Neighbourhood social and physical environment and general practitioner assessed morbidity

Physical urban environment and cardiometabolic diseases in the five largest Bulgarian cities

This study investigated the associations between residential environmental characteristics and the prevalence of cardiometabolic diseases in the five largest Bulgarian cities. Representative cross-sectional survey data (N = 4640 adults) was collected in Sofia, Plovdiv, Varna, Burgas, and Ruse. Participants self-reported diagnosis or medication intake for hypertension, ischemic heart disease (IHD), stroke, and diabetes mellitus, as well as domestic burning of solid fuel and having a domestic garden. Residential addresses were linked to greenspace (overall vegetation level, tree cover, urban greenspace), bluespace, walkability, air pollution (NO2), and traffic noise (Lden). In the 300 m buffer, bluespace presence was inversely associated with hypertension (odds ratio [OR] = 0.67; 95% CI: 0.45, 1.00), IHD (OR = 0.45; 95% CI: 0.21, 0.99), and diabetes (OR = 0.51; 95% CI: 0.25, 1.04). Higher walkability and tree cover were inversely associated with hypertension (OR per 2 units = 0.85; 95% CI: 0.75, 0.96) and diabetes (OR per 10% = 0.77; 95% CI: 0.62, 0.97), respectively. These associations were stronger in larger buffers. Solid fuel burning was associated with IHD (OR = 1.63; 95% CI: 1.07, 2.50). There was an indication of a positive association between aircraft Lden and both stroke and IHD. The direction of the associations for domestic gardens, NO2, road traffic and railway Lden was counterintuitive. We detected some nonlinear associations. In conclusion, people living in urban neighborhoods that were more walkable, closer to bluespace, and greener had lower prevalence of cardiometabolic diseases, while solid fuel burning was associated with higher odds of cardiovascular diseases. Unexpected associations with some exposures may be due to unaccounted for urban fabric characteristics. This study is among the first assessing an understudied region in Southeastern Europe. Its findings have the potential to inform public discourse and provide evidence to support the implementation of urban design conducive to cardiometabolic health.

Socioeconomic disparities and risk of recurrent cardiovascular events and cardiovascular disease-free life expectancy in patients with established cardiovascular disease

AIM

This study aimed to evaluate whether lower socioeconomic status (SES) is related to a higher risk of recurrent cardiovascular disease (CVD) events and reduced CVD-free life expectancy in a large cohort of patients with established CVD.

METHODS

9,477 patients with established CVD from the Utrecht Cardiovascular Cohort - Secondary Manifestations of ARTerial disease (1996-2022) study were included. SES scores were determined at the neighbourhood level using scores provided by the Netherlands Institute for Social Research, based on income, education and unemployment. The relationship between SES and recurrent CVD events was analysed using Cox proportional hazard models, adjusted for age, sex, and traditional CVD risk factors. Event-free life expectancy across SES quintiles was assessed using Kaplan-Meier survival estimates, with age as the time scale and accounting for competing risks.

RESULTS

Over a median follow-up of 9.0 years (IQI: 4.8-14.1), 2,090 recurrent CVD events occurred. Unfavourable CVD risk factors were more prevalent among low SES patients, who less frequently used preventive drug treatment. After adjusting for age and sex, patients in the lowest SES quintile had a higher risk of recurrent events compared to the highest SES quintile (HR: 1.35; 95%CI 1.17-1.56). This relationship persisted after adjusting for CVD risk factors potentially mediating the effect. The median event-free life expectancy was 5.5 years (95%CI 2.8-8.0) shorter comparing the lowest to highest SES quintile.

CONCLUSIONS

Among patients with established CVD, lower SES is related to a higher risk of recurrent CVD events independent of CVD risk factors, and to a shorter CVD-free survival. These findings underscore the need for targeted interventions to reduce health disparities.

Longitudinal mental health associations of relocation to supportive versus adverse neighborhood environments in the Netherlands

BACKGROUND

Mental health status may be associated with residential neighborhoods' physical and social characteristics; however, longitudinal evidence is limited, and the findings are inconsistent.

OBJECTIVES

To examine the longitudinal associations between neighborhood physical and social environments and mental health among adults after residential relocation.

METHODS

We used national-representative panel data of 3000 adults between 2008 and 2013 in the Netherlands. We included movers relocating to neighborhood environments identified as health-supportive or adverse; non-movers served as the control group. Mental health was measured pre- and post-move using the Mental Health Inventory. Time-varying exposure to physical environmental factors (i.e., green space, blue space, air pollution, and population density) and social environmental factors (i.e., socioeconomic deprivation and social fragmentation) were assigned based on adults' residential neighborhood histories. We used propensity score matching to select non-movers from the control group and difference-in-difference regressions to estimate the associations between environmental changes and mental health.

RESULTS

Our results showed that decreases in fine particulate matter (β = -3.869, 95% CI: [-7.583, -0.155]), population density (β = -5.893, 95% CI: [-9.468, -2.319]), and socioeconomic deprivation (β = -4.756, 95% CI: [-7.800, -1.712]) were significantly associated with improvements in mental health. An increase in neighborhood social fragmentation was significantly associated with improvements in mental health (β = -3.520, 95% CI: [-6.742, -0.298]). We observed null associations between changes in mental health due to changes in green and blue space.

CONCLUSIONS

Following relocation, changed neighborhood environmental conditions appear to have longitudinal mental health associations. Moving to a neighborhood with less air pollution, lower population density, and reduced socioeconomic deprivation was mental health-supportively associated. However, the finding that greater social fragmentation contributes to mental health improvements requires further investigation.

Examining the importance of neighborhood natural, and built environment factors in predicting older adults' mental well-being: An XGBoost-SHAP approach

BACKGROUND

Previous studies have shown that urban neighborhood environmental factors significantly influence the health outcomes of urban older adults. However, most cross-sectional studies exploring the health effects of these factors have failed to quantify the relative importance of each factor.

METHODS

We use XGBoost machine learning techniques and SHAPley Additive Interpretation (SHAP) to rank the importance of urban neighborhood environmental factors in shaping the mental health of urban older adults. To address self-selection bias in housing choice, we distinguish older adults living in private housing from those living in public as residents in private housing have more freedom to choose where to live.

RESULTS

The results show that both natural and built environmental factors in urban neighborhoods are important predictors of mental well-being scores. Five natural environmental factors (blue space, perceived greenery quantity, NDVI, street view greenness, aesthetic quality) and three built environmental factors (physical activity facilities quality, physical activity facilities quantity, neighborhood disorder) had considerable predictive power for mental well-being scores in two groups. Among them, blue space, perceived greenery quantity and street view greenness quantity became less important after controlling for self-selection bias, possibly because of the unequal distribution of quantity and quality, and the performance of neighborhood disorder, aesthetic quality and physical activity facilities quality was more sensitive in public housing.

CONCLUSIONS

These results highlight the nuanced and differential effects of neighborhood environmental exposures on mental well-being outcomes, depending on housing preferences. The results of this study can provide support for decision makers in urban planning, landscape design and environmental management in order to improve the mental well-being status of urban older adults.

