En i onmen al Resea ch 210 (2022) 112994
A ailable online 25 Feb ua y 2022
0013-9351/© 2022 The Au ho s. Published by Else ie Inc. This is an open access a icle unde he CC BY-NC-ND license (h p://c ea i ecommons.o g/licenses/by-
nc-nd/4.0/).
E ec s o esiden ial g eenness on a en ion in a longi udinal s udy a 8 and
11–13 yea s
A. Anabi a e
a
,
b
,
*
, J. Iba luzea
b
,
c
,
d
,
e
, G. Ga cía-Baque o
e
, L. San a Ma ina
b
,
d
,
e
,
A. Fe n´
andez-Somoano
e
,
,
g
, A. Ta d´
on
e
,
,
g
, M. Nieuwenhuijsen
e
,
h
,
i
, M. de Cas o
e
,
h
,
i
,
P. Dad and
e
,
h
,
i
, A. Le xundi
a
,
b
,
e
a
Depa men o P e en i e Medicine and Public Heal h, Facul y o Medicine, Uni e si y o he Basque Coun y (UPV/EHU), Leioa, 48940, Spain
b
Biodonos ia, En i onmen al Epidemiology and Child De elopmen G oup, San Sebas ian, 20014, Spain
c
Facul y o Psychology o he Uni e si y o he Basque Coun y, San Sebas ian, 20018, Spain
d
Heal h Depa men o Basque Go e nmen , Sub-di ec o a e o Public Heal h o Gipuzkoa, San Sebas ian, 20013, Spain
e
Spanish Conso ium o Resea ch on Epidemiology and Public Heal h (CIBERESP), Ins i u o de Salud Ca los III, Mad id, 28029, Spain
Depa men o P e en i e Medicine and Public Heal h, Uni e si y o O iedo, O iedo, 33006, Spain
g
Ins i u o de In es igaci´
on Sani a ia del P incipado de As u ias (ISPA), O iedo, 33006, Spain
h
ISGlobal, Ba celona, Spain
i
Uni e si a Pompeu Fab a (UPF), Ba celona, 08003, Spain
ARTICLE INFO
Keywo ds:
Longi udinal s udy
Ina en ion
NDVI
INMA
Child en
ABSTRACT
In an u banizing wo ld, wi h 55% o he popula ion li ing in ci ies, i is essen ial o design iendly and heal hy
ones. An eme ging body o e idence has associa ed g eenspace exposu e wi h imp o ed cogni i e de elopmen ,
including a en ional unc ion; howe e , he longi udinal s udies looking a he associa ion wi h a en ional
unc ion a e s ill sca ce. The e o e, he objec i e o his s udy was o analyze he associa ion o he exposu e o
g eenspace and a en ion in school child en. This s udy was based on 751 pa icipan s a 8 yea s and 598 a
11–13 yea s o wo sub-coho s o he INMA coho s udy in Gipuzkoa and As u ias, Spain. G eenspace exposu e
a home was cha ac e ized using ou indica o s: (i) a e age o No malized Di e ence Vege a ion Index (NDVI)
and (ii) Vege a ion Con inuous Field (VCF) in bu e s o 100 m, 300 m, and 500 m a ound he esiden ial add ess,
(ii) a ailabili y o a g een space wi hin 300 m om he esiden ial add ess, and (i ) esiden ial dis ance o g een
spaces. Pa icipan s’ a en ion was cha ac e ized wice a ages o 8 and 11 yea s, using he compu e ized
A en ional Ne wo k Tes (ANT). Gene al linea models we e used o he c oss-sec ional analyses and linea
mixed e ec s model o he longi udinal analyses. Ou c oss-sec ional analyses showed a s a is ical signi ican
p o ec i e associa ion be ween a e age NDVI a 300 m and ina en i eness (−7.20, CI 95%: 13.74; −0.67). In ou
longi udinal analyses, al hough we gene ally obse ed bene icial associa ions be ween g eenspace exposu e and
a en ion, none a ained s a is ical signi icance. No s a is ically signi ican indi ec e ec we e seen o NO
2
. Ou
indings add o he eme ging body o e idence on he ole o g een spaces in neu ode elopmen , which can
p o ide he e idence base o implemen ing in e en ion aimed a p omo ing neu ode elopmen in u ban
child en.
1. In oduc ion
The indus ializa ion accele a ed he p ocess o u al exodus o he
ci y in sea ch o be e li ing and wo king condi ions (Delgado Vi˜
nas,
2019). This u baniza ion p ocess has occu ed mos ly due o weal h
c ea ion and economic g ow h in ci ies (Be encou and Wes , 2010).
E en so, his p og essi e inc ease o he popula ion in ci ies had led he
scien i ic communi y o e alua e whe he cu en u ban en i onmen s
a e heal hy o people’s well-being (WHO, 2010).
Cu en u ban en i onmen s o en p omo e an unheal hy li es yle
such as lack o physical ac i i y and s ess and highe exposu es o
en i onmen al haza ds such as ai pollu ion, noise, and hea ha a e
de imen al o heal h (Nieuwenhuijsen and Kh eis, 2019). F om a public
heal h and u ban planning pe spec i e, in o de o ensu e people’s
* Co esponding au ho . Pl. de Elhuya , 2, 20018, Donos ia-San Sebas ian, Gipuzkoa, Spain.
E-mail add ess: [email p o ec ed] (A. Anabi a e).
Con en s lis s a ailable a ScienceDi ec
En i onmen al Resea ch
jou nal homepage: www.else ie .com/loca e/en es
h ps://doi.o g/10.1016/j.en es.2022.112994
Recei ed 20 Oc obe 2021; Recei ed in e ised o m 17 Feb ua y 2022; Accep ed 19 Feb ua y 2022
En i onmen al Resea ch 210 (2022) 112994
2
wellbeing, i is necessa y o design heal hie and mo e esilien and
sus ainable ci ies (Duhl and Sanchez, 1999; WHO, 2008). Abo e all,
g ea e emphasis needs o be placed on hose ulne able g oups o
whom he exposu e o hese en i onmen al ac o s has he g ea es e -
ec on heal h. The olde adul , people wi h ch onic diseases and hose
wi h low socioeconomic s a us a e mo e ulne able o noise, ex eme
empe a u es, and ai pollu ion exposu e han he gene al popula ion
(Eu opean En i onmen Agency, 2018). Child en a e also conside ed as
a ulne able g oup because hey ha e highe espi a o y equency han
adul s and he e o e a highe exposu e o ai pollu an s. In addi ion,
hei immune sys em and o gans a e no ye ma u e as hey a e unde
de elopmen and he e o e a e mo e suscep ible o he en i onmen al
haza ds (Eu opean En i onmen Agency, 2018).
