“It is about being outside”: Canadian youth’s perspectives of good health and the environment

Highlights

• Youth shared deep and unique perspectives of links between health and environment.

• Youth participated in individual and focus group interviews and used photovoice.

• For youth, the outside natural environment can be therapeutic and healing.

• The outside natural environment can also be uncomfortable and threatening for youth.

• We need to provide safe, clean and green natural and built environments for youth.

Abstract

Drawing on qualitative data generated from an ethnographic study exploring Canadian youth’s understanding of health, this paper examines youth’s perspectives of the relationships between health and environment. Seventy-one youth (12 to 19 years of age) took part in individual and focus group interviews, as well as in photovoice interviews. Although initial discourse about health mainly focused on healthy eating and exercise, youth were more enthused and able to share their thoughts and feelings about the relationships between health and environment during the photovoice interviews. For these youth, good health was defined and visualized as “being outside” in a safe, clean, green, and livable space. Youth talked about conditions contributing to healthy environments and how healthy environments contributed to a strong sense of place. Overall, the conversations about the environment evoked many feelings in the youth. Results are discussed in the context of current research and in relation to youth, but also more broadly in relation to research on health and environment.

Introduction

If we hope to develop effectual and meaningful services, programs and policies directed at improving the health and well-being of youth, we need to gain an understanding of the ways youth think about health and the various determinants including the environment that influence their health. In this paper we provide findings of a study that afforded urban youth from lower-income neighborhoods to share their perspectives of health and its relationship to their environment and place. Our findings revealed that the talk of the environment evoked many feelings in the youth. Youth valued healthy environments not only for their own health and sense of well-being but also for the world׳s health and survival.

How health is defined is an ongoing and sometimes confusing discussion since many different meanings can be attached to the word ‘health’ from a multitude of perspectives. Perhaps the most recognized understanding of health is from the World Health Organization’s (WHO) definition which states that “health is a complete state of physical, mental, and social wellbeing, not merely the absence of disease or infirmity” (WHO, 1946). But even this holistic understanding of health is not without debate. Coleman et al. (2007) note that while the WHO’s definition portrays health as a positive force that is multidimensional in nature incorporating more than just a biomedical understanding, they also argue it is too idealistic and does not account for change. Some (e.g., Balog, 2005) have claimed that a person’s physical state should be the main consideration when labeling someone as healthy or not healthy. However, others argue that emotional, social and mental states are just as valid to factor into an individual’s overall health or well-being (e.g., Burch, 2001, Kiefer, 2008, Sturgeon, 2007). In fact, researchers are increasingly emphasizing the holistic understanding of health which can vitally inform community design and planning (Cohen and Schuchter, 2012).

The notion of health then, is far from having a shared conceptualization or definition. Nevertheless, the meaning of health and what it means to be healthy has been interpreted from the perspectives of many different sub-groups including youth. The term youth is a flexible category that may include young people, teenagers and/or adolescents that are in the period of transition from childhood to adulthood (Berzin, 2010, UNESCO, N.d.). The age range for youth varies among different programs and studies. For example, the Boys and Girls Clubs of Calgary identifies the age range of 12–24 years, whereas the age of youth attending Motive‐Action Training Foundation youth programs in Calgary is between 18 and30 years (Doucette and Gilmour, 2010). For the purpose of this study youth is understood as young people of 12–19 years old.

Qualitative research investigating youth’s accounts of health and health behaviors have found youth’s health perspectives to be multidimensional in nature. For example, Buck and Ryan-Wenger (2003) interviewed adolescents aged 10–14 years as to their meanings of health and being healthy. Their results led them to formulate a hierarchical taxonomy of the concept of health which included: the absence of illness, physique, functional ability, health risk avoidance behavior, health promoting behavior, and holistic integration.

From a Canadian perspective, remarkably little is known about how health-related issues integrate within the daily lives of Canadian youth, despite Canada’s reputation as a leader in the development of health promotion concepts (Raphael, 2008). Also missing is research that examines youth’s views of how their environments contribute or do not contribute to their health. The findings presented in this paper are part of a larger study that examined how youth frame health within the context of their life-situations (Woodgate and Leach, 2010). Specifically, this paper describes youth’s perspectives of the relationship between health and environment.

