Journal of Mental Health and Aging

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Research Article - Journal of Mental Health and Aging (2022) Volume 6, Issue 2

Direct and indirect effects of built and natural environment on elderly mental health: A meta-synthesis

Mahdi Khakzand1*, Zohreh Rakhshani2

1Department of Landscape Architecture, Iran University of Science and Technology, Tehran, Iran

2Department of Architecture, Faculty of Architecture and Urban Design, Isfahan Art University, Isfahan, Iran

*Corresponding Author:
Mahdi Khakzand
Department of Landscape Architecture
Iran University of Science and Technology, Tehran, Iran
E-mail: [email protected]

Received: 27-Aug-2022, Manuscript No. AAJMHA-22- 39628; Editor assigned: 23-Aug-2022, PreQC No. AAJMHA-22- 39628 (PQ); Reviewed: 30-Oct-2022, QC No. AAJMHA-22- 39628; Revised: 16-Feb-2022, Manuscript No. AAJMHA-22- 39628 (R); Published: 18-Mar-2022, DOI:10.35841/AAJMHA-6.2.106

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Abstract

The places where people live affect their physical, social, and mental health. This is also true for the elderly. In this review, with the aim of increasing the understanding of how the built and natural environment impact elderly mental health, two scales of environment have been investigated, architecture (personal home and nursing home) and urban. Data were collected from three scientific databases (Science Direct, Scopus, and PubMed). The analysis of the meta-synthesis results demonstrates variety concepts that have direct and indirect effect. The extracted concepts were examined in three categories. By averaging determined that concepts related to Personal homes have a direct impact on mental health with 17.5%, whereas in nursing homes have indirect impact on mental health through physical health with 12.5% and in urban spaces have indirect impact through social health with 18%. Also, the connection with nature in all three spaces simultaneously created both types of effects. In the comparison among all the concepts in three categories, it was found that social interactions with 32% have the greatest impact on mental health

Keywords

Mental health, Elderly, Built environment, Natural environment, direct and indirect effect.

Introduction

In 1946, the World Health Organization (WHO) declared mental well-being as one of three fundamental components of health, along with physical and social well-being. More recently, in 2013, the WHO released its Mental Health Action Plan, which established mental health research as one of its goals [1]. Additionally, in 2015, the United Nations recognized the promotion of mental health and well-being as a health priority of the global development agenda effort [2]. In 2016, 44.7 million adults in the United States (US) lived with a mental illness [3]. Internationally, the WHO reported that in 2016, neuropsychiatric disorders were the third leading cause of disability-adjusted life years (DALYs) in Europe, behind only cardiovascular diseases and cancer. In 2017, the WHO reported that depression was the leading cause of disability worldwide. Specifically, depression was identified as the single largest contributor to nonfatal health loss globally [4]. In addition the whole world is aging; both the number and proportion of older people is increasing in post-industrial and developing nations. It is projected that by 2050, 21% of people will be more than 60 years old [5].

With the increasing global population of older adults, there is a need to consider built and natural environmental factors that directly and indirectly (through physical and social health) affect the mental health and emotional well-being of the elderly. Many studies have been carried out on the elderly and their mental, physical, and social needs, which in some cases have led to improved care for the elderly in private centres, but research conducted in the last decade shows that the cause of many elderly mental health problems is environment-related [6-8]. The purpose of this article is to synthesize peer research in a literature review, to understand how the environment (direct or indirect) affects the mental health of the elderly.

One of the today’s challenges in built and natural environment is supporting mental health for older users. The aging process brings about changes in elderly person´s physiological and psychological capacities, as well as predisposing them to depression, [9,10] that One of the important causes of depression is a decrease in the daily activities of the elderly. Thus, due to their loss of or reduction in autonomy, the built and natural environment gains more significance. Research demonstrates that mental health is closely related to physical and social health [10,11] all of which are influenced by environmental factors (Figure 1).

Figure

Figure 1. The relationship between environment and health.