U ban g eenspaces a e de ined as land ha is pa ly o comple ely
co e ed wi h g ass, ees, sh ubs, o o he ege a ion). G eenspace in-
cludes pa ks, communi y ga dens, and ceme e ies (Uni ed S a es En i-
onmen al P o ec ion Agency, n.d.). Acco ding o a ecen sys ema ic
e iew, u ban g eenspaces ha e po en ially posi i e e ec s on physical,
men al heal h and well-being o he popula ion (Gian edi e al., 2021).
These heal h bene i s could be in pa explained h ough he abili y o
g eenspaces o mi iga e he exposu e o he u ban- ela ed en i on-
men al haza ds such as ai pollu ion, hea , o noise and p omo e social
in e ac ions and physical ac i i y (Dad and e al., 2014; Dad and e al.,
2015a, 2015b; Dad and e al., 2019; Diene and Mudu, 2021; Ma ke-
ych e al., 2017; Nieuwenhuijsen and Kh eis, 2019; Wo ld Heal h O -
ganiza ion, 2017).
Mo eo e , acco ding o he A en ion Res o a ion Theo y (ART),
g eenspaces could es o e di ec ed a en ion. Based o his heo y, when
people en e a na u al space, hei a en ion is deac i a ed and ins ead,
hei e o less a en ion is ac i a ed, esul ing in he es o a ion o
di ec ed a en ion capaci y (Ha ig e al., 2014; Kaplan, 1995; Ma ke-
ych e al., 2017). I is du ing childhood and adolescence when cogni-
i e unc ions such as a en ion, expe ience a highe de elopmen , he
b ain de elops s eadily du ing he p ena al and pos na al pe iod, being
hese pe iods he mos ulne able o he possible e ec s o en i on-
men al pollu an s. Howe e i is du ing childhood and adolescence
when cogni i e unc ions such as a en ion, expe ience a highe de el-
opmen (Ande son, 2002; G andjean and Land igan, 2014).
Ea lie quasi-expe imen al s udies e alua ed he imp o emen o
a en ion ac oss wo exposu e g oups: ei he walking in a na u al en i-
onmen o walking in a non-na u al en i onmen in child en aged 4–10
yea s (Anabi a e e al., 2021; Schu e e al., 2017; S e enson e al.,
2019). These s udies, e alua ing he sho - e m e ec o na u al en i-
onmen on a en ion we e gene ally suppo i e o a bene icial associ-
a ion (Kuo and Fabe Taylo , 2004; Schu e e al., 2017; S e enson e al.,
2019). La e , epidemiological s udies s a ed o e alua e he associa ion
o he long- e m g eenspace exposu e on a en ion in child en. Amoly
e al. (2015) objec i ely measu ed esiden ial exposu e o g eenspace
and assessed, c oss-sec ionally, i s ela ionship wi h a en ion in chil-
d en a age o 7–10 yea s concluding ha highe esiden ial exposu e o
g eenspace was associa ed wi h be e a en ion. Dad and e al. (2015a,
2015b), e alua ed sho - e m memo y and ina en ion in a Spanish
coho o child en aged 7–10 yea s and ound ha exposu e o g een-
space a school was associa ed wi h imp o emen s in sho - e m mem-
o y and a en ion o e a pe iod o 12 mon hs. On he o he hand,
Dad and e al. (2017) analyzed he associa ion o exposu e o g een-
space wi h a en ion o e a longe pe iod o ime. These s udies ound
ha hose child en who had mo e exposu e o g eenspace had be e
a en ion and cogni i e de elopmen .
The e a e ew s udies analyzing he ela ionship be ween exposu e o
g eenspace and neu ode elopmen du ing childhood, and ew au ho s
ha e s udied his ela ionship longi udinally. The e o e, his s udy
aimed o e alua e he associa ion o long- e m exposu e o g eenspace
wi h a en ion using wo di e en app oaches: a longi udinal app oach
including wo epea ed measu emen s o a en ion (8 and 11–13 yea s
old) and a c oss-sec ional app oach aking in o accoun only one
measu emen o a en ion (8 o 11–13 yea s old).
2. Me hods
2.1. S udy se ing and popula ion
The INMA coho is a well-es ablished popula ion-based coho
aimed a e alua ing he ole o en i onmen al ac o s du ing p egnancy
and childhood on he g ow h and de elopmen o child en (Guxens
e al., 2012). The INMA coho is conduc ed in se en cen es ac oss
Spain, including Sabadell, G anada, Valencia, As u ias, Gipuzkoa,
Meno ca and Flix. This cu en s udy is based on da a om As u ias and
Gipuzkoa, bo h loca ed in he no h o Spain. They ha e a empe a e
clima e wi h mild summe s and wa e a ailabili y all o e he yea (C b
acco ding o K¨
oppen’s classi ica ion), so hey ha e high le els o a bo-
eal ege a ion (Gobie no de Espa˜
na, 2011).
P egnan women we e in o med abou he p ojec and ec ui ed
du ing he i s imes e s o p egnancy in heal h cen es and hospi als o
he public heal h sys em. The inclusion c i e ia we e he ollowing:
being olde han 16 yea s, ha ing a single on p egnancy, no ha ing
used assis ed ep oduc ion echniques, in en ion o gi e bi h in he
e e ence hospi al, and speaking and unde s anding Spanish o he local
language (Basque, in he case o Gipuzkoa). Since ec ui men , da a ha e
been collec ed in se e al ollow-up phases: in he i s and hi d
imes e o p egnancy, a bi h, and when he child was 14 mon hs, 26
mon hs, 4 yea s, 8 yea s and 11 yea s o age. A he beginning o he
s udy (2004–2007 in As u ias and 2006–2008 in Gipuzkoa), 1132
p egnan women we e ec ui ed (494 om As u ias and 638 om
Gipuzkoa), and 751 pa icipan s aged 8 yea s and 598 pa icipan s aged
11–13 yea s we e included in his s udy (Fig. 1). The e hical commi ees
o he hospi als in ol ed in he egions app o ed he p ojec and
in o med consen was ob ained om all pa icipan s in each wa e.
