Kerstin Persson Waye d , Maria Klatte e , Larisa Leist e , Thomas Lachmann e , f , Dirk Schreckenberg g , Christin Belke g , Gordana Ristovska h , Katja M. Kanninen i , Dick Botteldooren j , Timothy Van Renterghem j , Sonja Jeram k , Jenny Selander l , Arzu Arat l , Kim White m , Jordi Julvez n , p , Charlotte Clark o , Maria Foraster p , q , r , s , Irene van Kamp m a Department of Hygiene, Faculty of Public Health, Medical University of Plovdiv, Plovdiv, Bulgaria b Institute of Highway Engineering and Transport Planning, Graz University of Technology, Graz, Austria c Research Group “Health and Quality of Life in a Green and Sustainable Environment”, SRIPD, Medical University of Plovdiv, Plovdiv, Bulgaria d School of Public Health and Community Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden e Cognitive and Developmental Psychology, University of Kaiserslautern-Landau, Kaiserslautern, Germany f Centro de Investigaci´ on Nebrija en Cognici´ on, Facultad de Lenguas y Educacion, Universidad Nebrija, Madrid, Spain g Centre for Applied Psychology, Environmental and Social Research (ZEUS GmbH), Hagen, Germany h Institute of Public Health of the Republic of North Macedonia, Skopje, Macedonia i A.I.Virtanen Institute for Molecular Medicine, University of Eastern Finland, Kuopio, Finland j Department of Information Technology, Faculty of Engineering and Architecture, Ghent University, Ghent, Belgium k National Institute of Public Health, Ljubljana, Slovenia l Unit of Occupational Medicine, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden m National Institute for Public Health and the Environment, Netherlands n Institut d’Investigaci´ o Sanit` aria Pere Virgili (IISPV), Clinical and Epidemiological Neuroscience Group (Neuro` Epia), Reus, Spain o Population Health Research Institute, St George’s University of London, London, United Kingdom p ISGlobal, Barcelona, Spain q Universitat Pompeu Fabra (UPF), Spain r CIBER Epidemiología y Salud Pública (CIBEREsp), Spain s PHAGEX Research Group, Blanquerna School of Health Science, Universitat Ramon Llull (URL), Barcelona, Spain ARTICLE INFO Keywords: Anxiety Attention Cognition Depression Green space Nature Restoration Sport ABSTRACT Background The exposome approach can be a powerful tool for understanding the intertwining of social, physical, and internal influences that shape mental health and cognitive development throughout childhood. To distil conceptual models for subsequent analyses, the EU-funded project Early Environmental quality and Life-course mental health effects (Equal-Life) has conducted literature reviews on potential mediators linking the exposome to these outcomes. We report on a scoping review and a conceptual model of the role of restorative possibilities and physical activity. Methods Peer-reviewed studies published since the year 2000 in English, on the association between the exposome and mental health/cognition in children/adolescents, and quantitatively investigating restoration/restorative quality as a mediating variable were considered. Database searches were last updated in December 2022. We used an unstructured expert-driven approach to fill in gaps in the reviewed literature. Results * Corresponding author. Department of Hygiene, Faculty of Public Health, Medical University of Plovdiv, 15A Vassil Aprilov Blvd., 4000, Plovdiv, Bulgaria. E-mail addresses: [email protected], [email protected], [email protected] (A.M. Dzhambov). 1 These two authors contributed equally. Contents lists available at ScienceDirect Environmental Research journal homepage: www.elsevier.com/locate/envres https://doi.org/10.1016/j.envres.2023.116452 Received 19 December 2022; Received in revised form 15 April 2023; Accepted 16 June 2023 Environmental Research 233 (2023) 116452 2 Five records of three distinct studies were identified, indicating a scarcity of empirical evidence in this newly developing research area. Not only were these studies few in numbers, but also cross-sectional, lending only tentative support to the idea that perceived restorative quality of adolescent’s living environment might mediate the association between greenspace and mental health. Physical activity emerged as a mediator leading to better psychological outcomes in restorative environments. We provide a critical discussion of potential caveats when investigating the restoration mechanism in children and propose a hierarchical model including restoration, physical activity, and relational dynamics between children and their environment, including social context, as well as restorative environments other than nature. Conclusions It is justified to further explore the role of restoration and physical activity as mediators in the association between early-life exposome and mental health/cognitive development. It is important to consider the child perspective and specific methodological caveats. Given the evolving conceptual definitions/operationalizations, Equal-Life will attempt to fill in a critical gap in the literature. 