According to the American Psychiatric Association, emotions and cognitions (e.g. depressive thoughts) are related to mental health [11,12]. The environment can play an effective and direct role on mental health through emotions and cognitions and can play an indirect role through physical and social health. In research on the elderly, social health is determined through social relationships [12,13] and physical health is determined through physical activity and independence [6,14]

The built and natural environment related to elderly’s mental health can be examined according to two categories: architecture and urban. In this article, the architecture and urban literature in the fields of natural and built environment was analysed. The built architectural environment was then categorized into "personal home" and "nursing home" (Figure 2).

Figure

Figure 2. Analysis strategy, Direct and indirect factors affecting mental health.

Built environment and mental health

Indirect impact on mental health through physical health: Rural-urban interface of the Bangalore (two transects) was defined as a common space for interdisciplinary research. The northern transect (N-transect) is a rectangular strip of 5 km width and 50 km length, the lower part of this transect cuts into urban Bangalore, and the upper part contains rural villages. The Southern transect (S-transect) is a polygon covering a total area of 300 km2. Rural-Urban interface was further divided into three sub regions viz., Rural, Transition and Urban areas based on the simplified Survey Stratification Index (SSI) by following the logic of the Urban-Rural Index which considered distance to the city centre (Vidhana Soudha) and percentage of built-up area [4]. This classification of regions, formed basis for selection of 300 middle income households based on purposive random sampling, in the rural-urban interface of Bangalore. In which 479 women and 474 men were assessed for nutritional status. Studies demonstrate that the environment can help the physical health of the elderly and pave the way for physical activity [15,16]. There are several factors in designing an environment that can encourage movement and physical activity [17-19]. Detailed design is effective in aspects of interiors such as lighting, furniture and form [20-22], and in exterior attention to access and support facilities of the building [16,19]. Studies have also been conducted on the built environment factors affecting the mental health of the elderly in nursing homes, including: Research into the factors that promote physical activity [16], interior design factors, attention to materials, facilities and service of the building and support facilities, acoustics, lighting, and indoor air quality [21-24].

In addition to architecture, urban spaces are a subset of built environments. The components of urban design that are most related to mental health have been studied in the categories of “transportation”, “neighbourhood” and “urban landscape”. There is a lot of research on the effect of walking on the physical and mental health of the elderly, which represents the route choice model and the influence of street characteristics on elderly walking for transport [25-27].

Indirect impact on mental health through social health: The importance of social interactions on mental health in residential areas of the elderly has been proven. Studies on the place of residence of the elderly show that older people want have choices about where and how they age in place homes and communities [27]. Jennifer Reichstadt et al. stated in 2007: “Older adults place greater emphasis on psychosocial factors as being key to successful aging, with less emphasis on factors such as longevity, genetics, and absence of disease/ disability, function, and independence.” This study shows that psychosocial factors are more important for the elderly than physical factors [28].

Another important factor is child proximity as shown by the research conducted. For instance, Hongwei, in his studies, states “Overall grandparents who cared for grandchildren had better mental and physical health, compared with non-caregivers. There was some evidence that the ‘sandwich’ grandparents who cared for both grandchildren and great-grandparents reported greater life satisfaction, fewer depressive symptoms, and reduced hypertension compared with non-caregivers” [29]. Also Williams declared: “intergenerational co-residence was found to have some positive health effects for older Chinese adults” [30].

When considering the urban category, residential neighborhood is also one of the most effective aspects of urban design for the mental health of the elderly. Social interactions and sense of community are important factors in supporting mental health [31-36]. Walkable environments and the possibility of physical activity in neighborhoods are other notable factors [37-44]. Feng states in his research that public transportation accessibility instead of auto transportation accessibility, vegetable markets instead of supermarkets and convenience stores, open spaces and parks along with chess and card rooms instead of gyms and sports centers are more decisive in affecting the travel behavior and mental health of the elderly [45]. Lauwers and colleagues also examined how neighborhood environment affects mental health and stated: “a detailed description of physical neighborhood factors (green-blue spaces, services, design and maintenance, traffic, cellphone towers) and social neighborhood factors (neighbor ties, neighbor diversity, social security) are linked to mental well-being”. In addition to the above, a number of studies have examined street characters characteristics for mental health, including the street as a place for social interaction [46].

