Impacts of green space interventions in educational settings on children and young people’s mental wellbeing: a systematic review

Impacts of green space interventions in educational settings on children and young people’s mental wellbeing: a systematic review | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Impacts of green space interventions in educational settings on children and young people’s mental wellbeing: a systematic review View ORCID Profile Judith Eling , View ORCID Profile Steven Cummins doi: https://doi.org/10.1101/2025.01.09.25320287 Judith Eling a London School of Hygiene and Tropical Medicine , 15-17 Tavistock Place, London WC1H 9SH, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Judith Eling For correspondence: lshje3{at}lshtm.ac.uk Steven Cummins a London School of Hygiene and Tropical Medicine , 15-17 Tavistock Place, London WC1H 9SH, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Steven Cummins Abstract Full Text Info/History Metrics Supplementary material Data/Code Preview PDF Abstract In the context of a recent decline in mental wellbeing in children and young people, there is increasing policy and practice interest in the benefits of children’s engagement with the natural environment to improve mental wellbeing. Although there is a growing evidence base linking health outcomes across populations with exposure to nature, the evidence base for the health, wellbeing and educational attainment benefits of green space interventions in children and adolescents is of lower quality. The aim of this systematic review was to assess whether the current evidence enables us to draw conclusions about the relationship between different educational green space intervention types and different categories of mental wellbeing outcome. The review adopted an approach to mental wellbeing grounded in the field of positive psychology, which sees wellbeing as a positive resource, composed of emotional, psychological and social domains. A number of outcomes was grouped in each domain, for example attention and executive function skills were grouped in the psychological wellbeing domain. Green space interventions were categorised into five sub-types: environmental education, break-time or play in a green environment, school gardening, learning in nature and nature pre-school/forest school. Extensive searches of seven databases, updated in March 2024, identified 36 quantitative studies, including quantitative components of mixed-methods studies. Study quality was assessed using the EPHPP tool. Due to study heterogeneity, meta-analysis was not feasible; instead, a Synthesis Without Meta-analysis (SWiM) based on effect direction was performed; additionally, a narrative synthesis summarising the effect direction at study level was conducted where an outcome was only measured within a single study within the same intervention category. Out of 37 reports of 36 studies, two had a strong overall rating, ten had a moderate quality rating and 25 had a weak overall rating. Based on generally very low certainty of evidence, there was some evidence for the positive effects of environmental education and breaks in green spaces on emotional wellbeing outcomes; for beneficial effects of breaks in green spaces on social wellbeing outcomes; and for improved outcomes in particular categories of psychological wellbeing associated with breaks in green spaces, learning in nature and forest school. Weaknesses identified in studies were often linked to specific features in study design, such as intervention dilution, as well as to lack of sensitivity of measurement instruments. This is the first comprehensive systematic review aiming to assess the effects of green space interventions in educational settings on outcomes across all three dimensions of mental wellbeing in children and young people aged 0-18. Recommendations are made on how study design can be improved in order to generate a stronger evidence base, including by having separate control groups, using a larger exposure dose and duration, extending the length of follow-up, and designing more nuanced interventions. Introduction Many high-income countries have poor child wellbeing outcomes, with some of the wealthiest, including the USA, New Zealand and Republic of Ireland in the bottom third of a 41-country wellbeing league table ( 1 ). The United Nations Convention on the Rights of the Child states that every child has the right not only to survive, but to live to their fullest potential, developing healthily in conditions that do not adversely affect their physical and mental wellbeing ( 2 ). Children’s wellbeing is thought to be critical to a child’s social and educational attainment throughout their school career ( 3 , 4 ) as well as having important consequences for mental health and social outcomes in adult life ( 5 ). However, in many countries children’s mental wellbeing has declined, particularly over the past 4 years, as a result of prolonged collective stress during the COVID-19 pandemic ( 6 ) which has disproportionately affected poorer and more vulnerable children ( 7 , 8 ). There is increasing policy and practice interest in the benefits of children’s engagement with the natural environment to improve mental wellbeing ( 9 - 16 ). At the same time human populations globally are less likely to have contact with nature due to rapid urbanisation ( 17 ), habitat loss and diminishing biodiversity ( 18 ), as well as increasing restrictions on children’s independent movements ( 19 ). These changes have been felt most acutely by some disadvantaged populations, and inequitable access to green space has been well documented ( 20 - 22 ). Provision of opportunities for children to have contact with nature within educational settings may therefore help address