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. 2026 Feb 12;26:916. doi: 10.1186/s12889-026-26472-8

Association between exposure to green and blue spaces and respiratory health in the elderly: a scoping review

Gaia Surya Lombardi 1, Doris Zjalic 2,✉, Manuela Del Sario 3, Chiara Cadeddu 2, Walter Ricciardi 1, Leonardo Villani 1,4
PMCID: PMC12998278  PMID: 41680721

Introduction

Given the ageing global population, chronic respiratory diseases like COPD and emphysema are increasingly contributing to health and economic burdens. Green and blue spaces offer potential respiratory health benefits through improved air quality, increased physical activity, and reduced stress. However, evidence regarding their impact on older adults is limited, with few studies addressing this population's long-term respiratory health outcomes. This scoping review aims to assess the effects of exposure to green and blue spaces on the respiratory health of older adults.

Methods

Studies evaluating the impact of green and blue spaces on respiratory health in adults aged > 65 years were identified from Medline, Scopus, and Web of Science, with publications from August 2013 to August 2023 included. Both observational and experimental studies were considered. Inclusion criteria were defined based on the PCC framework (Population, Concept, Context). Data extraction and synthesis were conducted independently by multiple researchers.

Results

According to inclusion criteria, 27 studies were identified, including three intervention studies and 24 observational studies. Green spaces were linked to lower risks of mortality from lung cancer, pneumonia, and chronic obstructive pulmonary disease (COPD). However, the evidence for short-term effects was mixed, with some studies showing improvements in lung function and reduced respiratory symptoms after brief exposure to green spaces, while others found no significant changes. Only one study on blue spaces was retrieved, suggesting that coastal living may lessen the impact of air pollution on COPD hospitalizations.

Conclusion

This review suggests that exposure to green spaces can offer significant respiratory health benefits, particularly in reducing mortality from respiratory diseases. The evidence for blue spaces remains limited, and the mixed results for short-term effects highlight the need for further research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-026-26472-8.

Keywords: Green spaces, Blue spaces, Respiratory health, Elderly

Key messages

  • Chronic respiratory diseases are a significant global health issue, and green and blue spaces may offer potential health benefits, but there is limited evidence on their impact on older adults' respiratory health.

  • This review highlights that green spaces may reduce mortality from respiratory diseases in older adults, with mixed findings for short-term effects. There is limited evidence on blue spaces, with one study suggesting that coastal living may reduce COPD hospitalizations.

  • The study supports the integration of green spaces in public health and urban planning to benefit older adults' respiratory health. More research is needed on blue spaces and short-term effects to guide effective interventions and policies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-026-26472-8.

Background

Population ageing is a common trend that characterises almost every developed country worldwide. In the European Union (EU), in 2023, the number of people aged 65 years or older was approximately 90 million, representing approximately one-fifth (21.3%) of the total population within the EU-27 [1]. This demographic transition, characterized by an increase in the elderly population compared to the adult and paediatric population, is associated with an epidemiological transition, marked by a shift from infectious diseases to non-communicable diseases. In this context, the prevalence of chronic respiratory diseases, such as chronic bronchitis and emphysema, is projected to increase in the next few years [2]. These diseases account for much of the morbidity and mortality among the elderly, lower their quality of life, and cause substantial burdens on health systems [3]. Different risk factors cause or exacerbate respiratory diseases and some of them are modifiable, which means they could be the target of health policies designed to protect and promote respiratory health. Environmental exposure, such as air pollution, is known as an important risk factor that could be reduced by nature-based solutions [4, 5], such as creating new green spaces. Green space is a generic term often used to refer to spaces predominantly composed of vegetation, which can be urban (parks, gardens, green walls, tree-lined roads, etc.) or extra-urban (forest, woodland, etc.) [6]. Similarly, the term blue space refers to visible surface waters, including rivers, lakes, seas, etc. [7].