The direct impact on mental health: The built and natural environment can directly affect mental health and contribute to the mental well-being of the elderly. In fact, the factors that affect perception of environment and emotions can eliminate the symptoms of depression, stress and nervous tension [47]. A review of the literature shows the relationship between interior detail and elderly mental health. Yajing Wang in his article describes how light exposure had little effect on the physiological rhythm of the elderly, but it did affect the visual performance and psychological feelings of the elderly [48]. In nursing homes, architectural factors influence the sense of home in nursing homes [49] and the design of mental and behavioral health facilities [50] play an important role in the mental health of the elderly. Design based on perception is an issue that is important in housing design. Marie Monique Paiva et al. demonstrate that understanding how people 'feel' spaces is fundamental to the person-environment relationship and its effects on mental health.

Natural environment and mental health

In addition to the built environment, the natural environment can also be effective (directly or indirectly) on mental health. Exposure to nature does have positive influences including improvements in physical health [51,52], mental health [51] and cognitive function [53], and social health [54]. Connection to nature is analyzed at three levels: personal home, nursing home and urban.

Studies have shown that the outdoor environment of a personal home for the elderly must consider nature, comfort, accessibility, mobility, and security [54-56]. Urban landscape and proximity to nature have been considered in many studies. According to these studies, neighborhood exposure to blue and green space was significantly associated with elderly individuals' mental health [57-59]. The health effects of viewing landscapes have been studied in the Velarde’s research [60]. In a number of studies, other effects of urban landscape on mental health are expressed, including: Extent of “eyes on the streets” on participant’s street, extent of variety of built form on participant’s street [61] and characteristics of a built-in residential environment that affects the mental health of adults such as walling materials used on buildings and, density of dwelling units [62].

Materials and Methods

Data collection method

A literature search was conducted using Science Direct, Scopus, and PubMed to identify articles with two groups of keywords: one focusing on the “Mental Health of elderly and natural” and the second on “Mental health of elderly and built environment”

The results of the search were 6180 articles from Science Direct, 134 articles from Scopus, and 8715 articles from PubMed. The target period was 2000 to 2020; articles which were not directly or indirectly in the field of built and nature environments and the mental health of the elderly or were not in the desired time period were deleted. Finally, 100 articles remained and were used for review and meta-synthesis. Finally, results and percentages are obtained by averaging (Figures 3 and 4).

Figure

Figure 3. Classification of the environment and how it affects mental health.

Figure

Figure 4. Keyword search results in databases.

Method of Data Analysis

Qualitative analysis was carried out using, the meta-synthesis method. The aim of meta-synthesis is interpretive rather than deductive. The qualitative meta-synthesis method seeks to understand and explain phenomena [63]. Search results were categorized in two areas of architecture and urban spaces. The natural and built environment can affect mental health directly (cognition and emotion) (10] or indirectly (through social and physical health).

According to Theng’s research, social relationships are one of the most important factors that affect social health [64]. Social relationships free a person from isolation and subsequent depression by creating a sense of belonging to society and a sense of social identity. According to the WHO reports; Social health supports to mental health. As a result, all the factors of the natural and built environment that cause social relationships of the elderly contribute to the social health and thus have indirect effect on mental health. Also, interacting with others and accepting a role in society can help reduce depression by creating a sense of usefulness and worth, and thus have a direct effect on mental health [30,65] (Figure 4).

Many studies demonstrate that physical activity is one of the most important factors affecting physical health [15,66,67]. According to the WHO reports, physical health is very effective for mental health. As a result, any concept in the environment that helps promote physical activity and physical health can indirectly affect mental health. Also research has shown that independence in movement and physical activity is one of the factors that in addition to supporting physical health due to creating a sense of independence thus have a directly effect on mental health [14].

According to the above, design details in spaces related to the elderly, whether in private homes, care centres or urban spaces, which contribute to the physical activity and independent movement of the elderly, provide the basis for physical health and indirectly support mental health (Figure 2). In the following, we will review the studies conducted in these three areas of health and extract concepts from them.