The reflections of youth regarding the links between health and their experience of natural and built outdoor spaces provide a unique perspective on factors, circumstances and life situations that determine how youth conceptualize health. Moreover, many youth conceptualize health differently from academics or policymakers who tend to focus on such aspects of health as well-being and numerous social determinants of health (Woodgate and Leach, 2010, p. 1179). For example, Woodgate and Leach (2010) found that personal lifestyle practices of youth are among the key determinants of their health.

Ioannou (2003) interviewed youth aged 15–17 years about why they engage in smoking, eating, drinking alcohol, and exercise. Her findings revealed that the meanings youth assigned to these health choices were closely related to the everyday contexts of consumption and were products of a two-way relationship between structure and agency. Their health behaviors were tools through which to communicate with others and to experience themselves in various ways. O’Higgins et al. (2010) explored students’ (aged 12 to 13) perceptions of health by asking what made them healthy and influenced their health. They found health to be a holistic concept linked to mental and physical health and being happy. Students mentioned outside environmental influences (e.g., quality of air), food they ate, as well as in-home smoking environments affecting their health.

An important focus in understanding health is by looking at the interaction of people and their environment (Renalds et al., 2010). The Public Health Agency of Canada (2003) identified the natural environment (i.e., quality of air, water, food and soil) and built environments (e.g., housing, indoor air quality, community design and transportation systems) as key determinants of population health. Renalds et al. (2010) expanded the definition of built environments to include: green spaces and parks, the presence and condition of sidewalks, traffic flow, cleanliness and maintenance of public spaces, perceptions of safety and community security, zoning and land use mix, and population density, underground and overhead areas (e.g., power lines), the internal environment, and social capital. Renalds et al. (2010, p. 68) state that the built environment “can be considered a foundation for health and wellness” and it has been well established that both the natural and built environment influence adult physical and mental health.

In a systematic review of the relationship between the built environment and health, it was found that communities with urban designs promoting physical activity had lower body mass index (BMI), compared to others (e.g., with high commuter activity) which had greater obesity rates (Renalds et al., 2010). Moreover, the neighborhoods with higher number of fast food restaurants were associated with higher BMI rates. Most of the 23 articles reviewed, focused on physical activity and weight (n=16) and fewer were on social capital (n=4) and mental health (n=3). The age of the study samples were mainly adults, and data collection mostly involved large-scale telephone surveys and census data, and lacked face-to-face contact.

Environment and health research has demonstrated how specific neighborhood characteristics and social capital influence one’s mental health and well-being. Neighborhoods that are seen as more walkable were associated with increased physical activity, increased social capital, and lower rates of obesity, depression, and alcohol abuse predominantly among adults (Renalds et al., 2010). Stronegger et al. (2010) found that 15–60 years old residents of the areas that have perceived high social-environmental quality also report higher levels of self-rated health and individual physical activity. A Canadian study using concept mapping provided a community point of view of neighborhood characteristics that highly contribute to positive and negative mental well-being of adults (O’Campo et al., 2009). Highly important for good mental well-being were social services and resources such as accessible public transportation, affordable childcare, libraries, and access to health care services as well as items linked to safety, neighborhood cohesion and neighborhood green space. Negative community factors with high ratings for poor mental well-being included: violence, crimes, vandalism, and drug dealing. In other clusters low-income, high unemployment, discrimination and irresponsible landlords rated high for poor mental well-being.

Some qualitative studies have specifically explored children and young people’s health in relation to the built environment; however, these studies have focused predominantly on environments related to food consumption such as school or home and how the environment affects children’s eating habits, physical activity, and risks for obesity (Pearce et al., 2009, Briggs and Lake, 2011). For example, according to Kuh et al. (2013) outdoor spaces serve an important developmental need for physical activity and health of children. Further research is warranted that seeks to understand what youth think about health and how youth integrate health-related issues and behaviors into their everyday lives (Ioannou, 2005).