Exposure to natural environments, such as urban green and blue spaces, has been increasingly recognized for its potential health benefits [8]. These natural spaces may positively affect mental health by reducing stress and enhancing social interaction [9]. Increased physical activity, reduction of urban heat islands and improvement of air quality are some of the pathways through which green and blue spaces are linked to physical health in general [10, 11]. However, as it specifically pertains to respiratory well-being, the potential positive or negative impacts of exposure to green and blue spaces have been much less well understood so far. Existing evidence in this field is scarce and focuses primarily on the respiratory health of children [12].

Green spaces, through their vegetation, can contribute to improving the overall quality of air by filtering pollutants [13]. Besides, the presence of accessible green spaces enhances physical activity, which in turn have been shown to increase general lung function and reduce intensity of symptoms associated with respiratory disease [14]. However, green spaces can also be detrimental to respiratory health due to the presence of allergens [15]. This is particularly true among the population of allergic children, where proximity to sources of pollen such as trees and grass can exacerbate allergies and asthma [16–18]. As regards blue spaces, the presence of water bodies may reduce respiratory irritants and promote a healthier respiratory environment by interacting with the local climate and air quality [11, 19].

Since most previous studies have focused on specific populations, such as children with atopy [17, 18], there is a lack of synthesis regarding the effects of green and blue spaces on respiratory health in the elderly. The present scoping review addresses the above-mentioned research gap by evaluating the available evidence about the short- and long-term benefits of green and blue spaces on respiratory health among older adults.

Materials and methods

The protocol was registered in OSF Registries [20]. The scoping review was conducted and reported following the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) guidelines [21].

Eligibility criteria

The research question was formulated based on the PCC framework (Population, Concept, and Context) in accordance with the Joanna Briggs Institute (JBI) guidelines for scoping reviews.

P—Population: adults aged 65 and older.

C—Concept: the association between exposure to green and blue spaces and respiratory health in older adults. Both observational studies (e.g., exposure to existing green and blue spaces measured via satellite-based indices such as NDVI or percentage of green space in residential buffers) and experimental studies (e.g., interventions involving new green/blue infrastructures or activities within these environments) were included. Respiratory health outcomes included symptoms (e.g., shortness of breath, chronic coughing), physiological measures (e.g., lung function), acute and chronic diseases (e.g., COPD, asthma, lung cancer), and healthcare utilization metrics (e.g., hospitalizations, mortality).

C—Context: studies conducted in residential or experimental settings in which elderly individuals were exposed to green or blue spaces.

Exclusion criteria

Studies were excluded if:

  • they focused on virtual exposure to green and blue spaces;

  • they were case reports or non-original studies (e.g., reviews, commentaries, editorials).

Information sources and search strategy

The literature search was conducted in three electronic databases: Medline, Scopus, and Web of Science. Only relevant articles written in English and published between 01/08/2013 and 01/08/2023 were included. The search was performed in August 2023. The search strategy incorporated free-text and indexed terms related to green and blue spaces, respiratory health outcomes, and the elderly population. The detailed search strategy for each database is provided in the Supplementary Materials 1.

Selection process

All identified articles were uploaded to RAYYAN software [22] and duplicates were removed using Endnote. Two researchers (GSL; DZ) independently screened title and abstracts. During the full-text screening, four researchers (GSL; DZ; MDS; LV) independently assessed each article to determine eligibility. Reasons for exclusion at the full-text stage were documented and listed in the PRISMA-ScR flow diagram. Backward and forward snowballing were conducted to identify additional eligible studies. Any discrepancies during the screening or selection process were resolved through discussion.

Data collection process

Three researchers (GSL; DZ; MDS) independently extracted the following data from each included article:

  • reference;

  • study design;

  • study population;

  • type of exposure to green/blue spaces;

  • respiratory health outcome;

  • main findings.

The extraction table was constructed in Excel.

Study risk of bias assessment

A formal risk of bias assessment was not conducted due to the substantial heterogeneity in study designs.

Synthesis methods

The results were synthesised using a narrative approach.