Effect of pre- and post-migration neighborhood environment on migrants' mental health: the case of Shenzhen, China

Existing mental health studies usually disregard people's neighborhood experiences in the past, which may have long-lasting mental health effects. This may particularly be true for migrants. To assess how the perceived pre- and post-migration neighborhood environment shapes migrants' mental health later on in life, a quasi-longitudinal survey (N = 591) among migrants was conducted in Shenzhen, China. The risk of poor mental health was screened with the General Health Questionnaire (GHQ). Perceptions of the pre- and post-migration neighborhood environment were measured retrospectively and assessed with structural equation models. The results show that the direct pathways linking the perceived post-migration neighborhood physical (NPE) and social environment (NSE) to migrants' mental health are significant. No direct association is found between the pre-migration neighborhood environments and mental health. The indirect path between the pre-migration NPE/NSE and mental health is significantly mediated by the post-migration NPE and NSE. Migrants' SES development and their neighborhood attainment interplay overtime which have long-term impacts on their mental health. Our findings suggest that the pre-migration neighborhood plays a crucial role in migrants' mental health. This confirms a path dependency of migrants' neighborhood environment throughout their migrations. Future mental health studies are advised to incorporate neighborhood characteristics along migrants' residential histories.

Green space modified the association between air pollutants and hypertension in China

Evidence regarding the combined effects of green space and air pollutants on hypertension remains limited and complex. This study aims to investigate the varying effects of greenness under different air pollution levels in China, using data from the wave 2018 China Health and Retirement Longitudinal Study (CHARLS) involving 17 468 adults (aged ≥ 45 years). As a result, the prevalence rate of hypertension was 42.04%. Logistic regression analyses revealed the positive associations between air pollution concentrations at the city level and prevalent hypertension and the negative associations between NDVI and prevalent hypertension, all of which were more prominent in the populations of the eastern and rural regions. Notably, the negative effect of green space was greater at the lowest quartiles of each air pollutant (OR for PM2.5 quartiles = 0.724, 0.792, 0.740, and 0.931)  . Improving air quality and greenness could potentially reduce hypertension risk, and minimizing air pollution might optimize the protective effects of greenness.

Air pollution, traffic noise, greenness, and temperature and the risk of incident type 2 diabetes: Results from the KORA cohort study

Introduction

Type 2 diabetes (T2D) is a major public health concern, and various environmental factors have been associated with the development of this disease. This study aimed to investigate the longitudinal effects of multiple environmental exposures on the risk of incident T2D in a German population-based cohort.

Methods

We used data from the KORA cohort study (Augsburg, Germany) and assessed exposure to air pollutants, traffic noise, greenness, and temperature at the participants' residencies. Cox proportional hazard models were used to analyze the associations with incident T2D, adjusting for potential confounders.

Results

Of 7736 participants included in the analyses, 10.5% developed T2D during follow-up (mean: 15.0 years). We found weak or no association between environmental factors and the risk of T2D, with sex and education level significantly modifying the effects of air pollutants.

Conclusion

Our study contributes to the growing body of literature investigating the impact of environmental factors on T2D risks and suggests that the impact of environmental factors may be small.

Streets and Stress: A Pilot Study on How Quality and Design of Streets Impacts on Urban Stress

OBJECTIVES

To identify how quality and design of streets impacts urban stress.

BACKGROUND

Few studies have comprehensively addressed environmental factors affecting stress in urban public spaces. However, a remarkable portion of our everyday life is spent in public spaces, particularly streets.

METHOD

This study seeks to evaluate the effect of three types of streets as major public spaces on stress. These include a street with the dominance of green spaces (A), a motorist-oriented street (B), and a pedestrian street (C). For this purpose, we selected a group of participants (n = 16) aged 20-30, with an equal number of men and women who were generally healthy and had normal stress levels. Participants were asked to wear an electroencephalogram (EEG) headset, walk different streets, and answer the Perceived Restorativeness Scale (PRS) and urban design qualities questionnaires.

RESULTS

According to the results, participants experienced the highest stress in street type B and the lowest in type A.

CONCLUSIONS

Green space and vegetation, a sense of security, privacy and coziness, climatic comfort, and safety of space had the most positive effect on stress reduction. Whereas noise pollution, vehicle traffic, and crowdedness were the most critical factors of stress. Finally, our findings suggest that the component of green space has a more significant effect on stress reduction compared with the elimination of vehicle traffic.

The Weight of Place: Built Environment Correlates of Obesity and Diabetes

In recent decades, the prevalence of obesity and diabetes has risen substantially in North America and worldwide. To address these dual epidemics, researchers and policymakers alike have been searching for effective means to promote healthy lifestyles at a population level. As a consequence, there has been a proliferation of research examining how the "built" environment in which we live influences physical activity levels, by promoting active forms of transportation, such as walking and cycling, over passive ones, such as car use. Shifting the transportation choices of local residents may mean that more members of the population can participate in physical activity during their daily routine without structured exercise programs. Increasingly, this line of research has considered the downstream metabolic consequences of the environment in which we live, raising the possibility that "healthier" community designs could help mitigate the rise in obesity and diabetes prevalence. This review discusses the evidence examining the relationship between the built environment, physical activity, and obesity-related diseases. We also consider how other environmental factors may interact with the built environment to influence metabolic health, highlighting challenges in understanding causal relationships in this area of research.

Environmentally related gender health risks: findings from citizen science cross-sectional study

Background

Public engagement in the research of environmental epidemiological problems is becoming an important measure to empower citizens to identify the local environmental and health problems and to explain different environmental exposures affect estimates for males and females. This HORIZON2020 CitieS-Health Kaunas Pilot study examines the relationship between urban built and social environment, health behaviors, and health in men and women.

Methods

This cross-sectional study included 1086 18–74-year-old participants residing in 11 districts of Kaunas city, Lithuania. Using GIS, we measured traffic flow, noise, NO2, PM2.5, PM10, and greenness NDVI for the participants’ home addresses, determined participants’ perceptions of environmental quality, linked this information with personal sociodemographic data, and used multivariate logistic regression to assess the associations with health issues (physician-diagnosed chronic disease and self-rated general health) in men and women.

Results

Men and women similar rated the quality of the neighborhood environment, except for air pollution and satisfaction with the public transport in the district. The traffic-related health associations were stronger for women than for men. The prevalence of poor health increased with the increasing age of men and women, yet no significant differences between gender health risks were found in the total sample. Perceived air pollution, irregular visits to green space, and chronic diseases were consistently associated with poor health risks in men and women, yet part-time jobs and low income had a higher impact on women’s poor health.

Conclusions

Quality of the built neighborhood, air pollution, irregular visits to the green space, and chronic disease had a joint effect on the magnitude of the prevalence of poor health in men and women. Our results suggest that decreasing air pollution and improving the urban built neighborhood supporting citizens’ physical activity in green spaces, might reduce health risks for all.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13824-3.

Associations between the neighbourhood social environment and preschool children’s physical activity and screen time

Background

The neighbourhood social environment (NSE) has been associated with physical activity and screen time behaviours in adults and youth however less is known about this relationship in preschool-aged children (2–5 years). This study seeks to explore associations between the NSE and the physical activity and screen time behaviours of preschool-aged children.

