The neighborhoods in which children and their families live their daily lives are important settings for health-promoting actions and policy. One of the priorities outlined in the Ottawa Charter for health promotion is to create supportive environments for children and adolescents.1 Both physical or built characteristics (e.g. residential areas, pedestrian infrastructure, green spaces) and psychosocial characteristics (e.g. social cohesion, safety from crime) of neighborhoods can contribute to determining health and well-being in the younger population by either supporting or adversely influencing health.2,3 This systematic review addresses neighborhood built-environment determinants, such as buildings, land use, green spaces and the provision of facilities, and their potential to support activity participation and strengthen well-being in childhood and adolescence.
Well-being fosters resilience and enables individuals to function well and thrive. Strengthening actions that can contribute to promoting well-being is therefore highly important.4 Participation in meaningful activities, including organized activities, unstructured play, recreational activities or various forms of physical activity (PA) (e.g. walking, cycling and running), has several positive effects on both physical and mental health.5-7 All these activities occur in different settings, such as the neighborhood. Hence, supportive neighborhood environments that foster participation in activities and let children and adolescents expand their capabilities can contribute to enhancing well-being.
A rapidly urbanizing world creates challenges, and there is a need to maintain, upgrade and develop urban areas to promote public health.8 To ensure informed decision making and policy changes, initiatives need to rely on systematic development and the use of evidence-based knowledge and best practice.9 A comprehensive understanding of neighborhood built-environment determinants is therefore essential. The volume of literature that has examined the built environment as a modifiable determinant of health has expanded substantially over recent decades.10-12 Given the great number of studies, as well as the myriad methods applied, it has become increasingly difficult for researchers and stakeholders to have an overview of the evidence.12 A recently published umbrella review provides important insights showing that neighborhoods with high street connectivity, mixed land use and compact residential design were linked to higher levels of PA.10 Bird et al.10 also found that densely populated areas with good access to facilities increased PA and improved mental health in the general population. However, several gaps in the literature remain to be filled to better understand the health-promoting potential of neighborhood built environments.
Previous reviews of the built-environment determinants of health in childhood and adolescence have mainly focused on and synthesized results by merging together different types of PA into one overall, unspecified PA outcome or considering total PA over the course of specific time periods.13-16 A common finding of these reviews is that associations between the built environment and PA are inconsistent across studies. Alternatively, reviews that specifically address the determinants of active travel have consistently shown that active travel behavior is supported by neighborhoods that have pedestrian infrastructure for walking/cycling, high walkability, less traffic exposure, high safety as well as access to facilities.17-20 It is presumed that the relationship between the built environment and PA varies according to domains of activities, such as leisure-time PA, active travel to/from school and outdoor play.3,12,14,21 This highlights the importance of being outcome-specific in the synthesis of results, which is a shortcoming of several existing reviews. Furthermore, less attention has been paid to the possible benefits of the built environment for the well-being of children and adolescents. Clark et al.22 have shown that children's mental health was diminished by lack of access to green space and poor neighborhood quality, including derelict properties, graffiti, uneven pavements, lack of public and private recreation space, speeding traffic and high crime levels. New studies have added evidence since Clark et al. published their review, but more recent syntheses are limited to assessing green and natural environments.23-25 Reviews that have considered the broader built environment have mainly included people older than 16 years.26-29 One exception is Christian et al.30 who found that the presence of neighborhood facilities was positively associated with children's physical health, well-being and social competence. Nevertheless, this review considered only a small segment of the child population by exclusively focusing on those aged seven years or younger.
Specificity in the descriptions of how built-environment determinants are measured and operationalized has also been a limitation of previous studies.31,32 Only recently, Nordbø et al.33 developed a framework for how to categorize built-environment determinants, which can be useful in both future primary studies and review studies. Another important weakness of past syntheses of the literature is the lack of quality assessments of the individual studies. Bird et al.10 highlighted that around 45% of existing reviews did not report any quality assessments. This lack of methodological quality assessment pertains to several published reviews of environmental determinants of activity participation and well-being of children and adolescents.13,14,18,30 We therefore consider it necessary to comprehensively and critically review and synthesize the current evidence in a more specific and detailed manner to address the aforementioned gaps and shortcomings.