Results

Figure 3 shows the numbers of publications identified, screened, assessed for eligibility and included. In total, 15029 articles were identified through database searching and checking reference lists. After removing duplicates and reviewing titles, 927 publications remained in the sample. Finally, by studying the abstracts and removing the unrelated items, 100 articles remained which formed the basis for the meta-synthesis review study. (Table provided in Supplementary file 1).

The selected research was classified into two general categories of architecture and urban that architectural articles were divided into two sections: “personal home” and “nursing home”.

In this study, the constructs were expressed in five categories which are known to a specific effect mechanism on mental health with direct and indirect effects. The following tables describe the mechanism of each construct and its effects on mental health.

Discussion

As described above, articles collected from 2000 to 2020 in the field of architecture and urban were divided into two categories of built and natural environment. The results of extracting concepts show the direct and indirect effects of natural and built environmental factors on mental health.

From a total of 100 articles reviewed, 144 factors were extracted, of which 30 factors covered two or three areas of health and factors related to mental health as follows: in the field of architecture and the subdivision of personal homes, 25 direct factors, 15 indirect factors (through physical health) and 15 indirect factors (through social health) and 2 natural factors with common effects on mental health were found. In nursing homes, 7 direct factors, 18 indirect factors (through physical health) and 5 indirect factors (through social health) and 8 natural factors with common effects on mental health were found. In the field of urban, 6 direct factors, 11 indirect factors through physical health and 26 indirect factors through social health and 8 natural factors with common effects on mental health were found (Figures 5 and 6).

Figure

Figure 5. Method of data analysis.

Figure

Figure 6. Abundance of concepts in the categories of architecture and urban space.

Findings from previous research express the concepts that are created in the built and natural environment related to the elderly on their mental health. In this review, based on the concepts and factors extracted from the articles, two types of comparisons were made.

• Comparison between concepts and extracting the most effective concept supporting the mental health of the elderly.

• Comparing concepts in the environment related to the elderly and finding out how different types of environments affect mental health.

A review of articles conducted in the field of architecture and on the scale of the personal home of the elderly shows that environmental factors directly affect the mental health of the elderly. Factors such as built form, indoor space layout (private balcony, toilet, kitchen, and living room), external building characteristics, internal building environment, walling materials used on buildings, the quality of walling materials, light etc. (Table 1) These can directly lead to mental health improvements by reducing stress, anxiety and improving depression. In fact, the results suggest that in the personal homes of the elderly, the direct effects of environmental factors on mental health outweigh the indirect effects, as expressed by Wang in an article on the “Effect of light on health” whereby the short duration (i.e. 20 min) of light exposure had little effect on the physiological rhythm of the elderly, but it did affect the visual performance and psychological feelings of the elderly [20]. This may also be due to the emotional attachment to home and the sense of belonging to the place and neighbourhood mentioned in the article by Wiles et al [68]. Previous studies have shown that building factors are associated with mental health [69] and built environmental factors in homes directly affect mental health [27,47] (Figure 7).

