COST E39 Dutch Country report

Wednesday, 31 August, 2005

1. Introduction

For many Dutch people, nature is a place to relax and recover from the stresses of
day-to-day life. The hectic pace of modern society means that people are turning
more and more to nature for relaxation and recreation. However, in the Netherlands
with its increasing population and urbanised society, nature is no longer an inevitable
component of the immediate living environment. To find nature, we have to travel
greater and greater distances, by car, train or plane. The Dutch nature policy
recognises the increasing demand for ‘nature for people’, particularly in and around
towns and cities. In health-policy circles, there is currently little interest in the possible
benefits of nature in terms of health. However, more and more initiatives are
emerging in the healthcare sector, that indicate a renewed appreciation for nature as
a ‘curative’ phenomenon.

Definitions of ‘nature’ and ‘health’

‘Nature’ is not an easy term to define since it has been interpreted in so many different
ways. In the Netherlands, the human or social factor is, after all, frequently all too
evident in nature: carefully raked gardens, well-maintained parks and a solitary tree in
the market square are perceived by many as nature. We follow the example of Van
den Berg & Van den Berg (see section 3) in adopting the following, broader definition of
‘nature’:
We understand nature to be the environment in which organisms or their biotopes
expressly manifest themselves. In addition to nature reserves, this will also include
farmland, production forest, urban green spaces and back gardens.
Definitions of the term ‘health’ are many and varied. Some simply refer to the absence
of disease. One widely cited definition appears in the preamble to the Constitution of
the World Health Organisation: “Health is a state of complete physical, mental and
social well-being, and not merely the absence of disease or infirmity.” This definition
also embraces aspects of well-being and is said by some to correspond more closely to
happiness than to health. The Health Council of the Netherlands takes as its premise
the idea that health and well-being cannot be viewed in isolation from one another.
Physical, mental and social well-being influence the development and course of
diseases (and vice versa). The question of where health stops and well-being begins
can be circumvented by always stating precisely which symptoms are involved. This
approach also encompasses health promotion. Health promotion is, in part, aimed at
creating conditions conducive to physical, psychological and social development that
will lead to future well-being. For children, this means creating conditions under which
they can develop into healthy adults. For adults, personal growth is important to health
partly in so far as it teaches them to cope better with stressful life events and the fear
of illness, old age and death.

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Policy on ‘Nature and health’

It is remarkable that in the past decades so little has yet been done when framing
nature policy to explore the possible beneficial effect of nature on health. Health policy
too, displayed little kinship with nature. Only recently, policy-makers have been
showing greater interest in the link between nature and health. The Ministry of
Agriculture, Nature and Food Quality (LNV) is putting the conservation and
development of green spaces in and around towns and cities on its policy-making
agenda, not only in the interests of nature conservation but also with people in mind.
In 1999 the Ministry organised a conference on ‘The importance of nature for health
and well-being’. It was concluded that a more conscious effort needs to be made to
integrate nature into preventive health policy, that emphasis must be placed on the
importance of exercise and recreation in natural surroundings, and that a standard
needs to be established for the inclusion of natural areas in spatial planning. It was
also decided to request for a joint advice from the Health Council of the Netherlands
and the Dutch Advisory Council for Research on Spatial Planning, Nature and the
Environment (RMNO) regarding research into the relationship between nature and
health. This advisory report was published in June 2004 (see project list). The accent is
on knowledge acquired from scientific research. A second advisory report is being
produced under the direction of the RMNO. This will take a closer look at the issues from
a social and a policy perspective (linking with health policy priorities), giving due
consideration to research planning and knowledge infrastructure.

National health policy priorities: living longer in good health

Recently, with the publication of the report “Public Health Future Exploration 2002”
(VTV 2002), the National Institute for Public Health and the Environment (RIVM)
presented a probing picture of the health situation in the Netherlands. Although
people in the Netherlands are increasingly living longer, healthier lives, unhealthy
lifestyles in the Netherlands have pushed the nation towards the middle bracket in
Europe. The life expectancy of people in other European Union countries is currently
increasing faster than the life expectancy of the Dutch population. Since the early
1990s, the average life expectancy of women in the Netherlands is even lower than
that of the European Union (EU). Unhealthy lifestyles among young people are
rampant, which is not encouraging for the future. Even more worrying is that poor
health, illness and premature death are more prevalent in some population groups
than in others. Particularly people with limited education and low incomes are less
healthy, including many immigrants. Several observations about the unhealthy
lifestyles of the Dutch population are:
• One out of three smokes tobacco
• Nine out of then people eat too much saturated fat
• Three-quarters of the population eat too few fruit and vegetables
• More than half the population gets too little exercise
• Half of the male population and a third of the female population are too heavy
• The incidence of sexually transmissible disorders (STDs) is rising, along with the
incidence of abortions among teenagers

Unhealthy lifestyles have serious consequences. Among other things, they lead to
increased cardiovascular diseases, cancer, asthma and other pulmonary diseases,

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diabetes and symptoms of the motor system. That represents a major loss of quality
of life. Moreover, these diseases and symptoms cost society between 2.5 and
4 billion Euro. In the first instance, if these costs are to go down, it is the responsibility
of individuals: it is primarily a question of healthy lifestyles.