The concept of therapeutic landscapes provides a framework for analyzing natural, built, and other types of environments and their contribution to well-being, healing, and health (Williams, 2007, Williams, 1999). For example, one therapeutic landscape study focused on family leisure experiences spending time at the zoo and capturing family life and well-being through photographic images (Hallman, 2007). In reviewing the literature on health and the environment it is noteworthy that even though this field is gaining more attention among researchers there are still gaps in research on the health benefits and health promoting qualities of environments, specifically from the young people’s perspectives. There is increasing evidence that suggests that green space in one’s environment has a positive effect on one’s health (Maas et al., 2009, Maas et al., 2006, Pinder et al., 2009). For example, perceived general health appears better in people living in greener environments (Maas et al., 2006). In particular, natural open spaces create opportunities for relaxation, social interaction, and physical activities (Thompson and Aspinall, 2011). Moreover, research showed that less green space around people’s homes was associated with feelings of loneliness and with low perceived social support (Maas et al., 2009). This was apparent for children and young people as well. Natural environments or environments containing natural elements may decrease stress and increase mental well-being (Chawla et al., 2014, Thompson et al., 2012, Roe and Aspinall, 2011, Wells and Evans, 2003). In an experimental study of hospitalized students, the presence of indoor plants (versus a picture of an urban environment) reduced the feeling of stress and increased the perceived room attractiveness (Dijkstra et al., 2008). It is worth noting that perceived dissatisfaction of green space may influence physical health as well since it may hinder residents from partaking in physical activity (Agyemang et al., 2007).

Studies have examined how perceptions of one’s environment facilitate health and well-being, or act as a barrier. Milligan (2007) suggests that there is a need to distinguish between restorative and risk/fear-inducing effects of natural environments in the context of the study of therapeutic landscapes. Certain stressors in neighborhood environments have also been linked to self-rated health. For example, negative perceptions of one’s neighborhood such as drug misuse, bothersome neighbors, problem youth, street garbage, feeling unsafe, and dissatisfaction with the quality of green space can produce stress and negative health implications (Agyemang et al., 2007, Baum et al., 2009). Alternatively, Baum et al. (2009) found that positive perceptions of neighborhood cohesion and safety were linked to health because these resident perceptions fostered use of local facilities which contributed to health. Finally, Hill’s et al. (2012) research underscores the importance of considering perceptions of one’s neighborhood and contextual factors in relation to self-reported well-being. In their sample of 692 New Zealand adult residents they found that neighborhood perceptions were strongly associated with physical, psychological, social, and environmental health-related quality of life, even when sociodemographic variables were controlled. They noted that neighborhood and individual factors interact to influence social relationships among neighbors and friends, which, in turn, affected the social health of neighborhood residents. Overall, the studies that link environmental design and planning with the potential contributions of space to health and well-being have important practical and policy implications (Thompson, 2013, Bell et al., 2007, Gesler and Curtis, 2007).

A few studies have identified how neighborhood characteristics influence youth behavior. The condition of neighborhoods has been shown to impact children’s mental health and risk behaviors (Zuberi, 2012). Westley et al. (2013) found that the perceptions of parents regarding neighborhood safety can influence their children’s health behavior, specifically related to their use of parks, active transportation to parks and screen time. Moreover, access to resources in the built environment such as social services is important for youth (especially in neighborhoods with limited resources) in affecting sexual risk behavior (Burns and Snow, 2012). Similarly, the social aspects of neighborhoods including social bonds, absence of conflict, and observing physical activity were seen to affect at-risk youths’ health behavior (Lawman and Wilson, 2012).

In trying to understand how environments promote health, “… we need to first understand how people conceptualize those relationships, before we can attempt to measure or enhance them” (Pinder et al., 2009, p. 355). For example, Conradson (2005, p. 338) explores the relational dynamics between place and health and argues that the therapeutic landscape experience “emerges through a complex set of transactions between a person and their broader social-environmental setting.” Several recent studies explored young people׳s experiences of their environment and place in relation to various aspects of their well-being (Roe and Aspinall, 2012, Travlou et al., 2008, Milligan and Bingley, 2007, Thompson et al., 2008, Bell et al., 2003). However, youth have been afforded only limited opportunity to share their views on how their environments contribute or do not contribute to their health.