Construct Mechanism Result Direct Indirect Reference
Detail · Improving physical ability 1.  light effect (1) * * 1. Wang et al (2020)
2.  interior furniture (3,6)      
3. lifts and water supply (3) * * 2. Leung et al (2020)
4. Areas available for walks (6)   * 3. Leung et al (2020)
5. locking the premises limit the ability (6)   * 4,5,6,7. Mahrs Träff et al (2020)
6. corridors (6)   * 8. Li & Zhou (2020)
7. dining room (6)   * 9. Shikder et al(2012); Leung et al (2020)
8. design of interior components of housing (7)   * 10. Mahrs Träff et al (2020); Rodiek & Schwarz (2006)
9. lighting design (10)(3)   * 11. Jeste et al (2016)
10. increased contact and activity levels with the outdoors (30,6)   *  
11. safe outdoor (31)      
· Independent movement 1. smart homes(5) * * 1. Engineer et al (2018)
2. convenient transportation (31) * * 2. Jeste et al (2016)
3. building services and supporting facilities (4) * * 3. Leung et al (2017)
4. built form (9) * * 4. Qiu et al (2020)
Social interaction · social identity 1. housing location (8)   * 1,2,3. Friesinger et al (2019)
2. neighbourhood quality (8)   * 4. De Belvis, et al (2008); Routasalo et al (2006)
3. privacy and social identity (8)   * 5. Laditka et al (2009)
4. friends (18)(25)   *  
5. socially involved (24)   *  
Sense of community 1. age in place (12)   * 1. Wiles et al(2012)
2. intergenerational relationships (16)   * 2. Shin (2014)
3. intergenerational co-residence (17)   * 3. Williams et al (2017)
4. attachment to home (20)     4,5. Wiles et al (2009)
5. neighborhood (20)   * 6. Shin (2018)
6. multi-family housing (23)   *  
· A sense of worth 1. family social support (19) * * 1. Li et al(2019)
2. social contacts (21)(22) * * 2. Holmén & Furukawa (2002); Brown et al (2009)
·A sense of usefulness 1. proximity to grandparents and grandchildren (14) * * 1. Xu (2019)
2. the role played by grandparents (15)     2. Desiningrum (2018)
3. child proximity (17) * * 3. Williams et al (2017)
cognition Improve cognition ability 1.  built form (9) *   1. Qiu et al (2020)
2. attachment to home (20) *   2,3. Wiles et al (2009)
3. attachment to neighborhood (20) *   4,5.  Mercader-Moyano et al (2020)
4. perceived quality in pathways and routes (27)      
5. perceptions related to visual aesthetics (27) *    
Emotion Improve depression 1. indoor space layout (Private balcony, toilet, kitchen, and living room) can reduce depression (7) *   1,2,3,4. Li & Zhou (2020)
2. external building characteristics (7)     5,6. Liang (2020)
3. household facilities (7)      
4. internal building environment (7) *    
5. number of floors (13) *    
6. high-quality houses (13) *    
Reduce stress 1. light effect (1) *   1.Wang et al (2020)
2. built form (9) *   2. Qiu et al (2020)
3. walling materials used on buildings (29) *   3-10. Ochodo et al (2014)
4. density of dwelling units (29) *    
5. state of street lighting (29) *    
6. types of doors (29) *    
7. states of roofs (29) *    
8.  states of windows (29) *    
9. the quality of walling materials (95)      
10. density of dwelling units (95) *    
Connection to nature ·Encourage movement 1.  greenspace exposure89(28)   * 1. De Keijzer et al (2020)
· Reduce  stress 1.  Interact with nature64(32) *   1. Orr et al (2016)

Table 1. Constructs related to the elderly’s home shown to influence mental health outcomes.

Figure

Figure 7. Direct and indirect impact on mental health in built environment.

This study found that supporting mental health through social and physical health in the personal home is of secondary importance. In personal home, it is possible to interact with friends, neighbours and family, which plays a very effective role in creating a sense of social identity. Paul et al. stated that “a community is a social unit of any size that shares common values, or that is situated in a given geographical area (e.g. a village or town)”. It is a group of people who are connected by durable relations that extend beyond immediate genealogical ties, and who mutually define that relationship as important to their social identity and practice [70]. Family support and interaction with the family can reduce depression [71] and create a sense of worth, and the role of grand parenting, proximity of grandparents and grandchildren [30] and caring for children and grandparents can create a sense of usefulness and thus support mental health [72].

In addition, older people want choices about where and how they age in place. “Aging in place” was seen as an advantage in terms of a sense of attachment or connection and feelings of security and familiarity in relation to both homes and communities. Aging in place related to a sense of identity both through independence and autonomy and through caring relationships and roles in the places people live [27]. Connection with nature in personal homes affects mental health both directly and indirectly (Figure 8). Nature encourages the elderly to move and be active by creating a sense of vitality. Also, interacting with nature also helps reduce stress, thus affecting both types of effect (direct and indirect) at the same time [55]. Areas available for walks, corridors, design of interior components of housing, lighting design and the outdoors increase contact and activity levels and this contributes to physical health.