The benefits of healthy lifestyles

Prevention is better than cure. That certainly applies to health. The RIVM has
calculated that 15 percent of disabling illnesses (the aggregate of shorter and poorer
quality life through illness) is attributable to smoking, 7 percent to excessive use of
alcohol and 6 percent to obesity. The cabinet estimates that at least 20 percent of all
disabling illnesses are attributable to unhealthy lifestyles. The RIVM has also
calculated that between 5 and 9 percent of total expenses for health care are the
result of unhealthy lifestyles, obesity and high blood pressure.
For these reasons, the government – national and local authorities – have invested in
prevention for years. Current vaccination programmes against infectious diseases
are good examples of preventive measures that reduce (high) health-care costs in
the longer term. In 2004, the ministry of Health, Welfare and Sport (VWS) plans to
invest some 625 million Euro in prevention policy via the Special Medical Expenses
Act (AWBZ), particularly in national prevention programmes, youth health care, public
health information, health protection and research. In recent years, the cabinet has
strengthened youth health care, for example, and introduced a vaccination against
meningitis C, including a campaign to help young people in arrears to catch up.
However, the government is not the only source of prevention investment. Health
insurers, social organisations (e.g. in sport), social partners and businesses
increasingly do so, since they also realise that action is necessary.

Health benefits start by adopting different attitudes in a changing society, in which

inactivity stemming from technological developments, organisation of work, leisure
time and transport patterns increasingly threatens to become the norm. Prevention
policy will only succeed if we hold citizens directly accountable for their behaviours.
Health standards deserve greater attention. The changing attitudes towards smoking
are a good example of this. Most people are now convinced that non-smoking should
be the social norm at work and in public places. Similarly, healthy lifestyles should a
gain become the norm for everyone – except, perhaps, for people with disabilities or
chronic illnesses.

Practical aims in three action plans

The cabinet's policy document treats a large number of subjects in the field of
prevention that require action. This will also receive attention in the coming years.
They encompass three themes as spearheads. These themes stand out best in a
negative sense and are the ones that require the most attention.
These themes are:
• Smoking
• Obesity
• Diabetes
These spearheads concern the major risk factors of poor health, illness and
premature death. There will be an action plan with a practical goal for each
spearhead. For example, the number of smokers should decline by nearly a fifth; the
number of persons who are overweight should not increase; and diabetes among
young people must be reduced. Elaboration of the action plans will include advice

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from the Public Health Council (2001), from Health and Lifestyle (2003) and from the
'Obesity' Health Council (2003). Working with a package whose effectiveness has
generally been demonstrated, smoking policy is now firmly embedded. The aim is to
continue this policy forcefully during the coming years. In addition, there will be
priority measures to deal with obesity and diabetes, which are closely related. These
are relatively 'new' problems that require strong measures to counteract rising trends.
The approach to these spearheads will entail knowledge and insights from other
aspects of prevention policy. We concur with the actions started to make healthy
eating easier and to get people to exercise more, as presented in the cabinet's policy
document, 'Sport, Exercise and Health'. Besides the three spearheads, this
prevention policy document also focuses considerable attention on psychological
symptoms and alcohol addiction.

The action plans cannot be implemented without the co-operation of people in the
field. Of course, these parties also have a responsibility for taking action. The cabinet
would like to invite these parties in the Netherlands to co-operate actively in
implementing the action plans and to develop individual initiatives. Although people
are primarily responsible for their healthy (and unhealthy) lifestyles, people's health
does not always depend on their own actions. For example, municipalities,
companies, manufacturers, schools, health-care services and health insurers also
bear responsibility. The relevant parties, including the public at large, must bear their
share of the responsibility.

The public must again be more closely involved in prevention policy. Public health is
the sum total of the health of individual members of society. The cabinet has
therefore decided on an approach that will effectively reach people in practice – at
home, at school, at work, at places where people spend their leisure time, in local
neighbourhoods and in the doctor's consultation room. It is only in this way, for
example, that one can trace and deal with local health arrears or reach specific target
groups (youth, immigrants).
For the most part, these actions are possible by making better use of existing funds,
by linking them to the main problem areas and by better practical utilisation of
existing opportunities. To do this, the cabinet is deliberately seeking co-operation
with other parties. Additionally, in 2004, the cabinet has set aside an extra 5 million
Euro and, from 2005, a structural amount of 10 million Euro. These moneys will
primarily go towards implementing the spearheads, mainly for public information
activities and projects, and for activities in the large cities (due to the huge health
arrears there).
Starting in January 2006, an amount of 5 million Euro will go to help cover the 10-
million Euro cut in the national sport federation's budget. The federation will use half
of this re-investment to stimulate amateur sports, of which the Neighbourhood,
Education and Sport”-initiative (BOS) is the spearhead. The other half will go towards
activities designed to promote physical exercise. These activities will dovetail with the
spearheads from prevention policy, with particular emphasis on youth and poorly
educated workers with low incomes. The cabinet assumes that other parties will also
take responsibility for and continue to invest in prevention policies.

Effective research and targeted subsidies

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Investment in health care pays off, but it is expensive. The Dutch economy is
stagnating. We face choices, also in the area of prevention. We can only make these
choices if we clearly understand the nature and scale of heath-care risks, the options
for dealing with them, the cost and benefits of reducing risks or of measures to
improve health and, equally important, matters that the public itself considers
important . Continuing research and transfers of knowledge are essential. Our new
subsidy policy places emphasis on three aims: (1) maintaining and sharing
fundamental knowledge, (2) (temporary) stimulation of innovation and (3)
strengthening the position of vulnerable groups. Research in the field of health
should focus in the coming years on major problems, but also on the opportunities
that prevention offers for health. Much more than is the case at present, research
and transfer of knowledge are going to bolster (local) practices. Local partners should
be able to take immediate advantage of the knowledge acquired. Simultaneously,
this increases the effectiveness of the knowledge infrastructure.

Prevention, a Matter of Patience

Health is a valuable possession. Healthy people feel better, are seldom ill, work more
and longer. In short, they are more active. Improved health, reduction of disabling
illnesses, and premature death benefit the public as well as society. However, health
benefits through prevention are also a matter of patience. Naturally, the effects of this
policy are closely monitored. The cabinet would like to elevate healthy lifestyles –
naturally, within the limits of individual citizens – to the status of a social norm and,
together with those who share this responsibility, make good health a permanent
feature of the Dutch landscape.

