Urban Forestry & Urban Greening 20 (2016) 407–418

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Urban Forestry & Urban Greening

journal homepage: www.elsevier.com/locate/ufug

Does green space matter? Exploring relationships between green

space type and health indicators
Abdullah Akpinar a,∗ , Celestina Barbosa-Leiker b,c , Kerry R. Brooks c
a
Adnan Menderes University, Faculty of Agriculture, Department of Landscape Architecture, 09100 Aydin, Turkey
b
College of Nursing, Washington State University, Spokane, WA 99210-1495, United States
c
Department of Planning and Public Administration, Eastern Washington University, Spokane WA 99202, United States

a r t i c l e i n f o a b s t r a c t

Article history: This study explores whether general specification or specific types of green spaces are associated with
Received 1 April 2016 mental and general health. A sample of 5,148 respondents from the Behavioral Risk Factor Surveillance
Received in revised form 13 August 2016 System, conducted in 2006 in Washington State across 98 zip-codes, was analyzed. Measures included
Accepted 23 October 2016
mental health complaints (last 30 days), anxiety-depression complaints (last 14 days), and general health
Available online 27 October 2016
status. Percentage of green spaces was derived from the National Land Cover Dataset. The associations
were examined in both total and subsamples (urban vs. rural zip-codes). Bivariate correlations and mul-
tilevel regression analysis controlling for age, sex, race, income, education level, size of green space, and
zip-code population and socio-economic situation indicated ‘aggregated green space’ was not associated
with mental and general health. On the other hand, respondents in areas that have more forests report
fewer days of mental health complaints in total sample. Results also revealed that more urban green
space was associated with fewer days of mental health complaints in urban zip-codes. In addition, size of
forest in urban areas was associated with fewer days of mental health complaints. Our findings suggest
that types of green space should be considered individually rather than aggregated as ‘simply green’ and
‘size’ of forest in urban areas seems an important factor to affect the relationship between green space
and mental health.
© 2016 Elsevier GmbH. All rights reserved.

1. Introduction
According to the Centers for Disease Control (CDC), the life-
time prevalence of depression and anxiety among American adults
is 16.1% and 12.3%, respectively (Reeves et al., 2011). The World
Health Organization (WHO) also reports that by 2020 mental
health disorders are expected to be one of the major contribu-
tors to illnesses in all parts of the world (WHO, 2008). Additionally,
stress is a related significant phenomenon that triggers or worsens
depression and anxiety (Monroe and Simons, 1991) in addition to
facilitating other health co-morbidities (Sapolsky, 2004; AIS, 2013)
and is estimated to affect 75–90% people (AIS, 2013). It has also been
found that mental health is related to general health (Mechanic
and Hansell, 1987; Phelan et al., 2001; WHO, 2004; Chapman et al.,
2005). Research shows that people with mental disorders have an
increased risk of premature death (Harris and Barraclough, 1998)
∗ Corresponding author.
E-mail addresses: abdullah.akpinar@wsu.edu (A. Akpinar), celestina@wsu.edu
(C. Barbosa-Leiker), kbrooks@ewu.edu (K.R. Brooks).
and people with serious mental illness have higher rates of morbid-
ity and mortality from chronic diseases than the general population
(Robson and Gray, 2007). Ultimately, the WHO notes that “there is
no health without mental health” (WHO, 2004, p.10).
Given the prevalence and impacts of stress, depression and anx-
iety, researchers have for more than 30 years investigated the
association with green space, a major component of many environ-
ments. Numerous studies have demonstrated positive associations
between green space and reductions in stress (Nielsen and Hansen,
2007; Lafortezza et al., 2009; Van den Berg et al., 2010; Ward
Thompson et al., 2012) and in the risk of psychosocial and psy-
chological stress-related diseases (Francis et al., 2012; Adevi and
Lieberg, 2012; Kuo, 2015). Studies show that green space is asso-
ciated with reductions in depression (McCaffrey, 2007; Maas et al.,
2009; Berman et al., 2012; Beyer et al., 2014); anxiety (Maas et al.,
2009; Mackay and Neill, 2010; Beyer et al., 2014), and anger and
aggression (Ulrich, 1979; Kuo and Sullivan, 2001; Bodin and Hartig,
2003). In addition, green space is associated with positive physio-
logical well-being (Herzog and Strevey, 2008; Park et al., 2008).
Green space is also positively related to health and quality
of life (Richardson and Mitchell, 2010; Van Dillen et al., 2011;

