5.3: Promoting Wellbeing by Focusing on the Environment

We have previously discussed the impact of nature on general health and wellbeing, drawing upon the biophilia hypothesis as a theoretical background \cite{wilson1990}. Whilst these benefits are useful for the general population, a greater focus needs to be placed on contact with nature for those with chronic conditions as they face health issues on a daily basis, and have additional barriers in their life which may prevent them from easily accessing opportunities such as green spaces, accessibility issues being one example \citep{Meek_2018}. The link between nature and disease prevalence is outstanding, with a systematic review with study populations ranging from the thousands to the millions \citep{Gascon_2016} finding a negative correlation between cardiovascular disease mortality and residential greenness, the pathways through which this relationship occurs can be explained by \citet*{Kuo_2015}. Other research highlights the positive impact of natural environments on brain activity, the cardiovascular system, endocrine system, immune function and mental health outcomes \citep{Haluza2014,Bratman_2019}, along with increasing social capital for individuals \citep{Braubach_2017}, the benefits of which have been previously highlighted. The benefits of contact with nature has been found to be independent of cultural and climatic contexts \citep{van_den_Berg_2016}.
Introducing green spaces into communities and care homes is one route through which those with chronic illness and/or disabilities can easily access nature when living in an urban environment. Research on 126 care facilities across 17 European cities found green spaces within the facility grounds had a significant impact on the quality of life for the residents, with increased physical activity, recreation and social engagement, benefits were also reported among staff and visitors \citep{Artmann_2017}
Traditionally, care homes were designed for the safety of residents, neglecting what potentially improve their health and wellbeing, but this is beginning to change \citep{Ausserhofer_2016}. Simple additions, such as indoor plants, have reportedly reduced stress for patients in hospital \citep*{Dijkstra2008}.
In order to fully assess the impact of nature, \citet{Shanahan_2015} have propose using dose-response modelling when providing nature-based interventions to identify a cost-effective level of urban nature. They argue that manipulating the type and amount of nature exposure will subsequently impact differently on health outcomes. By applying this method in future research, it will allow researchers to better identify what types of nature-based interventions are effective and at what dose. With sufficient research, recommendations can then be made for future generations to utilise nature, and particularly green spaces for urban environments, to build health and wellbeing among all populations. The introduction of green spaces should be a focal point for urban areas, which will moderate the climate change impact, help prevent disease over a life course model, improve health and wellbeing and subsequently lessen the burden on the health care services. Feasibility research has been carried out to investigate the impact of urban green spaces on health \citep*{Pearce2016} and further development in this area may provide substantial health-related data associated with green spaces across a life course model.
Conclusions - chronic condition and mental health section 
Chronic conditions need to be managed and we have outlined several ways in which the impact of such conditions may be ameliorated. Barriers - health care systems are typically fragmented with disease specific focus. Typically, there are major division and lack of communication between mental health and physical health services (reference). This leads to a bias in non-pharmacological treatments, for example, people with physical health difficulties are typically prescribed physical health treatments. For example, people with CVD disease are typically advised to partake in healthier diets and physical activity. This is a missed opportunity to prescribe psychological therapies and social connectivity - which have also been shown to contribute to, and ameliorate symptoms (reference - optimism study Seligman CDV and others). Conversely, mental health services typically focus on offering psychological therapies whereas much research has shown that people with mental health conditions typical have poor diets (reference), sleep (reference), lower levels of physical activity (reference) and are more social isolated (reference). Moreover, interventions that target these health behaviours significantly ameliorate symptoms (reference). 
In addition, health professions are typically specialist in 'their area'. Although, specialisms can add value to the treatment of conditions the limitation of this approach is that complex interactions between factors contributing to disease is often poorly understood and treated. For example, emerging evidence shows that sleep disorders such as insomnia may exacerbate chronic conditions for example, asthma. However, sleep problems are not generally considered by clinicians in the management of chronic inflammatory conditions such as asthma \citep{Ranjbaran_2007}. Moreover, even if sleep problems are identified and recognised as an important contributor to the course of asthma symptoms, specialists in this area would not be skilled in treating sleep disorders and the person would need to be referred to another service, if indeed such a service exists. This results in fragmented and disjointed care. Now say something about trans diagnostic trans diagnostic approaches to the management of chronic conditions. conditions.