The objective of this review was to identify, evaluate, and synthesize the findings on built-environment determinants and their relationship to participation in different domains of activities, including PA, recreational and social activities, and well-being among children and adolescents from a broader public health perspective. In particular, the objective was to identify which built-environment determinants seem to promote participation in activities and well-being in childhood and adolescence.
This review considered studies that included the general population of children and adolescents between five and 18 years of age based on a holistic, population-based public health approach in the young segment of the population. Studies that also included participants below/above this age were considered if stratified results were provided for age groups within the predetermined age range.
Articles were eligible for inclusion if they examined exposure to one or several built-environment determinants. Built-environment determinants here refer to all modifiable factors in the neighborhood context, such as residential density, land use, buildings, roads and streets, traffic, pedestrian infrastructure, green space, safety, and esthetic features, as well as proximity to and the presence of facilities such as schools, shops, libraries, sports fields, and playgrounds. There were no restrictions on mode of measurement, and determinants could be assessed using, for example, geographic information systems (GIS), audits, or self-report. Articles were not considered if they validated specific methodologies for assessing the built environment. Additionally, considering the scope of this review and the notion that schools represent a separate setting for health promotion with their own structural and organizational characteristics, articles were not eligible for inclusion if they focused on the school area or schoolyard only.
Articles with activity participation or well-being (or both) as the main outcome were considered for inclusion. Activity participation encompassed the everyday activities of children and adolescents potentially related to the built environment, including different domains of PA (e.g. outdoor play, active travel) and recreational and social activities (e.g. spending time with friends and peers).3 Considering the scope of this review, studies examining sedentary behaviors (e.g. hours of screen time) were not eligible for inclusion. Well-being was broadly defined to encompass positive outcomes portraying individuals experiencing positive emotions and feelings, functioning well, and being able to realize their own abilities and thrive. The definition further included the contrasting outcomes characterized by negative emotions and feelings, as well as mental health and behavioral problems.4 There were no restrictions on mode of measurement.
Types of studies
This systematic review considered quantitative studies involving natural experiments occurring in the neighborhood and analytical observational studies, including retrospective or prospective longitudinal research, case-control studies, and cross-sectional studies. The studies had to report test statistics (e.g. odds ratio, regression coefficient, and prevalence ratio) for associations between the built-environment determinants and the outcomes, which means that descriptive cross-sectional studies were not eligible for inclusion.
This systematic review was conducted in accordance with an a priori protocol that was prospectively registered in PROSPERO (CRD42018114413). The PRISMA guidelines were followed throughout this review.34
A four-step search strategy was utilized to identify peer-reviewed studies within PubMed, Web of Science, Embase, MEDLINE, PsycINFO and CINAHL. The search was limited to English articles. Further, to avoid duplicating the results of previous reviews that have examined relationships between the built environment and PA among children and adolescents, the search was also limited to identify articles published since January 2010.13,14,18,19 To find relevant search terms, an initial limited search in Web of Science, PubMed, and MEDLINE was undertaken, followed by an analysis of text words contained in the titles, abstracts, and keywords. In PubMed and MEDLINE, the MeSH index terms used to describe the articles were also analyzed. This preliminary search informed the development of a full search strategy, which was tailored for each database. Next, a full search was performed in PubMed and MEDLINE using both keywords and MeSH index terms. Thirdly, a full search was undertaken across Web of Science, EMBASE, PsycINFO and CINAHL using the identified keywords only. The full search strategies for each database are detailed in Appendix I. Lastly, based on the large number of studies, as well as the limited resources and time available, the reference lists of 50% of the included articles were screened for additional studies.
All identified records were uploaded into EndNote X8.2 2018 (Clarivate Analytics, PA, USA) where duplicates were removed. The first author (ECAN) screened the titles and abstracts of the records. Uncertainty about inclusion or exclusion was resolved by seeking a second opinion from one of the co-authors (three instances during the screening process) or by obtaining confirmatory information from the full-text article. All papers selected for full-text retrieval were assessed for eligibility based on congruence with the inclusion criteria by the first author. Eligibility assessment was duplicated for 43 full-text articles by a co-author (HN: 11, RKR: 16 and GA: 16). Disagreements about inclusion or exclusion of four of the articles emerged during the eligibility assessment. In these four instances, all co-authors assessed the articles independently and disagreements whether to include or exclude were reconciled though group discussions.