inequalities in access to, and engagement with, nature to improve their health and wellbeing. However, to do this effectively it is important to ascertain which green space interventions in educational settings may be most likely to achieve positive impacts on emotional wellbeing. Although there have been high-quality evidence syntheses linking health outcomes across populations with exposure to nature ( 23 , 24 ), the evidence base for the health, wellbeing and educational attainment benefits of green space interventions in children and adolescents is of lower quality ( 12 , 15 , 16 , 25 - 34 ). Some reviews have focused on specific interventions, but with a broad and heterogenous range of outcomes. For example, a mixed-methods review of impacts of school gardening ( 29 ) found qualitative studies were of better quality than quantitative, ascribed a range of health and wellbeing benefits to school gardens, and suggested that students who were academically weaker particularly benefited. A review of the mental, physical and social health benefits of immersive nature-experience for children and adolescents ( 12 ) found inconclusive results for mood improvement, with conditional support for other outcomes such as resilience and academic performance. However, evidence was of mixed quality with risk of bias, insufficient sampling methods and unsuited comparison groups as common study limitations. A review of the impacts of unstructured nature play on health in early childhood ( 35 ) identified only two studies reporting emotional outcomes. Other reviews have focused on mental wellbeing in association with a broad range of nature interventions. A review of the effects of nature activities on wellbeing in children and young people ( 36 ) found that though a range of nature activities may impact on wellbeing outcomes, including positive affect, stress reduction and restoration, results were inconsistent. Some studies did not identify positive changes in certain outcomes, and two out of 14 studies reported negative effects. A recent review of the effect of nature on children’s psychological wellbeing ( 37 ) identified predominantly observational studies reporting on the effect of nature exposure in children’s wider environment (residential, as well as school) on wellbeing. Previous reviews have used thematic findings from qualitative studies to comment on possible causal pathways by which engagement with nature promotes wellbeing ( 29 , 38 ). A number of potential pathways had been proposed since the early 1980s. In 1981, Ulrich’s stress reduction theory (SRT) ( 39 ) postulated that natural environments promote recovery from stress, while urban environments tend to hinder the same process. The biophilia hypothesis ( 40 ), published in 1984, suggested that humans have an innate need to affiliate with nature and that this need has become biologically coded. In the late 1980s Stephen and Rachel Kaplan ( 41 , 42 ) published their attention restoration theory (ART) which suggests that mental fatigue and concentration can be improved by time spent in, or looking at nature. Kuo ( 43 ) suggested in 2015 that enhanced immune functioning may provide a satisfactory central pathway for nature’s positive impact. Further mechanisms proposed include beneficial effects of exposure to phytoncides (naturally occurring chemical compounds secreted by plants) ( 44 ), fractals (self-similar patterns occurring in nature) ( 45 ), sunlight ( 46 ), nature sounds ( 47 ), and soil bacteria ( 48 ). Building on the biophilia hypothesis, the construct of a measurable nature connectedness has been researched more extensively ( 49 ), and in particular, the benefits of nature connectedness as a mediator between nature exposure and wellbeing in children ( 50 , 51 ).Little agreement was found between reviews on what was meant by mental wellbeing, with some identifying a broad range of outcomes across all wellbeing domains, and others focusing on a subset such as emotions or attention restoration. Therefore, a brief definition of mental wellbeing follows for the purposes of this review. Concepts of mental wellbeing are multifaceted, going back historically to Aristotle’s notion of eudaimonia or happiness, to be accomplished by people’s full and balanced realisation of their capabilities ( 52 ). More recently, there has been debate about the eudaimonic vs hedonic dichotomy of discourse on wellbeing ( 53 , 54 ), with consensus now reached that these are two sides of the same concept ( 55 ). In the discourses of the capabilities approach to children’s mental wellbeing ( 56 ) and of positive psychology ( 57 ), wellbeing is seen as a positive resource and a separate dimension from mental health ( 58 ). The UK’s National Institute for Clinical Excellence (NICE) defines mental wellbeing as falling across three domains: emotional, psychological and social ( 46 ). This review adopts the latter view of wellbeing as being a positive resource, composed of emotional, psychological and social domains. It adds to previous reviews by focusing on green space interventions in educational settings (from ages 0-18) and reporting on the whole range of mental wellbeing outcome domains. It attempts to answer the following questions: 1. What are the impacts of greenspace interventions in educational settings on the mental wellbeing of children and young people under 18? 2. Do these impacts differ depending on the intervention type, duration of intervention and population attributes (such as age, gender, ethnicity and socioeconomic status)? 