Figure

Figure 8. Direct and indirect impact on mental health in natural environment.

One of the mechanisms that can create both types of impact at the same time is independence. Paying attention to design details that allow older people to move independently can improve depression by creating a sense of independence, and by encouraging older people to move contribute to their physical health. Smart Homes, convenient transportation, building services and supporting facilities, and built form can help create a sense of independence [18,73-75].

Unlike a private home, in nursing homes, environmental factors primarily support mental health indirectly through physical health. Factors such as space management, interior design factors, facilitate way finding, well-designed outdoor spaces and physical activity facilities encourage the elderly to move and be active. Also, acoustics, air quality, the indoor thermal climate, optimization of light and temperature adapts the space of the nursing home to the physical condition of the elderly and supports mental health by helping physical health. A review of research on nursing homes shows that environmental factors that can directly affect mental health are of secondary importance. One of the most important factors is having a private bedroom and personalization of the environment by the elderly and architectural factors that help reduce depression and isolation of the elderly by creating a sense of home [49,76,77]. Wang’s research suggests that reminiscence can help relieve depression [78]. On the other hand, the furniture used in care centres and the way they are arranged can create an intimate environment and provide a basis for reminiscence, and thus directly affect the mental health of the elderly. In addition to the entire above, positive technology, facilities and global design can help create a sense of independence and help improve depression and physical health of elderly (Figure 7).

In care centres, contact with nature has both direct and indirect effects. The results show that horticultural therapy improves physical function and reduces stress, and also supports social health due to social interaction with other elderly people [79]. Green spaces, gardens and lakes also play a supporting role in reducing stress (Figure 8).

In urban spaces (neighbourhoods and transportation routes), social health is the most effective component supporting mental health. Open spaces and parks along with chess, a walkable environment characterized by a high population density and proximate local, public transportation, mixed land use, eyes on the streets etc. (Tables 2 and 3) are factors that contribute to social health by creating the conditions for social interaction and thus support mental health. In urban spaces, there are also factors that contribute to social health by creating a sense of belonging to society, such as public transport, residential environment of neighbourhood, proximity to a wet market, aesthetics and natural space [31,38,80-85]. Having a social realm can also contribute to social health. A view from home to neighbourhood, neighbourhood security, neighbourhood services, public open space, etc. can help create a social realm [33,34,86-90]. The importance of social health has been proven in previous studies. Reichstadt et al. stated that older adults place greater emphasis on psychosocial factors as being key to successful aging [28,91-95] (Figure 7).

Construct Mechanism Result Direct indirect reference
Detail Improving physical ability 1.  facilitate way finding (36)   * 1. Ludden et al (2019)
2.  areas available for walks (6)   * 2,3,4,5. Mahrs Träff (2020)
3.  locking the premises limit the ability (6)   * 6. Anme et al (2013)
4.  corridors (6)   * 7. Leung et al (2020)
5.  dining room (6)   * 8,9. Leung et al (2019)
6.  wood (41)   * 10,11,12,13. Roelofsen (2014)
7.  interior design factors (43)   * 14. Zadeh et al (2018)
8.  space management (38)   * 15. Othman & Fadzil (2015)
9.  building services and supporting facilities (38)   *  
10. acoustics (40)   *  
11. light (40)      
12. air quality (40)   *  
13. the indoor thermal climate (40)      
14. optimization of light and temperature (45)      
15. well-designed outdoor spaces (53)      
Independent movement 1. positive technology (33) * * 1. Grossi et al (2020)
2. facilities (35) * * 2. Anthony & McCaffrey (2018)
3. universal design (46) * * 3. Mustaquim MM. (2015)
Social interaction social identity -      
Sense of community (social engagement) 1. environmental design (36) * * 1. Ludden et al (2019)
2. wood (41) *   2. Anme et al (2013)
social realm 1. Courtyards (44)   * 1. Mohammad et al (2016)
2. choices of bedrooms (44)(47)   * 2. Mohammad et al (2016); Paiva et al (2015)
3. furniture (3)   * 3. Leung et al (2020)
Cognition Improve cognition ability 1- feel of environment (47)     1. Paiva et al (2015)
Emotion Improve depression 1. reminiscence (2) *   1. Wang et al (2005)
2. furniture (3)     2. Leung et al (2020)
Reduce stress 1. architectural factors (34) *   1. Eijkelenboom et al (2017)
the sense of home 2. bedroom privacy (39) *   2. Tao et al (2018)
3. privacy personalization (45) *   3. Zadeh et al (2018)
4.  comfort98(47) *   4. Paiva et al (2015)
Connection to nature Physical
(improved physical ability)
1.  horticultural therapy (48)   * 1. Chan et al (2017)
Mental
(Reduce stress)
1. horticultural therapy (49) *   1. Han et al (2018)
2. Greenspace interventions (50) *   2. Masterton et al (2020)
3. Exposure to greenery and use of greenspace (51) *   3. Carver et al (2020)
4. Parks (96) *   4,5,6,7. Finlay et al (2015)
5. Gardens (96) *    
6. street greenery (96) *    
7.  lakes (96)      