http://dx.doi.org/10.1016/j.ufug.2016.10.013
1618-8667/© 2016 Elsevier GmbH. All rights reserved.
408 A. Akpinar et al. / Urban Forestry & Urban Greening 20 (2016) 407–418
McFarland et al., 2008). Green space has been shown to contribute
to better health outcomes, improve self-esteem and mood (Mitchell
and Popham, 2007; Barton and Pretty, 2010), improve health and
well-being (Maas et al., 2006; Mitchell and Popham, 2008; Ward
Thompson et al., 2012; Triguero-Mas et al., 2015), and improve
recovery time for surgical patients (Ulrich, 1984; Ulrich et al., 1993).
Although these studies have explored the relationships between
green space and stress, depression, anxiety, general health, and
well-being, most investigated the quantity of green space (Van
den Berg et al., 2015) and considered different types of green
space as “simply green”. In addition, studies examined the asso-
ciation between green space and health at individual and/or
neighborhood-levels (Maas et al., 2006, 2009; Van den Berg et al.,
2010; Stigsdotter et al., 2010; Richardson et al., 2010; Ward
Thompson et al., 2012; Beyer et al., 2014; Triguero-Mas et al., 2015).
While most studies (not all of them (see Richardson et al., 2010;
Picavet et al., 2016)) at the individual and/or neighborhood-level
found that more green space is related to better mental and gen-
eral health, city level studies did not find any relationship between
more green space and health (Richardson et al., 2012). On the other
hand, studies indicate that size of green space, sometimes referred
as scale, matters in terms of restoration (Nordh et al., 2009) and
investigated effects of green space in the living environment on
health, well-being, and restoration at different scales (i.e. macro,
intermediate, and micro scale) (Groenewegen et al., 2006). In
this respect, studies show that size of green space may affect
the restorative experience and mental health (Nordh et al., 2009;
Akpinar, 2016).
While most of the studies examined the relationship between
the amount of green space and health, recent studies indicate that
few studies (see de Vries et al., 2003; Maas et al., 2006; Barton and
Pretty, 2010; Van den Berg et al., 2014; Alcock et al., 2015; Picavet
et al., 2016) have explored which types of green space are relatively
effective for particular health outcomes and how health effects
may differ by type of green (de Vries et al., 2013; Nieuwenhuijsen
et al., 2014; Hartig et al., 2014). Therefore, little is known about the
strength of the relationships, and the spatial conditions (size, type,
layout of green space) that promote beneficial effects of nature (Van
den Berg et al., 2007; Jorgensen and Gobster, 2010; Hartig et al.,
2014). In this respect, recent studies recommended that future
studies should focus on trying to distinguish types of ‘green’ in
terms of health outcomes (Richardson et al., 2012; Hartig et al.,
2014; Van den Berg et al., 2014; Alcock et al., 2015; Picavet et al.,
2016).
Findings that differ with scale as well as a lack of studies and rec-
ommendations regarding types of green space demonstrate that
there are gaps in existing knowledge. Hence, the purpose of this
research was to address these gaps by exploring the relationship
between type of green space and mental and general health. To sup-
port this work, as described below, we took advantage of medium
resolution data describing green space, as well the results of a
US nationally administered health status survey that is in some
instances collected at a compatible scale −US postal zip-code areas.
A supporting effort further explored scale by examining the effect
of zip-code size on the relationship between green space and men-
tal/general health status.
1.1. The present study
In this study, we examined the relationship between mental and
general health with 1) all types of green space aggregated as “sim-
ply green” and labeled as “aggregated green space” and 2) each type
of green space (urban green space, forest, rangeland, agricultural
land, and wetland.) We examined the relationship between green
space and a regionally representative and self-reportedly healthy
sample of individuals at the zip-code level. We also conducted
subsample analyses to examine the relationship between green
space and health in urban and rural areas.
Based on the previous studies (de Vries et al., 2003; Maas et al.,
2006, 2009; Barton and Pretty, 2010; Van den Berg et al., 2010;
Richardson et al., 2010, 2013; Ward Thompson et al., 2012; Beyer
et al., 2014), our hypothesis for aggregated green space was that
there is a positive relationship between more aggregated green
space and better mental health and general health, where increased
green space is related to fewer days of mental health complaints
and better reported general health. Our hypothesis regarding the
types of green space was that based on the previous studies (de
Vries et al., 2003; Maas et al., 2006; Morita et al., 2007; White
et al., 2013a) urban green space, forest, and agricultural land are
positively associated with mental health and general health. For
rangelands and wetlands, we do not have enough theory to guide
the expectation. Therefore, we aimed to better understand the
relationship between rangelands, wetlands and mental health and
general health in this exploratory study.
2. Methods
2.1. Study area
This study was conducted in Washington State by analyz-
ing the data from the Behavioral Risk Factor Surveillance System
(BRFSS) and National Land Cover Data (NLCD). Washington State is
a unique state in that all counties, as well as all zip-code areas, were
sampled. Washington State consists of 532 zip codes as of 2006
which vary in size (minimum = 0.46 sq. mi, maximum = 1422.95 sq.
mi, M = 121.40 sq. mi.), population (minimum = 38 people, maxi-
mum = 64214 people, M = 12758 people), and population density
(minimum = 0.50 people per sq. mi, maximum = 17894.56 people
per sq. mi, M = 1249.58 people per sq. mi.).
Washington State contains a variety of eco-zones. Some are
heavily forested and are mostly concentrated in the west (i.e.,
Northwest Coast, Puget Trough, North and West Cascades ecore-
gions) and in the northeast area of the state (i.e., Canadian Rocky
Mountains ecoregion). The drier middle and southeast areas of the
state (i.e., Columbia Plateau ecoregion), heavily influenced by the
rain-shadow effect of the Cascade Range, contain large areas of
shrubland, grassland and both irrigated and dry land agriculture
(LandScope America, 2013). Seventy-five percent of Washington
State’s citizens live in the Puget Trough ecoregion on the western
side of the state (LandScope America, 2013). Population densities
vary across the state, with the higher densities mostly concentrated
in urban areas such as Vancouver, Centralia, Olympia, Tacoma, Seat-
tle, Everett, Bellingham, and Spokane.
2.2. Health indicators data
We obtained mental and general health data from the BRFSS,
conducted in Washington State in 2006 (Washington State
Department of Health, 2007). The BRFSS is a telephone survey
that is conducted by health departments of states with techni-
cal and methodological support of the Centers for Disease Control
and Prevention (CDC) to assess the health practices and distribu-
tion of risk behaviors among non-institutionalized adults (CDC,
2006; Mokdad, 2009). The BRFSS data contained responses coded
to the US postal zip-code of the respondent’s residence some-
where within the zip-code. The original dataset contained 23,760
responses in 668 zip-codes. We processed the BRFSS data to include