3. What is the quality of the evidence base, and how does this inform recommendations for future research? In face of inequalities in access to green space between socioeconomic groups in the wider environment ( 59 ), educational settings have the potential to act as levellers, reducing inequalities in health and wellbeing outcomes for children and young people ( 60 ). The findings of this review will therefore be useful to inform the design of future research as well as guiding policy makers and practitioners in education and health. Methods This review protocol was prospectively registered with PROSPERO (CRD42020225124), initially as a mixed methods rapid review. An amendment was subsequently accepted on to convert the study to a systematic review of quantitative studies. The findings were reported following PRISMA guidelines (suppl. file B). Search strategy Seven electronic databases were searched: Medline via Ovid, PsycINFO via EBSCOHost, GreenFILE via EBSCOHost, Web of Science, EMBASE, ERIC and Global Health via EBSCOHost. The search strategy was peer reviewed under PRESS guidance ( 61 ) and a sample search strategy is attached in suppl. file (B). Databases were searched from inception through to March 6 th 2024. The search concepts “green space” (intervention), “educational setting” (population) and “mental wellbeing” were examined using a combination of free-text terms and Medical Subject Heading (MeSH) terms, informed by previous systematic reviews. A grey literature search was conducted using thesis repositories (OATD, Global ETD Search and ProQuest), the English National Grey Literature Collection, the OpenGrey collection (archived in 2021), the online British Library catalogue and on institutional research repositories related to the field of study. A supplementary search was carried out by backward and forward citation chasing, searching key journals, authors’ publication lists and key literature reviews. Selection criteria Both quantitative and qualitative studies were included, if they met the criteria in table 1 . Articles were de-duplicated and initially included based on title screening in Endnote9 software. Abstracts were then imported into Rayyan software and assessed against inclusion and exclusion criteria. Screening of titles and abstracts was conducted by one author (JE). Full texts were appraised for any studies where there was any uncertainty regarding inclusion, and these studies were independently reviewed by the second author (SC), with discussion taking place afterwards and consensus being reached where assessments differed. The main reasons for excluding studies at the full text screening stage were: (i) studies not meeting the outcome criteria (for example, where title or abstract had included mental wellbeing, but the actual measures used were physiological wellbeing measures) or (ii) the study design being cross-sectional rather than longitudinal or (iii) studies not meeting the intervention criteria (for example, where the intervention had a residential component). View this table: View inline View popup Table 1: PICO inclusion and exclusion criteria Data extraction and quality appraisal Data items were extracted from the literature by a single reviewer (JE) using a pre-piloted data extraction template (appendix). The categories recorded were type of source, study design, country, inclusion and exclusion criteria, recruitment, sample size and characteristics, setting, description of the intervention and duration, comparator, outcome measures, main findings, study limitations and sources of bias. Any unclear results were discussed with the co-author (SC) and consensus reached. The summary of the extracted data can be found in suppl. file D (summary) and suppl. file E (results). The Effective Public Health Practice Project (EPHPP) tool ( 62 ) was used to assess the quality of included quantitative studies. Data synthesis It was not possible to perform a meta-analysis due to heterogeneity and studies not providing the appropriate data to support standardising. Instead, a Synthesis Without Meta-analysis (SWiM) based on effect direction was performed ( 63 ). This approach addresses the question of whether there is evidence of a positive or negative association. Findings were presented in a summary table (effect direction plot), with outcomes grouped by similar outcome categories within each outcome domain. Outcomes were grouped into the three NICE domains of mental wellbeing: (i) emotional (categories: emotional wellbeing, self-esteem, mood/affect/enjoyment and HRQoL/life satisfaction), (ii) psychological (categories: attention/attention restoration/stress recovery, executive function skills (memory/inhibition control/cognitive flexibility) and perceived restorativeness) and (iii) social (categories: perceptions of safety/injuries/bullying/gang activities, positive student interactions/pro-social behaviour/involvement and resilience (initiative/self-regulation/attachment)). The three effect direction plots present study level effect direction and, where more than one outcome was reported within an outcome category, it presents the overall outcome effect direction, following the methodology utilised in a previous review ( 38 , 64 ). In addition, a narrative synthesis summarising the effect direction at a study level was conducted where an outcome was only measured in one study within the same intervention category. Results Included studies After duplicates were removed, 52,412 articles remained, of which 51,787 ineligible articles were removed, leaving 625 abstracts to be screened. Of these, 483 abstracts were excluded, leaving 142 full-text articles to be screened. A total of 37 reports, from 36 unique studies, were retained in the final data set (PRISMA flow diagram figure 1 ). Download figure Open in new tab Figure 1: PRISMA flow chart Characteristics of included studies Study design The majority of the included quantitative studies (or quantitative components of mixed methods studies) employed a before-and-after design with a