Initiatives in healthcare practice

Besides the attention paid to the nature-health relationship in policy making, there have
also been bottom-up activities, i.e. activities that have their origin in the health sector.
For many decades there have been numerous therapies and care activities in which
nature plays an important role, such as gardening or looking after animals. In the
Netherlands, therapies and activities of this kind play a particularly important role in
treatment and day-care programmes offered to psychiatric patients. Also care homes
are increasingly developing initiatives that offer ‘green’ activities to their residents. Well-
known examples of the use of nature (and also of animals) in a therapeutic context are
garden therapies, healing gardens, and so-called ‘animal-assisted therapies’.
Two organisations in the Netherlands are actively engaged in this area. The Stichting
Natuurlijk Genieten (SNG, www.stichtingnatuurlijkgenieten.nl) encourages the use of
garden therapy in order to promote well-being in the elderly, while Bartiméus
Education, which runs its own school for visually handicapped children, helps people
with disabilities to reintegrate into the community. 1

A further important development is the emergence of ‘care farms’ – agricultural

holdings where vulnerable people can go for day care or for a supervised workplace in
a natural environment. Between 1998 and 2002, the number of care farms in the
Netherlands rose from 75 to around 320. Whereas these facilities initially mainly

1
Schuman H. Horticultural therapy and Bartiméus Education. Journal of Therapeutic Horticulture
2002;13: 52 – 59.

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catered to people with learning difficulties or psychiatric problems, they have more
recently also been gaining experience with other groups, such as (ex-)addicts, people
with “burnout” and “problem children”(Elings, van Erp and van Hoof, 2005; see project
list).
There are still scarcely any systematic evaluations of the effectiveness of stays at care
farms as far as the achievement of therapeutic goals for specific groups of clients is
concerned. Therapeutic applications are generally not focused on one specific
mechanism (e.g. recovery from stress and attention fatigue) but on a combination of
mechanisms, including promotion of social contact, exercise and sensory stimulation.
This hampers the development of methods for evaluation.

Healing environments in hospitals

Dutch architects designing hospitals and other care facilities are also taking a growing
interest in ‘healing environments’ (Van den Berg, 2005). A prominent example is the
creation of ‘healing gardens’ at hospitals. Hospitals and care facilities are, after all,
stressful environments, not only for patients, but also for visitors and personnel. April
13 – 15 2005 an international conference ‘The Architecture of Hospitals’ was held in
Groningen, organized by the University Medical Centre of Groningen
(www.thearchitectureofhospitals.org). Also, the building committee of the Erasmus
Medical Centre asked for ‘green design’ recommendations (see list of projects).

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2. Research projects

Below an overview of research projects, recently completed as well as in progress, is

given. The projects are (partially) ordered, in the sense that completed projects are
mentioned first. Furthermore, projects are ordered by the working group for which
they seem most relevant. Projects that are deemed relevant for several working
groups are mentioned first.

2.a Completed projects

Title: Nature and health; the influence of nature on social, psychological and physical
wellbeing (http://www.gr.nl/adviezen.php?ID=1019&highlight=nature)
Leading researchers: Fred Woudenberg (GGD Rotterdam), Magdalena van den
Berg (Health Council).
Abstract: This project entailed a critical overview of the research literature on the
relationship between nature and health by a Committee of the Health Council of the
Netherlands. The first topic is the link between nature and health. In this advisory
report three types of impact that nature has on health are identified:
• impact on the development and course of specific physical and mental illnesses;
• impact on physical, mental and social well-being;
• impact on physical, psychological and social development in children and personal
development in adults.
Once a link can be established between nature and health, the next question to be
answered is how that link manifests itself. In other words: in what way does nature
exert a beneficial effect on health? Five mechanisms of action are distinguished:
- recovery from stress and attention fatigue;
- encouragement of exercise;
- facilitation of social contact;
- stimulation of development in children;
- provision of opportunities for personal development and sense of purpose in adults.
The (international) research literature on the link between nature and health, as
well as on each of the five mechanisms, is discussed. The Committee notes that
follow-up research is required in order to provide further support for the indications
from existing theoretical and empirical research into the beneficial effect of nature on
health. Most evidence from empirical research relates to the effect on recovery from
stress and attention fatigue. Much less is known about the other mechanisms
(encouragement to exercise, facilitating social contact and influence on development
of children). In other cases, the evidence is weak, due to the methodological
limitations of the research (influence on personal development and a sense of
purpose). However, existing research already provides consistent clues for assuming
a positive link between nature and health. If further research confirms these results,
this will underline more attention in decision making for green strategies that many
people already perceive as good for health.
Duration: 2002-2004
Budget: ?
Completed/in progress: completed
Publications:

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* Health Council of the Netherlands and Dutch Advisory Council for Research on Spatial Planning,
Nature and the Environment. Nature and Health. The influence of nature on social, psychological and
physical well-being. The Hague: Health Council of the Netherlands and RMNO, 2004; publication no.
2004/09E; RMNO publication nr A02ae.
Relevance: working group 1, 3, 5