Full-text studies that did not meet the inclusion criteria were excluded, and the reasons for their exclusion are provided in Appendix II.
Assessment of methodological quality
Three independent reviewer pairs critically appraised the methodological quality of 90 out of 127 studies selected for inclusion (ECAN and HN: 30; ECAN and RKR: 30; ECAN and GA: 30). Inter-rater agreement was 87.0% (disagreed on 32 items), 90.4% (disagreed on 24 items), and 90.4% (disagreed on 23 items) for each pair, respectively. Disagreements were solved through discussions in pairs. The methodological quality of the remaining 37 studies was assessed by ECAN only. Standard critical appraisal tools tailored for the different study designs from JBI were used.35,36 The items were weighted equally (yes = 1 vs. unclear/no/not applicable = 0). A document clarifying what constituted acceptable levels of information for a study to receive a positive, negative, or unclear response was developed by two of the authors. This document was forwarded to all co-authors prior to the quality assessment. All studies, irrespective of quality, were included. Each article received a total score, and based on this score, articles were rated as being of “good”, “fair” or “poor” quality. Since cut-offs for the quality weighting of the evidence are not available for the critical appraisal tools, the weighting is based on the predetermined cut-offs. These cut-offs were based on the following criteria: i) poor quality if 50% or fewer of the items were not satisfactory, ii) fair quality if 51–85% of the items were satisfactory and iii) good quality if more than 85% of the items were satisfactory.
A data extraction form was developed and used to systematically record the following information from each paper: reference, country, age of the participants, total sample size, gender distribution, study design, built-environment determinants, health outcomes, mode of measurement for both determinants and outcomes, and key findings.37-163 Regarding the age of the participants, the mean age was extracted if this was the only information reported. Eleven studies (five from the USA94,103,117,122,128 and six from Canada61,88,89,100-102) reported grades instead of age. For consistency, grades were converted into age for these studies. These conversions were based on information written in government documents provided by Departments and Ministries of Education in USA and Canada as summarized by the Organisation for Economic Co-operation and Development.164 In the column for key findings, significant associations were reported and presented either as effect measures with 90% or 95% confidence interval (CI) or as effect measures with standard error (SE) and P-values, from adjusted multivariate analyses. ECAN extracted the data for all the papers. Data extraction was duplicated for 30 articles by a co-author (HN: 6, RKR: 13 and GA: 11).
Appendix III summarizes the general characteristics of the included studies. Appendix IV provides detailed characteristics and main findings of the included studies.
Statistical pooling was not possible due to the heterogeneity between the included studies in assessment of exposures and outcomes. Accordingly, the findings are presented in a narrative form with tables and figures to aid the presentation of data. The narrative synthesis involved two steps. First, studies were categorized based on their general study characteristics to facilitate the interpretation of results. Then, the relations between the built-environment determinants and the established categories of outcomes were synthesized using vote counting. These two steps are detailed below.
Categorizing the studies based on general study characteristics
Following the same logic as Ding et al.,14 studies were grouped into categories based on their general characteristics, such as year of publication, geographic origin, sample age, total sample size, study design, methods for assessing the built environment, and outcome measurement methods. The number of studies within each category was reported. Outcomes were grouped into different categories to assist the interpretation of results. These categories were developed in the review process and were governed by both the content of the material as well as the aim of being domain-specific in the synthesis of activity outcomes. The following six mutually exclusive categories were established:
- Unspecified PA: outcomes capturing different intensities of PA, such as moderate to vigorous PA and activity counts. For outcomes in this category, the context and domain of PA could not be specified into any of the following categories due to lack of information or the outcome of the study was total PA during a specific time period.
- Leisure-time PA: outcomes eliciting different intensities of PA or activity counts where it was evident that the activity occurred during leisure time (e.g. running for fitness) but the context was not possible to specify.
- Active travel: outcomes capturing walking and/or cycling to/from school or other destinations within the neighborhood.
- Outdoor play/activity: outcomes specifying that the activity/play occurred outside or at specific outdoor locations in the neighborhood, such as the street, park, beach, or playground.
- Organized sports: outcomes capturing participation in different sport activities, mainly organized sports such as handball, soccer, volleyball, football, dancing, karate, and gymnastics.