1. Introduction 1.1. Exposome perspective on child mental health and cognition There is increasing evidence that mental health and cognitive functioning are the result of a complex interplay between genetic, psychological, environmental, social, and other factors and experiences (Ventriglio et al., 2021; Barch, 2022; Deguen et al., 2022; Lachmann and Bergstr¨ om, 2023). Many mental health and cognitive problems in adulthood can be traced back to early developmental stages when the individual is more vulnerable to environmental and social adversities (Mulraney et al., 2021). Some of these early adversities can lead to epigenetic changes which increase the general risk for diseases via age acceleration (de Prado-Bert et al., 2021) or are specifically related to adult mental health problems (N¨ othling et al., 2020; Alameda et al., 2022). In general, children with symptoms of mental ill-health have shown poorer academic performance, quality of life, and social and mental functioning in later life (Luby et al., 2017; Copeland et al., 2021), creating a vicious circle, that is still insufficiently understood. Notably, anxiety, attention deficit hyperactivity disorder, conduct and depression disorders are among the most prevalent in children (Barican et al., 2022). Diagnosing these disorders at a young age is challenging and already during late adolescence and adulthood they cause considerable social and economic losses (GBD 2019 Mental Disorders Collaborators, 2022). The totality of exposures (detrimental or beneficial) over a complete lifetime is best captured by the concept of exposome, initially described by Wild (2005). This umbrella term can be divided into several non-genetic categories, internal and external, which is further subdivided into physical and social specific external, and general external exposomes (van Kamp et al., 2021). The exposome approach can be a powerful tool for conceptualizing and understanding the intertwining and cumulative effect of social, physical, and internal influences (Vineis and Barouki, 2022) that shape mental health and cognitive development across different contexts and microenvironments (e.g., home, public outdoor spaces, school) throughout childhood. Of note, the effects of different exposome components may vary in salience and strength across critical/sensitive developmental windows. However, the exposome effects on mental health and cognition in children and adolescents have been less studied and were predominantly focused on chemical, biological and physical exposures (e.g., Jedynak et al., 2021; Vineis and Barouki, 2022). Furthermore, the observed effects vary substantially, as only selected exposome factors or time windows were included and specific relationships among these factors and the social exposome (Deguen et al., 2022) were rarely explored especially with respect to mental health (cf. Mueller et al., 2019; Maitre et al., 2021) and cognition studies (cf. Julvez et al., 2021; Binter et al., 2022). The EU-funded project Early Environmental quality and life-course mental health effects (Equal-Life) employs the exposome framework in an integrated study of the broader determinants of children’s development and life course mental health (Van Kamp et al., 2021). Equal-Life is part of the European Human Exposome Network (http s://www.humanexposome.eu/; Vermeulen & Dillner, 2021). Apart from a non-targeted machine learning approach, Equal-Life relies on a set of theory-based questions formulated based on existing evidence, in order to explore the impact of multi-modal exposures (i.e., exposures interacting or mediating each other) on children’s mental health and cognition. To that end, datasets across Europe are used. Equal-Life builds on the original exposome concept (Wild, 2005, 2012) by further stressing the role of social influences, delineating them as a subdomain of the external exposome (Gudi-Mindermann et al., 2023 manuscript submitted to this issue). Central to our research endeavour is the understanding of putative pathways (i.e., mediators) underlying beneficial and harmful mental health effects of the child exposome. A mediator is an intervening factor, which is influenced by an exposure, which precedes it in time, and in turn leads to an outcome, which follows in time (VanderWeele, 2016). In addition, conceptual time-ordering of these is required (i.e., “the mediator must refer to a causal condition that emerges prior to the criterion outcome but not prior to the predictor”), even when dealing with cross-sectional data (Tate, 2015). The process of mediation then refers to a relationship between exposure, mediator, and outcome, where the mediator accounts for the effect of the exposure on the outcome either in part (partial mediation) or completely (full mediation). Addressing hypotheses about mediating processes is possible using regression-based statistical tools in an exploratory or confirmatory fashion to conduct mediation and moderation analyses. However, in addition to the mathematical and methodological attention, these require serious theoretical and conceptual consideration (Fiedler et al., 2018). To distil conceptual models that will inform subsequent empirical analyses, Equal-Life has conducted reviews of the literature on selected potential mediators (stress/restoration, sleep, and coping/selfregulation) believed to link the exposome to children’s mental health (including well-being and quality of life constructs) and cognition in different developmental phases. Our focus here is on the process of restoration and restorative possibilities, which can be seen as a conceptual focal point in a causal model where multiple pathways starting from the exposome converge to generate childhood health benefits (Dzhambov et al., 2018b). 