separate control group (n=16, 44%), 13 studies were before-and-after studies with a cross over design (36%)and the remainder employed a before-and-after design without controls (n=7, 20%). Sample size The total sample size of the combined studies was n=10,295. For controlled studies where this information was provided, intervention arms comprised n=2,064; control arms n=1,014. Many studies either did not have controls or had a crossover design. The majority (n=26, 72%) of studies were small or medium (sample size <300 pupils in the intervention group) with ten studies (28%) having intervention group sample sizes greater than n=300. Participant characteristics The included studies examined a diverse range of age groups from 0-18. Of the 18 studies where a mean age is reported, the largest group were those reporting a mean age from 5-9 years (n=9; 50%); followed by age 10-14 (n=6; 33.%), age 0-4 (n=2, 11%) and 15-17 (n=1, 6%). Of the 25 studies reporting sex or gender proportions, n=20 (80%) reported the proportion of males or boys as between 48%-54%, n=3 (12%) reported the proportion of males or boys as greater than 55%, n=1 (4%) reported it as less than 45%, and n=1 (4%)reported missing data for sex or gender. Only six studies reported the percentage of students belonging to minority ethnic groups and two studies reported the percentage of students from low socioeconomic groups. Intervention characteristics Most studies were conducted solely in primary schools (n=16; 44%), followed by studies conducted in early years settings (n=8; 22), studies conducted in both primary and secondary schools (n=7; 20%) and studies conducted solely in secondary schools (n=5; 14%). The countries where most interventions took place were the USA/Canada (n=13; 36%), the UK (n=10; 28%), Australia/New Zealand (n=4; 11%), Italy (n=4; 11%) with the remaining studies conducted in Spain, Austria, Germany, the Netherlands and Denmark (n=5; 14%). Intervention types identified by the authors are described in table 2 . The most common intervention types were “play or breaks in a natural environment” (n=12; 33%) and “environmental education” (n=9; 25%), followed by “learning in nature” (n=8, 22%) and “forest schools” (n=4; 11%) and “school gardening” (n=3; 9%). View this table: View inline View popup Table 2: Intervention types Quality of included quantitative studies The quality of each quantitative study, was assessed by the EPHPP tool ( 65 ); details can be found in suppl. file C. Of the 37 reports of 36 eligible studies, two had a strong overall quality rating, ten had a moderate quality rating and 25 had a weak overall rating. Figure 2 presents the quality ratings for all included studies for each EPHPP domain and for the overall rating. Typically, studies were rated weak because of selection bias, issues around confounding, lack of blinding and poor reporting of withdrawals and dropouts. Studies performed relatively well on use of valid and reliable data collection methods. Download figure Open in new tab Figure 2: Quality ratings as assessed by EPHPP tool Main Findings Tables 3 - 5 present the effect direction plots for the three wellbeing domains, per outcome category. Findings with additional details, including effect sizes and confidence intervals, for individual studies can be viewed in suppl. file C. View this table: View inline View popup Table 3: Emotional wellbeing outcomes View this table: View inline View popup Table 4: Social wellbeing outcomes View this table: View inline View popup Table 5: Psychological wellbeing outcomes 1) Environmental education a) Emotional wellbeing domain i) Emotional wellbeing scale outcomes (n=4 studies) Four studies reported a positive effect of environmental education on emotional wellbeing (measured on wellbeing scales); three were significant ( 66 - 68 ) Of these, one ( 66 ) reported a significant overall difference in wellbeing scores over time between intervention and control groups for an intervention delivered weekly in school grounds over a 7 week period (p=0.004), however the change in wellbeing scores was statistically significant only in those children who had low wellbeing scores initially. The study with a non-significant finding ( 69 ) used a similar design and population to this but reported no significant differences in the changes in the wellbeing scores (p>0.05) between the intervention and control groups. The third study ( 68 ), a before-and-after study without controls, consisted of two study cohorts, both of which were reported as having a significant improvement in psychological wellbeing outcomes after four sessions of environmental education in a nature reserve (p=0.000). The fourth study ( 67 ) also reported a significant improvement on a wellbeing scale (p<0.001) after visits to wildlife sites, with a significant interaction effect between baseline wellbeing and time. ii) Positive affect (n=3 studies) Two studies ( 66 , 70 )demonstrated a significant positive association between positive affect and environmental education One of these was a before-and-after study without controls ( 66 ) which reported a significant increase in positive affect (mean diff: 4.63; CI: 3.49,5.77) and a slight decrease in negative affect (mean diff: +-1.41; CI: -2.09,-0.73). The second study had a controlled before and after design, however only children in the intervention group completed mood surveys, with a significant beneficial effect on positive affect (p < 0.001). A third study ( 71 ) reported conflicting results, with both positive (mean diff: 0.28; CI: 0.03-0.54) and negative affect (mean diff: 0.44; CI: 0.18-0.71) increasing significantly in the nature setting versus the control, which the authors hypothesised may have been due to some children experiencing fear and anxiety in the nature