- Well-being: outcomes measuring aspects of well-being or positive mental health as well as negative mental health. This included perceived stress, self-esteem, quality of life, life satisfaction, happiness, well-being, behavioral problems, and emotional symptoms.
Coding and synthesizing relationships between the built environment and health outcomes
Findings were synthesized using the predetermined categories of built-environment determinants developed by Nordbø et al.33 (Figure 1). Esthetics was added to the list of categories to facilitate the interpretation of the findings. Each determinant from the separate studies was assigned into one of the 19 categories presented in the figure.
Overall, mainly results from adjusted multivariate analyses were considered for the review. The exceptions were three studies38,42,74 with adjusted bivariate analyses and two studies with unadjusted estimates.80,120 In one longitudinal study, only cross-sectional (baseline) results were considered, because the age at the six-year follow-up was 21 years and thus outside the target group.144 The direction of each association between a built-environment determinant and a particular health outcome was coded, with “+” indicating a positive significant association, “0” representing a non-significant association, and “-” signifying a negative significant association. The number of association codes for each study was counted. For several studies, multiple entries were reported based on sub-group analyses or because several determinants and outcomes were studied. Results were synthesized separately for the six outcome categories. After all of the results had been extracted, the total number and the percentages of positive, negative, and non-significant associations were calculated for each investigated built-environment determinant category.
Figure 2 presents the flow diagram for the evidence acquisition and study selection process. The searches identified 2030 unique records. The screening process resulted in 162 full-text articles, of which 43 articles were excluded after eligibility assessment (Appendix II). An additional eight articles were identified through the screening of reference lists. In total, 127 articles met the inclusion criteria for this systematic review.
The quality assessment rating for each study design is presented in Table 1, and the results from the critical appraisal are outlined in Appendix III. The quality of the included studies was quite good. The majority of the studies were rated as fair (57.4%), and 27.6% of the studies were of good quality. In cross-sectional studies of fair quality, the item most frequently rated as not satisfactory was the identification of confounders. Several studies also had weaknesses in their strategies to deal with confounding issues. The reason for not evaluating these items as satisfactory was that vital confounders, such as individual-level income or education, were not measured in the studies or were omitted from the statistical analyses. Additional issues of selection bias due to lack of representativeness in the recruitment of participants were a main problem in cross-sectional studies of both fair and poor quality. The longitudinal studies were all of fair quality (n = 14). The leading reasons for reduced quality scores in longitudinal studies of fair quality were the omission of important confounders and/or incomplete follow-up and lack of strategies to address study drop-out.
Characteristics of included studies
Of the 127 studies included in this review, 59.8% had been published since January 2014 (Appendix III). The majority of the studies (78.7%) were from North America and Europe. There were more studies on children than on adolescents, and the study designs were mainly cross-sectional (87.4%). The sample sizes ranged from 39 to 64,076. Active travel was the most studied outcome (n = 54), followed by unspecified physical activity (n = 46), whereas 11 studies examined the built-environment determinants of organized sports and well-being. Studies assessed unspecified and leisure-time physical activity, active travel, and outdoor play/activity using either accelerometers or questionnaires, whereas organized sports and well-being outcomes were self- or parent-reported. GIS-derived measures were most commonly applied to assess the built environment, either as the only method of measurement (n = 48) or combined with direct observation/audits (n = 10), self-reported measures (n = 28), or global positioning system (GPS) (n = 5).
The findings on built-environment determinants and their relation to participation in activities and well-being among children and adolescents are presented according to the established six categories of outcomes identified (i.e. unspecified PA, leisure-time PA, active travel, outdoor play/activity, organized sports and well-being).
The built environment and unspecified physical activity
Figure 3A shows the associations between built-environment determinants and unspecified PA. The count/proportion of facilities/amenities was the most studied determinant (n = 18). Total building density, urban-rural status, and land use or land cover have not been examined in relation to this outcome. Overall, 358 results were extracted from the 46 studies with unspecified PA as an outcome (Table 2). Few favorable associations were found between residential density, type of green/open space, esthetics, and unspecified PA. More than half of the studies (eight out of 13) that addressed road/street pattern and connectivity reported positive associations. Of these, there were three studies of good quality and five studies of fair quality. The proportion of positive associations was greatest for the composite determinant denoted as the facility and amenity index (77.8%). This determinant was investigated in relation to unspecified PA in 12 studies, of which half were rated as being of good quality. All the good-quality studies consistently reported positive associations (Table 2).