2.2. Exposu e o g eenspace
To cha ac e ize exposu e o g eenspaces a 8 and 11–13 yea s o age,
ou indica o s we e calcula ed a ound pa icipan s’ home: wo o hem
o cha ac e ize g eenness su ounding home and he o he wo o
cha ac e ize he access o u ban g eenspaces.
2.2.1. Residen ial su ounding g eenness
Sa elli e-based No malized Di e ence Vege a ion Index (NDVI) and
he Vege a ion Con inuous Fields (VCF) we e applied o cha ac e ize
esiden ial su ounding g eenspace. The NDVI is an index o he le el o
he pho osyn he ically ac i e g eenspace o a gi en a ea (Tucke , 1979).
The index is calcula ed by he di e ence o he su ace e lec ance in he
isible wa eleng h (0.4
μ
m–0.7
μ
m) and he nea -in a ed wa eleng h
(0.7
μ
m–1.1
μ
m), he nea in a ed (NIR) and ed band mus be
Fig. 1. Numbe o pa icipan s in each ollow-up and a ailable da a in As u ias,
Gipuzkoa and o al.
A. Anabi a e e al.
En i onmen al Resea ch 210 (2022) 112994
3
combined (Equa ion 1). This in o ma ion was ob ained h ough sa elli e
images om Landsa 4–5 Thema ic Mappe (TM) and Landsa 8 Ope -
a ional Land Image (OLI) and The mal In a ed Senso (TIRS) wi h a
esolu ion o 30 ×30 m in he maximum ege a ion pe iod (Supple-
men a y Ma e ials, Table S1). The index anges om −1 o +1, wi h a
alue o 1 indica ing he highes g eenspace, nega i e alues in he
images ha e been eclassi ied o null alues p e iously (James e al.,
2015; Weie and He ing, 2000). The image y had been selec ed ac-
co ding o he ollowing c i e ia: i) cloud co e less han 10%, ii)
S anda d Te ain Co ec ion (Le el 1 T) and iii) g eenes pe iod o he
yea .
The VCF indica es he pe cen age o woody ege a ion g ea e han
5 m in heigh in each 30 ×30 m pixel. This a iable is a p oduc de i ed
om Landsa -5 Thema ic Mappe (TM) and/o Landsa -7 Enhanced
Thema ic Mappe Plus (ETM+) bands (Sex on e al., 2013). To calcula e
VCF a bo h ollow-ups sa elli e images o di e en da es we e used in
As u ias and Gipuzkoa (Supplemen a y Ma e ial Table S1).
We de ined esiden ial su ounding g eenspace and ee co e as he
a e age o NDVI and VCF, espec i ely, ac oss bu e s o 100 m, 300 m,
and 500 m (Dad and e al., 2017; Rammah e al., 2021) a ound he
pa icipan ’s esiden ial add ess a each ollow-up.
2.2.2. Residen ial access o g eenspaces
The esiden ial access o g eenspaces was cha ac e ized by (i) he
a ailabili y o an u ban g eenspace la ge han 5000 m
2
(based on WHO
ecommenda ion) wi hin, sepa a ely, 100, 200, and 300 m (WHO
Regional O ice o Eu ope, 2016) om he esiden ial add ess (yes/no),
and by (ii) he esiden ial dis ance, in me e s, o his la ge g eenspace.
This in o ma ion was ob ained om U ban A las 2012 and EUNIS 2009
(Eu opean Na u e In o ma ion Sys em) o As u ias and Gipuzkoa,
espec i ely.
2.3. A en ion
A en ion was cha ac e ized using he A en ion Ne wo k Tes (ANT)
(Fan e al., 2002; Rueda e al., 2004) a he 8 as well as 11-13y
ollow-ups. This compu e es cha ac e izes a en ion in child en
olde han 6 yea s (Rueda e al., 2004). Pa icipan s ha e o p ess he le
o igh a ows on a keyboa d depending on which way he cen al
a ow o he i e ho izon al a ows on he sc een is acing, in case o
success pa icipan s will ecei e a posi i e audi o y ein o cemen (Woo
hoo!) (Suades-Gonz´
alez e al., 2017). All pa icipan s ecei ed he same
ins uc ions, which we e ag eed upon by all ins uc o s. The i s
ime-block was always o aining and once he ins uc o s checked ha
each child had unde s ood how o do he es , he aining ended and he
es s a ed, which consis ed o ou blocks o 32 ials each (128 ials in
o al). Median esponse ime calcula ed om he esponse ime collec ed
in he 128 ials (Hi R median), which could indica e he speed o he
pa icipan s in answe ing each es . The highe Hi R median hence
sugges i e o less a en ion. We also calcula ed he s anda d e o o he
esponse ime (HRT-SE), which indica es he speed consis ency in
esponse ime be ween he di e en es s o each pa icipan . The highe
HRT-SE could indica e mo e inconsis ency in esponding, hence mo e
ina en ion (Dad and e al., 2017; Pozuelos e al., 2014; Sua-
des-Gonz´
alez e al., 2017). The es was adminis e ed by a pe son p e-
pa ed o his pu pose in each coho o each ollow-up. The same
compu e was used o all pa icipan s in each coho and all we e gi en
he same explana ion.
2.4. Co a ia es
The sociodemog aphic a iables used in he models o his s udy
we e iden i ied h ough a DAG model designed a p io i based on he
a ailable li e a u e (Supplemen a y Ma e ial Figu e S1). The a iables
sex, p ema u i y (<37 weeks’ ges a ion), bi h weigh (con inuous),
pa i y (con inuous), ma e nal educa ion (p ima y o wi hou educa ion,
seconda y o uni e si y), social class based on occupa ion (1: highes
social class o 3: lowes social class) and smoking du ing p egnancy (yes
o no) we e collec ed in he p egnancy ollow-up. Type o b eas eeding
(ma e nal b eas eeding, mixed o o mula eeding) and nu se y (yes o
no) we e collec ed du ing he pos na al 24 mon hs ollow-ups. Time
spen in seden a y ac i i ies (con inuous) and ma e nal IQ we e
collec ed in he 4-yea ollow-up. Ma e nal sco es on he Simila i ies
sub es o he Wechsle Adul In elligence-Thi d Edi ion (WAIS-III)
(Wechsle and Kau man, 2001) we e assessed as a p oxy o ma e nal IQ,
gi en ha his sub es has been shown o be a good p edic o o global IQ
(Wechsle , 1997). Time sleeping in hou s (con inuous) was collec ed in
he 8-yea ollow-up and hou s wa ching TV pe week (con inuous) was
collec ed in he 8-yea and 11-13-yea ollow-ups. Finally, he neigh-
bou hood’s socioeconomic s a us was collec ed h ough he dep i a ion
index o he MEDEA2011 p ojec o each ollow-up, c ea ed by he
ollowing indica o s: manual wo ke , unemploymen , empo a y
wo ke s and insu icien educa ion o e all and in young. This index has
been c ea ed using he census sec ion, he smalles adminis a i e uni ,
as he adminis a i e uni . (Domínguez-Be j´
on e al., 2008). Sex, p e-
ma u i y and bi h weigh we e collec ed h ough he clinical his o y.