Table 2. Constructs related to the elderly’s nursing home shown to influence mental health outcomes.

Construct Mechanism Result Direct indirect reference
Transport Improving physical ability 1. street characteristics (54)   * 1. Hatamzadeh & Hoseinzadeh (2020)
2. walking for transport (55)(56)   * 2. Borst et al (2009); Cheng et al (2020)
3. land use (57)   * 3. Frank et al (2019)
4. walkable environment (65)(72)(77)(80)(83)   * 4.Koohsari  et al (2019); Loo et al (2017)a; Chaudhury et al (2016); Bird et al (2018); Balfour & Kaplan (2002)
5. accessibility (78)     5.Gao et al (2016)
Independent movement 1. pedestrian networks (58) * * 1.Gaglione et al (2020)
2. accessible homes (61) * * 2.Oswald et al (2002)
3. short distance access to vehicles (86) * * 3.Fernández-Niño et al (2019)
4. commerce and mixed land use (71) * * 4.Danielewicz et al (2018)
5. a road network buffer had (82)     5.Melis et al (2015)
6. Predominant setback of buildings from street (97) * * 6.Burton et al (2011)
Residential neighborhood Social interaction 1. open spaces and parks along with chess instead of gyms and sports centers (66)   * 1.Feng (2017)
2. feeling safe from traffic (68)     2,3,4.Gómez et al (2010)
3. areas with middle park area (68)   * 5.Levasseur et al (2015)
4. quality of the sidewalks (68)   * 6.Koohsari et al (2019)
5. social participation (81)     7. Feng (2017)
6. walkable environment characterized by a high population density and proximate local (65)     8,9. Danielewicz et al (2018)
7. public transportation  (66)   * 10.Lauwers et al (2020)
8. commerce land (71)     11. Loo et al (2017)b
9. mixed land use (71)   * 12.Chen & Yuan (2020)
10. social security (84)   * 13. Burton et al(2011)
11. walkable environment (88)   *  
12. exposure to the especially blue space (90)   *  
13. eyes on the streets (97)   *  
Sense of community(social engagement) 1. land use (57)   * 1. Frank et al (2019)
2. public transport (59)   * 2. Melis et al (2015)
3. residential environment of neighborhood (62)(67)(71)(72)(73)(77)(83)   * 3. Zhang & Zhang (2017); Mohammad & Abbas(2012); Danielewicz et al (2018); Loo et al (2017)b; Walker & Hiller(2007); Chaudhury et al (2016); Balfour & Kaplan(2002)
4. walkable environments (69)(70)     4. Marquet & Miralles-Guasch (2015); Distefano et al (2020)
5. proximity to a wet market (85)     5. Lane et al (2020)
6. aesthetics (87)   * 6. Zhao & Chung (2017)
7. natural space (92)   * 7. Rugel et al (2019)
social realm 1. observed from the home (74)   * 1. Lager et al (2015)
2. neighborhood security (75)     2,3,4. Cramm et al (2013)
3. neighborhood services (75)   * 5. Francis et al (2013)
4. neighborhood social capital (75)   * 6. Qiu et al (2019)
5. public open space (79)   *  
6. Safety (82)      
cognition Improve cognition ability 1. different urban environments (60) *   1. Tilley et al (2017)
2. subjective indicators (64) *   2. Dujardin et al (2014)
3. safety (78)(99) *   3. Gao et al (2016); Wang et al (2019)
4. variety of built form (98) *   4. Nishigaki et al (2020)
Emotion Improve depression 1. independence (63) *   1. El-Gilany et al (2018)
Reduce stress 2. building configurations (91) *   2. Zhifeng & Yin (2020)
Connection to nature (physical) Physical • improved physical ability 1. urban green and blue spaces (89)   * 1. El-Gilany et al (2018)
2.  street environment (94)   * 2. Kabisch et al (2020)
Mental