The built environment and leisure-time physical activity
Figure 3B shows that 15 environmental determinants have been investigated in relation to leisure-time PA. The determinant entailing traffic exposure and safety features was the most studied (n = 10), followed by count/proportion of facilities/amenities (n = 7). Overall, 437 results were extracted from the 22 studies examining determinants of leisure-time PA (Table 3). Few significant associations were identified for population density, residential density, building density, land use mix, road/street pattern and connectivity, pedestrian infrastructure, and distance to green/open space as well as type of green/open space in terms of supporting leisure-time PA. However, only a few studies examined several of these determinants. The facility and amenity index showed the largest proportion of positive associations (38.4%) with leisure-time PA as well, but none of these studies were rated as being of good quality.
The built environment and active travel behavior
The determinants associated with active travel are presented in Figure 3C. Traffic exposure and safety features (n = 37), road/street pattern and connectivity (n = 25), distance to facilities/amenities (n = 25) and pedestrian infrastructure (n = 24) were most frequently studied. Overall, 623 results were extracted from the 54 studies investigating determinants of active travel (Table 4). Less traffic and higher safety were associated with increased active travel in all the 17 studies that reported positive associations, of which one study was rated as good, 14 were rated as fair, and two studies were of poor quality. Increased traffic exposure and safety concerns reduced the likelihood of active travel in 13 out of 15 studies that reported negative associations. The studies with deviating results found that the number of slow points, which are considered to encourage slower driving, was associated with less active travel in adolescent girls53 and that more traffic lights were related to less walking for transport.64 Consistency in associations was found for pedestrian infrastructure, walkability and distance to facilities/amenities. The total proportion of significant associations for walkability was 62.7% (58.8% positive and 3.9% negative). Of the 12 studies that reported any significant influence, the majority of studies were of either good or fair quality (n = 11). Higher walkability was associated with more active travel in 11 studies, whereas one study found that active travel behavior was more frequent in areas of lower walkability.116 Distance to facilities/amenities was associated with active travel in 20 out of 25 studies, of which five studies were rated as poor. The total proportion of significant associations was 78.2% (21.8% positive and 56.4% negative). All the significant associations consistently reflected that shorter distances increased whereas longer distances reduced active travel behavior.
The built environment and participation in outdoor play/activity
Figure 4A shows that 17 different determinants have been investigated in relation to outdoor play/activity among children and youth. Several of these determinants had few studies (nine with two studies or fewer). Overall, 247 results were extracted from 21 studies for outdoor play/activity (Table 5). Traffic exposure and safety features (n = 10) and count/proportion of facilities/amenities (n = 9) were the most studied determinants. All six studies that reported positive associations for traffic and safety features found that less traffic and/or higher safety increased outdoor play/activity, but two of the studies were of poor quality. Of the studies that reported negative associations, two found that more traffic and safety concerns were associated with less outdoor play/activity,43,73 whereas three presented results that conflicted with this.37,50,121 In these studies, less traffic and/or higher safety were associated with less outdoor play/activity. The contradictory findings were mainly observed for adolescents and boys. Increased count/proportion of facilities/amenities was associated with more outdoor play/activity in six out of nine studies, but three of these studies also reported associations in the opposite direction.37,50,74
The built environment and participation in organized sports
Eight built-environment categories had been examined as determinants of participation in organized sports (Figure 4B). In total, 37 results from 11 studies were extracted for this outcome (Table 6). All the studies were of either good or fair quality. Walkability was the most investigated determinant (n = 4), followed by distance to facilities/amenities, count/proportion of facilities/amenities, and the facility/amenity index, which were investigated in three studies each. The majority of the results for neighborhood walkability were non-significant (71.4%). The five significant associations reported for distance to facilities/amenities were contradictory. Longer distance was associated with more participation in organized sports in one study,67 but reduced the likelihood of participating in sports activities in another study.138 In a third study, the authors reported that greater access to facilities increased participation in organized sports among 10- to 11-year-olds.131
The built environment and well-being
Figure 4C shows that only six different determinant categories were considered in the studies examining relationships between the built environment and well-being, of which three were neighborhood green/open space factors. The count/proportion of green/open space was the most frequently studied determinant (n = 7). The other determinants had been investigated in two studies or fewer. Overall, 123 results were extracted for the well-being outcomes (Table 7). Increased count/proportion of green/open space was associated with fewer behavioral problems,39 less perceived stress,75 greater well-being,76,90 and better self-perceived health99 but unrelated to quality of life.110 All of the studies that reported any significant associations between count/proportion of green/open space and well-being were of either good or fair quality. Two studies of good quality examined distance to green/open space as a determinant of well-being. One of the studies reported that longer distance to green space was associated with increased risk of hyperactivity/inattention and peer relationship problems,106 whereas the other study did not find any favorable associations.39 The studies considering neighborhood esthetics found that less favorable esthetic conditions were associated with more behavioral and mental health problems,49,145 which accounted for 58.3% of the associations extracted.