1.2. Concept of restoration Responding to an excess of demands relative to the resources needed to cope with those demands is taxing and, in turn, depletes adaptive resources, which require periodic restoration (von Lindern et al., 2017). In other words, restoration can be defined as a process through which adaptive capacities diminished in ongoing efforts to meet adaptive demands are renewed, recovered, or re-established (Hartig, 2004). Thus, the restoration perspective necessarily complements and transacts with the stress and coping perspectives in human adaptation processes to the A.M. Dzhambov et al. Environmental Research 233 (2023) 116452 3 environment. Importantly, restoration is carried by person-environment transactions and is not an automatic outcome of objective exposure or simply being in a particular environment during time one might have available for restoration (von Lindern et al., 2017). Environment’s restorative quality depends on its potential to both permit and promote restoration, depending on contextual factors and individual differences (Hartig, 2004, 2021). Two influential theories have proposed psychological mechanisms by which nature experience can provide restorative benefits: the Kaplan’s (Kaplan and Kaplan, 1989; Kaplan, 1995) attention restoration theory (ART) and Ulrich’s psycho-evolutionary theory, usually referred to as stress recovery theory or stress reduction theory (SRT; Ulrich, 1979; Ulrich et al., 1991). Both theories supplement each other – the SRT is more focused on recovery from psycho-physiological stress, while ART deals with recovery from directed attention fatigue (mental fatigue). To be restorative, SRT requires an environment without uncontrollable threat, with moderate levels of complexity, with the perception of natural content or other visual stimuli to reduce psychophysiological arousal and induce positive affect. In ART, the perception of being away from hassles and routines or experienced fascination (e.g., in nature), among other perceptual facets, gives rest to neurocognitive processes involved in sustaining directed attention, and thus improves cognitive abilities (Hartig, 2021). This does not necessarily require the person to be in nature alone (Korpela and Staats, 2020; Hartig, 2021). It can be the experience of social support/cohesion or walking with friends, which Hartig (2021) is framing as “restoration of relational resources” or the psychological distance or feelings of “being away” through physical exercise. A recent theoretical work has emphasized the role of offsetting loneliness through nature contact as a pathway to better health (Astell-Burt et al., 2022). Regardless of which resource has become depleted, a precondition for its restoration is that the given socio-physical environment will support that restorative process and reduce stress and cognitive load (Hawthorne et al., 2019; Stevenson et al., 2019). Notably, the presence of positive features is the basic requirement of a “restorative environment”, which not only affords opportunities for restoration, but also encourages activities and experiences leading to restoration (Hartig, 2021). Another important aspect is that an environment of high restorative quality can afford opportunities to acquire new adaptive resources (i.e., instoration) and in turn support mental health/directed attention restoration and foster health in general (Markevych et al., 2017). For example, the likelihood of playing, engaging in other outdoor physical activities, or simply hanging out with friends is determined by characteristics of the built environment (Nordbø et al., 2020a). Recent evidence supports a role of restoration in the mechanisms behind mental health and cognitive development of children and adolescents (Berto et al., 2015; Collado and Staats, 2016; Amicone et al., 2018). However, consideration of the child perspective and how child experiences and restoration needs may differ from those of adults is still less well understood (Collado and Staats, 2016). 1.3. Aim and scope We report on a scoping review of the role of restorative possibilities and physical activity as pathways from the exposome to mental health and cognition in children and adolescents. We present a critical appraisal of research gaps in the existing literature that are potentially relevant to Equal-Life. Other scoping reviews in the series, which share the same literature search strategy, are focused on a conceptual framework for the exosome perspective in relation to mental health and cognitive development (Persson Waye et al., 2023a manuscript in preparation/A) and on the pathways – stress (Belke et al., 2023 manuscript in preparation), sleep (Persson Waye et al., 2023b, manuscript in preparation/B), and coping/self-regulation (Leist et al., 2023 manuscript in preparation/A) linking the exposome to mental health and cognitive development. 2. Methods 2.1. Organization of the review and conceptual model building The intent of this work was to generate a conceptual model of the relationships between the exposome, restoration, and child/adolescent’s mental health/cognition. As building blocks for that model, we leveraged existing empirical evidence and theoretically-indicated pathways that were evaluated as plausible enough to merit investigation in EqualLife, even if no direct evidence on them was available. In its structure, the present work echoes the structure of other works that start with a systematic review of the literature, which later feeds into a larger conceptual mechanistic model (Astell-Burt et al., 2022). The model building in the current review went through several stages, where empirical results on the role of restoration as a mediator linking different exposome domains to mental health/cognition served as a foundation. First, we conducted a scoping review of studies that specifically explored pathways from the exposome to restoration and then to mental health/cognition (1 layer of evidence). Second, we drew on empirical supporting evidence on partial associations, i.e., studies that examined the constituent pathways in a piecewise fashion (e.g., from exposome to restoration or from restoration to outcome). Here we looked at single exposures only, still addressing the mechanism via restoration, or instead of restoration explored mediation by instoration (e.g., via physical activity or social interaction in a restorative setting) (2 layer of evidence). Thus, while the scoping review followed a systematic and structured approach to evidence retrieval and synthesis, in the 2nd layer we adopted a more unstructured expert-driven approach to fill in gaps in the scoping review literature or add evidence that became available after the completion of the formal literature searches for the scoping review. The final model was developed through an iterative process. 