setting. iii) Health-related Quality of Life (HRQoL) (n=3 studies) A controlled before-and-after study ( 67 )did not find a significant effect of contact with nature, resulting from four monthly visits to nature reserves, on life satisfaction. The authors speculated that this might have been due to the timing and intensity of the intervention. Two studies, using similar populations and interventions, used different study designs to investigate the effect of monthly field trips combined with classroom based environmental education on HRQoL domains. A before-and-after study ( 72 ) found a significant improvement in emotional health functioning after the intervention (p<0.001). The controlled before-and-after study ( 73 ) found a significant improvement in emotional functioning in the intervention group (p<0.001) whereas the control group showed significant reductions in the score, hypothesised by the authors as being due to change in the seasons, from spring to autumn, during the study period. b) Social wellbeing domain i) Positive student interactions/prosocial behaviour/involvement (n=1 study) In a study exploring primary school children’s pro-social behaviour after a visit to a nature school, children had significantly higher pro-social scores on the majority of tasks, compared with their scores after a visit to an aviation museum ( 71 ). c) Psychological wellbeing domain i.) Resilience (n=1 study) A single, large UK study exploring this outcome did not find a significant change in resilience scores after participation in regular lessons about biodiversity in the school grounds over 21 weeks ( 69 ), compared to a control group. 2) Break/play in green environment a) Emotional wellbeing domain i.) Emotional wellbeing scale outcomes (n=2 studies) One study ( 74 ), using a controlled before-and-after design, reported a significant increase in mean wellbeing scores after an intervention to green the schoolyard, and a significant difference in the change between intervention and control groups (p=0.006). A before-and-after study with a crossover design ( 75 ) found a significantly reduced reduction in mood lowering in secondary school students who had their break in forest settings compared to students who had their break in a small or medium sized urban park (p=0.001). ii.) Self-esteem (n=2 studies) Neither of the two eligible studies in this group demonstrated a significant change in self-esteem as a result of play in green spaces. A before-and-after study with a crossover design ( 76 ) did not find a significant difference in self-esteem after a nature-based orienteering activity in school grounds, compared to free play on a concrete playground (p>0.05). The second study, using the same design, also did not find a significant change in self-esteem after play in green areas of the school playground, compared to concrete areas (p>0.05). iii.) Positive affect (n=1 study) A before-and-after study with a crossover design ( 77 ) reported a significant increase in positive individual behaviours in preschool children after a free-play activity in nature (p=0.007), which did not occur after free-play in the indoor preschool environment. iv.) HRQoL (n=1 study) A large (n=2,031children) controlled before-and-after study ( 78 ) did not detect a significant change in outcomes on the emotional subscale of the paediatric QoL scale, 48 months after greening the playgrounds of a number of schools (p>0.05). b) Social wellbeing domain i.) Perceptions of safety/injuries/bullying/gang activities (n= 1 study_ A single study ( 79 ) reported outcomes on negative social behaviour, and did not find any significant changes in a number of measures (gang-related activity, bullying, injuries) reported retrospectively by teachers, after renovation and greening of primary and middle school playgrounds. ii.) Positive student interactions/pro-social behaviour/involvement (n=6 studies) Six studies ( 77 - 82 ) reported results on these outcomes, and overall, a positive and significant association was found between children playing in a green environment, and positive social behaviour. Two large studies ( 81 , 82 ) found a significant decrease in antisocial behaviour and increase in prosocial behaviour 4 months and 16 months after a primary school playground greening measure, and a third large study ( 79 ) found that pro-social interactions had increased significantly 6 months after greening and renovation of playgrounds. Two small studies in early years settings found a significant increase in positive relational behaviour when children were able to engage in free play in nature areas ( 77 ), and a significant increase in prosocial behaviour after green modification of play areas ( 80 ). However, a large study of the effects of playground greening in the Netherlands ( 78 ) did not find a significant impact of greening on pro-social orientation, nor on the majority of aspects of social functioning. The authors conceded that greening of schoolyards was modest in some cases and may have led to an underestimation of the effect of greening. c) Psychological wellbeing domain i.) Attention/attention restoration (n=5 studies) Five studies ( 74 , 75 , 78 , 83 , 84 ) in this category reported these outcomes, with an overall positive significant effect associated with playing in green spaces. Two studies reported significant increases in attention measures after play, breaks or games in green spaces compared to a control condition ( 75 , 83 ), whilst a third study found that attention restoration had increased significantly at the study’s second follow-up point, 2 years after greening ( 78 ). However, two studies did not find a significant effect: a medium sized study in Spain did not find any evidence that participation in a relaxing activity in a green versus a grey space affected attention restoration ( 84 ), and a middle school study in Austria ( 74 ) found a small, non-significant (p=0.053) improvement in recovery from stress in a greened secondary school playgrounds after renovation. 