Method

Cross-sectional data was collected in 2019. Parents (n = 214) of preschool-aged children (m = 3.8 ± 0.8 years), from 187 different Australian postcodes representing all states and territories were invited to complete an online survey where they answered questions about their NSE (perceived social cohesion, social interaction, sense of community, social norms and neighbourhood crime) and proxy-reported their child’s usual physical activity and screen time (minutes/day). Two hierarchical linear regressions were run separately to assess relationships between NSE predictor variables and physical activity and screen time. Three logistic regressions were run to determine associations between NSE constructs and the likelihood of meeting: 1) physical activity (≥ 180 min/day including ≥ 60 min of moderate-to-vigorous-intensity), 2) screen time (≤ 60 min/day) and 3) both physical activity and screen time guidelines. Child age, gender, childcare attendance, and neighbourhood level socioeconomic status (SES) were controlled for in all analyses.

Results

Social interaction was associated with increased daily physical activity (b = 17.76, 95%CI = 0.81, 34.71), decreased daily screen time (b = -12.77, 95%CI = -23.23, -2.23) and improved the likelihood of meeting physical activity (OR = 1.81, 95%CI = 1.20, 2.75) and combined physical activity and screen time guidelines (OR = 1.51, 95%CI = 1.03, 2.21). Higher neighbourhood crime was associated with a lower likelihood of meeting screen time guidelines (OR = 0.47, 95%CI = 0.47, 0.99). Social cohesion, sense of community and social norms were not statistically significant predictors of daily physical activity, screen time or meeting guidelines.

Conclusion

Social interaction showed the most consistent associations with physical activity and screen time. Future research should consider potential mediators of this relationship, including parental facilitation of children’s outdoor time. Improving understanding of the relationship between the NSE and physical activity and screen time in young children can help to guide community-based initiatives striving to optimise behavioural, health and social outcomes.

Association between greenspace and blood pressure: A systematic review and meta-analysis

Many studies have investigated the association between greenspaces and blood pressure (BP), but the results remain mixed. We conducted a systematic review and meta-analysis to comprehensively evaluate the evidence concerning greenspaces with BP levels and prevalent hypertension. Systematic literature searches were performed in Web of Science, PubMed, and Embase up to 25 April 2021. Combined effect estimates were calculated using random-effect models for each greenspace exposure assessment method that had been examined in ≥3 studies. Sensitivity analysis, subgroup analysis, and publication bias were also conducted. Of 38 articles (including 52 analyses, 5.2 million participants in total) examining the effects of normalized difference vegetation index (NDVI) (n = 23), proportion of greenspace (n = 11), distance to greenspace (n = 9), and others (n = 9) were identified. Most studies (65%) reported beneficial associations between greenspaces and BP levels/hypertension. Our results of meta-analyses showed that higher NDVI_500m was significantly associated with lower levels of systolic blood pressure (SBP = -0.77 mmHg, 95%CI: -1.23 to -0.32) and diastolic blood pressure (DBP = -0.32 mmHg, 95%CI: -0.57 to -0.07). We also found that NDVI in different buffers and the proportion of greenspaces were significantly associated with lower odds (1-9%) of hypertension. However, no significant effect was found for distance to greenspaces. In summary, our results indicate the beneficial effects of greenspace exposure on BP and hypertension. However, future better-designed studies, preferably longitudinal, are needed to confirm and better quantify the observed benefits in BP and/or hypertension.

Multiple environmental exposures along daily mobility paths and depressive symptoms: A smartphone-based tracking study

Few studies go beyond the residential environment in assessments of the environment-mental health association, despite multiple environments being encountered in daily life. This study investigated 1) the associations between multiple environmental exposures and depressive symptoms, both in the residential environment and along the daily mobility path, 2) examined differences in the strength of associations between residential- and mobility-based models, and 3) explored sex as a moderator. Depressive symptoms of 393 randomly sampled adults aged 18-65 were assessed using the Patient Health Questionnaire (PHQ-9). Respondents were tracked via global positioning systems- (GPS) enabled smartphones for up to 7 days. Exposure to green space (normalized difference vegetation index (NDVI)), blue space, noise (Lden) and air pollution (particulate matter (PM_2.5)) within 50 m and 100 m of each residential address and GPS point was computed. Multiple linear regression analyses were conducted separately for the residential- and mobility-based exposures. Wald tests were used to assess if the coefficients differed across models. Interaction terms were entered in fully adjusted models to determine if associations varied by sex. A significant negative relationship between green space and depressive symptoms was found in the fully adjusted residential- and mobility-based models using the 50 m buffer. No significant differences were observed in coefficients across models. None of the interaction terms were significant. Our results suggest that exposure to green space in the immediate environment, both at home and along the daily mobility path, is associated with a reduction in depressive symptoms. Further research is required to establish the utility of dynamic approaches to exposure assessment in studies on the environment and mental health.

Associations of residential greenness with hypertension and blood pressure in a Chinese rural population: a cross-sectional study

Limited epidemiological literature identified the associations between residential greenness and hypertension in low-/middle-income countries. A random sampling strategy was adopted to recruit 39,259 residents, ≥ 18 years, and from 5 counties in central China. Blood pressure was measured based on the protocol of the American Heart Association. Hypertension was defined according to the 2010 Chinese guidelines for the management of hypertension. The satellite-derived normalized difference vegetation index (NDVI) and enhanced vegetation index (EVI) were applied to estimate the residential greenness. Mixed logit model and mixed linear model were utilized to explore the relationships of residential greenness with hypertension and blood pressure. Higher residential greenness was associated with lower odds of hypertension and blood pressure levels. For instance, an interquartile range (IQR) increase in NDVI_500m was linked with lower odds of hypertension (OR = 0.92, 95%CI 0.88 to 0.95), a decrease of -0.88 mm Hg (95% CI -1.17 to -0.58) and -0.64 mm Hg (95% CI -0.82 to -0.46) in SBP and DBP, respectively. The effect of residential greenness was more pronounced in males, smokers, and drinkers. Long-term exposure to residential greenness was linked with lower odds of hypertension. More prospective studies are needed to verify the hypothesis.

Mental and physical health problems before and after detention: A matched cohort study

Background

Individuals with poor health are largely overrepresented in prison populations. However, it remains unclear whether their poor health status already exists prior to their detention or reflects an effect of detention. We examined the health of detainees in the year before and after their detention and compared this with the health of matched non-detainees.

Methods

In this matched cohort study, we linked national data on all persons detained in the Netherlands in 2014/2015 to electronic health records (EHR's) of a representative sample of general practitioners in the Netherlands. Participants include 952 detained persons and 4760 matched non-detained persons (matched on age, sex and general practice). Prevalence rates of health problems in the year before and after detention and odds ratios with 95% confidence intervals were calculated. Rates for a variety of physical and mental health problems are presented.

Findings

Detainees and matched controls differed statistically significant in their pre-detention health status. Compared with controls, male detainees were more likely to report psychological (odds ratio [OR] 3·64 [95% CI 3·11–4·26]), social (1·96 [1·46–2·64]), neurological (1·34 [1·02–1·76]), digestive (1·23 [1·02–1·49]), genital system-related (1·36 [1·07–1·72]), and unspecified health problems (1·32 [1·10–1·59]) in the year before their detention. For example, 43·7% of detainees and 17·6% of controls reported psychological problems in this pre-detention year. To some extent these pre-detention health differences were related to socioeconomic differences. Nevertheless, after taking these characteristics into account, a number of pre-detention health differences between detainees and controls remained statistically significant. No statistically significant changes in prevalence rates from pre- to post-detention and no differences in the levels of change across detainees and controls were observed. For female detainees a similar pattern was found.