2.2. Scoping review protocol We had no prior information on the extent of the literature on child exposome, restoration, and health, but we anticipated that the body of evidence would be heterogeneous. We were also mindful that the question we aimed to produce an answer to was rather broadly defined: “What is the evidence on restoration acting as a mediator linking the exposome to childhood mental health/cognition?”. Therefore, a systematic review framework was deemed too restrictive. Rather than a systematic review, we employed a scoping review framework, which is suitable for mapping heterogeneous knowledge base on an understudied subject and identifying research gaps, but at the same time shares the principles of transparent and reproducible reporting essential to systematic reviews (Peters et al., 2015). We followed the guidance for conducting scoping reviews outlined by Arksey and O’Malley (2005) and Peters et al. (2015). 2.2.1. Eligibility criteria We employed strict criteria for studies to be included in the review (Table 1). Study records had to be available in English, study the association between the exposome and child/adolescent mental health/ cognition, and quantitatively investigate restoration/restorative quality as a mediating variable. We did not include studies, in which no specific effort was made to evaluate mediation (i.e., studies in which restoration was merely adjusted for and treated as a confounder). Empirical studies of observational or experimental design were eligible, but reviews and ecological studies lacking individual-level data were excluded. Participants of any gender, nationality, and health status were eligible for inclusion, but they had to be under or equal to the age of 21, within the age range criterion for cohorts in Equal-Life. Studies that included different age groups were also included, if participants’ median age was ≤21 years. Participants could be members of the general population or a specific subgroup. A.M. Dzhambov et al. Environmental Research 233 (2023) 116452 4 We considered papers dealing with multiple, cumulative, or combined exposures. We aimed to retrieve both studies that formally stated having used the exposome framework, and studies that considered the effect of multiple exposures in the spirit of the exposome approach, even if they did not specifically use pertinent terminology. At least two physical exposures (e.g., air pollution and traffic noise) or at least one physical exposure in combination with other exposures pertaining to the social (e.g., social support) or the internal exposomes (e.g., biomarkers) were prerequisites for including a study in the scoping review. Our focus on physical exposures was influenced by a knowledge gap regarding the effects and potential mechanisms of cumulative physical exposures on children’s and adolescents’ mental health and cognition, either in connection to social exposures or as interacting physical exposures (van Kamp et al., 2021). For further details on this approach, we refer to Persson Waye et al. (2023a) (manuscript in preparation/A). Outcomes of interest are listed in Table 1 and included measures of mental health, positive or negative affect, externalizing behaviours or internalizing symptoms, cognitive functioning, and academic performance. 2.2.2. Information sources and search strategy Electronic searches of peer-reviewed studies published since the year 2000 were performed in two databases, Scopus and PsycINFO. These searches based on title and abstract were conducted by librarians at the University of Gothenburg on June 17, 2020 and later updated on October 5, 2020. The search strategy was discussed within the research team and with the librarians. Given the time gap between these initial searches and the completion of the evidence synthesis, we updated the searches one last time just prior to submission of this paper. The updated searches were extended from 2020 until December 1, 2022. The search terms in each search block, as well as the keyword strings used in the latest searches are shown in Table S1, Section S1 and Section S2. In addition, we searched papers based on the cohorts and school studies included in Equal-Life (https://www.equal-life.eu/en), and reference lists of relevant review papers and articles. To augment the list of included studies, personal libraries of experts within the consortium and suggested papers from the Equal-Life advisors were screened. To manage the review at the screening phase, we used Rayyan (Ouzzani et al., 2016). The first screening was based on title and abstract only. Two reviewers independently assessed each record against the list of inclusion/exclusion criteria. Study records were judged as relevant, not relevant, or potentially relevant. Conflicts between the reviewers were resolved through consensus or by a third reviewer. Papers deemed relevant and potentially relevant were advanced to the eligibility phase, in which a new pair of reviewers assessed each full text. Noteworthy, co-authors of the present review were not involved in screening or assessing the eligibility of their own studies identified in the electronic searches. 