Pa i y, ma e nal educa ion, social class, smoking du ing p egnancy, ype
o b eas eeding, nu se y, ime in seden a y ac i i ies, ime sleeping and
ime wa ching TV we e collec ed by ques ionnai e. No all a iables
we e used o he model adjus men .
2.5. S a is ical analysis
Fi s , wi h he aim o desc ibing he sample, a desc ip i e analysis o
bo h he cha ac e is ics o he sample, and he exposu e and e ec
a iables was ca ied ou . The p o ile o he sample a 8 and 11–13 yea s
o age was e alua ed using nonpa ame ic es s (
χ
2 o quali a i e a -
iables and Mann-Whi ney o quan i a i e a iables). In addi ion o
be ween ollow-ups, hose who pe o med he es (included) we e also
compa ed o hose who did no (excluded) a 8 and 11–13 yea s o age
and in o al.
Fig. 2. Vege a ion index, NDVI. As u ias (A) and Gipuzkoa (B) s udy a ea.
A. Anabi a e e al.
En i onmen al Resea ch 210 (2022) 112994
4
2.5.1. C oss-sec ional analyses
Once he a iables o in e es we e iden i ied h ough pe o ming
DAG model (supplemen a y ma e ial Figu e S1), we used gene al linea
models (Madsen and Thy egod, 2010) o es o he e ec o ei he
g eenspace (NDVI/VCF), a ailabili y o dis ance o g eenspaces on each
o he Hi R median and HRT-SE o each ollow-up. Da e o measu e-
men s was in oduced in he models as an o se a iable. Residuals o
each model we e e alua ed o alida ion pu poses. Fo his pu pose, we
used he unc ion lm() o package s a s in R so wa e (R Co e Team,
2020). The objec i e o his analysis is o e alua e whe he exposu e o
he g een en i onmen has be e a en ional esul s in hose who a e
mo e exposed in compa ison o hose who a e less exposed a home.
Al hough g een en i onmen exposu e is a 8 yea s and 11–13 yea s, i is
assumed ha mos pa icipan s ha e been exposed since bi h o a leas
3 yea s ago, because acco ding o he ollow-up esul s, o e e y 10
pa icipan s only 2 changed esidence be ween bi h and 8 yea s and
only 9% om 5 o 8 yea s. The e o e, we can assume ha mos o hem
ha e had a long- e m exposu e. Ne e heless, a sensi i i y analysis was
pe o med wi h only hose who ha e no mo ed and wi h hose who
we e no p e e m o assess he consis ency o he esul s ob ained. We
adjus ed he a o emen ioned models o socioeconomic s a us, age a he
ime o a en ion es , sex, p e e m, ma e nal IQ, ma e nal smoking
du ing p egnancy and coho (Table S3).
2.5.2. Longi udinal analyses
Likewise, we used gene al linea mixed-e ec s models (Madsen and
Thy egod, 2010) o es o he e ec o bo h age and ei he g eenspace
(NDVI/VCF), a ailabili y o dis ance o g eenspaces on each o he e-
sponses Hi R median and HRT-SE, once he e ec o adjus ing a iables
had been accoun ed o . Since esponses we e measu ed in he same
subjec s a wo di e en ages (8- and 11-13-yea -old), subjec (nes ed
wi hin coho ) was i ed as a andom ac o . The esponse a iables is
exp essed by he di e ence be ween a en ion measu ed a 8 and a
11–13 yea s (Hi R median a 8 yea s – hi median a 11–13 yea s and
HRT-SE a 8 yea s – HRT-SE a 11–13yea s). To co ec he obse ed
wi hin-g oup he e oscedas ici y, a cons an a iance s uc u e was
in oduced in he models o allow o di e en a iances acco ding o
he le els o coho and age. These models we adjus ed o age a he
ime o a en ion es , socioeconomic s a us, sex, p e e m, ma e nal IQ,
ma e nal smoking du ing p egnancy and coho . Fo his pu pose, we
used he unc ion lme() o package nlme (Pinhei o e al., 2018) in R
so wa e (R Co e Team, 2020).
When models we e s a is ically signi ican , media ion models using
NO
2
as media o we e i ed. Mo e in o ma ion abou hese media ion
models is gi en in supplemen a y ma e ial.
3. Resul s
In he i s imes e o p egnancy 1132 woman we e ec ui ed (494
om As u ias and 638 om Gipuzkoa) in INMA. Longi udinal da a up o
he 8-yea ollow-up was a ailable o 66% o he ec ui ed amilies,
being 61% o hose om Gipuzkoa and 73% om As u ias. A he 11–13
yea s ollow-up, we collec ed in o ma ion om 53% o he ec ui ed
amilies, being 59% o hose om Gipuzkoa and 37% om As u ias. In
he case o As u ias, he no able dec ease in he sample o he las ollow-
up was due o lockdown measu es aken due o he COVID-19 pandemic.
Table 1 shows he cha ac e is ics o he s udy samples a bo h ollow-
ups. Women made up 49% o he sample, unde 5% o child en had he
his o y o p e e m deli e y, and a ound 12–13% o he mo he s we e
smoke du ing p egnancy. The median o mo he ’s IQ was 9.76 o he
possible ange o 0–14. The neighbou hood socioeconomic s a us o he
pa icipan s changed signi ican ly be ween he wo ollow-ups. A 8
yea s ollow-up 64% o he had a high socioeconomic le el (indexes 1
and 2) while a 11–13 yea s 72% o he amilies had hese socioeco-
nomic le els. Mo eo e , child en’s sleeping ime was signi ican ly
highe a he 11-13-yea s ollow-up. Fo he es o cha ac e is ics we did
no obse e any no able di e ence be ween he ollow-ups.