3) School gardening a) Emotional wellbeing domain i.) Positive affect (n=1 study) A study which taught the standard school science curriculum in the course of hands-on gardening lessons and compared this intervention with the same lessons taught in a classroom ( 85 ), reported that three out of ten emotions (happiness, pride, surprise) were measured significantly more often after the school garden lessons (p<0.001), and two emotions (disgust, anxiety) were measured more often in the classroom (p<0.05). ii.) HRQoL (n=1 study) A large (n=475 children) controlled before-and-after study ( 86 ) reported a statistically non-significant difference in mean quality-of-life scores between the intervention group, who had participated in a weekly school kitchen garden programme, and the control group (mean diff: 1.23; CI: -0.2 to 2.7; p = 0.09). b) Social wellbeing outcomes i.) Positive student interactions/pro-social behaviour/involvement (n=2 studies) Two large controlled before-and-after studies ( 86 , 87 ) examined the impact of school gardening on positive social interactions, and both found no difference in these outcomes between children who participated in a school kitchen garden programme and those who did not. The authors of one of the studies ( 86 )commented that there may have been a “ceiling effect”, with high child cooperative behaviour scores recorded at baseline. 4) Learning in nature a) Emotional wellbeing outcomes i.) Emotional wellbeing scales (n=2 studies)_ Of the two studies examining the effects of learning in nature on outcomes on emotional wellbeing scales, one study ( 88 ) reported a significant effect on wellbeing associated with instructed activities in an outdoor nature area in a preschool daycare centre, compared with play outdoors without caregiver interaction; the other study ( 89 ) found a small, non-significant effect (p=0.28) associated with an art-in-nature intervention in a primary school. The summary effect direction was therefore a positive association with the intervention, but effects were not statistically significant. ii.) Self-esteem (n=1 study) A before-and-after study with a crossover design ( 90 ) did not find a significant effect on self-esteem of a physical exercise lesson in nature versus in the school grounds (p = 0.72). iii.) Positive affect (n=3 studies) None of the three studies examining the impact of learning in nature on mood found a significant effect. A small (n=37 children) before-and-after study with a crossover design ( 91 ) did not find a significant difference in outcomes between children being taught in outdoors nature versus being taught in an indoor classroom (t = 1.71, p = 0.097). The authors hypothesised that participant fatigue relating to the measurement tool might have been a contributing factor. The second study, using the same study design, found no significant difference in change in positive affect before and after a lesson taught in a green environment versus a lesson taught in a classroom (p=0.234). Students with higher emotional difficulties were found to have a statistically significant larger increase in positive affect after the school lesson in greenness than after the classroom lesson (p=0.01), and a larger decrease in negative affect in greenness, although this difference did not reach statistical significance (p=0.09). The positive and negative affect of students with lower emotional difficulties did not vary as a function of the lesson environment. The third study ( 90 ) did not find a significant difference in perceived enjoyment between students taking part in a PE lesson in greenness versus the standard school grounds (p=0.66). b) Social wellbeing outcomes i.) Prosocial behaviour (n=4 studies) The summary effect direction for the four studies ( 88 , 91 - 93 ) reviewing the association between learning in nature and prosocial behaviour was of conflicting findings, with only one study reporting significant findings. A controlled before-and-after study in Denmark ( 92 )assessed the effects of teaching 20% (one day per week) of school lessons in a forest over a three-year period, and found a significant difference in social relations outcomes (p < 0.001) between forest and school settings, however this was a very small study with only 13 respondents. c) Psychological wellbeing outcomes i) Attention/attention restoration (n=3 studies) The summary effect direction for the three studies in this category was for a significant effect associated with the intervention, with two studies reporting positive outcomes that were statistically significant. A medium sized study in Italy found that primary school children performed better in tests for selective and sustained attention after a single lesson taught in the school garden, compared with a lesson taught indoors ( 94 ), and a small before-and-after study in the USA found an improved score (p < 0.001)for the ability to attend and engage after four weeks of a daily 4-hour programme of preschool education in a natural environment ( 93 ). ii) Executive function skills The two studies in this category reported a positive effect of the intervention, which was statistically significant, and the summary effect direction was therefore positive. The US study investigating impacts of teaching preschool children outdoors ( 93 ) found improved problem-solving scores (p < 0.001) after the intervention, and a Canadian study ( 95 ) found an association (p < 0.001) between performance in a self-regulation task and taking part in daily outdoor preschool lessons for a minimum of 30 minutes daily, compared to a maximum of 60 minutes weekly. iii.) Resilience (n=1 study) A single study in this category ( 93 ) found a statistically significant association between a preschool outdoor education programme and improved scores on resilience dimensions (ps < 0.05). 