2.2.3. Data charting In the eligibility phase, reviewers extracted data on the following study characteristics: study design, location and period, sampling strategy and sample size, exposure definition and assessment, outcome definition and assessment, mediator definition and assessment, and statistical analysis. These data were extracted in a pre-designed form by one reviewer and verified by another reviewer. 2.3. Supporting mechanistic evidence We used further evidence on partial associations between exposome to mediators and/or mediators to outcomes identified at earlier stages of the screening for the scoping review. That is, studies from other sources and those excluded from the scoping review because they did not fulfil all inclusion criteria that were used to support specific associations within our model. For example, if a study only looked at one exposure, such as air pollution, it would be excluded from the scoping review, but could provide useful information for constructing our conceptual model. Further, we performed a non-systematic rapid search for studies in PubMed and Google Scholar of evidence published after the last update of the scoping review. Physical activity-related terms were also used in these searches. We incorporated existing models and theories to construct a conceptual model, which could later inform analyses in Equal-Life. The level of detail at this stage was limited to constructs related to restoration and instoration (i.e., physical activity, social interaction), while more distal constructs that lay closer to other mediators of interest in Equal-Life (stress, sleep, coping and self-regulation) will be covered in the other reviews in this series. 2.4. Synthesis of findings Study characteristics were described in narrative and tabulated. The pathways between exposome, restoration/instoration, and mental health/cognition were graphed. 3. Results 3.1. Search results Fig. 1 shows the study selection flow chart. Electronic searches and expert suggestions yielded 3429 hits, of which 2996 were left after removing duplicate records. Following title and abstract screening, we excluded additional 2738 records on relevance. Of the 228 remaining full texts we assessed for eligibility, 223 were excluded. That left us with five (partially overlapping) study records of three distinct studies (i.e., datasets). 3.2. Study characteristics The characteristics of studies included in the narrative synthesis are given in Table 2 (Dzhambov et al., 2017, 2018a, 2018b, 2018c; Dzhambov, 2018). All five reports were published by the same research Table 1 Inclusion and exclusion criteria used to screen study records in the scoping review. Inclusion criteria Exclusion criteria Population Humans, children/adolescents (0–21 years) or at least >50% of participants ≤21 years old Animal studies, <50% of participants <21 years old, pregnant women Study design Cross-sectional, case-control, cohort, case crossover, (quasi-) experimental, randomized controlled trial Reviews, ecological/area-level studies Exposures Multiple physical exposures or at least two exposures pertaining to different exposome domains, one of which to the physical exposome; objectively measured and/or self-reported Single exposures or multiple exposures from only social or internal exposome domain Outcomes Child/adolescent mental health and/or cognition and/or wellbeing/quality of life; objectively measured or self-reported (different than above; mental health, positive or negative affect, externalizing or internalizing symptoms, cognitive functioning, and academic performance. Only maternal outcomes, perceived general health, physical health outcomes Mediators Actual or perceived restoration, environmental restorative quality/restorativeness; objectively measured or selfreported Restoration/restorative quality only treated as a confounder, but not an intermediate variable; no formal test or interpretation of mediation by restoration/restorative quality Note. For a detailed list of the indicators and search terms, see Table S1. A.M. Dzhambov et al. Environmental Research 233 (2023) 116452 5 group and some of them shared subjects, leaving us with only three unique datasets. Since they reported on different mechanistic pathways, we retained them in the review but took care not to double count evidence on the same pathway when based on the same sample. The studies were conducted in the city of Plovdiv, Bulgaria, where convenience samples of university and high school students were surveyed cross-sectionally. Only one study was of panel design and collected data at two time points, the beginning and the end of the academic year (Dzhambov, 2018). The outcome in these studies was a composite of anxiety and depression symptoms measured with the 12-item version of the General Health Questionnaire (Goldberg and Blackwell, 1970). The main physical exposures investigated were natural outdoor environments and traffic emissions. Generally, multiple indicators were used to operationalize greenspace, including satellite-derived vegetation indices, availability of greenspace land use/cover, and distances to green and blue spaces from participants’ residential address. Long-term traffic noise and air pollution were measured more crudely with single