The cha ac e is ics o child en and hei mo he s pa icipa ing and
non-pa icipa ing a each wa e, 8 and 11–13 yea s o age, a e shown in
he supplemen a y ma e ial (Table S2), being he main di e ence ha o
he mo he ’s IQ.
As shown in Table 2, a he age o 8 yea s NDVI was highe in
Gipuzkoa han in As u ias o he h ee bu e s (p <0.05) and, a he age
o 11–13 yea s, he di e ence was also obse ed wi h NDVI 500 m (p <
0.05), bu no o he bu e s o 100 and 300 m. Rega ding he di e -
ences be ween ollow-ups, he e we e s a is ically signi ican di e ences
in all NDVI bu e s, being g eenspace sco es highe a 11–13 yea s. Fo
VCF, signi ican di e ences we e ound be ween coho s a bo h wa es,
8 and 11–13 yea s, a he 100 m and 300 m bu e s; di e ences we e also
seen be ween wa es a 8 and 11–13, al hough VCF 300 m di e ence was
ma ginally signi ican . Unlike NDVI, he a e age VCF alue was highe
in he As u ias han in he Gipuzkoa coho . No di e ences in VCF we e
obse ed o 500 m, nei he be ween coho s no be ween ollow-ups.
Almos all amilies (97%) li ed wi hin 300 m o a g eenspace la ge
han 5000 m
2
. The a ailabili y a g eenspace la ge han 5000 m
2
only
di e ed s a is ically o he 100-m bu e be ween coho s a bo h
ollow-ups. No di e ences in he a ailabili y o la ge g eenspaces we e
Table 1
Desc ip ion
a
o cha ac e is ics o he s udy pa icipan s a 8 and 11–13 yea s
ollow-up.
Cha ac e is ics 8 yea s ollow-up
(n =751)
11–13 yea s ollow-
up (n =598)
p-
alue
b
Sex ( emale) 0.489 0.507 0.547
P e e m bi h(yes) 0.049 0.046 0.965
Age (mean (min-max)) 8.10 (7.7–9.7) 11.4 (10.3–13.1) –
Ma e nal IQ
c
(0–14) 9.76(3.67) 9.76(3.67) 0.704
Ma e nal smoking du ing
p egnancy (yes)
0.132 0.121 0.495
Neighbou hood
socioeconomic s a us
0.005
1 Be e 0.309 0.370
2 0.326 0.362
3 0.186 0.137
4 0.137 0.102
5 Lowe 0.041 0.029
Pa i y 0.978
0 0.590 0.599
1 0.364 0.350
2 0.040 0.044
3 0.005 0.007
4 0.001 0.002
Bi h weigh (g .) 3290 (545) 3290 (558.75) 0.976
Time wa ching TV 8y(min.) 60 (60) 60 (75) 0.989
Time wa ching TV 11-13y
(min.)
60 (30) 60 (30) 0.873
Time sleeping (h s.) 10.29 (0.93) 10.36 (0.68) 0.016
Time spen in seden a y
(h s.)
90.5 (13) 90.5 (12.28) 0.908
Ma e nal educa ion 0.967
P ima y o wi hou
educa ion
0.118 0.114
Seconda y 0.401 0.395
Uni e si y 0.482 0.490
Social class 0.802
I- Mo e ich 0.420 0.443
II 0.227 0.226
III-Less ich 0.353 0.319
Type o b eas eeding 0.645
Ma e nal b eas eeding 0.273 0.283
Mixed 0.547 0.563
Fo mula eeding 0.181 0.153
Nu se y a 24 mon hs(yes) 0.722 0.741 0.487
a
Ca ego ical a iables we e desc ibed h ough pe cen ages and o con in-
uous a iables, wi h median and IQR.
b
p- alue o di e ence be ween he wo ollow-ups using chi-squa ed es o
he ca ego ical a iables and Mann-Whi ney U es o he con inuous a iables.
c
Simila i ies sub es .
A. Anabi a e e al.
En i onmen al Resea ch 210 (2022) 112994
5
seen be ween he wo ollow-ups. The dis ance o g eenspaces o la ge
han 5000 m
2
was s a is ically longe be ween he wo coho s and be-
ween wa es, being he dis ance in As u ias smalle han in Gipuzkoa.
3.1. C oss-sec ional associa ion be ween exposu e o g eenspace and
a en ion
As p esen ed in Table 3, o he 8-yea ollow-up we only obse ed a
ma ginally signi ican in e se (i.e. p o ec i e) ela ionship be ween VCF
a 500 m bu e and HRT-SE. Al hough no o he signi ican ela ionship
was ound, NDVI and VCF dis ance o a g eenspace showed an in e se
ela ionship wi h HRT-SE esponse and a posi i e ela ionship wi h
dis ance o g eenspace. Hi R median was no associa ed wi h any o he
g eenspace indica o s a his wa e.
A 11–13 yea s ollow-up we ound an in e se ela ionship be ween
NDVI (300 m bu e ) and Hi R median and HRT-SE, being s a is ically
ma ginally and s a is ically signi ican , espec i ely. Also, a ma ginal
in e se ela ionship was seen be ween NDVI (500 m bu e ) and HRT-SE.
The es o he esiden ial g eenspace indica o s did no show any sig-
ni ican associa ion wi h any o a en ion measu emen s.
When epea ing he analyses only wi h hose pa icipan s who did
no change hei esidence (Supplemen a y ma e ial Table S4-5), and
wi h hose ha we e no p e e m, we did no obse e any no able change
in he a o emen ioned indings (Da a no shown).
3.2. Longi udinal associa ion be ween g eenspace exposu e and a en ion
In o al, he e we e 555 child en wi h a en ion es measu emen s in
he wo ollow-ups (206 om As u ias and 349 om Gipuzkoa). No
signi ican ela ionships we e obse ed in he longi udinal analyses
be ween g eenspace indica o s and a en ion measu emen s (Table 4).
No indi ec e ec be ween NDVI 300 and NO
2
-media ed HTR-SE was
ound. The esul s can be ound in supplemen a y ma e ial (Figu e S3).
4. Discussion
The objec i e o his s udy was o analyze he associa ion be ween
exposu e o g eenspace and a en ion a he age o 8 and 11–13 yea s.
Ou s udy was based on wo well-es ablished and well-cha ac e ized
Table 2
Desc ip ion o measu es o g een exposu e measu emen s (measu ed a home) a age o 8 and 11–13 yea s.