only valid zip-codes for which there exist geographic (polygonal)
boundaries. Thus, we excluded from the BRFSS dataset zip-codes
that represented point locations such as Post Office Boxes and pri-
vate companies where respondents clearly do not reside. The GIS
 A. Akpinar et al. / Urban Forestry & Urban Greening 20 (2016) 407–418
zip-code dataset contained 532 zip-codes. Those zip-codes were
matched to the BRFSS data. Non-matching zip-codes were also
excluded, yielding 509 zip-codes. We also excluded cases coded
as Don‘t know/not sure, Refused or Missing for zip-codes as well
as for the needed health and mental variables (listwise deletion).
This exclusion resulted in 9009 complete responses (37.91% of total
responses), distributed in 472 zip-codes.
To maximize external validity, we excluded zip-codes with
fewer than 30 responses. This last exclusion yielded 5148 com-
plete responses distributed across 98 zip-codes which vary
in size (minimum = 2.20 sq. mi, maximum = 1422.95 sq. mi,
M = 169.59 sq. mi.), population (minimum = 2450 people, max-
imum = 64214 people, M = 26065 people), population density
(minimum = 4.10 people per sq. mi, maximum = 9393.63 people per
sq. mi, M = 1532.61 people per sq. mi.), household income (min-
imum = $22418, maximum = $91904, medium = $44902), unem-
ployment (minimum = 2.58%, maximum = 14.97%, M = 6.53%), and
education level (i.e. bachelor degree or above) (minimum = 6.65%,
maximum = 84.22%, M = 21.70%). The exclusion of those zip-codes
with fewer than 30 respondents did not alter the substantive
results.
The BRFSS Self-Reported Health and Healthy Days data has been
shown to have adequate test-retest reliability (Andresen et al.,
2003). In addition, general health and mental health items demon-
strated adequate test-retest reliability (Kapp et al., 2009). Hence,
the following variables were employed in this study:
1 Mental health complaints: Participants were asked “Now thinking
about your mental health, which includes stress, depression, and
problems with emotions, for how many days during the past 30 days
was your mental health not good?” scores could range from 0 to
30 days.
2 Anxiety-Depression complaints: This is measured with eight
questions. Respondents were asked “How many days each of the
following has occurred in the past 2 weeks: having little pleasure
doing things, feeling down, depressed or hopeless, having trouble
falling asleep or staying asleep or sleeping too much, feeling tired
or had little energy, having a poor appetite or eaten too much, feel-
ing failure or letting family down, having trouble concentrating on
things, and talking or moving slower or faster than usual.” Scores
could range from 0 to 14 days.
3 General health status measured by the question “Would you say
that in general your health is 1 = Excellent, 2 = Very good, 3 = Good,
4 = Fair, 5 = Poor?”
2.3. Green space data
Green space is defined as lands that consist predominantly of
unsealed, pervious, soft surfaces such as soil, grass, shrubs and
trees, with few structures present (Forman, 2008). Within this con-
text, we find a variety of definitions for types of green space. Forman
(2008) defines types of green space as playing fields, wetlands, nature
reserves, tree corridors, and market-gardening areas while Maas et al.
(2006) and Van den Berg et al. (2010) define types of green space
as urban green space, forest, nature conservation areas, and agricul-
tural green space. These authors used the Dutch National Land Cover
Classification (LGN4) which is a database in 25 × 25 grid cell reso-
lutions that distinguishes 39 land-cover classes such as crop types,
forest types, water, various urban classes and semi-natural vegeta-
tion types in the Netherlands (de Wit and Clevers, 2004). Barton and
Pretty (2010) defined types of green space as urban green, waterside,
forest/woodland, wilderness/type habitat, and countryside/farmland.
These definitions are a mixture of the ‘cover’ of the land as well as
the ‘use’ of the land. In this study, we considered all urban green
space, forest, agricultural land, rangeland, and wetlands as types of
409
Table 1
NLCD Green space variables (Source: The authors).
The NLCD Code Reclassification Aggregation
21: Developed Open Space Urban Green Green Space
22: Developed Low Intensity Space “Simply
41: Deciduous Forest Forest Green”
42: Evergreen Forest
43: Mixed Forest
52: Shrub/Scrub Rangeland
71: Grasslands/Herbaceous
81: Pasture/Hay Agricultural
82: Cultivated Crops Land
90: Woody Wetland Wetland
95: Emergent Herbaceous Wetland
green space based on the US National Land Cover Dataset (NLCD),
as described below.
Similar in resolution to the above-referenced LGN4, the NLCD
2006 is a gridded database with a 30 × 30 m resolution (Fry et al.,
2011) having 80% overall accuracy (Wickham et al., 2013). Based on
classification of Landsat Thematic Mapper imagery, the NLCD 2006
distinguishes 20 land-cover classes such as water, various urban
classes, barren, forest types, rangelands (shrublands and grass-
lands), agricultural lands, and wetlands across the coterminous USA
(Fry et al., 2011).
Based on the above-given definition of green space types, we
reclassified land cover classes in the NLCD 2006 into five types
of green space (i.e. urban green space, forest, rangeland, agricul-
tural land, and wetland) (see Table 1). Among the NLCD 2006 Land
Cover classes, only urban green space is not comprehensively iden-
tified; rather the NLCD 2006 identifies four classes of land use
(i.e. developed-open space, developed-low intensity, developed-
medium intensity, and developed-high intensity) in which built-on
land is mixed with natural vegetation. These four classes are dis-
tinguished by the percentage of impervious land (i.e., pavement,
asphalt, etc.) in the cell. For our urban green space category we
included the developed-open space and developed-low intensity
classes where impervious surfaces account for less than 20% and
20% to 49% of total cover respectively. Based on the Forman‘s (2008)
definition of green space and similar work in the Netherlands (Van
den Berg et al., 2010) we omitted the developed-medium intensity
and developed-high intensity classes where impervious surfaces
account for 50% to 79% and 80% to 100% of total cover respec-
tively due to large amount of impervious surfaces. Examples of the
land uses included in the selected urban categories include large-
lot single-family housing units, parks, golf courses, and vegetation
planted in developed settings for recreation, erosion control, or
aesthetic purposes (Fry et al., 2011).
The reclassification of the green space categories given in
Table 1, resulted in one aggregated green space value and up to five
green-space types for each zip-code area. We calculated the pro-
portion (normalized amount) of each type of green space in each
zip-code using this reclassified data. These values represent the
total proportion of a green space type within a zip-code area; at
this aggregate level, no information regarding clustering or adja-
cency of the types is available. In addition, the structural metrics
were also analyzed included fragmentation, size, and connectivity
using FRAGSTATS (McGarigal et al., 2012). Patches in every zip-code
were calculated based on the specific metrics of three structural
metrics. In FRAGSTATS the specific metrics employed included the
largest patch index (LPI) for fragmentation, the patch area weighted
mean (AREA AM) for size, and the cohesion index (COHESION) for
connectivity.
410 A. Akpinar et al. / Urban Forestry & Urban Greening 20 (2016) 407–418