indicators (i.e., day-evening-night sound pressure levels and nitrogen dioxide). Three of the studies treated air pollution and noise not simply as co-exposures, but also as mediators that stood on the path from greenspace to mental health (Dzhambov, 2018; Dzhambov et al., 2018a, 2018b). Furthermore, objective measures of these physical exposures were supplemented with perceived measures of green and blue spaces, and annoyance by noise, air pollution and vibration (forming an environmental annoyance scale), which were in turn assumed to operate as intermediate variables leading to mental health. Perceived neighbourhood restorative quality, measured with items from the Perceived Restorativeness Scale (Hartig et al., 1997a, 1997b) that captured feelings of being away and fascination with the neighbourhood environment, emerged as a central mediator. It was associated with more greenspace, higher physical activity and social cohesion, and lower perceived noise and air pollution. In turn, those mediating variables led to better mental health. In one study (Dzhambov et al., 2018a), traffic noise related to mental ill-health via Fig. 1. Flowchart of the paper selection process for the scoping review. A.M. Dzhambov et al. Environmental Research 233 (2023) 116452 6 Table 2 Summary of findings in the scoping review. Study Design Population Setting Exposome Mediator Outcome Analysis method Results Physical Social Dzhambov et al. (2018b) Crosssectional Students (N =720) Median age: 21 (range 18–35 yrs) 64.2% female Residential (Bulgaria) Greenness (NDVI, tree cover), Green space land cover, Distance to green space, Perceived greenness scale Distance to bluespace, Perceived bluespace scale Air pollution (NO 2 ) and traffic noise (L day ) conceptualised as mediators in the analysis Perceived neighbourhood social cohesion conceptualised as mediator in the analysis Restoration Perceived restorative quality of the neighbourhood Instoration Social cohesion, Physical activity Stress Environmental annoyance (noise, air pollution, vibration) Others Perceived neighbourhood green/blue space, noise and air pollution General mental health (GHQ-12) Structural equation modelling Other covariates in SEM: sex, age, ethnicity, month, SES, population density, settlement, duration of residence, time spent at home, stressful events ⁃ Higher greenness associated with better mental health through higher perceived greenspace, higher restorative quality, and subsequently higher physical activity ⁃ Mediation also via lower noise exposure and higher perceived greenspace, and then lower annoyance ⁃ Bluespace associated with higher perceived bluespace, restorative quality, and physical activity ⁃ Bluespace also associated with higher noise exposure and annoyance Dzhambov (2018) Crosssectional & 2wave panel Students (N =109) Median age: 21 (range 18–35 yrs) 45% female Residential (Bulgaria) Greenness (NDVI) Distance to bluespace Air pollution (NO 2 ) and traffic noise (L day ) conceptualised as mediators in the analysis Perceived neighbourhood social cohesion conceptualised as mediator in the analysis Restoration Perceived restorative quality of the neighbourhood Instoration Social cohesion, Physical activity Stress Environmental annoyance (noise, air pollution, vibration) Others Air pollution, noise General mental health (GHQ-12) Cross-sectional single mediation models; longitudinal mediation using cross-lagged panel single mediation models Other covariates in SEM: sex, age, ethnicity, SES, duration of residence, time spent at home ⁃ Cross-sectional analysis: higher residential greenness associated with better mental health only indirectly through higher physical activity and restorative quality. Blue space: mediation by physical activity and restorative quality; ⁃ Longitudinal analysis: higher greenness and nearer blue space associated with better mental health, but no mediation. Dzhambov et al. (2018a) Crosssectional Students (N =720) Mean age: 21 yrs (range 18–35 yrs) 66% female Residential (Bulgaria) Air pollution NO 2 , Traffic noise LAeq Perceived neighbourhood social cohesion conceptualised as mediator in the analysis Restoration Perceived restorative quality of the neighbourhood Instoration Social cohesion, Physical activity Stress Environmental annoyance (noise, air pollution, vibration) Sleep disturbance Difficulty falling General mental health (reduced GHQ-11) Structural equation modelling Other covariates in SEM: sex, age, ethnicity, month, income, population density, duration of residence, time spent at home ⁃ Association between higher L Aeq and GHQ ⁃ L Aeq associated with higher annoyance, and through it with lower restorative quality, and then with lower physical activity, and thus with higher GHQ. ⁃ Higher annoyance associated with higher sleep (continued on next page) A.M. Dzhambov et al. Environmental Research 233 (2023) 116452 7 Table 2 (continued) Study Design Population Setting Exposome Mediator Outcome Analysis method Results Physical Social asleep +waking up during the night disturbance, and then with higher GHQ. ⁃ NO 2 associated with GHQ only indirectly through higher annoyance, lower restorative quality, and lower physical activity Dzhambov et al. (2017) Crosssectional High school and university students (N =399) Mean age: 17.89 yrs (range: 15–25 yrs) 32.1% female Residential (Bulgaria) Road traffic noise (L den ) Perceived neighbourhood social cohesion conceptualised as mediator in the analysis Restoration Perceived restorative quality of the neighbourhood Instoration Social cohesion, Physical activity Stress Road traffic noise annoyance General