Title: The Architecture of Hospitals: Healing environments

Leading researcher: A.E. van den Berg, Alterra/WUR
Abstract: The aim of this project was to provide a systematic overview of scientific
evidence for the health benefits of nature and natural elements as components of
healing environments. Four key features were selected that have been the topic of
extensive research inside and outside clinical settings: nature, daylight, fresh air and
‘quiet’ (or absence of noise). A total number of 97 publications met the criteria of the
review. The outcomes of these studies suggest that there is growing evidence for the
health impacts of healing environments. How this will affect future research and in
what way it will enrich the architecture of hospitals will be among the fundamental
issues that evidence-based design will have to address in the near future.
Duration: 2004-2005
Budget: 25.000 euro
Completed/in progress : completed
Publications:
 Van den Berg, A.E. (2005).Health Impacts of Healing Environments. A review of evidence for
benefits of nature, daylight, fresh air, and quiet in healthcare settings. Groningen: Foundation 200
years University Hospital Groningen. www.thearchitectureofhospitals.org
Relevance : working group 1,3

Title: Epidemiological research on green space and self-reported health

Leading researcher: Sjerp de Vries, Alterra, Wageningen
Abstract: Are people living in more green areas healthier than people living in less
green areas? This hypothesis was empirically tested by combining Dutch data on the
self-reported health of over 10,000 people with land use data on the amount of green
space in their living environment. In the multi-level analysis we controlled for socio-
economic and demographic characteristics, as well as urbanity. Living in a green
environment was positively related to all three available health indicators, even
stronger so than urbanity at the municipal level. Analyses on subgroups showed that
the relationship between green space and one of the health indicators was somewhat
stronger for housewives and the elderly, two groups that are assumed to be more
dependent on, and therefore exposed to the local environment. Furthermore, for all
three health indicators the relationship with green space was somewhat stronger for
lower educated people. Implications for policy-making and spatial planning are
discussed briefly.
Duration: not a formal project
Budget: none (staff time only)
Publications:
 Vries, S. de, Verheij, R.A., Groenewegen, P.P. (2000). Natuur en gezondheid. Een verkennend
onderzoek naar de relatie tussen volksgezondheid en groen in de leefomgeving. Mens en
Maatschappij, 75 (4).
 Vries, S. de (2001). Nature and Health; the importance of green space in the urban living
environment. Proceedings of the symposium “Open space functions under urban pressure”, 19-21
September 2001, Ghent.

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 Vries, S. de, Verheij, R.A., Groenewegen, P.P. & Spreeuwenberg, P. (2003). Natural
environments – healthy environments? An exploratory analysis of the relationship between
greenspace and health. Environment and Planning A, vol. 35, pp. 1717-1731.
Completed/in progress : completed
Relevance : working groups 1 & 5

Title: Green recreation opportunities and urban liveability

Leading researcher: Sjerp de Vries (Alterra)
Abstract: Earlier research has shown that in the Netherlands the amount of local
green space and self-reported health are positively related (De Vries et al. 2003).
However, the mechanism behind this relationship remained unclear. One possible
mechanism is that it is by means of the opportunities for outdoor recreation it offers,
that green space affects human health and well-being positively. Another line of
ongoing research deals with recreation as such. An instrument called AVANAR has
been developed to identify whether and where shortages in recreational opportunities
for walking and cycling exist (De Vries et al. 2004). Both indicators suggest that many
urban neighbourhoods are dealing with severe shortages. However, these indicators
are quite normative in content. For the identified shortages to be taken seriously,
empirical corroboration is highly desirable. It is here that the two lines of research
meet: this corroboration is sought in the negative consequences that an insufficient
supply may have for urban liveability, such as less satisfactory recreational
experiences. Some first (secondary) data analyses suggest that indeed relations
exist between the normatively defined shortages and at least some of the expected
negative consequences of ‘real’ shortages. The results are discussed with regard to
the importance of (the use of) recreational opportunities as a link between local green
space and human well-being.
Duration: 2003 - 2004
Budget: 40.000 Euro
Completed/in progress: completed
Publications:
 De Vries, S., Hoogerwerf, M. & Regt, W. (2004). Analyses ten behoeve van een Groene
Recreatiebalans voor Amsterdam; AVANAR als instrument voor het monitoren van vraag- en
aanbodverhoudingen voor basale openluchtrecreatieve activiteiten. Alterra-rapport 988.
Wageningen, Alterra.
 De Vries, S. & Van Zoest, J. (2004). The impact of recreational shortages on urban liveability.
Proceedings of the international conference on inclusive outdoor environments, “Open Space,
People Space”. 27-29 October 2004, Edinburgh (UK). Edinburgh: Open Space (CD-rom).
Relevance: working groups 1 & 5

Title: Green design recommendations for Erasmus Medical Centre

Leading researcher: A.E. van den Berg, Alterra/WUR
Abstract: The aim of this project was to advise the building committee of the
Erasmus Medical Centre about the added value of investing in a green environment.
Special attention was paid to the translation of scientific research finding in design
recommendations. Recommendations included the application of seven “design
patterns”
1. Promote views of nature inside and outside the hospital
2. Make use of pictures and paintings of nature in spaces in which real nature
constitutes a risk (e.g., operating theatre, neonatal units)

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 3. Create green spaces in and around the hospital that are accessible, legible,
comfortable, and usable.
4. Promote the application of plants and flowers, but reduce the reduce the risks.
5. Use the fascinating power of green, water and animals to divert people’s
attention from ruminations about sickness and death.
6. Use the existential meaning of green to learn people how to accept illness and
death
Duration: 2003/2004
Budget: 10.000 euro
Publications:
 Berg, A.E. van den (2004). Ontwerpnotitie Groen, Nieuwbouw Erasmus Medisch Centrum. Internal
report. Rotterdam: Erasmus Medical Centre.
Completed/in progress: completed
Relevance: working group 1