Results

A total of 1745 articles were found in the three databases. 89 duplicates were removed and the remaining 1656 articles were screened by title and abstract. Overall, 68 papers were considered suitable for inclusion according to the eligibility criteria and were read in full text. Of these, 22 articles were finally selected for inclusion in this scoping review. In addition, 4 papers were included from backwards snowballing and 1 from forward snowballing, leading to a final number of included papers of 27. The selection process is reported in Fig. 1 (PRISMA-ScR flow diagram).

Fig. 1.

Fig. 1

Open in a new tab

PRISMA-ScR flow diagram

Characteristics of the included studies

The characteristics of the included studies are summarised in the Supplementary Material 2. Three studies were intervention studies evaluating the short-term effects of exposure to green spaces [23–25], 21 were observational studies evaluating the long-term effects of green or blue spaces [26–46] and three evaluated effect modification of short-term effects of temperature [47] or air pollution [48, 49].

The studies were conducted in various countries, including several countries in the European Region (Spain, Italy, the UK, the Netherlands, Belgium), the United States, China, South Korea, and Taiwan.

These studies ranged in size from small intervention studies with 18 patients [24] to large population cohorts of over one million residents [38]. Three studies [34–36] involved the same population but reported different outcomes, such as mortality and hospitalizations, or had extended follow-up periods. The follow-up period varied considerably among the studies. Some of the studies had a very short follow-up of one day [23], while some population-based cohort studies had follow-up periods of over 10 years [38, 41].

In 18 observational studies, exposure to green spaces was determined primarily by satellite-based NDVI (Normalised Difference Vegetation Index) [26, 27, 29, 34–46, 50, 51]. NDVI is calculated from the visible and near-infrared light reflected by vegetation [52]; therefore, it covers all kinds of green spaces, from public gardens and street greenery to areas not open to the public. Several other studies have used other indices of land cover, such as Leaf Area Index (LAI) [38], Enhanced Vegetation Index (EVI) [45], Modified Soil-Adjusted Vegetation Index (MSAVI2), Urban Atlas (UA) and CORINE Land Cover (CLC) [28].

The outcomes measured in the studies varied and included: levels of biomarkers [24], mortality due to respiratory diseases, lung cancer and chronic obstructive pulmonary disease (COPD) in sixteen studies [27, 28, 30–32, 34–38, 41, 43, 44, 46, 47, 49] hospital admissions and emergency room visits in two studies [53, 54], prevalence or incidence of respiratory diseases such as COPD, lung cancer, and COVID-19 in three studies [42], respiratory symptoms and/or lung function indices in five studies [23, 26, 40].

Long-term effects of green spaces on respiratory mortality

This scoping review found limited but consistent evidence of a protective association between residential proximity to green spaces and respiratory mortality, in particular mortality from lung cancer, pneumonia, and COPD. Of the sixteen studies that assessed respiratory mortality, nine reported statistically significant protective associations [36, 49, 50]. Surrounding green spaces were linked to a reduced risk of cause-specific mortality, including respiratory and lung cancer mortality, whereas in the same studies air pollution was linked to a higher risk of both non-accidental and cause-specific mortality [36]. Overall, these associations were stronger among non-elderly population than among elderly populations. Additionally, higher levels of residential greenness appeared to alleviate the long-term association between air pollution and respiratory mortality. Among a large prospective cohort of elders in Hong Kong [49], those living in areas with greenness had a higher risk of pneumonia mortality attributed to NO2 (p = 0.049) and O3 (p = 0.025). Similarly, in James et al., the protective association between NDVI and respiratory mortality in the US Nurses Health study is partly mediated by PM2.5 exposure, social engagement, and mental health [50].

Other studies, however, have found non-significant association [35, 38, 45, 47] or even adverse associations [30, 31] of green space exposure and respiratory mortality among elderly population. In Gou et al., COPD mortality was positively correlated with FVC (Fractional vegetation cover) in 63% of the township areas in Chongqing and negatively correlated in 37% of the areas. In most municipalities in Chongqing where COPD mortality is positively associated with FVC, a plausible explanation is that regions with high FVC are often rural and mountainous. These areas typically have limited access to medical resources, which may lead to elevated mortality despite higher levels of vegetation.