mental health (GHQ-12) Linear regression mediation models (product of coefficients method), structural equation modelling Other covariates in SEM: sex, SES, ethnicity, noise sensitivity ⁃ Higher noise exposure associated with worse mental health only indirectly. ⁃ Single and parallel mediation models: mediation by annoyance, social cohesion, and physical activity. ⁃ SEM: higher annoyance associated with less social cohesion, and in turn with worse mental health ⁃ Annoyance also associated with lower restorative quality, then with less social cohesion and physical activity, and in turn with worse mental health Dzhambov et al., 2018c Crosssectional Students from high schools and universities (N =399) Mean age: 17.89 yrs (range: 15–25 yrs) 32.1% female Residential (Bulgaria) Greenness (NDVI, SAVI, tree cover), Distance to green space, Perceived greenness scale Air pollution (NO 2 ) and Traffic noise (L day ) conceptualised as mediators in the analysis Neighbourhood social cohesion conceptualised as mediator in the analysis Restoration Perceived restorative quality of the neighbourhood Instoration Social cohesion, Physical activity Stress Road traffic noise annoyance Other Perceived air pollution General mental health (GHQ-12) Single mediation models with mediators tested one-at-a-time (product of coefficients method) Parallel mediation model with mediators assumed to act independently Theoreticallyindicated serial mediation models Other covariates in SEM: sex, age, ethnicity, SES, population density, duration of residence, time spent at home, school, month ⁃ No direct association between objectivelymeasured greenspace and mental health ⁃ Restorative quality mediated the relationship between NDVI and mental health in some single mediation models. ⁃ No indirect effects in parallel mediation models ⁃ In serial mediation models, higher greenness associated with better mental health via higher restorative quality, and then higher physical activity and (continued on next page) A.M. Dzhambov et al. Environmental Research 233 (2023) 116452 8 higher annoyance and sleep disturbance. The social exposome was represented by perceived neighbourhood social cohesion, which was conceptualised as one of the mediators that connected restorative quality to mental health. Pathways for which evidence of significant mediation was found (i. e., statistically significant indirect effect reported) are shown in Fig. 2. The studies employed formal mediation analyses, comparing single, parallel, and serial mediation models, or fitting complex structural equation models that attempted to model the interrelationships between objective and perceived physical exposures, restorative quality, and the instoration variables social cohesion and physical activity. Physical activity was consistently associated with better mental health, working in serial with higher restorative quality. Of note, the panel study found evidence of mediation by restorative quality and physical activity only at baseline (cross-sectional analysis), but not in the longitudinal analysis (Dzhambov, 2018). 3.3. Supporting evidence Studies that were excluded from the scoping review or that were published after the last update of the searches or that came from personal libraries that reported relevant information on specific pathways of interest, were reviewed at this stage (see Table 3). Seven additional studies supplemented the limited evidence provided by the scoping review. None of these were identified in the searches for the scoping review because they were not addressing exposures in the title/abstracts in an explicit exposome/cumulative approach according to Equal-life’s strategy (Persson Waye et al., 2023a manuscript in preparation/A). The reason for excluding most of these studies from the scoping review was the lack of a second exposome indicator in most of them. Most studies were of cross-sectional design, but their samples were considerably larger and more diverse than the convenience samples included in the scoping review. Different age groups were covered, including children, teenagers, and university students. One cohort study investigated mental and psychomotor development indicators in infants, followed from birth until the age of two years (Liao et al., 2019). Most studies focused on the psychological effects of exposure to residential greenspace, measured objectively with a satellite imagebased vegetation index or with perceptual measures of greenness, such as perceived general neighbourhood greenness or green window views from home. One study measured perceived greenspace quality rather than availability (Putra et al., 2021). Other studies did have a second exposome indicator but did not directly measure restoration as a process or the restorative quality of a setting, while two studies looked at perceived restorative quality (Hipp et al., 2016; Gulwadi et al., 2019) but not from an exposome perspective. Besides greenspace, Nordbø et al. (2020a) measured population density, number of facilities/amenities, playgrounds, and schools in the neighbourhood, and Liao et al. (2019) conceptualised fine particulate matter air pollution as a mediator for greenness. Three studies (Wang et al., 2019; Nordbø et al., 2020a; Putra et al., 2021) conceptualised social cohesion/social interaction as a mediator between greenspace and health. Physical activity was also frequently tested as a mediator, with the cohort study by Liao et al. (2019) looking at maternal physical activity during pregnancy. Some studies also considered air pollution and noise (Liao et al., 2019), perceived air pollution and noise