Interpretation

People who experience detention have high and complex health needs both pre- and post-detention. While this study did not show a health deteriorating effect of detention, it also did not show a health improving effect. This latter finding may indicate a missed opportunity for health care services to address detainees’ health, especially since persons entering detention have elevated health problems. Knowledge on detainees’ specific health problems may help health care providers in prisons and in the community to adequately address the health care needs of this vulnerable group.

Funding

None.

Perceived Neighborhood Conditions, Self-Management Abilities, and Psychological Well-Being Among Chinese Older Adults in Hawai'i

Using survey data collected from January to September 2018 (N = 430), this study examined how neighborhood physical conditions and social cohesion were associated with psychological well-being via pathway of self-management abilities among Chinese older adults living in Honolulu, Hawai'i. Results showed that, for the whole sample, neighborhood physical conditions and social cohesion were significantly associated with psychological well-being, and the main associations were mediated by self-management abilities in the amount of 34% and 60%, respectively. Similar results were found for the foreign-born, whereas for the U.S.-born, psychological well-being was significantly related to neighborhood physical conditions only. Our findings reveal the importance of neighborhood conditions and individual psychological resources on psychological well-being of Chinese older adults.

Evaluating the plausible application of advanced machine learnings in exploring determinant factors of present pandemic: A case for continent specific COVID-19 analysis

Coronavirus disease, a novel severe acute respiratory syndrome (SARS COVID-19), has become a global health concern due to its unpredictable nature and lack of adequate medicines. Machine Learning (ML) models could be effective in identifying the most critical factors which are responsible for the overall fatalities caused by COVID-19. The functional capabilities of ML models in epidemiological research, especially for COVID-19, are not substantially explored. To bridge this gap, this study has adopted two advanced ML models, viz. Random Forest (RF) and Gradient Boosted Machine (GBM), to perform the regression modelling and provide subsequent interpretation. Five successive steps were followed to carry out the analysis: (1) identification of relevant key explanatory variables; (2) application of data dimensionality reduction for eliminating redundant information; (3) utilizing ML models for measuring relative influence (RI) of the explanatory variables; (4) evaluating interconnections between and among the key explanatory variables and COVID-19 case and death counts; (5) time series analysis for examining the rate of incidences of COVID-19 cases and deaths. Among the explanatory variables considered in this study, air pollution, migration, economy, and demographic factor were found to be the most significant controlling factors. Since a very limited research is available to discuss the superiority of ML models for identifying the key determinants of COVID-19, this study could be a reference for future public health research. Additionally, all the models and data used in this study are open source and freely available, thereby, reproducibility and scientific replication will be achievable easily.

Green Space and Health Equity: A Systematic Review on the Potential of Green Space to Reduce Health Disparities

Disadvantaged groups worldwide, such as low-income and racially/ethnically minoritized people, experience worse health outcomes than more privileged groups, including wealthier and white people. Such health disparities are a major public health issue in several countries around the world. In this systematic review, we examine whether green space shows stronger associations with physical health for disadvantaged groups than for privileged groups. We hypothesize that disadvantaged groups have stronger protective effects from green space because of their greater dependency on proximate green space, as they tend to lack access to other health-promoting resources. We use the preferred reporting items for systematic reviews and meta-analyses (PRISMA) method and search five databases (CINAHL, Cochrane, PubMed, Scopus, and Web of Science) to look for articles that examine whether socioeconomic status (SES) or race/ethnicity modify the green space-health associations. Based on this search, we identify 90 articles meeting our inclusion criteria. We find lower-SES people show more beneficial effects than affluent people, particularly when concerning public green spaces/parks rather than green land covers/greenness. Studies in Europe show stronger protective effects for lower-SES people versus higher-SES people than do studies in North America. We find no notable differences in the protective effects of green space between racial/ethnic groups. Collectively, these results suggest green space might be a tool to advance health equity and provide ways forward for urban planners, parks managers, and public health professionals to address health disparities.

The Relationship between Nature Deprivation and Individual Wellbeing across Urban Gradients under COVID-19

Lockdown aiming at slowing COVID-19 transmission has altered nature accessibility patterns, creating quasi-experimental conditions to assess if retracted nature contact and perceived nature deprivation influence physical and emotional wellbeing. We measure through on-line survey methods (n = 529) how pandemic mandates limiting personal movement and outdoor nature access within the United States affect self-assessed nature exposure, perceived nature deprivation, and subsequent flourishing as measured by the Harvard Flourishing Index. Results indicate that perceived nature deprivation strongly associates with local nature contact, time in nature, and access to municipal nature during the pandemic, after controlling for lockdown mandates, job status, household composition, and sociodemographic variables. Our hypothesis is that individuals with strong perceived nature deprivation under COVID-19 leads to diminished wellbeing proved true. Interaction models of flourishing showed positive modification of nature affinity with age and qualitative modification of nature deprivation with race. Our results demonstrate the potential of local nature contact to support individual wellbeing in a background context of emotional distress and social isolation, important in guiding public health policies beyond pandemics.

Green Space Exposure Association with Type 2 Diabetes Mellitus, Physical Activity, and Obesity: A Systematic Review

Type 2 diabetes mellitus (T2DM) is a public health challenge that must be addressed considering the large number of risk factors involved in its appearance. Some environmental risk factors are currently described as predictors of diabetes, with access to green spaces being an element to consider in urban settings. This review aims to study the association between exposure to green spaces and outcomes such as diabetes, obesity, and physical activity in the general population. A systematic review was carried out using the PubMed, Embase, and LILACS databases and other sources. The search strategy was carried out from October 2019 to October 2020. Cross-sectional and cohort studies were included. The article selection was made by a pair of reviewers, and data extraction was carried out using a data extraction sheet. The quality assessment of the included studies was carried out using a validated tool. Finally, 19 scientific articles were included in this review. Evidence supports that people and communities exposed to green spaces, especially in their neighborhood, reduce the risk of T2DM and reduce the risk of being obese and increase the likelihood of physical activity. The onset of T2DM can be moderated by using green spaces, improving physical activity levels, and reducing the risk of being overweight and obese.

Residential urban greenspace and hypertension: A comparative study in two European cities

BACKGROUND

Living in green areas has been associated with several health benefits; however, the available evidence on such benefits for hypertension is still limited. This study aimed to investigate and compare the association between residential exposure to greenspace and hypertension in Barcelona, Spain and Brussels, Belgium.

METHODS

This cross-sectional study was based on data from the 2016 Barcelona Health Interview Survey (HIS) (n = 3400) and the 2013 Belgian HIS (n = 2335). Both surveys were harmonized in terms of outcomes, confounders and exposure assessment. Residential exposure to greenspace was characterized as 1) surrounding greenspace (normalized difference vegetation index (NDVI) and modified soil-adjusted vegetation index 2 (MSAVI2)) across buffers of 100 m, 300 m, and 500 m; 2) surrounding green space across 300 m and 500 m buffers; and 3) Euclidean distance to the nearest green space. Our outcome was self-reported hypertension. We developed logistic regression models to evaluate the city-specific association between each greenspace measure and hypertension, adjusting for relevant covariates.