Va iables 8-y ollow-up 11-13-y ollow-up
To al (n =
751)
As u ias (n =
359)
Gipuzkoa (n =
392)
p-
alue
a
To al (n =
598)
As u ias (n =
219)
Gipuzkoa (n =
379)
p-
alue
a
p-
alue
b
Residen ial Su ounding g eenspace
(NDVI) (median(IQR))
100 0.312
(0.177)
0.298(0.202) 0.319(0.158) 0.027 0.379
(0.185)
0.382(0.221) 0.378(0.159) 0.850 0.000
300 0.389
(0.172)
0.377(0.209) 0.405(0.155) 0.000 0.461
(0.165)
0.457(0.226) 0.462(0.143) 0.504 0.000
500 0.454
(0.148)
0.424(0.175) 0.477(0.137) 0.000 0.514
(0.133)
0.507(0.214) 0.519(0.121) 0.012 0.000
Residen ial su ounding ee co e
(VCF) (%)
100 9.31 (7.1) 11.44 (5.35) 6.89 (4.89) 0.000 8.59 (6.35) 11.2 (4.93) 6.67 (4.82) 0.000 0.035
300 12.07
(7.48)
13.01 (6.58) 10.97 (7.9) 0.000 11.75 (7.25) 13.01 (6.1) 10.68 (7.89) 0.000 0.087
500 15.62 (8.3) 15.28 (7.6) 16.11 (10.17) 0.300 15.32 (8.71) 14.98 (6.45) 15.76 (10.2) 0.368 0.252
G een a ailabili y (>5.000m
2
) (%)
100 62.55 69.16 57.14 0.001 61.990 69.95 57.94 0.007 0.884
200 89.48 89.41 89.54 1 89.14 90.16 88.62 0.679 0.917
300 97.33 97.51 97.19 0.979 96.85 96.89 96.83 1.000 0.726
Dis ance o a g een a ea >5.000m
2
(m)
73.17
(99.7)
57.42 (84.17) 83.9 (103.04) 0.003 75.62
(102.74)
58.46 (81.74) 83.9 (107.47) 0.004 0.539
No e: p- alues a e epo ed o chi-squa ed es o ca ego ical a iables and Mann-Whi ney U es o con inuous a iables. Fo con inuous a iables, median (IQR)
and o ca ego ical a iables coun (pe cen age) o each ca ego y has been epo ed. p- alue
a
o he di e ence be ween child en in each coho . p- alue
b
o he
di e ence be ween child en wi h a en ion a ailabili y da a a he 8-yea ollow-up and a 11-13-y ollow-up.
Table 3
Coe icien s ( oge he wi h 95%CI) o he eg ession models es ima ing he as-
socia ion be ween se e al e sions o exposu e measu emen s (NDVI, VCF,
g een a ailabili y, g een dis ance) and wo measu emen s o a en ion sco e (Hi
R median/HRT-SE), once ha he e ec o he co a ia es ha e been accoun ed
o .
8 yea s n =751 11–13 yea s n =598
Hi R median HRT-SE Hi R
median
HRT-SE
NDVI - 100 m
bu e s
9.69 (−6.24;
25.62)
−0.47
(−7.23;
6.30)
−8.15
(−19.49;
3.19)
−4.18
(−10.83;
2.48)
300m bu e s 2.57 (−13.43;
18.57)
−1.03
(−7.82;
5.75)
−10.33
(−21.49;
0.83)
−7.20
(−13.74;
−0.67)*
500m bu e s 0.69 (−15.59;
16.98)
−2.81
(−9.71;
4.09)
−8.11
(−19.29;
3.08)
−6.56
(−13.10;
0.01)
VCF - 100m
bu e s
3.49 (−13.26;
20.24)
−0.01
(−7.12;
7.09)
2.13
(−10.00;
14.26)
4.31 (−2.79;
11.41)
300m bu e s −8.08
(−23.79;
7.63)
−4.59
(−11.25;
2.06)
−6.62
(−18.02;
4.78)
−3.48
(−10.17;
3.21)
500m bu e s −10.74
(−26.28;
4.79)
−6.48
(−13.06;
0.09)
−3.66
(−14.85;
7.53)
−3.18
(−9.74;
3.38)
G een
a ailabili y
100
8.60 (−24.39;
41.59)
5.27 (−8.87;
19.42)
0.04
(−23.44;
23.53)
−1.29
(−14.96;
12.36)
G een
a ailabili y
200
7.59 (−44.29;
59.46)
−3.57
(−25.81;
18.68)
−6.59
(−44.16;
30.97)
−14.69
(−36.51;
7.12)
G een
a ailabili y
300
−15.97
(−123.67;
91.74)
7.89
(−38.29;
54.08)
−20.31
(−87.81;
47.19)
−22.48
(−61.71;
16.75)
G een
dis ance
−1.79
(−17.81;
14.22)
−0.49
(−7.36;
6.37)
3.62 (−8.06;
15.29)
3.58 (−3.21;
10.36)
*p <0.05. Adjus ed o socioeconomic s a us, age a he ime o a en ion es ,
sex, p e e m, ma e nal IQ, ma e nal smoking du ing p egnancy and coho .
A. Anabi a e e al.
En i onmen al Resea ch 210 (2022) 112994
6
bi h coho s wi h epea ed assessmen o a en ion using objec i e
compu e ized es s and a p ospec i ely-collec ed co a ia e da a since
p egnancy. In ou c oss-sec ional analyses we obse ed a p o ec i e
associa ion be ween a e age NDVI a 300 m bu e a ound he esi-
den ial add ess and HRT-SE (an indica o o ina en i eness) a 11–13
yea s, which was no seen a 8 yea s. Fo he es o he c oss-sec ional
associa ions and all longi udinal associa ions, we gene ally obse ed
bene icial associa ions be ween esiden ial su ounding g eenspace and
Hi R mean and HRT-SE; howe e , none o hese associa ions a ained
s a is ical signi icance. In gene al, he c oss-sec ional and he longi u-
dinal s udies wi hin his esea ch wo k led o simila , consis en , esul s
(in gene al e ms, no signi ican e ec s we e ound). None heless, in he
c oss-sec ional s udy, and only o he esponse HRT-SE a 11–13 yea s
o age and exposu e NDVI a 300 m bu e s, we ound one signi ican
e ec [−7.20 wi h 95% C.I. (−13.74, −0.67)]. In he longi udinal s udy,
a nea ly signi ican e ec (p =0.083) was ound o only o he
esponse Hi R median and VCF 500 m bu e s [es ima e o he e ec :
3.900 wi h 95% C.I. (−8.30, 0.50)]. These indings s ayed unchanged
a e we limi ed pa icipan s o hose who did no change hei add ess
since 4-yea ollow-up. Conduc ed media ion analysis did no e ealed
NO
2
-media ed e ec s o NDVI 300 m on HTR-SE a 11 yea s.