This systematic review comprehensively evaluated and summarized evidence from 127 studies investigating the built-environment determinants of activity participation and well-being among children and adolescents. A broad range of environmental features were considered, which underscores the complexity of determinants. The built environment was most extensively studied in relation to active travel and unspecified PA, and the evidence suggests associations between some of the determinants and the two outcomes. Limited evidence existed for the relationship between the built environment and well-being among children and adolescents.
A novel finding in this review was that the facility and amenity index was most consistently related to unspecified PA and, to some extent, leisure-time PA. The majority of the studies supporting such a beneficial association were of good quality. The facility and amenity index is a combined measure or score of several determinants, such as facilities, green space, traffic safety, and pedestrian infrastructure.33 Composite measures include synergy between different determinants, and a higher facility and amenity index score represents neighborhoods that, for example, have both mixed residential and commercial land use, connected streets with direct access for pedestrians, and a variety of facilities. The determinants likely influence health through complex interactions, and assessing relationships through a composite measure may result in a cumulative impact.165 However, it is not straightforward to use composite determinants. Conceptual, as well as empirical, knowledge of the interrelationships among the determinants, along with knowledge about their relationships with specific outcomes, are required to reasonably assemble them into indexes.166 Additionally, composite measures are often inconsistently defined and inadequately reported in studies.33 These inconsistencies lead to difficulties in interpreting the findings, which in turn complicates the use of results for planning purposes.
Another key finding was a lack of consistency across studies for the rest of the built-environment determinants in relation to unspecified PA and leisure-time PA. There could be two main explanations for this inconsistency. First, the included studies were highly methodologically heterogeneous. The outcomes, neighborhood areas and built-environment determinants were measured and operationalized in multiple ways across studies. Different measurement approaches can provide distinct and inconsistent results between studies and, in turn, mask consistencies in the syntheses of evidence.167,168 Second, this systematic review considered subjects aged between five and 18 years. According to the socio-ecological model of health, there are dynamic relations between the environment and individuals. The same built-environment determinants might influence people's health and well-being differently depending on factors such as age, which also could explain this review's inconsistent finding.169,170 Nevertheless, the inconsistent results in associations between the built environment and PA is in line with a previously published literature review in which no built-environment determinants were unambiguously associated with PA.14 Contrary to the review findings of Ding et al.14 who reported that higher residential density was related to increased PA in children, this systematic review found no favorable associations for residential density. The relationship between density and the ability to participate in activities appears to be complex. Kyttä et al.171 have suggested that the association between density and PA is mediated by accessibility. A dense area without arenas for PA, or where such arenas have blocked access because of heavy traffic, will not enhance participation.
Compared to unspecified PA and leisure-time PA, more consistency was found in associations between several of the determinants and active travel. Neighborhoods with low traffic and/or high safety, pedestrian infrastructure for walking/biking, shorter distances to facilities, and greater walkability could be beneficial in terms of facilitating active travel behavior. These findings correspond with the results from several previous reviews of the determinants of active travel.17-19 Although the vast majority of this review's results derived from cross-sectional studies of fair quality, the findings provide additional confirmatory evidence that these determinants are promising in terms of promoting active travel between different destinations in the neighborhood among children and adolescents.