Title: Environmental preference and restoration

Leading researcher: A.E. van den Berg, Alterra/WUR
Abstract: This experimental research examined whether people’s widely
documented tendency to prefer natural over built environments is mediated by
greater restorative potential of natural environments. Participants were exposed to a
fearful movie, and then were shown a video recording of either natural or built
environments. The results indicated that participants perceived the natural
environments as more beautiful than the built environments. In addition, watching
natural environments elicited more improvements in positive and negative mood
states and marginally better concentration than watching built environments.
Mediational analyses revealed that affective restoration accounted for a substantial
proportion of the preference for natural over built environments. Together, these
results serve to substantiate the adaptive functions of people’s environmental
preferences.
Duration: not a formal project
Budget: none (staff time only)
Completed/in progress: completed
Publications:
 Van den Berg, A.E., Koole, S.L & Van der Wulp, N.Y (2003). Environmental preference and
restoration: (How) are they related? Journal of Environmental Psychology, 23, 135-146.
Relevance: working group 1

Title: Landbouw en groen voor een gezonde samenleving [Agriculture and green
space for a healthy society]
Leading researcher: Jan Hassink, Plant Research International
Abstract: The goal of this programme was to improve the contribution of agriculture
and green space to the social, mental and physical wellbeing of the inhabitants of
(especially) urban areas. When suited to the needs of urban dwellers, agriculture and
green areas are assumed to reduce typical metropolitan problems such as nuisance
caused by drug addicts and troublesome youth, social isolation, stress and burn-out.
The programme tried to stimulate innovations by:
- naming, visualising, quantifying, corroborating, spreading and anchoring the
values of green space and agriculture in and around the city;
- connecting networks and expertises, bringing together professional, scientific, and
experiential knowledge out of specific projects;

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- developing visions on and options for optimal utilisation of green space and
agriculture in and around cities for the society at large
- strengthening the knowledge infrastructure and drawing up a research as well as
a policy agenda with relevant parties, knowledge centres and policymakers
The focus is on supporting innovative green entrepreneurs that want to develop and
professionalize new products (green healthcare services). To realise transitions,
much effort is put into relations with potential clients and customers, with policy
bodies, and with facilitating agencies.
Duration: 2003 - 2004
Budget: 500.000 Euro
Completed/in progress: completed
Publications: in preparation
Relevance: working group 3

Title: How often and how do elderly walk in their neighbourhood? (Hoeveel en hoe
wandelen ouderen in de wijk?)
Leading Researcher: Jeroen Borst (TNO Built Environment and Geosciences)
Abstract: Walking is important for elderly to maintain physical function and health.
Therefore, it is useful to investigate the relation between the environmental
characteristics of neighbourhoods and walking behaviour of elderly. A model for the
number of walks and a model for the route choice of walking elderly was developed,
the latter describing the influence of physical street characteristics on the
attractiveness to walk and the route choice of walking elderly. The route choice of
trips was modeled by applying resistance factors on links in the walking route
network. The model was fitted on empirical data on street characteristics (including
trees, green areas and parks), information on attractiveness of streets and walking
routes of trips made by independently living elderly (age 60 – 80) in the city of
Schiedam (the Netherlands). Trees and parks were found to increase the
attractiveness of walking routes, but did not decrease the resistance of links to
certain destinations.
Duration: 2002-2004
Budget: 150.000 Euro (ZONMw/TNO)
Completed/ in progress: completed
Publications:
 Borst, H.C., Miedema, H.M.E. (2004). Hoeveel en hoe wandelen ouderen in de wijk? Een
model voor het aantal wandelingen en een model voor de routekeuze (How often and how do
elderly walk in their neighbourhood?). TNO Inro report 2004-35.
 Borst, H.C., Miedema, H.M.E., de Vries, S.I. van Dongen, J.E.F. (in preparation). Modelling
route choice of elder pedestrians on the basis of physical street characteristics.
Relevance: working group 5

Title: Walking during lunch time (Lunchwandelen)

Leading researcher: Ingrid Hendriksen, Vincent Hildebrandt (TNO Quality of Life)
Abstract: It was investigated whether walking during lunch time is an attractive way
for organizations and employees to be more physically active. To stimulate walking
during lunch time a promotion campaign was tested in two organizations. Promotion
material was developed, such as posters, route maps and lunch bags. Afterwards,
the effect of the campaign on the behaviour and on the fitness of the employees was
tested. In a previous study, a nationwide survey was done among approximately

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1000 employees and 1000 personnel officers (see report) The purpose of this study
was to investigate the actual practice of physical activity during lunch time in the
Netherlands, and to find out which factors promote or hinder walking during lunch
time. The most frequently mentioned stimulating factors are the presence of a park or
footpaths nearby and a planned walking route. An unattractive environment and no
time are the most important barriers of walking during lunch time.
Duration:
Budget:
Completed/in progress : completed
Publications:
 Hendriksen, I.B.M., Middelkoop, M. van, Bervaes, J.C.A.M. (2003). Wandelen tijdens de lunch
(Walking during lunch time). TNO report R0314106/018-44263. (www.lunchwandelen.nl)
Relevance : working group 5

