The number of children regularly playing in nature and wild places in the last 30 years in the UK fell by 90%(Natural Childhood Report, 2012). The People and Nature Survey (Natural England, 2020) suggested that this decline was exacerbated by Covid-19 as six in ten children (60%) reported spending less time outdoors. However, children who reported spending more time outside and more time noticing nature/wildlife were more likely to report that ‘being in nature makes me very happy’ (91% and 94% respectively). Furthermore, 46% of parents believed their children seem happier outside, and 42% believed that nature is more important than ever. The wealth of research demonstrating that natural environments have a positive impact on health and wellbeing has led to prescription of nature-based health interventions and green prescribing, although evidence for its use is predominantly limited to adults.

There is also evidence that arts education can aid physical, cognitive, linguistic, social and emotional development (APPG, 2017), as well as improving mental health, wellbeing, and social inclusion (Durham Commission on Creativity and Education, 2019). The evidenced impact of creativity and engagement with art has been also applied to guide policy towards supporting wellbeing (Fancourt, Warran & Aughterson, 2020). However, what has received scant attention in literature so far is the interconnection between the two: arts and nature. This systematic review synthesises the literature surrounding the interconnectedness between arts and nature, and their impact on the health and wellbeing of children and young people.

To date, information with regards to the theoretical frameworks, techniques, practices and dosage (i.e., frequency, duration, intensity of sessions) in arts-based interventions delivered in nature and outdoor spaces for children and young people has yet to be synthesised. Further research is also required to systematically report on how such interventions have been implemented and to evaluate the quality of existing evidence. The present systematic review aimed to address this gap with the following research questions:

a) What types of arts-based interventions and services have been implemented in nature and outdoor spaces? What are their theoretical frameworks, techniques, and dosage?

b) How do arts-based interventions and services in nature and outdoor spaces support the health and wellbeing of children and young people?

This systematic review was conducted in accordance with the Cochrane Handbook for Systematic Reviews (Higgins & Green, 2011). Methods were pre-specified and documented in advance in a protocol that was published on PROSPERO database for systematic reviews (Registration no.: CRD42021286574). The eligibility criteria were determined based on the PICOS framework (Bowling & Ebrahim, 2005) and were independently assessed by two reviewers. The search strategy included the most relevant keywords for a) arts; b) nature and outdoor spaces; and c) children and young people. Eight major electronic databases were systematically searched, specifically: PsycINFO, CINAHL, ERIC, MEDLINE, DoPHER/ePPI, Education Abstracts Wilson, Campbell Collaboration library and Cochrane library databases, including CDSR, CENTRAL, HTA. The search also included 20 most relevant journals, five books, and contact with experts in this area. Studies were restricted to those published in English until April 30th, 2021. The screening process was recorded in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines (Page et al., 2021) to ensure that it was undertaken systematically and transparently at all stages. Zotero software was used to identify and remove duplicate titles, and Covidence software was used to organise and manage all relevant information from the studies. The TIDieR Template for Intervention Description and Replication checklist (Hoffmann, 2014) was used to extract information based on study and intervention characteristics. Considering that implementing experimental studies with children and young people may be highly challenging for methodological and ethical reasons, qualitative and quasi-experimental designs were also included in this review. As such, our study included experimental and quasi-experimental studies (e.g. RCTs, pilot-, cluster-, quasi-RCTs, controlled before and after studies), qualitative studies (i.e., interviews, focus groups), as well as arts-based studies (e.g. artifacts, photographs, diaries). The quality of the included studies was assessed by two reviewers and any discrepancies were resolved with the involvement of a third reviewer. For the quality analysis of the quantitative synthesis, the assessment criteria according to the ROBIS tool (Higgins and Green, 2011) were based on establishing the following: sequence generation; allocation concealment; blinding of participants; personnel and outcome assessors; incomplete outcome data; selective reporting bias; and other potential risks of bias. For the qualitative synthesis, the criteria of credibility, transferability, dependability, and confirmability were assessed (Higgins & Green, 2011; Hannes, 2011).

Eleven studies were included, which were conducted in the UK, USA, Ireland, Australia, and Hong Kong, in a range of spaces such as forests, woodlands, beaches, parks, fields, gardens, and school playgrounds. The review encompasses data from 602 participants in total. Studies included action research (Murphy, 2018), grounded theory (Adams & Beauchamp, 2018; 2019; 2020), ethnographic-inspired co-production (Tiplady & Mentor, 2021), controlled before-and-after designs (Arbuthnott & Sutter, 2019), uncontrolled before-and-after designs (Bruni, Winter, Schultz, Omoto & Tabanico, 2017; Gray & Birrell, 2015; Gray & Thomson, 2016; Moula, Walshe & Lee, 2021), and a two-arm randomised control trial (Sobko, Liang, Cheng & Tun, 2020). Most studies drew upon the construct of connectedness with nature (Nisbet, Zelenski & Murphy, 2009; Schultz, 2002), suggesting that nature connectedness correlates positively with wellbeing. Wilson’s biophilia theory (Kellert & Wilson, 1995) was also widely adopted, while one study drew upon Amartya Sen’s human capabilities (1993) as a proxy for wellbeing. Arts-in-nature offered an inclusive medium to engage all children and young people, especially those who might otherwise remain disinterested about environmental issues and disengaged with educational programs. Further, arts-in-nature provided stimuli to increase nature connectivity, understand environmental issues and explore ways to prevent environmental disasters. This led to higher environmental awareness and pro-environmental behaviours, and potential decrease in eco-anxiety. Based on this, we have developed a framework that illustrates the additional benefits of engagement with the arts in nature and outdoor spaces. Implications for research, policy, and practice are discussed, such as methods to strengthen future interventions. Scaling-up existing interventions may lead to wider recognition and inclusion of arts-in-nature in future health guidelines.

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