The activity behaviors of children and adolescents are influenced by the different contexts in which the activities are undertaken.3 Active travel between destinations only occurs within the built environment, whereas unspecified and leisure-time PA can be carried out in other contexts (e.g. indoors). The active travel behavior of children and adolescents thus depends more likely on the different facilitators and barriers in the built environment than on the other two physical activity outcomes, which is reflected in this review's findings. Furthermore, the unspecified and leisure-time PA outcomes mainly considered children's and adolescents’ total activity independent of context. Assessing PA independent of context can result in low specificity of PA measures, which can explain both the absence of associations and the inconsistent results identified for the determinants of these two outcomes. A solution to increase the specificity of measures is to monitor the activity levels of the target group and locations simultaneously, using both accelerometers and GPS.172 A few studies included in this review measured activity outcomes in this manner,39,96,112,141,160,161 among which one found that the highest physical activity intensities occurred in green space compared to other outdoor and indoor areas.160
Many built-environment determinants of outdoor play/activity have been investigated, but only a few studies examined several of these determinants. These few studies provided limited evidence. Nevertheless, in studies of good or fair quality, some consistent associations were found between less traffic and/or higher safety and more outdoor play/activity, particularly among children, whereas contradictory results were observed for adolescents. These findings can be explained by the fact that children generally have more parental constraints than adolescents and that traffic danger and safety concerns are often important reasons for parental restrictions.173,174 Consequently, children and adolescents use their neighborhood surroundings differently, which can provide mixed results in these age groups. Nearby streets may offer opportunities for outdoor play/activity for children, and it has been pointed out that cul-de-sacs could be a key determinant in that regard.175 The disparities found between age groups highlight the importance of stratified analyses to detect such variations. The results also show that ensuring low traffic exposure or more safety features could potentially be relevant to support outdoor play/activity among children. Similar findings have been reported for children below the age of seven.30 However, more research is needed to clarify the potential of traffic- and safety-related determinants to support outdoor play/activity.
This review identified a limited number of studies addressing relationships between the built environment and participation in organized sports. Although these studies were of good or fair quality, the 37 extracted results did not provide any clear evidence from which to draw conclusions, especially considering that several of these results were contradictory. In regard to well-being, a few studies provided some insight showing that more neighborhood green/open space was linked to fewer behavioral problems, less perceived stress, greater well-being, and better self-perceived health. Similar findings have been reported elsewhere, both among children and adolescents23,24 and in the general population.25 As reported in previous reviews, this review found that poorer neighborhood esthetic conditions were associated with more mental health and behavioral problems.22,27 However, only a small number of studies examined well-being outcomes, and there were more non-significant than positive findings. Thus, this review continues to support the inconclusive nature of associations reported in previous syntheses.22-25,27
Although investigations of the built-environment determinants of health have increased rapidly over the last two decades, this field of research is still quite young and under development.11 This review has identified that there remains a substantial gap in understanding the relationship between built-environment determinants and well-being as well as other activity outcomes, such as organized and social activities. Further, study quality issues and methodological challenges, such as inconsistent use of operational definitions and measures of the environmental determinants, remain to be resolved.33 Thus, it might be too early to dismiss the potential of all non-significantly or inconsistently associated determinants to support participation in activities and well-being in childhood and adolescence.
Strengths and limitations of this review
A major strength of this review is its inclusivity. A broad range of built-environment determinants and health outcomes from recently published studies were considered. Outcomes were grouped and results were synthesized separately for each outcome category. This enabled an outcome-specific synthesis of associations, which addressed an important shortcoming in the existing reviews. This review's findings are based on adjusted associations, with a few exceptions. Due to prominent confounding issues in associations between the built environment and health, this is considered a strength.11 The review also assessed if confounders were adequately considered in each study, and the limited adjustment or omission of important confounders was accounted for by the quality assessment weighting.
This review's authors acknowledge the importance of measuring the built environment using different methods to provide evidence in this field. Therefore, studies using a variety of measurement approaches were included in this review, resulting in high heterogeneity across studies. This can be viewed as both a strength and a limitation. Mode of measurement is shown to greatly influence the consistency of associations between the built environment and PA.14 Since the focus of this review was to provide an outcome-specific synthesis, results were not synthesized based on different measurement modes. Furthermore, similar built-environment constructs were assigned to predetermined categories to facilitate the interpretation of the results. The determinants were measured differently across studies and some determinants may have been grouped incorrectly. Nevertheless, it is important to consider the total evidence in this outcome-specific synthesis, and future reviews could provide results specific to different modes of measurement.