Title: Physical (in)activity of children living in Dutch urban neighbourhoods and the
association with neighbourhood characteristics; the SPACE study
Leading researcher: Ingrid Bakker (TNO Quality of Life)
Abstract: The objective of the Spatial Planning and Children’s Exercise (SPACE)
study was to investigate the association between neighbourhood characteristics and
children’s physical (in)activity level in order to guide urban planners in remodeling
‘non-activity friendly’ into ‘activity-friendly’ neighbourhoods. It involved 1238 6- to 11-
yr old children recruited from twenty elementary schools in ten Dutch ‘disadvantaged’
neighbourhoods. Physical activity was assessed by activity diaries and ActiGraph
accelerometers. Neighbourhood characteristics were scored using a checklist.
Preliminary results show that the number of days on which the children met the
guideline of 60 minutes of moderate-intensity activity per day significantly increased
with the presence of sport grounds, green facilities, water, car parks, low-rise
buildings, and residential areas with limited access to traffic. Parking places in the
street, intersections, heavy bus and lorry traffic, and the presence of a tram in the
neighbourhood, were negatively associated with the number of days on which
children met the physical activity guideline. In this study, the percentage of children
meeting the 60 minute guideline is considerably lower than what has been found in
national surveys. In addition, compared to national surveys, a much higher
prevalence of overweight and obesity have been found. In future research, the study
should be extended to more ‘activity-friendly’ areas. Furthermore, the measurements
of the SPACE study should be repeated in the ten neighbourhoods after spatial
restructuring of five of them, to investigate its effect on children’s physical (in)activity
levels and the prevalence of overweight and obesity.
Duration: 2004-2005
Budget: 150.000 Euro (Dutch Ministry of Health, Welfare and Sport and the Dutch
Ministry of Housing, Spatial Planning and the Environment)
Completed/in progress: completed
Publications:
 TNO report will become available at:
http://www.tno.nl/kwaliteit_van_leven/preventie_en_zorg/jeugd,_preventie_en_beweg/bewege
n_en_gezondheidd/
Relevance: working group 5

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2.b Ongoing projects

Title: Vitamin G1; Natural environments – healthy environments. Exploring the

mechanisms
Leading researcher: Jolanda Maas (NIVEL) Robert Verheij (NIVEL)
Abstract: Aim of the project is to gain insight into the relations between aspects of
people’s living environment, especially the amount and type of green space, and their
health, wellbeing and feelings of safety. Epidemiological research on data from 1988
has shown a positive relationship between the amount of green space in people’s
living environment and indicators of self evaluated mental and physical health (Vries
de, Verheij, Groenewegen, Spreeuwenberg 2003). Little is known, however, about
the mechanisms behind this relationship and whether or not the relationship extends
to aspects of people’s wellbeing and feelings of safety.
In this project we will further investigate the nature of the relationship by not only
investigating the effects on people’s health, but also on their wellbeing and feelings of
safety. Furthermore, we will investigate the mechanisms involved: social selection,
health behaviour, and exposure. Insight into these mechanisms is important for policy
making in spatial planning, public health, and social safety.
Three individual-level, geocoded datasets that cover the whole of the country, will be
combined with a geographical dataset on land use. The individual level dataset
contain information on people’s perceived general health and visits to a family doctor
in a 12 month period (N=300.000); a number of more specific perceived health
indicators and health behaviour (N=13.000) and feelings of safety (90.000). Al three
datasets contain information on socio-economic and demographic characteristics that
will be used as covariates.
Duration: 2005-2008
Budget: 125.000
Completed/in progress : in progress
Publications: none yet
Relevance : working group 1 & 5

Title: Vitamin G2, Effects of greenery in urban neighbourhoods on health, wellbeing

and social safety
Leading researcher: Sjerp de Vries (Alterra)
Abstract: Health outcomes of residents of urban neighbourhoods with varying
amounts and types of local greenery will be related to possible differences in stress
levels, physical activities, and social safety. In addition, this project will pay special
attention to the characteristics of the available local greenery. We will apply a twofold
methodology: a longitudinal study based on existing neighbourhood data and a
cross-sectional study based on primary data collection. For the longitudinal study, we
will compare data of municipal health services (GGD's) collected prior to and after a
considerable change in the local green structure of residential areas. The cross-
sectional study is more detailed in nature. About eight large Dutch cities will be
selected, having a comparable level of urbanity. Within each of these cities about ten
neighbourhoods will be selected with a similar population, to diminish the possibility

13
of strong selection effects and to enable comparison of people with similar social-
economic characteristics across local greenery situations. The neighbourhoods will
have to differ on the set of local greenery characteristics that are considered relevant.
Based on a review of the literature the most important aspects of the local greenery
for each of the proposed mechanisms will be identified (e.g. amount, structure, type,
design, maintenance). Data will be collected by means of a postal self-administered
questionnaire. The way questions are posed will be coordinated with those in the
other two Vitamin G projects.
Duration: 2005 - 2008
Budget: 125.000,- Euro
Completed/in progress : in progress
Publications: none yet
Relevance: working groups 1 & 5

Title: Vitamin G3
Leading researcher: Agnes van den Berg (Wageningen University)
Abstract: In this project we will study health benefits of allotment gardens. Residents
from deprived urban neighbourhoods with a lack of gardens and public green space
will be compared to residents from the same neighbourhoods who own an allotment
garden with overnight stay permit. The difference in exposure to green space
between these groups is assumingly one of the largest that can be found in The
Netherlands. In keeping with the other two projects in this programme, the groups will
be compared with respect to their health condition, as well more general perceptions
of wellbeing and social safety. With respect to the possible mechanism underlying
relations between allotment gardens and health, this project will focus on physical
activities (cultivation) and opportunities for social contact as mechanisms that have
been found relatively important in previous research.
Duration: 2005 - 2007
Budget: 93.538 euro
Completed/in progress : in progress
Publications: none yet
Relevance : working groups 1 & 5

Title: Modelling the living environment

Leading researcher: Sabine Janssen (TNO Built Environment and Geosciences)
Abstract: The relationship between physical and social characteristics of the urban
living environment and wellbeing of inhabitants is modelled using data gathered in
the Knowledge Base on the Living Environment (KBL). This database comprises both
objective and subjective data at a low level of aggregation from the area of
Rotterdam Rijnmond (a large industrial area in the western part of the Netherlands)
and from the cities of Hengelo and Breda. Physical aspects of the living environment
that are studied include green space, noise, air quality, facilities, infrastructural and
architectural characteristics, social aspects include social density and police reports
of offences. The relation of these characteristics with self-reported wellbeing
(residential satisfaction, perceived safety and health) is investigated, controlling for
individual and dwelling characteristics. The objective is to obtain a model that can be
used in urban planning and design.

