For many of us, COVID-19 has meant restrictions on what we do and where we go. These restrictions may include lockdowns, which prevent us from leaving our homes, through to supervised quarantine, often in hotels. These restrictions have been criticised because of the limitations they pose on our rights, as well as the discomfort of spending so much time indoors, particularly where there is no access to outdoor space or sometimes even to fresh air.

These restrictions, while potentially uncomfortable and inconvenient, are made potentially more tolerable because we know that they have both served an important purpose and that they will be imposed for a relatively short period (although it might not always feel that way!).

What has largely been overlooked, is that there are millions of people who already cannot regularly access outdoor spaces, and who might not have access to fresh air on an ongoing, perhaps even permanent basis. These people include those in hospitals and rehabilitation centres long term, those in residential care, and those who are incarcerated. Even people living in their own homes with limited mobility and/or confidence may have limited their access to the outdoors.

We need to reflect on what our relatively short experience of such limited access means for those who experience this limitation on an ongoing basis and work towards increasing their access to outdoor spaces.

Jessica Stanhope (PhD)

Jessica Stanhope (PhD)

Associate Lecturer University of Adelaide

Dr Jessica Stanhope is a researcher and educator with a background in physiotherapy and epidemiology. She has extensive experience in cross-disciplinary research and a particular research interest in how healthy ecosystems help improve human health outcomes.

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So why does this matter?

The issue of outdoor access goes beyond our discomfort of not having fresh air, or not being able to go out – there are several health implications. Green space exposure has been associated with a range of health, social, developmental and educational benefits. For example, certain types of green space exposure have been associated with improved mental health (1,2) and cardiovascular outcomes, reduced risk of diabetes, lower incidence of asthma, and improved self-reported health (3). Green space exposure may also improve pain outcomes (4), and has been associated with decreased loneliness (5), improved social integration (6), and increased physical activity (7, 8). The mechanisms underpinning these relationships are not currently well understood, but may include specific elements (e.g. exposure to environmental microbiota, biogenic volatile organic compounds, negative air ions, and the sights and sounds of nature (4), reduced exposure to pollution (9, 10), or more generic elements (e.g. the above mentioned increases in social integration and physical activity, as well as sunlight exposure) (4).

For our patients to benefit from these potential health gains, we as physiotherapists need to improve access to outdoor green spaces for everyone we treat, and this may involve advocacy, facilitating co-design, and changes in the way we conduct our physiotherapy sessions. All people should have access to outdoor green spaces, so we need to advocate for the development of new and enhancement of existing green spaces. These spaces may be in health care settings and goals to maximise opportunities for their use. With the special needs of these populations in mind, such spaces should be designed by multidisciplinary teams with direct involvement from end-users. Such a process would ensure these spaces are functional from a social and ecological perspective, that they are spaces people want to spend time in, and that they can comfortably spend time in. Where possible, involving the end-users in the construction of these spaces (including planting) may provide a sense of ownership in the space, but participation in such activities in and of itself is likely health-giving.

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We also need to advocate for public green spaces, outside of healthcare settings. Public green spaces may have additional challenges, including catering for a broader range of people, the need to consider amenities, transport, and often the need for people to be able to access and feel safe and confident if alone in these spaces.

In our more traditional, clinical roles we can also optimise green space exposure. We can use the above mentioned green spaces in health care settings and/or public spaces in our clinical work (where local rules permit it). This change in the way we practice has two key benefits. Firstly, it allows our patients and clients to spend time in green spaces while being supervised, thus directly increasing their exposure to green spaces safely. Secondly, by conducting therapy sessions in green spaces we can increase an individual’s confidence in spending time in these spaces, and work to overcome barriers. Such an approach to clinical practice is important for it is more likely that our patients and clients will be able to spend time in these spaces outside of clinical sessions, and post-discharge.

Indeed, we need to be considering people’s safety and confidence in using green spaces before discharge, to ensure they do not become or remain community members who do not feel able to access outdoor green spaces.

Finally, we can also consider ways of bringing the outdoors indoors. One such approach might be to increase exposure to elements of green space or to allow exposure where real outdoor exposure is truly not possible. We may bring plants into therapy spaces, homes and patient rooms, we may play recordings of natural sounds (e.g. birds), watch nature films, use infusers to expose people to the smells of nature, and (were possible) even just opening blinds and the windows themselves to increase exposure to natural settings outdoors. This final suggestion has implications for the design of residential settings, including hospitals, where windows should be able to be (at least partially) opened (where safe), and where we need to consider what is directly outside of the windows.

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The COVID-19 pandemic has brought with it many challenges, including health, social and economic challenges. But we need to learn what we can from this experience, which includes how important exposure to outdoor green spaces is, and how for many this exposure is not possible on a long-term basis. By using our skills in advocacy, safe design and creative clinical practice, we can improve the health and wellbeing of some of the most vulnerable people we work with.

For further information please see our article: 

Stanhope J, Weinstein P. (2021). Public health lessons from the COVID-19 pandemic: the importance of green spaces for vulnerable populations. Perspectives in Public Health. 


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