2.4. Socio-economic and demographic characteristics Table 2

Characteristics of the BRFSS results.

Because health may differ according to people’s background Items BRFSS

characteristics, we obtained gender, age (in years), level of edu- N = 5148
cation, and household income of each respondent. Income level Sex Male 39.2%
was categorized from less than $10,000 to $75,000 or more. Level Female 60.8%
of education was categorized from never attended school or only Age 18 to 24: 4.1%
25 to 34: 12.1%
attended kindergarten to college 4 years or more (College gradu-
35 to 44: 17.1%
ate.) We were also concerned at the potential for zip-code level 45 to 54: 21.6%
confounding variables that might affect the associations. There- 55 to 64: 20.8%
fore, we obtained data at the zip-code level describing population, 65 to 74: 13.5%
75 or older: 10.8%
size (sq. mi), population density, socio-economic status (SES) (i.e.
Education Never attended school or only attended 0.2%
median household income, occupation (unemployment rate), and kindergarten: 1.6%
education level (bachelor’s degree or higher)) from U. S. Census Grades 1 through 8 (Elementary): 4.3%
2000 data. Grades 9 through 11 (Some high school): 22.1%
Grade 12 or GED (High school graduate): 32.7%
College 1 year to 3 years (Some college or technical 39.1%
2.5. Analytic strategy
school):
College 4 years or more (College graduate):
Preliminary analyses examined the normality of the variables. Income Less than $10,000: 3.1%
The responses to the general health questions were normally $10,000 to less than $15,000: 3.9%
$15,000 to less than $20,000: 5%
distributed. To help clarify the relationship between anxiety-
$20,000 to less than $25,000: 10.3%
depression and green space, eight questions were reduced to one $25,000 to less than $35,000: 13.9%
factor (i.e. anxiety-depression index) using maximum likelihood $35,000 to less than $50,000: 18.1%
exploratory factor analysis. The factor analysis was used because $50,000 to less than $75,000: 19.3%
these questions together were intended to measure the level of $75,000 or more: 26.3%
Race White (Non-Hispanic and Hispanic): 89.5%
anxiety-depression. Each question asked a different symptom of
African American: 2.2%
anxiety-depression so that they should be considered together. We Asian: 2.1%
then examined the distribution of mental health complaints and Native Hawaiian or Other Pacific Islander: 0.4%
anxiety-depression complaints. Because the distributions of these American Indian, Alaska Native: 1.4%
Multiracial: 1.7%
variables were positively skewed, we applied a log-transformation
Other races: 2.7%
y = loge (x + 1) to these two outcomes on which all test statistics are
based. However, our untransformed results were similar to those of
the transformed data, and therefore we report the untransformed
results.
We first assessed the bivariate relationships between mental classification of urban and rural areas was done based on the
and general health with aggregated green space using correlational Bureau of the Census classification, which classifies a popula-
analyses (Pearson’s r). A p-value of 0.05 was used to indicate statis- tion density of at least 1000 people per sq. mi. as an “urbanized
tical significance for the bivariate relationships. Next, we examined area” and less than 1000 people per sq. mi. as a “rural area” (US
the relationships between aggregated green space, mental and Census Bureau, 1995). In addition, we created three different sub-
general health while controlling for individual respondent char- groups for rural zip-codes due to the size differences of rural
acteristics at the individual level, and zip-code characteristics at zip-codes.
the zip-code level via multilevel linear regression analyses. Prior
to performing multilevel linear regression analyses, we checked 3. Results
for presence of multicollinearity issues between independent vari-
ables. Lastly, we examined the relationships between the five types 3.1. Characteristics of participants
of green space, mental and general health while controlling for
the possible confounding factors as for aggregated green space. As seen in Table 2, 39.2% of the BRFSS respondents were male
All regression results can be viewed in terms of “as x increases by and 60.8% were female among the 5148 participants. The average
1, then y increase by beta”, noting that our dependent variables age of the participants was 52.40 years old. The highest partici-
are log-transformed due to non-normal distributions. A p-value of pation age cohort in the BRFSS sample was ages 45 to 54 (21.6%)
0.05 was used to indicate statistical significance. SPSS version 18 and the lowest was ages 18 to 24 (4.1%). The highest degree
was used for all statistical analyses (SPSS Inc, 2009). In addition, in of education achieved by the respondents (college graduate or
order to verify that results were consistent when dependent vari- more) was 39.1%. In terms of the total annual household income,
ables were viewed as ordinal, we ran all analyses also using ordinal 26.3% of the BRFSS respondents were in the highest income level
regressions. ($75,000 or more). Regarding race, the BRFSS sample was 89.5%
We also conducted additional stratification analyses to exam- White.
ine the relationship between green space and health in urban and
rural areas. This was done because previous studies found differing 3.2. Descriptive statistics of the health indicators responses
associations between green space and health at the neighborhood
level (i.e. significant positive relationship; de Vries et al., 2003; The mean of the mental health complaints was 3.11 days while
Maas et al., 2006, 2009; Van den Berg et al., 2010; Stigsdotter median was 0 days; the minimum response was 0 days while the
et al., 2010; Richardson et al., 2010, 2013; Ward Thompson et al., maximum was 30. The mean of the anxiety-depression complaints
2012; Beyer et al., 2014 and at the city level (i.e. non-significant was 1.53 days and median was 1 day; the minimum response was
relationship; Richardson et al., 2012). In this study, zip-codes 0 days while the maximum was 14. For the general health sta-
vary in size from 2.20 sq. mi to 1422.95 sq. mi and smaller tus, the mean of the general health was 2.40 while median was
zip-codes are mostly located in urban areas (see Fig. 1). The 2; the lowest response was 1 and the highest response was 5.
 A. Akpinar et al. / Urban Forestry & Urban Greening 20 (2016) 407–418
Fig. 1. Urban and rural areas in the study.
Among all individuals, only 13.9% respondents rated their health
in general as fair or poor. The descriptive statistics indicates that
our data consists of self-reportedly healthy sample of individu-
als.
3.3. Descriptive statistics of urban and rural zip-codes and green
space types by zip-code
As seen in Table 3, the mean of zip-code size in urban areas is
12.02 sq. m., while the mean zip-code size in rural areas is 262.55
sq. m. In terms of population, the mean population in urban areas
is 33628.28 people, whereas the mean of population in rural areas
is 21594.57 people. In regard to population density, the mean of
population density in urban areas is 3680 people per sq. mi, while
the mean of population density in rural areas is 263.82 people per
sq. mi. In terms of zip-code SES, the medium household income in
urban areas is $52088.81, whereas the medium household income
in rural areas is $41942.34. For unemployment rate, the mean of
unemployment rate in urban areas is 5.58%, while the mean of
unemployment rate in rural areas is 7.26%. Lastly, the mean of edu-
cation level (i.e. bachelor degree or above) in urban areas is 26.21%,
whereas the mean of education level in rural areas is 19.04%.
Regarding green space, the mean percentage of aggregated
green space in zip-codes is 85.40% (minimum = 13.54%, maxi-
mum = 99.94%) (see Fig. 2). The mean of percentage of urban
green space in zip-codes is 26.69% (minimum = 0.75%, maxi-
mum = 66.26%). The mean of percentage of forest is 27.86%
(minimum = 0%, maximum = 77.62%). For the rangeland, the mean
of percentage is 16.35% (minimum = 0%, maximum = 69.84%). The
mean of percentage of agricultural land is 11.54% (minimum = 0%,
maximum = 87.83%). Lastly, the mean of percentage of wetlands is
3.16% (minimum = 0%, maximum = 16.71%) (see Fig. 3).
411
3.4. The relationships of aggregated green space to mental and
general health
We first examined the correlations between aggregated green
space and mental and general health (data not shown). The results
showed that there was not a significant relationship between
aggregated green space and the mental health and anxiety-
depression variables. Green spaces showed a positive, but weak
correlation with the general health variable (r = 0.03, p< 0.05),
where more aggregated green space was related to poorer reported
general health. We also performed a series of multilevel linear
regression analyses to further explore the factors that are associ-
ated with the health indicators. In this analysis, we found multi-
collinearity issues between aggregated green space fragmentation
and connectivity, urban green space fragmentation and connectiv-
ity, forest fragmentation, size, and connectivity, agricultural land
fragmentation, size, and fragmentation, wetland fragmentation,
zip-code size, and population density. Hence, we excluded these
variables from the regression model due to the multicollinearity
issue. These results are presented immediately below. In addi-
tion, our ordinal regressions analyses showed same results across
regression type (data not shown).
3.4.1. Regression analyses of aggregated green space to mental
and general health
As presented in Table 4, the multilevel regression analysis
revealed that aggregated green space was not related to mental
health complaints after controlling for the covariates. The regres-
sion results indicated that males (␤= −0.988, SE = 0.197, 95% CI
−1.374, −0.602), those in a higher income (␤= −0.708, SE = 0.057,
95% CI −0.819, −0.596) levels, and those in higher education lev-
els (␤= −0.294, SE = 0.111, 95% CI −0.512, −0.075) reported fewer
days of mental health complaints, as did older adults (␤= −0.062,
SE = 0.006, 95% CI −0.073, −0.050). In addition, those identifying as
412 A. Akpinar et al. / Urban Forestry & Urban Greening 20 (2016) 407–418

Table 3
Descriptive statistics of urban and rural zip-codes.

Urban Zip-codes Rural Zip-codes

Min. Max. Mean Medium Min. Max. Mean Medium

Size (sq. mi) 2.20 33.15 12.02 – 21.41 1422.95 262.55 –

Population 13540 64214 33628.28 – 2450 47202 21594.57 –
Population density (per sq. mi) 1028.49 9393.63 3680 – 4.10 874.68 263.82 –
Household income ($) 29056 91904 – 52088.81 22418 77181 – 41942.34
Unemployment rate (%) 2.68 11.89 5.58 – 2.58 14.97 7.26 –
Education (% Bachelor or above) 11.70 84.22 26.21 – 6.65 83.83 19.04 –

Fig. 2. Percent aggregated green space by zip-code in Washington State. (For interpretation of the references to colour in this figure legend, the reader is referred to the web
version of this article.)