levels (Wang et al., 2019), and psychological symptoms as mediators (Putra et al., 2021). Overall, better psychological wellbeing and less behaviour problems were observed in children/adolescents living or going to school in a greener neighbourhood. Although these studies employed less advanced mediation analysis (tested single mediators) than those included in the scoping review, they could still detect that part of the effect on psychological wellbeing and behaviour problems was mediated by higher perceived restorative quality (Hipp et al., 2016; Gulwadi et al., 2019), higher or more frequent engagement in outdoor physical activity (Wang et al., 2019; Nordbø et al., 2020a; Putra et al., 2021), and more social interaction (Wang et al., 2019; Nordbø et al., 2020a; Putra et al., 2021). Lower air pollution (Liao et al., 2019) and perceived traffic emissions (Wang et al., 2019) also emerged as mediators. Findings were not entirely consistent. For example, Putra et al. (2021) found stronger mediation evidence for child mental health via health-related quality of life than via physical activity and social interaction; this evidence was also more pronounced in late childhood and when the outcome (prosocial behaviour) was caregiver-reported. Another study did not detect mediation by physical activity and only reported an association between distance to greenspace and hyperactivity/inattention in boys, and not Table 2 (continued) Study Design Population Setting Exposome Mediator Outcome Analysis method Results Physical Social higher social cohesion Note. Abbreviations: GHQ – General Health Questionnaire; L Aeq – equivalent A-weighted sound pressure level; L day – daytime sound pressure level; L den – day-eveningnight sound pressure levels; NDVI – normalized difference vegetation index; NO 2 – nitrogen dioxide; SAVI – soil-adjusted vegetation index; SES – socio-economic status; SEM – structural equation modelling. Fig. 2. Pathways for which evidence of mediation (i.e., statistically significant indirect effect) was found in the scoping review. Note. Several studies based on the dataset supplied evidence for construction of the diagram. Green arrows indicate positive associations, and red arrows, negative associations. Abbreviations: GS – greenspace, BS – bluespace. A.M. Dzhambov et al. Environmental Research 233 (2023) 116452 9 Table 3 Summary of studies providing supporting evidence about pathways from the physical exposome to child mental health/cognition involving restoration/instoration. Study Design Population Setting Exposome Mediator Outcome Analysis method Results Physical Social Hipp et al., (2016) Crosssectional Students from three universities (N =441) Mean age: 23.6 yrs. 78.2% female School campus (USA and Scotland) Perceived greenness scale No Restoration Perceived restorative quality (PRS), subscales: Being away, Fascination, Coherence, Compatibility Quality of life (WHOQOLBREF) Single mediation analysis (product of coefficients method) ⁃ Higher perceived campus greenness associated with greater quality of life via higher perceived campus restorativeness Liao et al., (2019) Cohort New-borns followed for 2 yrs (N = 1312) Age 2 Residential (China) Greenness (NDVI) Air pollution (PM 2.5 ) conceptualised as mediator in the analysis No Instoration Physical activity of mother during pregnancy Other Air pollution Mental development, Psychomotor development (Bayley Scales of Infant Development) (expert administered) Single mediation analysis (causal steps approach) ⁃ Reduced levels of traffic-related air pollution explained 13.6%– 28.0% of the association between exposure to green space and early childhood psychomotor development Wang et al., (2019) Crosssectional Teenagers (N =4538) Mean age: 14.57 yrs. 51% female Residential (USA) Greenness (NDVI) Social cohesion conceptualised as mediator in the analysis Instoration Social cohesion, Physical activity Stress Self-reported stress Other Perceived air quality and noise in the neighbourhood Psychological distress (K6) Single mediation analysis (difference of coefficients method) ⁃ Streetscape greenery and NDVI were positively associated with mental wellbeing. ⁃ Significant partial mediators for the streetscape greenery were physical activity, stress, perceived air quality and noise, and social cohesion ⁃ For NDVI, only physical activity and social cohesion were significant partial mediators Markevych et al., (2014) Crosssectional Children (N =1625) Mean age: 10.1 yrs. 49% female Residential (Germany) Distance to green space, Greenness (NDVI) No Instoration Physical activity proxies – Time spent outdoors, Time spent in front of a screen Behavioural problems (SDQ - different subscales and total score) Parallel mediation analysis (Difference of coefficients method – adjusting for mediator) ⁃ Greater distance between the residence and the nearest green space associated with higher odds of hyperactivity/ inattention ⁃ This association was only statistically significant among males. ⁃ Behavioural problems were not associated with the distance to forests or residential surrounding greenness Gulwadi et al., (2019) Crosssectional Students (N =1079) Mean age: 21.5 yrs. 61% female School campus (Turkey and USA) Greenness (NDVI) No Restoration Perceived restorative quality Other Perceived greenness Quality of life (WHOQOLBREF) Serial mediation analysis (Product of coefficients method) ⁃ Higher greenness directly associated with better overall quality of life ⁃ Indirect associations mediated by perceived greenness and (continued on next page) A.M. 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