RESULTS

One interquartile range (IQR) increase in residential distance to the nearest green space was associated with higher risk of hypertension in Barcelona [odds ratio (OR): 1.15; 95%CI 1.03-1.29 (IQR: 262.2)], but not in Brussels [OR: 0.95; 95%CI 0.77-1.17 (IQR: 215.2)]. Stratified analyses suggested stronger associations in older participants (≥65 years) for both cities. Findings for residential surrounding green space and greenspace were not conclusive. However, in Brussels, we found protective associations in older participants for both residential surrounding greenspace metrics [NDVI 300 m buffer OR: 0.51; 95%CI 0.32-0.81 (IQR: 0.21) and MSAVI2 300 m buffer OR: 0.51; 95%CI 0.32-0.83 (IQR: 0.18)]. We did not find any indication for the modification of our evaluated associations by sex and education level.

CONCLUSION

Our study suggests that living closer to greenspace could be associated with lower risk of hypertension, particularly in older age. Future research is needed to replicate our findings in other settings and shed light on potential underlying mechanism(s).

Cross-classified multilevel models (CCMM) in health research: A systematic review of published empirical studies and recommendations for best practices

Recognizing that health outcomes are influenced by and occur within multiple social and physical contexts, researchers have used multilevel modeling techniques for decades to analyze hierarchical or nested data. Cross-Classified Multilevel Models (CCMM) are a statistical technique proposed in the 1990s that extend standard multilevel modeling and enable the simultaneous analysis of non-nested multilevel data. Though use of CCMM in empirical health studies has become increasingly popular, there has not yet been a review summarizing how CCMM are used in the health literature. To address this gap, we performed a scoping review of empirical health studies using CCMM to: (a) evaluate the extent to which this statistical approach has been adopted; (b) assess the rationale and procedures for using CCMM; and (c) provide concrete recommendations for the future use of CCMM. We identified 118 CCMM papers published in English-language literature between 1994 and 2018. Our results reveal a steady growth in empirical health studies using CCMM to address a wide variety of health outcomes in clustered non-hierarchical data. Health researchers use CCMM primarily for five reasons: (1) to statistically account for non-independence in clustered data structures; out of substantive interest in the variance explained by (2) concurrent contexts, (3) contexts over time, and (4) age-period-cohort effects; and (5) to apply CCMM alongside other techniques within a joint model. We conclude by proposing a set of recommendations for use of CCMM with the aim of improved clarity and standardization of reporting in future research using this statistical approach.

Perceived neighbourhood characteristics and depressive symptoms: Potential mediators and the moderating role of employment status

Multiple neighbourhood characteristics have been linked to depressive symptoms. However, few studies have simultaneously considered multiple mechanisms that explain this relationship, and how they might interact. Further, most studies regard exposure to the residential environment as constant, and therefore disregard variation in exposure by individual factors. This study investigates whether and to what extent stress and physical activity mediate the association between neighbourhood characteristics and depression, and also to what extent employment status moderates this relationship. A population-representative survey of n = 11,505 people in the Netherlands was conducted. Depressive symptoms were measured using the Patient Health Questionnaire (PHQ-9). Neighbourhood characteristics were perceived green and blue space, pleasantness, environmental disturbance, social cohesion and safety. Employment status was combined with place of work to establish two groups: those who were non-working or who worked from home ('at home'), and those who worked somewhere outside of the home ('working'). Multi-group structural equation modelling was employed to understand the theorised relationships for both groups. Perceived environmental disturbance, social cohesion and safety were significantly indirectly related to depressive symptoms via stress, with larger effect sizes in the 'at home' group. Pleasantness was also significantly indirectly related to depressive symptoms via stress, in the 'at home' group only. There was no evidence for physical activity as a mediator. Our findings suggest that neighbourhood social characteristics may have a greater influence on depressive symptoms than physical characteristics. Stress appears to be a key mediator of this relationship. In addition, the neighbourhood appears to exert a greater influence on those who spend more time in their neighbourhood. Interventions to promote mental health should focus on the social environment, and in particular pay attention to those who are spatially confined in poorer quality neighbourhoods.

Neighborhood Social and Built Environment and Disparities in the Risk of Hypertension: A Cross-Sectional Study

Citizens’ participation in urban environmental quality assessment is important when identifying local problems in the sustainable development and environmental planning policy. The principal aim of this study was to analyze whether any social differences exist between the joint effect of built neighborhood quality and exposure to urban green spaces and the risk of hypertension. The study sample consisted of 580 participants residing in 11 districts in Kaunas city, Lithuania. Using geographic information systems (GIS), individual data on the socioeconomic status (SES) and health were linked to the participants’ perceptions of the environmental quality and exposure to green spaces (NDVI). We used multivariate logistic regression to estimate associations as odds ratios (OR). Those study participants with lower education and those study participants with higher education on low incomes rated their health significantly worse. Low SES persons residing in areas with low exposure to green spaces had a significantly higher risk of hypertension when sex, age, family status, smoking, and income were accounted for (OR 1.83, 95% CI 1.01–3.36). This citizen science study provided evidence that the social environment and the quality of the built environment had a complex effect on disparities in the risk of hypertension.

Role of perceived neighbourhood crime in the longitudinal association between perceived built environment and type 2 diabetes mellitus: a moderated mediation analysis

BACKGROUND

We examined to what extent perceived neighbourhood crime moderates, associations between type 2 diabetes mellitus (T2DM) and perceived local amenities, recreational facilities, footpaths and public transit, and potential mediation of environmental characteristics-T2DM association by physical activity, social contact, sleep and body mass index (BMI).

METHODS

The 45 and Up Study data of 36, 224 individuals collected from 2010 to 2015 were analysed in 2019 using multilevel logistic regression to examine the association between T2DM and clustering of unfavourable built environment, and any difference in the association with increasing unfavourable environment and area disadvantage. We performed causal mediation analyses stratified by crime to examine whether crime moderated the strength of identified local amenities-T2DM pathways.

RESULTS

The results showed that irrespective of crime, perceived lack of local amenities was associated with increased odds of developing T2DM, and BMI mediated 40% and 30.3% of this association among those who reported unsafe and safe daytime crime, respectively. The proportion mediated by BMI among those who reported unsafe and safe night-time crime was 27.3% and 35.1%, respectively. Walking mediated 5.7% of the local amenities-T2DM association among those who reported safe daytime crime. The odds of T2DM increased with rising unfavourable environment and area disadvantage.

CONCLUSIONS

The results suggest that the availability of neighbourhood amenities may lower T2DM risk by increasing walking and reducing BMI regardless of area crime. Policies to enhance access to local amenities and prevent crime, especially in disadvantaged areas, may support healthy behaviour and physical health that can potentially reduce T2DM risk.