Table 4
Unstandardized multilevel regression coefficients.

Mental Healthcomplaints Anxiety-Depressioncomplaints General Healthstatus

Age −0.062 (.006) ∗∗∗ −0.017 (.002) ∗∗∗ .010 (.001) ∗∗∗
Sex (Male) −0.988 (.197) ∗∗∗ −0.310 (.058) ∗∗∗ .095 (.027) ∗∗∗
Income Level −0.708 (.057) ∗∗∗ −0.284 (.017) ∗∗∗ −0.140 (.008) ∗∗∗
Education Level −0.294 (.111) ∗∗ −.153 (.033) ∗∗∗ −0.143 (.015) ∗∗∗
African American 1.227 (1.082) −0.228 (.319) .143 (.150)
Asian −1.765 (.711) ∗ −0.565 (.209) ∗∗ .117 (.099)
Native Hawaiian/Pacific Islander −0.081 (1.623) −0.301 (.478) .038 (.225)
American Indian, Alaska Native 1.715 (.987) .060 (.291) .135 (.137)
Multiracial −1.656 (.633) ∗∗ −1.019 (.187) ∗∗∗ .244 (.088) ∗∗
Other races 3.069 (.624) ∗∗∗ .813 (.184) ∗∗∗ .435 (.087)∗∗∗
Aggregated Green Space .004 (.007) −0.001 (.002) −0.001 (.001)
Aggregated Green Space Size −0.001 (.000) −0.001 (.002) .001 (.000)
Zip-code Population .001 (.000) −0.001 (.000) .001 (.000)
Zip-code Income Level .001 (.000) .001 (.000) .001 (.000)
Zip-code Occupation Level −0.043 (.056) −0.017 (.016) −0.001 (.008)
Zip-code Education Level .000 (.008) −0.003 (.002) −0.002 (.001) ∗
R2 .069∗∗∗ .098∗∗∗ .159∗∗∗

***p ≤ 0.001, **p ≤ 0.01; *p ≤ 0.05, Units: B and (Std. Error). White race is the reference group.
 A. Akpinar et al. / Urban Forestry & Urban Greening 20 (2016) 407–418 413

Fig. 3. Distributions of types of green space in zip-codes. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this
article.)

Table 5
Unstandardized multilevel regression coefficients for the types of green space.

Mental Healthcomplaints Anxiety-Depressioncomplaints General Healthstatus

Age −0.062 (.006) ∗∗∗ −0.017 (.002) ∗∗∗ .010 (.001) ∗∗∗
Sex (Male) −0.991 (.197) ∗∗∗ −0.307 (.058) ∗∗∗ .095 (.027) ∗∗∗
Income Level −0.708 (.057) ∗∗∗ −0.285 (.017) ∗∗∗ −0.140 (.008) ∗∗∗
Education Level −0.310 (.112) ∗∗ −.155 (.033) ∗∗∗ −0.143 (.015) ∗∗∗
African American 1.128 (1.083) .265 (.319) .133 (.150)
Asian −1.794 (.711) ∗ −0.568 (.210) ∗ .116 (.099)
Native Hawaiian/Pacific Islander −0.163 (1.623) .323 (.478) .034 (.225)
American Indian, Alaska Native 1.685 (.987) .039 (.291) .132 (.137)
Multiracial −1.563 (.635) ∗ −0.990 (.187) ∗∗∗ .251 (.088) ∗∗
Other races 3.019 (.624) ∗∗∗ .801 (.184) ∗∗∗ .433 (.087)∗∗∗
Urban Green Space .022 (.015) .005 (.005) −0.001 (.002)
Forest −0.021 (.010) ∗ .001 (.003) .000 (.001)
Rangeland .005 (.015) .001 (.004) −0.001 (.002)
Agricultural Land .004 (.013) −0.001 (.004) −0.001 (.002)
Wetland −0.045 (.057) −0.009 (.017) −0.004 (.008)
Urban Green Space Size −0.001 (.000) .001 (.000) .001 (.000)
Forest Size .001 (.000) .001 (.000) −0.001 (.000)
Rangeland Size −0.001 (.000) −0.001 (.000) −0.001 (.000)
Agricultural Land Size .001 (.000) −0.001 (.000) .001 (.000)
Wetland Size .001 (.002) .001 (.001) .000 (.000)
Zip-code Population .001 (.000) −0.001 (.000) .001 (.000)
Zip-code Income Level .001 (.000) .001 (.000) −0.001 (.000)
Zip-code Occupation Level −0.024 (.059) −0.014 (.017) .001 (.008)
Zip-code Education Level .004 (.009) −0.001 (.003) −0.002 (.001)
R 2
.071∗∗∗ .103∗∗∗ .160∗∗∗