Long-term effects on other respiratory outcomes

The findings for other respiratory health outcomes, such as the prevalence or incidence of respiratory diseases, hospitalisation, and biomarkers, are inconsistent and based on a limited number of studies. The cross-sectional study by Fan et al., for instance, showed that higher levels of neighbourhood greenness were associated with an increased risk of COPD in younger age groups (40–65 years), but not in participants aged over 65 years, across all NDVI buffer sizes [29]. Similarly, Jones et al. found no significant associations between asthma admissions and the impervious surface index (a measure quantifyin the extent of areas that impede the filtration of water into the soil) in elderly Black males and females [53]. Conversely, a protective association was observed between residential greenness and COVID-19 severity. Specifically, a population-based study reported that, in adjusted models, a 0.1-unit increase in both NDVI and the Enhanced Vegetation Index (EVI) within a 1,000-m buffer was associated with a 7.6% (PR: 0.924, 95% CI: 0.889–0.960) and 10.0% (PR: 0.900, 95% CI: 0.853–0.949) reduction in the prevalence of severe COVID-19, respectively [39]. The authors suggested that air pollution may mediate the association between greenness and COVID-19 severity.

Short-term intervention evidence

Although the number of experimental studies is small (n = 3) [23–25], these studies underline short-term effects of green space exposure on respiratory function, inflammatory markers, cardiovascular indices, and respiratory symptoms in patients with COPD and other respiratory diseases. Lee et al. studied the short-term effects of one-day forest walking compared with city walking in patients with COPD [37]. Participants in the forest-walking group showed a significant increase in pulmonary function ((FEV₁: 0.19 vs 0.01 L; FEV₆: 0.22 vs 0.04 L) and a reduction in blood pressure (both systolic −8.16 vs −0.78 mmHg and diastolic −7.35 vs −0.78 mmHg) and arterial stiffness (−0.42 vs −0.11) compared with those in the city-walking group. Similarly, Sinharay et al. found that COPD patients experienced more cough (OR = 1.95, 95% CI 0.96–3.95), sputum production (OR = 3.15, 1.39–7.13), shortness of breath (OR = 1.86, 0.97–3.57), and wheeze (OR = 4.00, 1.52–10.50) after walking in a commercial street compared with walking in a park [25]. Park walking was also associated with improvements in lung function (FEV₁ and FVC) and reduction in pulse wave velocity (PWV) and augmentation index, persisting for up to 26 h after the walk. The findings of these two RCTs are consistent with the biomolecular changes reported in the RCT by Jia B. B. et al. [24]. This r study compared flow cytometry, ELISA, and the Profile of Mood States (POMS) in COPD patients participating in a forest bathing versus a city trip. The authors found that forest bathing reduced the systemic inflammation level of COPD patients by downregulating pro-inflammatory cytokines (IFN-γ, IL-6 and IL-8), and improved mood state, whereas no significant changes were observed in the city group. However, these associations are based on imprecisely defined exposure categories, such as 'forest bathing' or 'park/forest walks/trips'. As a result, the observed health benefits may be partly attributed to reduced air pollution exposure in the intervention settings rather than to green space exposure per se.

Effects of blue spaces on respiratory health of the elderly

This review did not identify any studies specifically examine the effects of blue spaces on elderly respiratory health, apart from one study assessing COPD hospitalisation in coastal vs. non-coastal areas [54]. This study compared COPD hospitalizations between residents of coastal versus non-coastal areas. This study found that air pollution (SO2 and NO2 concentrations) had a weaker association with COPD hospital admissions in coastal cities compared with non-coastal cities..