5) Forest school a) Emotional wellbeing outcomes i) Emotional wellbeing scale outcomes (n=1 study) A moderately sized (n=123 students) before-and-after study with a crossover design ( 96 ) found no significant difference in change in WEMBWS outcomes after participation in forest school versus usual school lessons (p=0.78). However, the study reported a significant difference for males only (p=0.025). The authors hypothesised that this might have been as a result of boys interacting differently with the natural environment, or having a lower life satisfaction at the baseline. ii) Positive affect (n=1 study) A small (n=18 students) before-and-after study with a crossover design ( 97 ) reported a significant effect on some dimensions of mood of participation in forest school for one day, versus normal school lessons. Energy increased significantly after forest school versus standard school (p=0.007). There was a borderline beneficial effect on stress (p=0.52), and a significant beneficial effect on hedonic tone (p=0.007) and anger (p=0.02), with the poor behaviour group (n=12 students) benefiting more than the good behaviour group. b) Social wellbeing outcomes i) Prosocial behaviour (n=1 study) A controlled before-and-after study ( 98 ) found that daily attendance at a full-day nature kindergarten was associated with a significant effect on outcomes on a social skills rating scale, compared to attendance at a standard kindergarten (ps<0.01 for teacher ratings). c) Psychological wellbeing outcomes i) Attention/attention restoration (n=1 study) A single study in this category ( 98 ) found no difference in outcomes for directed attention in a small Canadian study of the effects of attendance at nature kindergarten. ii) Executive function skills (n= 2 studies) Neither of the two studies in this category ( 98 , 99 ) found a difference in executive function skills outcomes between children attending a nature-based preschool versus those attending a standard preschool. iii) Resilience (n=2 studies) The two studies in this category ( 96 , 99 ) reported statistically significant positive effects associated with the intervention, leading to a positive and statistically significant summary effect direction. A US before-and-after study ( 99 ) found a significant increase in resilience ratings in children attending the nature preschool, but no increase in the non-nature preschool. A UK study found that secondary school student attending forest school one day per week had a significant increase in resilience scores (p<0.015), which did not occur in the control group. Conclusions and discussion This review aimed to understand whether five different categories of green space intervention in educational settings impact on children’s mental wellbeing, which was defined as encompassing emotional, social and psychological wellbeing. Based on generally very low certainty of evidence, findings from effect direction plots indicated positive associations between environmental education and improved outcomes for wellbeing scales, mood and health-related quality of life. There were insufficient studies for social and psychological wellbeing outcomes of environmental education to derive a summary effect direction. Positive associations were also found for improved outcomes on emotional wellbeing scales after breaks or playtime in a green environment, but findings on self-esteem lacked statistical significance, and there were insufficient studies for the other emotional wellbeing categories to derive a summary effect direction. Findings from the effect direction plots indicated a positive association between pro-social behaviour and play in nature-rich playgrounds, whilst there was insufficient evidence for an association between frequency of bullying and gang activities and this intervention category. Effect direction plots also indicated a positive association between green play and attention scores, with insufficient studies investigating executive function skills and resilience. There were insufficient or no studies investigating effects of school gardening on emotional wellbeing outcomes to be able to derive summary effect directions. Findings from effect direction plots suggested conflicting findings for the effect of school gardening on pro-social behaviour, and there were no studies at all exploring its effect on psychological wellbeing outcomes. For studies investigating “learning in nature” interventions, effect direction plots suggested results were not statistically significant for emotional wellbeing scale and mood outcomes, with insufficient or no studies for self-esteem and quality of life outcomes. For studies exploring the effect of school gardening on social wellbeing outcomes, effect direction plots indicated conflicting findings. Positive associations were indicated by effect direction plots for attention and executive function skills outcomes after learning in nature, with insufficient studies for resilience outcomes. Lastly, for studies exploring effects of forest school, there were insufficient or no studies on emotional and social wellbeing outcomes, and it was not possible to arrive at a summary effect direction. For psychological wellbeing outcomes associated with forest school, there were insufficient studies investigating attention outcomes, and effect direction plots suggested no clear effect for executive function skills outcomes, whilst a positive association was indicated by the effect direction plot for resilience measures and forest