***p ≤ 0.001, **p ≤ 0.01; *p ≤ 0.05, Units: B and (Std. Error). White race is the reference group.

Asian (␤= −1.765, SE = 0.711, 95% CI −3.158, −0.371) and Multira-
cial (␤= −1.656, SE = 0.633, 95% CI −2.898, −0.416) reported fewer
days of mental health complaints, whereas those identifying as
“other races” (␤= 3.069, SE = 0.624, 95% CI 1.845, 4.291) reported
more days of mental health complaints compared to White partic-
ipants.
The results showed that aggregated green space was not sig-
nificantly related to anxiety-depression complaints (see Table 4).
The results also revealed that males (␤= −0.310, SE = 0.058, 95% CI
−0.424, −0.196), older adults (␤= −0.017, SE = 0.002, 95% CI −0.021,
−0.014), and those who have higher income levels (␤= −0.284,
SE = 0.017, 95% CI −0.317, −0.252), and education levels (␤= −0.153,
SE = 0.033, 95% CI-0.218, −0.089) reported fewer days of anxiety-
depression complaints. In addition, those identifying as Asian
(␤= −0.565, SE = 0.209, 95% CI −0.976, −0.154) and Multiracial
(␤= −1.019, SE = 0.187, 95% CI −1.386, −0.654) reported fewer days
of mental health complaints, whereas those identifying as “other
414 A. Akpinar et al. / Urban Forestry & Urban Greening 20 (2016) 407–418
races” (␤= 0.813, SE = 0.184, 95% CI 0.452, 1.173) reported more days
of mental health complaints compared to White participants.
Lastly, the multilevel linear regression model showed that
aggregated green space was not significantly related to gen-
eral health (see Table 4). Those who have a higher income
(␤= −0.140, SE = 0.008, 95% CI −0.156, −0.125) levels, and edu-
cation levels in both individual, (␤= −0.143, SE = 0.015, 95% CI
−0.174, −0.113) and zip-code level (␤= −0.002, SE = 0.001, 95%
CI −0.004, 0.000) were associated with better reported general
health, while older adults (␤= 0.010, SE = 0.001, 95% CI 0.008, 0.011)
and males (␤= 0.095, SE = 0.027, 95% CI 0.041, 0.148) reported
poorer general health. Among races, those who identify as Mul-
tiracial (␤= 0.244, SE = 0.088, 95% CI 0.072, 0.416) and “other races”
(␤= 0.435, SE = 0.087, 95% CI 0.265, 0.605) reported poorer general
health compared to White participants.
3.5. Relationships between types of green space and mental and
general health
To determine the factors that are correlated with the health indi-
cators, we also performed a series of multilevel linear regression
analyses that examined relationships between types of green space
and the BRFSS variables. As seen in Table 5, after controlling for
covariates, the multilevel regression analysis revealed that forest
was significantly related to mental health complaints (␤= −0.021,
SE = 0.010, 95% CI −0.038, −0.003), where more forest was asso-
ciated with fewer days of mental health complaints. Regression
results also showed that no type of green space was significantly
related to anxiety-depression complaints and general health. In
terms of covariates, the results were very similar to aggregated
green space results.
3.6. Stratified analyses of urban and rural zip-codes
We conducted stratification analyses to examine the relation-
ship between aggregated and types of green space and health in
urban areas (n = 1912) and rural areas (n = 3236) as well as sub-
groups of rural areas. The rationale for this analysis was discussed
previously.
As seen in Table 6, there was not a significant association
between aggregated green space and health indicators (mental
health complaints, anxiety-depression complaints, and general
health) in both urban and rural areas including sub-groups of rural
zip-code areas (data not shown). However, the regression model
showed that urban green space was significantly associated with
mental health complaints (␤= −0.028, SE = 0.017, 95% CI −0.060,
−0.005), where more urban green space was associated with fewer
days of mental health complaints in urban areas (see Table 7).
In addition, forest size was significantly associated with mental
health complaints (␤= −0.003, SE = 0.001, 95% CI −0.005, 0.001),
where larger forest was associated with fewer days of mental health
complaints in urban areas. No other types of green space were asso-
ciated with health indicators in both urban and rural areas including
sub-groups of rural zip-code areas.
4. Discussion
The purpose of this study was to explore the relationship
between green space and BRFSS-reported indicators of mental and
general health at the zip-code level. After controlling for confound-
ing factors, aggregated green space was not associated with mental
and general health in analyses. The lack of association with mental
health and general health was unexpected and in contrast to results
from most existing studies (Maas et al., 2006, 2009; Van den Berg
et al., 2010; Stigsdotter et al., 2010; Richardson et al., 2010, 2013;
Ward Thompson et al., 2012; Beyer et al., 2014; Triguero-Mas et al.,
2015). However, it was consistent with Richardson et al. (2012)
and Picavet et al. (2016) findings. Based on the results we found,
our hypothesis for aggregated green space was rejected.
In examining the five types of green space for all the valid zip-
codes, we found that greater percentages of forest were associated
with fewer days of mental health complaints as expected (Maas
et al., 2006; Morita et al., 2007; White et al., 2013b). The results also
revealed that more urban green space was associated with fewer
days of mental health complaints in stratified analyses as expected
(Grahn and Stigsdotter, 2003; Matsuoka and Kaplan, 2008; Niemelä
et al., 2011; White et al., 2013a). On the other hand, we did not find
any significant association between, agricultural lands and men-
tal health and general health, which was unexpected (de Vries
et al., 2003; Maas et al., 2006). Therefore, our hypothesis for urban
green space and forest was accepted, whereas it was rejected for
agricultural lands. In addition, we did not find any significant rela-
tionships between rangelands, wetlands, and mental health and
general health in our analyses. We have highlighted several points
that explain the differences between our study and the previous
studies.
Most of the previous studies (see review Van den Berg et al.,
2015) assumed that those who live in relatively more abundant
green space may have better mental and general health than those
who live in less abundant green space conditions. However, this
assumption is not supported by our aggregated green space (i.e.
urban green space, forest, agricultural land, rangeland, and wet-
land) findings similarly to Picavet et al. (2016) and Richardson
et al. (2012) studies. If “living in more abundant green” leads
to better health, then we should have found significant associa-
tions. However, we found no evidence in that direction. Similarly,
a recent longitudinal study did not find any significant association
between aggregated green space (i.e. urban green space, agricul-
tural green, forest, and natural areas) and health (Picavet et al.,
2016). It is important to note that, each type of green has different
characteristics and human perception of landscapes is found to be
associated with health and stress reduction (Ulrich, 1984; Ulrich
et al., 1991), increased neighborhood satisfaction (Kaplan, 2001),
and better restoration (Van den Berg et al., 2014). Wetlands, for
example, may not be aesthetically pleasing and are perceived neg-
atively (Nassauer, 2004; Gobster et al., 2007). Similarly, rangeland
is perceived as less natural (Lamb and Purcell, 1990) and natural-
ness is a powerful predictor of human preferences (Kaplan et al.,
1972; Ulrich, 1977; Herzog et al., 1982; Lamb and Purcell, 1990;
Kaplan, 2001; Van den Berg et al., 2014). On the other hand, forests
were found to be associated with restoration (White et al., 2013b)
and received higher restoration scores (Laumann et al., 2001).
Therefore, considering all our study suggests that green spaces
should not be seen as a “simply green,” rather they should be con-
sidered by type.
Another alternative possibility for the non-significant associ-
ations between aggregated green space and mental and general
health is the size of study areas. In previous studies, the relation-
ship was mostly examined in a 1–3 km radius around participants’
homes (de Vries et al., 2003; Maas et al., 2006; Van den Berg et al.,
2010) or at the neighborhood level (Richardson et al., 2013; Beyer
et al., 2014) while we examined green space at the zip-code level
which varies in size from 2.20 sq. mi to 1422.95 sq. mi. Many studies
emphasized that distance is an important factor in the relationship
between green space and health (Maas et al., 2009; Stigsdotter
et al., 2010; Ward Thompson et al., 2012); therefore, consider-
ing the size of zip-codes areas in our study respondents may not
have engaged with green space in large zip-codes. Hence, possi-
bly longer distances to green space may have also contributed to
differences in results that we did not find a significant association
between aggregated green spaces in our study. In addition, as many
studies emphasized, the quality rather than the quantity of green
 A. Akpinar et al. / Urban Forestry & Urban Greening 20 (2016) 407–418 415

Table 6
Unstandardized multilevel regression coefficients (standard errors) of urban and rural zip-codes for aggregated green space.