Discussion

This scoping review assessed the effect of exposure to green and blue spaces on respiratory health in older adults. Overall, findings suggest a generally positive association between exposure to green spaces and respiratory health outcomes, though the evidence remains heterogeneous. The findings indicate that residential proximity to green spaces is often associated with reduced respiratory mortality, particularly due to lung cancer, pneumonia, and COPD. While the relationship between exposure to green spaces and long-term mortality outcomes is well-documented in the included studies, there is limited evidence regarding short-term effects or other respiratory outcomes, such as disease incidence, hospitalizations, and symptom exacerbations. Short-term studies typically assess immediate changes in physiological parameters or symptoms following brief exposure to these natural environments, which may vary depending on factors such as duration and frequency of exposure, environmental conditions, and individual health status. In the included studies, the effects observed have been inconsistent, with some showing positive short-term outcomes, such as improved lung function or a reduction in respiratory symptoms, while others found no significant changes. Even in the studies reporting positive short-term changes, there is no evidence that improvements are sustained over time, suggesting that short-term exposure may not always lead to significant or long-lasting health benefits. This lack of short-term evidence highlights the need for further studies with standardized methodologies to better understand how immediate exposure to natural spaces may influence respiratory health, particularly among vulnerable populations, such as the elderly or individuals with pre-existing conditions. The results of this review are in line with prior evidence focused on wider populations, which showed that the protective effects of green spaces are mostly mediated by mechanisms such as improved air quality, increased physical activity, and psychosocial benefits [32, 33]. Conversely, potential adverse effects, mainly due to allergen exposure, underscore the complexity of these interactions, as observed in studies on younger populations. For example, early sensitization to pollen may increase the risk of developing asthma, as documented in birth cohorts studies [17, 18]. For blue spaces, the scarcity of evidence in the elderly population limits the ability to draw definitive conclusions from this review, while prior isolated studies suggest potential benefits via improved air quality and climatic effects [55].

Green and blue spaces can enhance population health by improving outcomes such as mental well-being, cardiometabolic health, and physical activity. In this context, green prescriptions have emerged as a valuable therapeutic option, demonstrating significant benefits. Encouraging the use of green and blue spaces through nature-based interventions for disease prevention is essential as the population ages, preventable chronic diseases increase, and the climate crisis worsens, impacting the quality of life, especially in cities. Public health efforts, in collaboration with key stakeholders, are crucial to effectively promoting these spaces. Prioritizing interventions in education, training, accessibility, and usability ensures these environments contribute meaningfully to health and well-being. In particular, health and climate education activities on the importance of using these spaces should start with schools, given the reduced time children spend outdoors in favour of increased screen time [56], while also addressing adulthood and the elderly. Likewise, it is important to encourage training activities for health professionals, who need to be aware of the potential benefits, as well as potential null or negative effects of green and blue prescriptions. Finally, a key and challenging point are the usability of such spaces, which requires rethinking urban environments and involving various stakeholders, from policymakers to architects, for urban health interventions aimed at transforming urban spaces [27, 28].

Limitations

The findings of this review must be interpreted with caution due to the limitations inherent to both the included evidence and the review methodology itself. One major limitation is the substantial heterogeneity in study designs, exposure assessment methods, and health outcomes. Green space exposure was measured through different measurement approaches. Observational studies predominantly used satellite-based vegetation indices (NDVI, LAI, EVI, MSAVI2) measured within residential buffers of varying sizes (ranging from 100 to 1000 m), quantify vegetation density objectively and consistently, while intervention studies used descriptors such as "forest bathing" or "park walking" that are subjective, poorly standardised, and depend on the specific context, location, and implementation of the activity. These approaches capture different aspects of greenness that are not comparable. Similarly, outcome measures ranged from mortality and hospitalization rates to biomarkers and reported subjective symptoms. Combining these heterogeneous outcomes in a pooled analysis would obscure rather than clarify the relationship between green space exposure and respiratory health, as the underlying causal mechanisms, confounding structures, and appropriate effect measures differ fundamentally across outcome types. Studies varied dramatically in exposure duration and follow-up periods, ranging from single-day interventions with same-day outcomes to cohort studies with over 13 years of follow-up. The inclusion of both observational studies and experimental studies with fundamentally different abilities to address confounding further complicated quantitative synthesis. Observational studies are subject to residual confounding by socioeconomic status, baseline health status, and health behaviours that may be incompletely adjusted, while RCTs provide stronger causal inference but only for short-term outcomes. Due to this heterogeneity, a meta-analysis was not feasible, as pooling non-comparable effect estimates would violate core principles of evidence synthesis. Therefore, a structured narrative synthesis was considered the most appropriate approach for this scoping review. Consistent with scoping review methodology, no formal risk of bias assessment was conducted. While appropriate for the exploratory aims of this review, it means that our synthesis does not differentiate between high-quality studies with robust methods and those with significant methodological limitations. Consequently, findings from studies with inadequate confounder adjustment, exposure misclassification, or other biases are given equal weight in the narrative synthesis. This limitation is particularly relevant given the potential for confounding by socioeconomic status (individuals living near green spaces often have higher income, better healthcare access, and healthier behaviours) which may not have been adequately addressed in all included studies.