Although a large number of studies was reviewed, it is possible that articles were missed in the retrieval process. Only papers written in English were included, and reviewers had limited access to databases. Additionally, only PubMed and MEDLINE were searched with MeSH terms and not all reference lists were screened for additional articles. Furthermore, the exclusion of unpublished/gray literature could have been a weakening factor as studies showing statistically significant, positive results are more likely to be published than those that do not.176 Consequently, this present systematic review is vulnerable to publication bias, and the findings are likely to be biased toward positive results. Nevertheless, the likelihood of publication bias in the analysis and synthesis of the review findings was minimized by counting all positive, negative and non-significant results from the articles. It was not possible to use two independent reviewers throughout the entire review process due to time and resource constraints. However, the reviewers tried to reduce the risk of bias at all stages, and particularly focused on providing a rigorous quality assessment.
This systematic review follows up on previous reviews of the built-environment determinants of health in childhood and adolescence and includes an assessment of the most recently published literature on health-promoting environments for children and adolescents. This review found that the facility and amenity index was consistently associated with unspecified PA and, to some extent, leisure-time PA. The small number of studies examining participation in organized sports and well-being provided limited evidence, which prevents us from drawing specific conclusions regarding relationships between the built environment and these outcomes. The most consistent associations were found between active travel and the following determinants: less traffic exposure and/or higher safety, pedestrian infrastructure for walking/biking, shorter distances to facilities, and higher walkability. Policies and planning processes should consider these determinants in order to strengthen children's and adolescents’ health and well-being. However, there are remaining research gaps and important avenues for future research that need to be addressed before more specific and robust conclusions can be drawn.
Recommendations for practice
The evidence from this review suggests that the determinants of less traffic exposure and/or higher safety, pedestrian infrastructure for walking/biking, shorter distances to facilities, and higher walkability may be essential in supporting children and adolescents to travel actively to and from their daily destinations. This finding ought to be used for the improvement and specification of relevant public health and planning policies as well as spatial planning practice. It must be emphasized that this recommendation is largely based on results from cross-sectional studies, which is problematic, as associations do not equal causation. However, the associations observed were largely desirable and appear to outweigh unfavorable levels of physical inactivity.
Recommendations for research
One key area for further research is to investigate a greater variety of activity outcomes in more depth. Increased focus on a broader range of activities could contribute to expanding the knowledge on how the built environment can provide opportunities for activity participation. There is also an urgent need for studies examining the built-environment determinants of positive mental health and well-being. Neighborhood green space seems to have gained the focus in studies to date that address relationships between the built environment and well-being. In this respect, more attention should be directed toward a broader spectrum of built-environment determinants. Some determinants may not be directly associated with activity participation or well-being, and potential mediators and effect modifications need more exploration. Furthermore, subgroup analyses and increased specificity in outcome and built-environment measures, as well as clear definitions of the geographical units and built-environment determinants of interest, are important to strengthen the study results. As identified by the quality assessment, there is a need for improved study quality. Particularly, the consideration of confounders has to be more rigorous, and in studies with longitudinal assessment, there should be strategies to minimize loss to follow-up. The vast majority of the reviewed studies relied on cross-sectional designs, and research adopting longitudinal designs and natural experiments should be conducted to strengthen any causal associations.
In this current systematic review, the focus was on the entire segment of the younger population and to providing an outcome- and determinant-specific synthesis. The complexity of built-environment determinants and their links to activity participation and well-being in childhood and adolescence revealed herein raise additional issues that warrant detailed exploration in future evidence syntheses. Focusing on a narrower age range may improve the review findings and give a clearer picture of the evidence base. Further, it seems necessary to synthesize results based on objective and perceived environmental measures separately due to the heterogeneity in measurement approaches.
E.C.A. Nordbø is a PhD fellow at the Norwegian University of Life Sciences. A doctoral fellowship and seed money funded by the Faculty of Landscape and Society, Norwegian University of Life Sciences, supported this work.
Appendix I: Search strategies
Web of Science
Appendix II: Studies ineligible following full-text review
Appendix III: General characteristics of included studies
Appendix IV: Detailed characteristics and main findings of included studies
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