Zip-codes in Urban Areas (n = 1912) Zip-codes in Rural Areas (n = 3236)

Mental Health Anxiety-Depression General Health Mental Health Anxiety-Depression General Health
complaints complaints status complaints complaints status

Age −0.081 (.009) ∗∗∗ −0.018 (.003) ∗∗∗ .008 (.001) ∗∗∗ −0.051 (.008) ∗∗∗ −0.017 (.002) ∗∗∗ .011 (.001) ∗∗∗
Sex (Male) −0.823 (.300) ∗∗ −0.284 (.089) ∗∗∗ .102 (.043) ∗ −1.099 (.259) ∗∗ −0.325 (.076) ∗∗∗ .089 (.035) ∗
Income Level −0.822 (.090) ∗∗∗ −0.285 (.027) ∗∗∗ −0.128 (.013) ∗∗∗ −0.641 (.073) ∗∗∗ −0.283 (.021) ∗∗∗ −0.146 (.010) ∗∗∗
Education Level −0.628 (.182) ∗∗∗ −0.307 (.054) ∗∗∗ −0.156 (.026) ∗∗∗ −0.145 (.141) −0.081 (.041)∗ −0.139 (.019) ∗∗∗
African American 1.807 (1.292) −0.091 (.384) .126 (.185) .077 (1.793) −0.462 (.526) .158 (.246)
Asian −1.285 (.818) −0.374 (.243) .114 (.117) −2.505 (1.257) ∗ −0.849 (.369) ∗ .130 (.172)
Native Hawaiian/Pacific Islander 2.016 (1.930) .339 (.574) .149 (.276) −3.849 (2.701) −1.374 (.793) −0.180 (.370)
American Indian, Alaska Native 2.342 (1.066) .003 (.477) .126 (.230) −2.128 (2.813) .023 (.367) .138 (.171)
Multiracial 1.687 (.976) −1.185 (.290)∗∗ .408 (.139)∗∗ 1.295 (1.251) −0.938 (.242) ∗∗∗ .159 (.113)
Other races 3.411 (.986) ∗∗∗ .649 (.293) ∗ .373 (.141) ∗∗ 2.919 (.800) ∗∗∗ .904 (.235) ∗∗∗ .469 (.110) ∗∗∗
Aggregated Green Space .021 (.015) .004 (.004) −0.001 (.002) .003 (.050) −0.006 (.015) .003 (.007)
Aggregated Green Space Size −0.001 (.000) −0.001 (.000) .001 (.000) −0.001 (.000) −0.001 (.000) .001 (.000)
Zip-code Population −0.001 (.000) −0.001 (.000) .001 (.000) .001 (.000) −0.001 (.000) .001 (.000)
Zip-code Income Level −0.001 (.000) −0.001 (.000) −0.001 (.000) .001 (.000) .001 (.000) ∗∗ .001 (.000) ∗
Zip-code Occupation Level −0.252 (.105)∗ −0.050 (.031) −0.013 (.015) .053 (.069) .002 (.020) .009 (.009)
Zip-code Education Level .000 (.012) −0.004 (.004) −0.003 (.002) .002 (.011) −0.002 (.003) −0.001 (.002)
R2 .117∗∗∗ .134∗∗∗ .159∗∗∗ .053∗∗∗ .092∗∗∗ .162∗∗∗

***p ≤ 0.001, **p ≤ 0.01; *p ≤ 0.05, Units: B and (Std. Error). White race is the reference group.

Table 7
Unstandardized multilevel regression coefficients (standard errors) of urban and rural zip-codes for types of green space.

Zip-codes in Urban Areas (n = 1912) Zip-codes in Rural Areas (n = 3236)

Mental Health Anxiety-Depression General Health Mental Health Anxiety-Depression General Health
complaints complaints status complaints complaints Status

Age −0.083 (.009) ∗∗∗ −0.018 (.003) ∗∗∗ .008 (.001) ∗∗∗ −0.052 (.008) ∗∗∗ −0.017 (.002) ∗∗∗ .011 (.001) ∗∗∗
Sex (Male) −0.821 (.300) ∗∗ −0.282 (.089) ∗∗ .102 (.043) ∗ −1.112 (.259) ∗∗ −0.323 (.076) ∗∗∗ .088 (.035) ∗
Income Level −0.823 (.090) ∗∗∗ −0.287 (.027) ∗∗∗ −0.128 (.013) ∗∗∗ −0.640 (.073) ∗∗∗ −0.282 (.021) ∗∗∗ −0.145 (.010) ∗∗∗
Education Level −0.638 (.183) ∗∗∗ −0.310 (.055) ∗∗∗ −0.155 (.026) ∗∗∗ −0.168 (.141) −0.083 (.041) ∗ −0.139 (.019) ∗∗∗
African American 1.623 (1.292) −0.120 (.384) .118 (.185) .049 (1.795) −0.502 (.527) .143 (.246)
Asian −1.313 (.817) −0.379 (.243) .112 (.117) −2.482 (1.256) −0.836 (.369) ∗ .128 (.172)
Native Hawaiian/Pacific Islander 2.075 (1.932) .324 (.575) .160 (.277) −3.887 (2.700) −1.393 (.793) −0.189 (.370)
American Indian, Alaska Native 2.441 (1.605) .014 (.478) .124 (.230) 1.277 (1.250) .007 (.367) .135 (.171)
Multiracial −1.794 (.976) −1.210 (.291)∗∗∗ .405 (.140) ∗∗ −1.580 (.828) −0.893 (.243) ∗∗∗ .167 (.114)
Other races 3.412 (.985) ∗∗∗ .647 (.293) ∗ .374 (.141) ∗∗ 2.864 (.801) ∗∗∗ .894 (.235) ∗∗∗ .469 (.110) ∗∗∗
Urban Green Space −0.034 (.019)∗ .006 (.006) .001 (.003) .014 (.021) .007 (.006) .000 (.003)
Forest -.028 (.031) .002 (.009) −0.003 (.004) .015 (.009) .004 (.003) .001 (.001)
Rangeland −0.072 (.062) −0.017 (.018) .001 (.009) .005 (.011) .001 (.003) .000 (.001)
Agricultural Land −0.082 (.046) −0.006 (.014) −0.001 (.007) −0.000 (.069) −0.001 (.003) .000 (.001)
Wetland −0.030 (.140) −0.021 (.028) −0.002 (.013) −0.096 (.071) −0.009 (.021) −0.008 (.010)
Urban Green Space Size .000 (.000) −0.001 (.000) .001 (.000) −0.001 (.000) −0.001 (.000) .001 (.000)
Forest Size −0.003 (.001) ∗ .001 (.000) .001 (.000) .001 (.000) .001 (.000) −0.001 (.000)
Wetland Size .005 (.016) −0.001 (.000) .001 (.000) .003 (.003) .001 (.001) .000 (.000)
Zip-code Population −0.001 (.000) −0.001 (.000) .001 (.000) .001 (.000) .001 (.000) .001 (.000)
Zip-code Income Level −0.001 (.000) −0.001 (.000) −0.001 (.000) .001 (.000) .001 (.000) .001 (.000)
Zip-code Occupation Level −0.234 (.114) ∗ −0.041 (.034) −0.017 (.016) .082 (.072) .009 (.021) .012 (.010)
Zip-code Education Level −0.004 (.013) −0.005 (.004) −0.003 (.002) .010 (.012) .000 (.004) .000 (.002)
R2 .123∗∗∗ .136∗∗∗ .159∗∗∗ .056∗∗∗ .094∗∗∗ .162∗∗∗