Rega ding esiden ial g eenspace, di e en le els o g eenspace
measu ed by NDVI ha e shown an associa ion on a en ion; o example,
s udies conduc ed in Medi e anean a eas wi h lowe NDVI le els han
ou s ha e also obse ed a ela ionship be ween g eenspace exposu e and
a en ion in child en o he simila age (Amoly e al., 2015; As a e al.,
2021; Dad and e al., 2017). In con as , we did no obse e any asso-
cia ion be ween g eenspace measu ed by VCF and a en ion, and nei he
did he only o he s udy ha analyzed he ela ionship be ween VCF and
a en ion (Dad and e al., 2017). To ou knowledge, only one s udy
besides his one has analyzed he imp o emen o a en ion a di e en
ages ela ed o exposu e o esiden ial g eenspace (Dad and e al.,
2017), his s udy was also ca ied ou in he INMA p ojec , bu in his
case in he coho s o Sabadell and Valencia. A en ion da a we e
collec ed a he 4–5 and 7–8 yea ollow-ups and he analyses we e
ca ied ou c oss-sec ionally. P e ious longi udinal s udies ha e ound a
ela ionship be ween g eenspace and a en ion om age 4–10 yea s,
he e o e, his s udy ex ends he posi i e esul s p e iously obse ed
(As a e al., 2021; Dad and e al., 2017; Dad and e al., 2015a, 2015b;
Liao e al., 2020). In ou case, no associa ions we e obse ed a 8 yea s o
age, al hough he end was owa d educed ina en ion.
I should be no ed ha he e a e also o he s udies in which associ-
a ion be ween exposu e o g eenspace and A en ion-De ici /
Hype ac i i y Diso de (ADHD) is in es iga ed. The e a e s udies ha
ha e s udied he ela ionship be ween NDVI and ADHD (Dono an e al.,
2019; Ma ke ych e al., 2018; Thygesen e al., 2020; Yang e al., 2019),
and also wi h access o g een spaces (Ma ke ych e al., 2014). Some
s udies ha e seen an associa ion be ween NDVI and ADHD diagnosis
(Dono an e al., 2019; Ma ke ych e al., 2018; Thygesen e al., 2020)
and ano he , in con as , wi h ADHD symp oma ology (Yang e al.,
2019). Ano he s udy saw a ela ionship be ween access o u ban g een
spaces and ADHD symp oma ology (Ma ke ych e al., 2014). These
s udies ha e gene ally epo ed ha highe g eenspace exposu e is
associa ed wi h lowe isk o ADHD and i s symp oma ology. The e o e,
his s udy p o ides e idence on he e ec o esiden ial g eenspace
exposu e on a en ion.
In ou cu en s udy, no associa ion was seen be ween esiden ial
su ounding ee co e and a en ion, excep o a ma ginal associa ion
a age 8 wi h HRT-SE. No e ec wi h highe ee co e was seen in his
s udy ei he . Unlike he s udy abo e men ioned, which was mainly
loca ed in a Medi e anean clima e and he e o e does no ha e much
ee co e highe han 5 m, his cu en s udy was conduc ed in an a ea
wi h an A lan ic clima e in which la ge ees p edomina e. The e o e, in
his case, we could expec signi ican esul s wi h he use o VCF. On he
o he hand, as he pa icipan s we e in an A lan ic clima e wi h a lo o
ege a ion, his could lead o almos no a iabili y in exposu e o g een
spaces and i could be ha he high exposu e o g eenspace a ound he
neighbou hood does no lead o signi ican es o a ion o a en ion. Jus
as he possible es o a i e e ec o di e en ypes o g eenspace should
be s udied, i would be in e es ing o analyze whe he hose who a e
mo e exposed on he day- o-day es o e less a en ion han hose who
in e ac wi h g eenspace spo adically.
A 8 yea s, in an A lan ic clima e, we obse ed highe NDVI le els
han in simila s udies conduc ed by Dad and e al. (2017) in Sabadell
and Valencia (Spain) wi h 7-yea -olds and by As a e al. (2021) con-
duc ed in Rome (I aly) also wi h 7-yea -olds in a eas wi h a Medi e a-
nean clima e. On he one hand, despi e ha ing highe le els o
g eenspace (measu ed as he NDVI a e age) in he A lan ic zone, no
associa ions we e obse ed a 8 yea s o age. On he o he hand, sig-
ni ican associa ions be ween a e age o NDVI in a 500 m bu e a ound
esiden ial add ess and a en ion we e obse ed a 7 yea s in Sabadell
and Valencia and Rome. I should be no ed ha As a e al. ound an
associa ion be ween NDVI a 500 m a ound he esidence and a en ion
wi h e y simila alues o his s udy, bu no associa ion was ound in
ou s udy. We pos ula e ha his may be due o wo possible easons. On
he one hand, i could be he di e en ypes o ege a ion ha can be
ound in di e en clima es and on he o he hand, i could be due o ou
ela i ely modes sample size ha limi ed ou s a is ical powe .
G eenspaces could ha e an e ec on heal h h ough h ee pa hways:
he mi iga ion o en i onmen al pollu an s such as ai pollu ion o noise,
he ins o a ion o social cohesion and physical ac i i y and h ough he
educ ion o s ess linked o he S ess Reduc ion Theo y (STR), and he
es o a ion o a en ion linked o he ART heo y (Ma ke ych e al.,
2017). Acco ding o scien i ic li e a u e, i is no only exposu e o
g eenspaces ha can ha e an e ec on a en ion ia ART. Acco ding o
se e al s udies, exposu e o g eenspaces can educe ai pollu ion
Table 4
Coe icien s ( oge he wi h 95%CI) o he eg ession mixed e ec models es i-
ma ing he associa ion be ween se e al e sions o exposu e measu emen s
(NDVI, VCF, g een a ailabili y, g een dis ance) and wo measu emen s o
a en ion sco e (Hi R median/HRT-SE), once he e ec o he co a ia es ha e
been accoun ed o .