school. Of the 36 studies identified which reported mental wellbeing outcomes across the three dimensions of mental wellbeing, 16 employed a before-and-after design with a separate control group, 13 studies were before-and-after studies with a cross over design and seven employed a before-and-after design without controls. Studies had a relatively uneven geographical spread over the high-income, temperate latitude countries included, with the majority located in the UK and USA. This may have been the case due to non-English language publications being excluded. Most studies had small to medium sample sizes (<300 individuals in the intervention group) and ten studies had large sample sizes. Of the 37 reports of studies, only two were rated as strong overall, ten were rated as moderate, with the remainder rated as weak. Data collection methods tended to be valid and reliable, and studies performed relatively well on study design and data collection, but they scored poorly on other assessment categories (blinding, managing confounding, reporting dropouts and selection bias). Weaknesses identified in studies were often linked to specific features in study design. For example, a before and after study ( 89 ) in UK primary schools used a complex intervention consisting of multiple components (physical exploration of the natural environment, followed by more structured artist-led activities). Without controlling for these individual components, it is difficult to attribute changes in children’s wellbeing to the nature exposure specifically. Another weakness mentioned by authors was that the duration of the intervention may have been insufficient to produce a significant effect ( 67 , 72 , 73 , 76 , 96 , 100 ), or that the intervention was diluted due to lack of funding ( 74 , 78 ). Some authors questioned whether the instruments used to measure wellbeing were sensitive enough to change ( 68 , 86 , 101 ). A further weakness of instruments used with young children was that they might have suffered participant fatigue due to repeated daily use of very simple instruments such as a “Faces Survey” ( 91 ). Several authors raised the possibility of social desirability and observer bias ( 77 ) as observations and measurements were often taken by teachers or the study investigators, rather than independent observers, or students rated themselves ( 75 ). The majority of studies introduced a control situation by having a cross-over design (with the risk of a carry-over effect), and two studies had parallel control groups. These were not necessarily well matched, for example the experimental and control schools in an Austrian study ( 74 ) were different school types. In other studies, the equivalence of lessons given in different environments was not assessed or known to be poor ( 85 , 90 , 94 , 97 ). Authors also highlighted that there may have been contamination bias due to exposure to natural settings outside school, and that findings from studies might not be generalisable to other settings, in particular from urban to rural settings ( 78 ). In summary, based on summary effect directions, there was some evidence for the positive effects of environmental education and breaks in green spaces on emotional wellbeing outcomes; for beneficial effects of breaks in green spaces on social wellbeing outcomes; and for improved outcomes in particular categories of psychological wellbeing associated with breaks in green spaces, learning in nature and forest school. Strengths and limitations of the review This is the first comprehensive systematic review aiming to assess the effects of green space interventions in educational settings, across all ages from 0-18, on outcomes across the three dimensions of mental wellbeing. The protocol was registered to PROSPERO and a thorough search of seven databases, as well as websites and theses conducted, and updated in March 2024. The search strategy was peer reviewed under PRESS guidance, and full text articles were assessed independently by a second reviewer where there was doubt as to their inclusion. In spite of these strengths, there were some limitations that were partially mitigated. Title and abstract screening could not be completed in duplicate, and not all full papers received duplicate screening, however the second author (SC) reviewed full papers where there was any uncertainty about meeting inclusion criteria and a discussion-based consensus reached. We excluded studies in which interventions were targeted at children with mental health diagnoses, special educational needs or other diagnoses, and there is therefore a gap in the findings, and potential for a further review, to determine whether children in these groups would benefit to a greater extent from nature interventions. It is possible that the EPHPP tool used to assess quantitative studies, which was designed for clinical intervention studies, tended to provide weak ratings in a field where it is difficult to adhere to a gold standard of research practice. Recommendations for future research To enable us to improve the evidence base, research needs to improve study design. Most of the studies reviewed were rated moderate or weak on study design, with small or medium sample sizes (<300), and control groups often insufficiently powered. More than half of the studies included did not have separate control groups, utilising either a cross-over design or no control group at all. The review also found that many studies used a small exposure dose i.e. interventions either did not have “enough nature” or were very short-lived. Future studies therefore need to ensure there is sufficient exposure dose and duration. A further area for improvement is around the nuance of the nature intervention. 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