***p ≤ 0.001, **p ≤ 0.01; *p ≤ 0.05, Units: B and (Std. Error). White race is the reference group.

spaces may be important in the relationship between green space
and health (Akpinar, 2016; Richardson et al., 2010; Richardson and
Mitchell2011; Van den Berg et al., 2007; Maas et al., 2006; de Vries
et al., 2003). Therefore, these possibilities should be investigated in
future studies.
Our results revealed that forest and forest size were associated
with fewer days of mental health complaints, which is consistent
with previous studies (Morita et al., 2007; Pretty et al., 2007; Park
et al., 2008, 2010; White et al., 2013b). On a theoretical level, as
Attention Restoration Theory (Kaplan and Kaplan, 1989; Kaplan,
1995) describes, forests would appear to provide all components
of restorative environments. Forests are rich in complexity so that
they can generate fascination, their vegetation may contribute to a
sense of extent and being away, and forests also can support differ-
ent activities to ensure the compatibility (Van den Berg et al., 2014).
Parallel with these notions, previous studies showed that taking in
the atmosphere of the forest (i.e. Shinrin-yoku) is an effective form
of relaxation and has positive physiological and health effects (Park
et al., 2008, 2010). Similarly, White et al. (2013b) found that visits
to forests were associated with better restoration. In terms of size,
studies indicate that in order to experience positive psychological
outcomes people should spend some time in nature where people
can have the opportunity to expose nature and experience psycho-
logical benefits that lead to mental well-being (Stigsdotter, 2004;
Herzog and Strevey, 2008; Pretty et al., 2007; Park et al., 2008).
Hence, size of forests appears to be important to in order for people
to contact green space and experience its health benefits in urban
areas. In this respect, this study suggests that large forest in urban
areas may provide opportunities for people to immerse themselves,
spend some time, and experience psychological benefits that lead
to mental well-being.
416 A. Akpinar et al. / Urban Forestry & Urban Greening 20 (2016) 407–418
Findings of this study also showed that while urban green
space was associated with fewer days of mental health complaints,
which is in line with previous studies (Matsuoka and Kaplan,
2008; Niemelä et al., 2011; White et al., 2013a), agricultural land
was not significantly correlated, which was unexpected (de Vries
et al., 2003; Maas et al., 2006). Previous studies showed that green
exercise (walking, running, jogging, etc.in the presence of green
space/nature) provides mental health benefits by reducing depres-
sion, anxiety, and improving well-being (Pretty et al., 2007; MacKay
and Neill, 2010; Barton and Pretty, 2010). A recent study reveals
that more urban green space was associated with more physi-
cal activity (i.e. sports and bicycling), whereas more agriculture
green was associated with less physical activity (Picavet et al.,
2016). Considering these findings, since urban green spaces are the
largest green areas in urban zip-codes (see Fig. 3), it is possible
that people may have found more opportunities to engage with
urban green space resulting a better mental health status. On the
other hand, in Washington State, many agricultural lands in the
intense agricultural areas of the state are ‘big’ or ‘industrial’ agri-
culture. Therefore, it would not be considered desirable to live or
do physical activity amongst those landscapes. For these reasons,
respondents in our study may not have perceived agricultural lands
positively.
The main strength of the present study is that it addresses a gap
in the existing literature as suggested by recent studies (Richardson
et al., 2012; Hartig et al., 2014; Van den Berg et al., 2014; Alcock
et al., 2015; Picavet et al., 2016). Another strength of this paper
is that this study analyzed the data from a wide spread of geo-
graphic places in Washington State. Despite the contribution, this
study has some limitations. Our primary limitation is that the BRFSS
does not provide respondents’ exact locations within the zip-codes.
Therefore, it was possible only to analyze the data at the zip-
code level contrary to the previous studies 1–3 km radius around
respondents’ homes (Van den Berg et al., 2010; Maas et al., 2006;
de Vries et al., 2003). Future research may seek to examine rela-
tionships between health and green space where exact locations
of participants are known. In our study, it was also not possi-
ble to know whether respondents engaged with green spaces or
not. In this study, we could not address, for example, measures of
green views from participants’ homes, the quality of green space
nor their levels of use. Nevertheless, some studies (Mitchell and
Popham, 2008) found a relationship between exposure to green
space and health that is independent on the level of engagement.
The other limitation is that although we controlled for size and
population of zip-codes, our relational study cannot fully disentan-
gle the effects of green space and crowding on mental and general
health.
In addition, when spatial data is aggregated to a larger unit,
such as in our data, the information about its distribution within
the larger unit is lost. Therefore, in this study it is not possi-
ble to say anything about the distribution within the zip codes
(i.e. while we tried to analyze the distribution of green spaces,
we could not analyze due to the multicollinearity issue). In this
respect, future studies should address the distribution of green
space. The cell size of the NLCD is another limitation in this study.
The NLCD data is comprised of 30 m cells, therefore our results
did not include finer resolution details such as small-scale natu-
ral elements and areas like trees along streets, green roadsides,
or greenery were not explicitly represented in our study. This
could mean that the actual amount of green space in some areas
might be somewhat different from what we measured. Lastly and
most importantly, as this research was cross-sectional we can-
not conclude that green space leads to better mental and general
health, only that there is a cross-sectional, associative relation-
ship.
5. Conclusion and recommendations
Landscape has been recognized since the earliest times as not
only providing for human nutritional needs, but as also supportive
of human beings at every level of their well-being (Ward Thompson,
2011). A hundred years ago, Frederick Law Olmsted emphasized
the importance of the green space to human health (Todd, 1982).
Today, once again health professionals and policy makers are open
to an ecological approach to public health (Morris et al., 2006). Our
study offers insights into links between green space and mental
and general health through an approach that explored green space
as “simply green” and as “type” in the zip-code level. This approach
allowed us to assess the relationship of green space as “simply
green” and as well as different types, with health indicators. Our
results revealed that aggregated green space is not associated with
the status of human mental and general health, while forest is sig-
nificantly associated with fewer days of mental health complaints
after controlling for confounding factors. We also found that more
urban green space and large forest are associated with fewer days
of mental health complaints in our subsample.
In this respect, green spaces should not be seen as a “simply
green,” rather they should be considered by type. We concluded
that it is important how and where to design, create, preserve or
restore some types of green space rather than simply having “more”
green space. In doing so, green spaces may merit a central posi-
tion in landscape planning, design, and decision-making processes.
For instance, urban green space and forest are positively related to
mental health so that policy makers, designers, and planners could
take the amount of certain green space (urban green space and for-
est) in the living environment into account when endeavoring to
improve human health. Alternatively, when evaluating, designing,
and planning new residential developments or renovating exist-
ing urban infrastructure or consulting on land use priorities, the
amount of urban green space and forest could be provided.
We recommend that future research should consider the dis-
tance to green space, size, naturalness, structure and distribution
(sprawled or concentrated, large or small), and quality and char-
acteristics of green space. When examining the characteristics of
green space, the level of biodiversity should also be considered
as some studies found positive association between the level of
biodiversity and perceived restorativeness and well-being (Carrus
et al., 2015) and good health prevalence (Wheeler et al., 2015). Such
research would clarify which components or characteristics of spe-
cific types of green space constitute the most important drivers of
human health. Finally, finer resolution of land cover data would be
desirable in order to have better and more accurate results in terms
of green space calculation.
Acknowledgment
This research was carried out by the first author as a doctoral
dissertation under the supervision of Dr. Kerry R. Brooks in the
Interdisciplinary Design Institute at Washington State University.
We would like to thank the Washington State Department of Health
for providing the BRFSS data.
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