Conclusion

This review synthesizes the evidence on the effects of green and blue spaces on respiratory health in the elderly, revealing a potential protective association, particularly regarding respiratory mortality. However, the evidence for other respiratory outcomes remains uncertain, with limited findings for short-term effects. The heterogeneity of study designs and exposure assessments complicates the interpretation of the results: the narrative synthesis reveals general patterns, such as protective associations between residential greenness and respiratory mortality being more consistent than associations with other outcomes, but cannot provide precise effect estimates or dose–response relationships. Future systematic reviews focusing on specific, narrowly defined questions with rigorous quality assessment and, where appropriate, meta-analysis of homogeneous studies would be needed to generate pooled effect estimates suitable for evidence-based policy recommendations.

Supplementary Information

Supplementary Material 1. (108.2KB, docx)
Supplementary Material 2. (14.9KB, docx)
Supplementary Material 3. (27.2KB, docx)
Supplementary Material 4. (29.4KB, docx)

Acknowledgements

We would like to thank all those who supported and contributed to this work: Chiara Badaloni (DEP), Silvia Brini (ISPRA), Giacinto Ciappetta (ARPACAL), Anna Chiesura (ISPRA), Annamaria Colacci (ARPAE), Gianpiero Di Francesco (Ministero della Salute), Marco Domenicali (UniBo), Massimo Giusti (ARPA), Elena Maestri (CINSA), Laura Mancini (ISS), Nelson Marmiroli (CINSA), Sisto Milito (ASP Cosenza). This study is part of the Italian project "Promozione e prevenzione della salute: il contributo della natura e degli spazi verdi e blu—VeBS" -“The proper use of green and blue spaces for the promotion of health and well-being”, carried out with the technical and financial support of the Ministry of Health within the framework of the National Complementary Investment Plan to the PNRR (PNC) – Investment E.1 Health–Environment–Biodiversity–Climate (project code PREV-B-2022-12377017).

Authors’ contributions

All authors contributed to the study conception and design. Material preparation and data collection were performed by GSL and DZ. The first draft of the manuscript was written by GSL, DZ and MDS; WR, CC, and LV commented on the latest version of the manuscript. LV supervised the study. All authors have read and agreed to the published version of the manuscript.

Funding

This study is part of the Italian project "Promozione e prevenzione della salute: il contributo della natura e degli spazi verdi e blu—VeBS"—“The proper use of green and blue spaces for the promotion of health and well-being”, carried out with the technical and financial support of the Ministry of Health within the framework of the National Complementary Investment Plan to the PNRR (PNC) – Investment E.1 Health–Environment–Biodiversity–Climate (project code PREV-B-2022–12377017).

Data availability

All data generated or analysed during this study are included in this published article and its supplementary information files.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Associated Data

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Supplementary Materials

Supplementary Material 1. (108.2KB, docx)
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Supplementary Material 3. (27.2KB, docx)
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Data Availability Statement

All data generated or analysed during this study are included in this published article and its supplementary information files.

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