The association between natural outdoor environments and common somatic symptoms

There is growing evidence that urban natural outdoor environments (NOE) may positively impact health by reducing stress and stress-related symptoms. However, there is limited research investigating this link across a range of NOE indicators. This cross-sectional study investigated the association between neighbourhood NOE (availability, use, and satisfaction with NOE) and common somatic symptoms and the role of potential mediators. Data were analysed from 3481 adults from Barcelona (Spain), Doetinchem (Netherlands), Kaunas (Lithuania) and Stoke-on-Trent (United Kingdom). NOE data were obtained through self-reported data and environmental measurements. Common somatic symptom data were self-reported. Mixed effects regression models were used for analysis, with models adjusted for potential sociodemographic confounders. Higher satisfaction with neighbourhood NOE was associated with lower prevalence of common somatic symptoms (exp(β) 0.97; 95% CI 0.96, 0.98); an association partially mediated by mental health, social cohesion and air quality concern. A longer time spent in NOE was associated with lower prevalence of common somatic symptoms in low socioeconomic status neighbourhoods (exp(β) 0.98; 95% CI 0.96, 1.00). A higher number of neighbourhood green spaces (300m buffer) was associated with higher prevalence of common somatic symptoms (exp(β) 1.03; 95% CI 1.00, 1.05). No statistically significant associations were found for other NOE indicators. Study findings suggest that higher satisfaction with NOE may be associated with lower prevalence of common somatic symptoms, with mental health, social cohesion and concern about air quality playing partial mediating roles. Little evidence was found of an association between objective NOE measurements and common somatic symptoms, underlining the importance of perceptions of NOE for conferring health benefits.

Environmental Justice in The Netherlands: Presence and Quality of Greenspace Differ by Socioeconomic Status of Neighbourhoods

Making our cities more sustainable includes the need to make the transition a just one. This paper focuses on distributive justice with regard to greenspace in cities. Urbanisation and densification will likely result in less greenspace in urban residential areas, especially in deprived neighbourhoods. This is a threat to the aim of healthy and liveable cities, as greenspace has positive effects on human health and well-being. In this study, we show that in The Netherlands, neighbourhoods with a low socioeconomic status already tend to have a lower presence and quality of greenspace than those with a high socioeconomic status. This outcome is independent of the greenness metric that was used. However, depending on the precise greenness metric, socioeconomic differences in greenness between neighbourhoods are smaller in highly urban municipalities than in less urban municipalities, rather than larger. The paper discusses the implications of these outcomes for policy and planning regarding urban greenspace.

The Enigma of Gender Differences in an Environment-Behavior-Health Model of Elderly People: The Choice Between Individually and Sociality

Gender difference in the health of elderly people has become an important perspective to consider when studying their health. However, the gender differences in terms of “environment–behavior–health” from the social ecology perspective remain unknown. On the basis of survey data from Shanghai, China, including 2839 samples, this study explored the gender differences of outdoor environment–behavior–activity ability in elderly people from two aspects of the mean value of variables and the path relationship, utilizing the structural equation model analysis method combined with social ecology theory. The results showed that, at the level of the mean of variables, the elderly males had significantly higher mean values than the females in terms of individual behaviors, but had significantly lower values in terms of social behaviors. At the level of path relationships, there were similarities in that the health of elderly males was more likely to be affected by individual factors, whereas that of the females was more effected by social factors. Through the great positive effect of the high-level social behaviors, the health of the elderly females was progressively promoted. The study provided some useful insights for future research, aiming at promoting gender-sensitive urban design.

The Care Farming Sector in The Netherlands: A Reflection on Its Developments and Promising Innovations

This paper describes the development of care farming in the Netherlands, one of the pioneering countries in this sector, where care farming has developed into a very diverse sector, with some farmers focussing primarily on agricultural production and others more specifically on providing care services. Care farms are increasingly open to a diversity of participants. The sector has become professionalised with the establishment of strong regional organisations and a steady growth increase in revenues, providing employment opportunities and boosting the economy of rural areas. In this paper, we highlight two promising innovations in care farming: education for school dropouts and the establishment of social farming activities in cities. These innovations face the challenge of connecting not only the agricultural and care sectors, but also the educational sector and the urban context. Initiators face a number of challenges, like trying to embed their activities in the educational sector, a mismatch in regulations and a lack of legitimacy in the case of education on care farms, as well as problems gaining access to land and a lack of recognition in the case of social farming in urban areas. However, the prospects are promising in both cases, because they match the changing demands in Dutch society and are able to integrate social, ecological and economic benefits.

Relative importance of perceived physical and social neighborhood characteristics for depression: a machine learning approach

PURPOSE

The physical and social neighborhood environments are increasingly recognized as determinants for depression. There is little evidence on combined effects of multiple neighborhood characteristics and their importance. Our aim was (1) to examine associations between depression severity and multiple perceived neighborhood environments; and (2) to assess their relative importance.

METHODS

Cross-sectional data were drawn from a population-representative sample (N = 9435) from the Netherlands. Depression severity was screened with the Patient Health Questionnaire (PHQ-9) and neighborhood perceptions were surveyed. Supervised machine learning models were employed to assess depression severity-perceived neighborhood environment associations.

RESULTS

We found indications that neighborhood social cohesion, pleasantness, and safety inversely correlate with PHQ-9 scores, while increasing perceived distance to green space and traffic were correlated positively. Perceived distance to blue space and urbanicity seemed uncorrelated. Young adults, low-income earners, low-educated, unemployed, and divorced persons were more likely to have higher PHQ-9 scores. Neighborhood characteristics appeared to be less important than personal attributes (e.g., age, marital and employment status). Results were robust across different ML models.

CONCLUSIONS

This study suggested that the perceived social environment plays, independent of socio-demographics, a role in depression severity. Contrasted with person-level and social neighborhood characteristics, the prominence of the physical neighborhood environment should not be overstated.

Twenty-five years of Health & Place: Citation classics, internationalism and interdisciplinarity

To mark 25 years of Health & Place Health & Place, we identify and appraise some key contributions to the journal over this period. We use citation data to identify 'classics' from the journal's back catalogue. We also examine trends in the international reach and disciplinary homes of our authors. We show that there has been a near 7-fold increase in the number of published papers between the early and most recent years of the journal and that the journal's citation levels are amongst the top 2% of social science journals. Amongst the most cited papers, some clear themes are evident such as physical activity, diet/food, obesity and topics relating to greenspace. The profile of the journal's authors is becoming more internationally diverse, represents a broader range of disciplines, and increasingly demonstrating cross/interdisciplinary ways of working. Although Anglophone countries have led the way, there is an increasing number of contributions from elsewhere including emerging economies such as China. We conclude with some comments on likely future directions for the journal including enduring concerns such as greenspace, obesity, diet and unhealthy commodities (alcohol, tobacco, ultra-processed food) as well as more recent directions including planetary health, longitudinal and lifecourse analyses, and the opportunities (and challenges) of big data and machine learning. Whatever the thematic concerns of the papers over next 25 years, we will continue to welcome outstanding research that is concerned with the importance place makes to health.

Dynamic Urban Environmental Exposures on Depression and Suicide (NEEDS) in the Netherlands: a protocol for a cross-sectional smartphone tracking study and a longitudinal population register study

INTRODUCTION

Environmental exposures are intertwined with mental health outcomes. People are exposed to the environments in which they currently live, and to a multitude of environments along their daily movements and through their residential relocations. However, most research assumes that people are immobile, disregarding that such dynamic exposures also serve as stressors or buffers potentially associated with depression and suicide risk. The aim of the Dynamic Urban Environmental Exposures on Depression and Suicide (NEEDS) study is to examine how dynamic environmental exposures along people's daily movements and over their residential histories affect depression and suicide mortality in the Netherlands.