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Duration: 2003-2006
Budget: (Dutch Ministry of Housing, Spatial Planning and the Environment)
Completed/in progress: in progress
Publications: none yet
Relevance: Working group 1

Title: Restorative environments research programme

Leading researcher: Henk Staats, University of Leiden (in co-operation with Terry
Hartig, Uppsala University, Sweden)
Abstract: In an ongoing research programme, several hypotheses about
psychological restoration, its antecedents and its consequences are being tested.
Relevant findings from recently completed projects demonstrate that environmental
preference changes as a function of attentional fatigue, that social context influences
restoration, and that the assumed phases of restoration may need to be
reconsidered. Current projects deal with (a) the ecological validity of findings
assessed in the laboratory, with (b) examination of the culturally determined
expectations of environmental preferences and restorative quality, with (c) the
question whether aesthetic quality or environmental category is primarily responsible
for restorative effects, with (d) the relationships between Attention Restoration
Theory and Ego Depletion Theory, € the role of constrained vs unconditional
restoration, and other issues.
Duration: ongoing
Budget: none (staff time only)
Completed/in progress: in progress
Publications:
 Staats, H., Kieviet, A., & Hartig, T. (2003). Where to recover from attentional fatigue:
 An expectancy-value analysis of environmental preference. Journal of Environmental Psychology,
23, 147-157.
 Hartig, T. & Staats, H. (2003). Guest editors’ introduction: Restorative Environments. Journal of
Environmental Psychology, 23, 103-107.
 Staats, H., & Hartig, T. (2004). Alone or with a friend: A social context for psychological restoration
and environmental preference. Journal of Environmental Psychology, 24, 199-211.
Relevance: working group 1

Title: Effectiveness of working on a care farm for different target groups

Leading researcher: Jan Hassink, Plant Research International
Abstract: In two different subprojects the effectiveness of working on a care farm is
investigated. The two subprojects differ in research design. In the first project, on a
newly founded care farm annex research facility (Hoge Born) a systematic and
extensive monitoring programme is developed and put into practice to track the
development of clients with a psychiatric background, as well as the costs associated
with the treatment. It is mainly a casuistic outcome study. In the second project less
extensive monitoring will take place on a number of (regular) care farms, but also on
a number of facilities for occupational therapy of a different type, making
comparisons possible. This second study also focuses on clients with a psychiatric
background, but also includes people with a history of addiction.
Duration: 2005 - 2007
Budget: ?
Completed/in progress: in progress

15
Publications:
 Elings, M., Erp, N. van & Hoof, F. van (2005). De waarde van zorgboerderijen voor mensen met
een psychiatrische of verslavingsachtergrond; voorstudie en aanzet tot onderzoeksprogramma.
Rapport 97. Wageningen: Plant Research International.
Relevance: working group 3

Title: Nature for children

Leading researcher: K Both, Springzaad/Oasis Foundation (Beuningen)
Abstract: A review of research about the importance of natural playscapes and
learnscapes for a healthy development of children and developing a concern for
environmental conservation.
Duration: ending 31/12/2005. Will be continued from 01/01/2006 into the project
‘Living with nature. A caring perspective on nature education. PhD research
(promotor prof dr Kris van Koppen University of Utrecht)
Budget: nn 2005: € 2000
Publications:
-Ruimte voor de jeugd en voor de natuur (Place for children, place for nature). Internal report Oasis
Foundation, 2004
-Een tuin bij de school. Schoolterrein als leerlandschap (School garden als learnscape). De Wereld
van het jonge Kind, April 2002
-Engelse ervaringen met leerlandschappen (Learnscapes in England), De Wereld van het jonge Kind,
January 2003
-Natuurtuin als bron van inspiratie (Natural gardens: their affective, cognitive and spiritual value for
children), De Wereld van het Jonge Kind, June, 2003
-Kinderen lezen het schoolterrein (Children ‘reading’ their schoolgrounds). De Wereld van het Jonge
Kind, February 2004
-Natuur voor kinderen (Nature for children). Pedagogiek in Praktijk, december 2004
-Kindergarten: tuin voor kinderen (Kindergarten: garden for children). De Wereld van het Jonge Kind,
January 2005-08-31
-Kinderen hebben natuur nodig (Children need nature). JSW January 2005
-De buitenklas (The outdoor classroom), JSW, June 2005
-Aarde-kinderen (Earth Children), De Wereld van het Jonge Kind, October 2005
Relevance: working group 3

Title: Gezond werken in het groen [Healthy work in a green environment]

Leading researcher: Anne Oosterbaan, Alterra
Abstract: The project aims to make an inventory of the number of people with
specific health problems or care needs that are involved in landscape, nature or
forest maintenance activities for therapeutical or welfare purposes. It focuses on
large organisations, i.e. organisations that manage many and/or large areas such as
the State Forest Service. Besides the (quantitative) inventory by means of a survey
among the aforementioned large organisations, the project also intends to explore
the reasons for employing these specific groups, from the side of the management
agencies as well as from the side of the healthcare or welfare organisations involved.
A limited number of interviews will be conducted for this purpose.
Duration: 2005
Budget:
Completed/in progress: in progress
Publications: none
Relevance: working group 3

16
17
3. Relevant publications, organizations, and initiatives to enhance
policy implementation

Besides research projects and publications reporting their outcomes, there are also
publications, organisations and initiatives that focus more on the implementations of
the findings (or sometimes: beliefs) regarding the beneficial effects of nature.