• Reduced stress
• Stimulation of the senses
1. urban green and blue spaces (84)(89) * * 1. Lauwers et al (2020); Kabisch et al (2017)
2. exposure to the especially blue space (90) *   2. Chen & Yuan (2020)
3. viewing landscape (93) *   3. Velarde et al (2007)
4. tree density (98) *   4,5. Nishigaki et al (2020)
5. rural areas (98)     6. Liu et al (2020)
6. water space (100)      

Table 3. Constructs related to urban shown to influence mental health outcomes.

Considering the urban category, the impact of environmental factors on physical health is of secondary importance. Street characteristics, a walkable environment and accessibility are among the items that contribute to physical health and indirectly to mental health by providing physical activity conditions. Also, pedestrian networks, accessible homes, short distance access to vehicles, a road network buffer and predominant setback of buildings from street are cases that support physical, social, and mental health by helping the elderly to move independently [96-101]. Urban green and blue spaces, viewing landscape, tree density and rural areas have a direct impact on mental health (Figure 8) [102-109].

Examining the frequency of concepts in all environments related to the elderly also indicates that, in general, the greatest effects of environment on mental health are indirectly through the provision of social interactions (Figures 9 and 10) [110-117].

Figure

Figure 9. Frequency of concepts from 2000 to 2020.

Figure

Figure 10. Conceptual model, Relationship between health categories and environment (thickness and type of lines indicate the degree of connection).

Conclusion

In this review study, the results obtained using the metasyntheses method show the direct and indirect effects of natural and built environment on the elderly’s mental health. Twenty-two percent of the concepts extracted from the articles overlap in support of mental health, physical health and social health. In general, in summarizing the existing concepts and by using averaging, it was found that social interactions have the greatest effect on the mental health of the elderly, but the analysis shows a significant difference in how different environments affect the elderly’s mental health. In the personal homes, the greatest effect on mental health is achieved directly with the impact on the cognition and emotions of the elderly, while in the nursing home, the effect on mental health is indirect and through physical health and in urban spaces indirectly and through social health. In other words, it can be inferred that in any environment, direct and indirect effects on mental health are caused by the components of that environment. In urban spaces, due to the abundance of environmental factors that enable social interaction, positive mental health is created indirectly through social health. In care centres, due to the abundance of factors that affect physical ability, positive mental health is indirectly created through physical health. In private homes, the environment directly affects mental health due to the many factors that stimulate the emotions and cognition of older people. As a result, by further study of the factors and components of the environment, the type of effects on the mental health of the elderly can be changed. Furthermore, some aspects of the built and natural environment have been very little studied to date, but the absence of evidence does not mean that there are no effects, simply that they have not yet been studied or studied meaningfully. It is evident there is a need for research into the components of the environment and its effects on mental health. Applying an interdisciplinary team approach with social scientists, engineers, architects and building scientists will aid in generating research that improves understanding in the field.

Acknowledgement

We acknowledge the financial support received from Department of Biotechnology, GOI for the project “Urbanization effects on consumption pattern, dietary diversification and human nutritional status in Bangalore” (I-C04) as part of the Indo-German collaborative research project FOR-2432.

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