METHODS AND ANALYSIS

The research design comprises two studies emphasising the temporality of exposures. First, a cross-sectional study is assessing how daily exposures correlate with depression. A nationally representative survey was administered to participants recruited through stratified random sampling of the population aged 18-65 years. Survey data were enriched with smartphone-based data (eg, Global Positioning System tracking, Bluetooth sensing, social media usage, communication patterns) and environmental exposures (eg, green and blue spaces, noise, air pollution). Second, a longitudinal population register study is addressing the extent to which past environmental exposures over people's residential history affect suicide risk later in life. Statistical and machine learning-based models are being developed to quantify environment-health relations.

ETHICS AND DISSEMINATION

Ethical approval (FETC17-060) was granted by the Ethics Review Board of Utrecht University, The Netherlands. Project-related findings will be disseminated at conferences and in peer-reviewed journal papers. Other project outcomes will be made available through the project's web page, http://www.needs.sites.uu.nl.

Neighbourhood-level air pollution and greenspace and inflammation in adults

Inflammation has been proposed as a pathway from adverse physical environments to poor physical and mental health. We estimated longitudinal associations of neighbourhood-level air pollution and greenspace with individual-level inflammation (measured with C-reactive protein and fibrinogen), using data from over 8000 adults living in England and Wales who participated in Understanding Society. Using linear regression, we found that neighbourhood-level nitrogen dioxide predicted later levels of fibrinogen, but not C-reactive protein. Area air pollution, but not area greenery, appears to predict inflammation, even after accounting for social deprivation in the area.

Depressive symptoms among Chinese residents: how are the natural, built, and social environments correlated?

Background

Depression has become a severe societal problem in China. Although many studies have analyzed how environmental characteristics within neighborhoods affect depression, only a few have dealt with developing countries, and even fewer have considered built, natural, and social environments concurrently.

Methods

Based on a sample of 20,533 Chinese residents assessed in 2016, the present study examined associations between depressive symptoms and respondents’ built, natural, and social environments. Depressive symptoms were measured using the Center for Epidemiologic Studies Depression Scale (CES-D), and multilevel regression models were fitted accounting for potential covariates.

Results

Results indicated that living in neighborhoods with more green spaces and a higher population density were negatively associated with CES-D scores. Living in neighborhoods with more social capital was protective against depression. Furthermore, results showed that the social environment moderated the association between the built environment and depression.

Conclusions

Social environments moderate the relationship between the built environment and depression. As environments seem to interact with each other, we advise against relying on a single environment when examining associations with depressive symptoms.

Residential self-selection, perceived built environment and type 2 diabetes incidence: A longitudinal analysis of 36,224 middle to older age adults

Much of the existing studies on the built environment and type 2 diabetes are cross-sectional and prone to residential self-selection bias. Using multilevel logistic regression analysis of 36,224 participants from a longitudinal study, we examined whether perceived built environment characteristics are associated with type 2 diabetes. We found that the odds of diabetes incidence varied geographically. Those who reported that there were no local amenities and reported day- and night-time crime rates made walking unsafe in the neighbourhood had higher odds of developing incident type 2 diabetes. These associations persisted after accounting for some predictors of residential self-selection. More longitudinal studies are needed to corroborate the findings. Changing the features of the residential built environment may be an important point of intervention for type 2 diabetes prevention.

Is moving to a greener or less green area followed by changes in physical activity?

Green areas might provide an inviting setting and thereby promote physical activity. The objective of this study was to determine whether moving to different green area surroundings was followed by changes of physical activity. Data from a large population-based cohort of adults in Stockholm County responding to surveys in 2010 and 2014 were analysed (n = 42611). Information about walking/cycling and exercise were self-reported and living area greenness data were satellite-derived (NDVI, Normalized Difference Vegetation Index). Multinomial logistic regression analyses were performed separately for changes in levels of walking/cycling and exercise (decrease, stable, increase). Greenness was defined as a change in NDVI quartile to less green, same, or greener. Odds ratio's (OR) with 95% confidence intervals (CI) were presented adjusted for gender, age, education and area-based income. Contrary to what we hypothesized, those moving to a greener area were more likely to decrease their levels of walking/cycling (OR = 1.42, CI = 1.28-1.58), whereas those moving to a less green area were more likely to increase their walking/cycling (OR = 1.26, CI = 1.13-1.41). Exercise behaviour showed another pattern, with people being more likely to decrease exercise both when moving to a greener (OR = 1.25, CI = 1.22-1.38) and to a less green area (OR = 1.22, CI = 1.09-1.36). Studying subpopulations based on sociodemographic characteristics did not aid to clarify our results. This cohort study with repeated measurements did not support the currently available cross-sectional studies showing a strong positive relation between greenness and physical activity. Nevertheless, our findings have shown spatial patterns related to green areas and physical activity which imply a need for place-specific health policies.

Using deep learning to examine street view green and blue spaces and their associations with geriatric depression in Beijing, China

BACKGROUND

Residential green and blue spaces may be therapeutic for the mental health. However, solid evidence on the linkage between exposure to green and blue spaces and mental health among the elderly in non-Western countries is scarce and limited to exposure metrics based on remote sensing images (i.e., land cover and vegetation indices). Such overhead-view measures may fail to capture how people perceive the environment on the site.

OBJECTIVE

This study aimed to compare streetscape metrics derived from street view images with satellite-derived ones for the assessment of green and blue space; and to examine associations between exposure to green and blue spaces as well as geriatric depression in Beijing, China.

METHODS

Questionnaire data on 1190 participants aged 60 or above were analyzed cross-sectionally. Depressive symptoms were assessed through the shortened Geriatric Depression Scale (GDS-15). Streetscape green and blue spaces were extracted from Tencent Street View data by a fully convolutional neural network. Indicators derived from street view images were compared with a satellite-based normalized difference vegetation index (NDVI), a normalized difference water index (NDWI), and those derived from GlobeLand30 land cover data on a neighborhood level. Multilevel regressions with neighborhood-level random effects were fitted to assess correlations between GDS-15 scores and these green and blue spaces exposure metrics.

RESULTS

The average cumulative GDS-15 score was 3.4 (i.e., no depressive symptoms). Metrics of green and blue space derived from street view images were not correlated with satellite-based ones. While NDVI was highly correlated with GlobeLand30 green space, NDWI was moderately correlated with GlobeLand30 blue space. Multilevel regressions showed that both street view green and blue spaces were inversely associated with GDS-15 scores and achieved the highest model goodness-of-fit. No significant associations were found with NDVI, NDWI, and GlobeLand30 green and blue space. Our results passed robustness tests.

CONCLUSION

Our findings provide support that street view green and blue spaces are protective against depression for the elderly in China, yet longitudinal confirmation to infer causality is necessary. Street view and satellite-derived green and blue space measures represent different aspects of natural environments. Both street view data and deep learning are valuable tools for automated environmental exposure assessments for health-related studies.