Hi R median HRT-SE
Value p-
alue
Value p-
alue
NDVI – 100m
bu e s
72.817 (−207.211;
352.846)
0.610 −9.052 (−131.197;
113.093)
0.884
300m bu e s −58.803
(−338.487;
220.880)
0.680 3.585 (−119.127;
126.297)
0.954
500m bu e s −93.634
(−391.159;
203.890)
0.537 −25.755
(−156.792;
105.283)
0.700
VCF – 100m
bu e s
0.847 (−5.529;
7.223)
0.794 −1.000 (−3.787;
1.786)
0.481
300m bu e s −2.814 (−7.553;
1.924)
0.244 −0.065 (−2.718;
1.428)
0.541
500m bu e s −3.900 (−8.302;
0.504)
0.083 0.949 (−2.880;
0.982)
0.335
G een
a ailabili y
100
−17.401 (−97.394;
62.593)
0.669 3.909 (−30.770;
38.587)
0.825
G een
a ailabili y
200
10.606 (−116.171;
137.383)
0.870 22.623 (−32.822;
78.068)
0.423
G een
a ailabili y
300
−18.206
(−256.378;
219.965)
0.881 80.267 (−22.953;
183.486)
0.127
G een dis ance 0.087 (−0.399;
0.574)
0.725 −0.049 (−0.262;
0.164)
0.654
*p <0.05. Mixed e ec s models wi h andom coho e ec adjus ed o socio-
economic s a us, age a he ime o a en ion es , sex, p e e m, ma e nal IQ,
ma e nal smoking du ing p egnancy and coho , coho x age and exposu e x
age.
A. Anabi a e e al.
En i onmen al Resea ch 210 (2022) 112994
7
(Dad and e al., 2012; Dad and e al., 2015a, 2015b) and noise (Van
Ren e ghem e al., 2015), ac o s ha ha e been linked o poo e
a en ion (Sunye e al., 2015; an Kempen e al., 2012). In addi ion, he
p omo ion o physical ac i i y by g eenspaces (James e al., 2015) may
imp o e a en ion (de G ee e al., 2018), and i may be ha he p o-
mo ion o social cohesion by g eenspaces is also an enhancing mecha-
nism o imp o ing a en ion (Ma ke ych e al., 2017).
Wi h espec o limi a ions, i should be no ed ha his s udy is no
ee o hem. Fi s ly, due o he COVID-19 pandemic, da a collec ion o
he 11–13 yea s phase in As u ias was suspended and, he e o e, only
pa (app oxima ely 50%) o he o al sample o he As u ias coho
could be included. This may be one o he easons o he di e ences in
socioeconomic s a us be ween hose included and excluded om his
phase in he As u ias coho . In addi ion, he e may be some a iables
no collec ed in he p esen s udy like amily con ex o bio-gene ic
ac o s ha a e in e e ing in he ela ionship be ween g eenspace
exposu e and a en ion. Second, gi en ha we had collec ed he social
class a iable indi idually in he p egnancy ollow-up and his measu e
was p obably ou da ed o he cu en analyses, we decided o use he
MEDEA dep i a ion index. Despi e his la e measu e was mo e ecen
in ime, i is less in o ma i e because i is calcula ed a census sec ion
le el (smalles adminis a i e uni ) so we could lose accu acy. Howe e ,
i is also ue MEDEAs dep i a ion index comp ises se e al socio-
economic indica o s making i mo e comple e han he simple social
class a iable (Domínguez-Be j´
on e al., 2008). Thi d, he possible e ec
o blue spaces, as a co-exposu e wi h g eenspace, has no been aken in o
accoun (Amoly e al., 2015). Finally, no measu es ha e been aken o
exposu e o g eenspaces in child en’s schools, whe e hey spend a
ele an pa o hei ime du ing wo k days and he quali y o g een-
spaces has also no been measu ed.
5. Conclusion
The p esen s udy p o ides e idence on a po en ial bene icial impac
o exposu e o g eenspace on a en ion in childhood. Speci ically, a
signi ican and posi i e associa ion was ound be ween g eenspace
measu ed by NDVI in 300 o he home and a en ion a 11–13 yea s o
age, bu no a 8 yea s o age. These esul s highligh bo h he need o
u he esea ch on he subjec and he need o c ea e heal hy spaces in
ci ies, such as g eenspaces, as a p io i y. I would be ecommended ha
u u e s udies ake in o accoun he possible exposu e o pa icipan s o
he noise, in o de o measu e he indi ec e ec be ween g eenspaces
and a en ion. Including exposu e o blue spaces would also be impo -
an . Ou indings, i con i med by u u e s udies, could in o m policy-
make s abou implemen ing in e en ions aimed a imp o ing a en ion
and neu ode elopmen in gene al in u ban child en.
Funding
This s udy was unded by g an s om Ins i u o de Salud Ca los III
(Red INMA G03/176, CB06/02/0041, FIS-PI04/2018, PI06/0867, FIS-
PI09/00090, FIS-PI09/02311, FIS-PI13/02187, FIS-PI13/02429, FIS-
PI18/00909, FIS-PI18/01web237 and FIS-PI18/01142 incl. FEDER
unds), Depa men o Heal h o he Basque Go e nmen (2005111093,
2013111089, 2015111065 and 2018111086), P o incial Go e nmen o
Gipuzkoa (DFG06/002 and DFG15/221), annual ag eemen s wi h he
municipali ies o he s udy a ea (Zuma aga, U e xu, Legazpi, Azkoi ia,
Azpei ia and Beasain), CIBERESP, Ob a Social Cajas u /Fundaci´
on Lib-
e bank and Uni e sidad de O iedo.
The e hical commi ees o he hospi als in ol ed in he egions
app o ed he p ojec and in o med consen was ob ained om all pa -
icipan s in each wa e (29/2003, 07/2005, 24/2009, 09/2010, 56/
2016, PI2013164, PI2018059).
Decla a ion o compe ing in e es
The au ho s decla e ha hey ha e no known compe ing inancial
in e es s o pe sonal ela ionships ha could ha e appea ed o in luence
he wo k epo ed in his pape .
Acknowledgmen s
AA would like o hank he Depa men o Educa ion, Language
Policy and Cul u e o he Go e nmen o he Basque Coun y o a p e-
doc o al esea ch aining g an .
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