3.a References

Van den Berg, A & Van den Berg, M. (2001). Van buiten word je beter; een essay
over de relatie natuur en gezondheid [The outdoors heals]. Wageningen: Alterra.

Van den Berg, A.[E.] (2000): Voor je gezondheid [For your health]. In: B. van
Leeuwen, J. van Leeuwen & W. van Strien (red.), Organiseer je eigen natuur;
wegwijzer voor natuurprojecten. Utrecht: KNNV, blz. 39-43.

Van Zoest, J. (2004) Gezond met groen. [Healthy with greenery] Themanummer
Stad en Groen, nr.4. Uitgave van de Dienst Ruimtelijke Ordening Gemeente
Amsterdam www.dro.amsterdam.nl (English summary)

3.b Organisations

Groenforum
Groenforum is a non-profit Dutch organisation to protect and promote urban nature
for the benefit of inhabitants and because of the economic importance of nature. A
wide range of organisations and companies participate with the same goal: to protect
and increase the quality and quantity of urban nature. Groenforum does so by
organising meetings and conferences where people with a ‘green background’ meet
with people from the healthcare sector and urban policy and decision makers.
Groenforum writes and distributes publications and participates in projects to improve
the green characteristics of urban areas. Groenforum also participates in
Tradeshows such as ‘Urban Design’.
Website: www.groenforumnederland.nl
Contact: info@groenforumnederland.nl

3.c Initiatives

Programma Natuur = gezond [Programme Nature = Healthy]

Stichting Natuur en Milieu, the Netherlands Society for Nature and Environment
(N&M), is an independent organization committed to securing amongst other issues a
healthy natural environment. Our main strengths are debating and influencing the
policy-making process. We conduct research and publish our findings. We conduct
publicity campaigns and stimulate discussion and debate. We mobilize public opinion
and put pressure on key policymakers in the field of nature and environment to make
sustainability a cornerstone of policy and legislation. We move in circles where
decisions are made, at the European, national and local levels.

18
 In 2004-2006 N&M is and will be working on the programme ‘nature = healthy’.
With this program N&M aims to put the positive relationship between nature and
health higher on the political agenda and to raise more public awareness. The
programme consists of the following stages
1. Informing and convincing:
We will inform and try to convince organizations and companies of the positive
impact nature has on health. Herewith we will form a new ‘web’ of organizations
that can underline the need by politicians and policy makers for more green and
therefore more healthy people in the Netherlands.
2. In 2005 we will organize a conference about the ‘green healthy city’, in which we
will emphasize the importance of green for the health of city people.
3. Developing a collective agenda:
Together with at least two national health care organizations and a number of
nature conservation organizations we will present to the minister of Agriculture,
Nature and Food Quality and the minister of national Health, Well Being and
Sports a collective policy document which contains arguments for more green and
more healthy people in the Netherlands
4. Collective action:
Together with a number of health organizations we will look for possibilities and
opportunities for a national campaign ‘Green = Healthy’
5. Strengthen the political and public attention for nature and health
The long term effect of the programme is to maintain the existing funds for nature
policy and lobby for extra funds. Health is an extra argument in that lobby
Another effect of the programme is to further expand and strength the health
organizations web.
Duration: 2004-2006
Website: www.natuurenmilieu.nl (of organisation, not of programme)
Contact: Karin de Feijter, k.de.feijter@natuurenmilieu.nl

Health Concordat
The Dutch Forestry Commission (Staatsbosbeheer) and VGZ-IZA group, the # 1
private Health Insurance Company in the Netherlands, signed a Health Concordat.
We will work together to develop innovative projects to demonstrate the role of the
outdoors in delivering health and well-being. We will start with projects to deliver:
 Development of the Working in Nature Conservation Programme for
employees with stress and burn-out to reduce health costs.
 An analysis of a new Nature & Health destination for real estate in
conservation areas eg. Hospices and Maternity Hospitals.

Nederland Actief! [The Netherlands Active!]

The Netherlands Active! coalition is campaigning for more awareness in the role of
the green surroundings for the health of citizens in municipalities. The Netherlands
Active! consists of the Royal Dutch Touring Club, the Netherlands Olympic
Committee*Netherlands Sports Confederation, the sector organisation representing
the providers of care insurance and the Dutch Forestry Commission
(Staatsbosbeheer). We will promote an active lifestyle and will stimulate
municipalities to create green spaces for physical activities.

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4. Relevant research institutes

Alterra, Green World Research (part of WUR)

Website: www.alterra.wur.nl
Contact: Sjerp.deVries@wur.nl

Department of Environmental Sciences (part of WUR)

Website: www.dow.wur.nl
Contact: Agnes.vandenBerg@wur.nl

Louis Bolk Instituut

Website: www.louisbolk.nl
Contact: Erik Baars

Netherlands Institute for Health Services Research (NIVEL)

Website: www.nivel.nl
Contact: r.verheij@nivel.nl (Robert Verheij)

Netherlands Institute of Mental Health and Addiction (Trimbos Instituut)

Website: www.trimbos.nl
Contact: Hans Kroon

National Institute for Public Health and the Environment (RIVM)

Website: www.rivm.nl
Contact: Ton Dassen

Plant Research International (part of WUR)

Website: www.plant.wur.nl
Contact: Jan.Hassink@wur.nl

Netherlands Organization for Applied Scientific Research (TNO)

TNO Built Environment and Geosciences and TNO Quality of Life
Website:
www.tno.nl/ruimtegebruik_en_infrastructuur/kwaliteit_van_de_leefomge/leefomgevin
g_en_gezondhei/ and www.tno.nl/kwaliteit_van_leven/preventie_en_zorg/
Contact: Sabine.Janssen@tno.nl

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