Community greenness, blood pressure, and hypertension in urban dwellers: The 33 Communities Chinese Health Study

BACKGROUND

Living in greener areas has many health benefits, but evidence concerning the effects on blood pressure remains mixed. We sought to assess associations between community greenness and both blood pressure and hypertension in Chinese urban dwellers, and whether the associations were mediated by air pollution, body mass index, and physical activity.

METHODS

We analyzed data from 24,845 adults participating in the 33 Communities Chinese Health Study, which was conducted in Northeastern China during 2009. We measured each participant's blood pressure according to a standardized protocol. We assessed community greenness using two satellite-derived vegetation indexes - the Normalized Difference Vegetation Index (NDVI) and the Soil Adjusted Vegetation Index (SAVI). Particulate matter ≤2.5 μm and nitrogen dioxide were used as proxies of ambient air pollution. We applied generalized linear mixed models to investigate the association between greenness and blood pressure. We also performed mediation analyses.

RESULTS

Living in greener areas was associated with lower blood pressure and hypertension prevalence; an interquartile range increase in both NDVI_500-m and SAVI_500-m were significantly associated with reductions in systolic blood pressure of 0.82 mm Hg (95% CI: -1.13, -0.51) and 0.89 mm Hg (95% CI: -1.21, -0.57), respectively. The same increases in greenness were also significantly associated with a 5% (95% CI: 1%, 8%) and 5% (95% CI: 1%, 9%) lower odds of having hypertension, respectively. These associations remained consistent in sensitivity analyses. The associations were stronger among women than men. Air pollutants and body mass index partly mediated the associations, but there was no evidence of mediation effects for physical activity.

CONCLUSIONS

Our findings indicate beneficial associations between community greenness and blood pressure in Chinese adults, especially for women. Air pollution and body mass index only partly mediated the associations.

Cross-sectional associations between long-term exposure to particulate matter and depression in China: The mediating effects of sunlight, physical activity, and neighborly reciprocity

BACKGROUND

Although numerous studies have speculated about the direct and indirect linkage between long-term air pollution (i.e., PM_2.5) concentrations and mental health in developed countries, evidence for developing countries is limited. Our aim was to examine the mediation effects of sunlight, physical activity, and neighborly reciprocity on the association between air pollution and depression.

METHODS

In a sample of 20,861 individuals in China in 2016, depression was measured using the Center for Epidemiological Studies Depression screener (CES-D) and linked to annual city-wide PM_2.5 data. We used multilevel regression models to assess the associations between depressive symptoms and PM_2.5 and tested the mediation of sunlight, physical activity, and neighborly reciprocity in this association. Propensity score matching was used to evaluate whether selection bias may affect the association between CES-D scores and PM_2.5.

RESULTS

PM_2.5 concentration was positively associated with depression symptoms. All mediators were significantly and negatively associated with PM_2.5. Our mediation analyses indicated that physical activity, neighborly reciprocity, and exposure to sunlight are important mechanisms through which PM_2.5 affects depressive symptoms.

LIMITATIONS

The limitations of the present study were the cross-sectional nature of the data and modifiable areal unit problem.

CONCLUSIONS

Our findings suggest not only that PM_2.5 is directly associated with depression, but also that this association seems to be partially mediated by physical activity, neighborly reciprocity, and sunlight.

Spatiotemporal Contextual Uncertainties in Green Space Exposure Measures: Exploring a Time Series of the Normalized Difference Vegetation Indices

Environmental health studies on green space may be affected by contextual uncertainties originating from the temporality of environmental exposures and by how the spatial context is delimitated. The Normalized Difference Vegetation Index (NDVI) is frequently used as an outdoor green space metric capturing the chlorophyll content in the vegetation canopy. This study assessed (1) whether residential NDVI exposures vary over time, and (2) how these time series of NDVI scores vary across spatial context delimitations. Multi-temporal NDVI data for the period 2006–2017 for the Netherlands were obtained from the Moderate Resolution Imaging Spectroradiometer (MODIS) satellite platform. Annual NDVI exposures were determined across multiple buffer sizes (i.e., 300, 600, and 1000 m) centered on a random sample of 10,000 Dutch residential addresses. Besides the descriptive statistics, pairwise Wilcoxon tests and Fligner–Killeen tests were used to determine mean and variance differences in annual NDVI scores across buffer widths. Heat maps visualized the correlation matrices. Significance levels were adjusted for multiple hypotheses testing. The results indicated that annual NDVI metrics were significantly correlated but their magnitude varied notably between 0.60 to 0.97. Numerous mean and variance differences in annual NDVI exposures were significant. It seems that the disparate buffers (i.e., 300 and 1000 m) were less strongly correlated, possibly because variance heterogeneity is reduced in larger buffers. These results have been largely consistent over the years and have passed Monte Carlo-based sensitivity tests. In conclusion, besides assessing green space exposures along different buffer sizes, our findings suggest that green space–health studies should employ NDVI data that are well-aligned with epidemiological data. Even an annual temporal incompatibility may obscure or distort green space–health associations. Both strategies may diminish contextual uncertainties in environmental exposure assessments.

Greenspace seems protective of both high and low blood pressure among residents of an Alpine valley

BACKGROUND

There is some data suggesting that residential greenspace may protect against high blood pressure in urbanized areas, but there is no evidence of effects on hypotension, in less urbanized areas, and in idiosyncratic geographic contexts such as mountain valleys.

OBJECTIVES

The current study aimed to investigate the associations between residential greenspace and blood pressure in an alpine valley in Austria.

METHODS

We conducted a cross-sectional survey of a representative sample of 555 adults living in the Lower Inn Valley, Austria. Several definitions of blood pressure were employed: continuously-measured systolic (SBP) and diastolic blood pressure (DBP), doctor-diagnosed hyper- and hypotension, and high- and low blood pressure medication use. Greenspace metrics considered were: Normalized Difference Vegetation Index (NDVI), Soil Adjusted Vegetation Index (SAVI), and tree cover as measures of surrounding greenness in circular buffers of 100 m, 300 m, 500 m, and 1000 m around the home; distance to different types of structured green space; and having a domestic garden and a balcony. Relationships were examined across different definitions of blood pressure and greenspace and evaluated for potential effect modification by demographic factors, presence of a domestic garden/balcony, adiposity, and traffic sensitivity.

RESULTS

Higher overall greenness was associated with 30-40% lower odds of hyper/hypotension and 2-3 mm Hg lower SBP. Similar pattern was revealed for tree cover, however, associations with hypertension were less consistent across buffers, and SBP and DBP were lower only in association with greenness in the 100-m buffer. Having a domestic garden also seemed protective of high DBP. Residing near to forests, agricultural land, or urban green spaces was not related to blood pressure. Higher NDVI_500-m was stronger associated with lower SBP in those having a domestic garden, while the effect on DBP was stronger in overweight/obese participants.

CONCLUSION

These findings support the idea that greenspace should be considered as protective of both high and low blood pressure, however, underlying mechanisms remain insufficiently understood.

Urban residential greenness and adiposity: A cohort study in Stockholm County

BACKGROUND

Increasing evidence suggests that exposure to residential greenness is associated with positive health outcomes among urban populations. However, few studies have considered effects on adiposity development in a longitudinal setting.

OBJECTIVES

This study aimed to explore the association between long-term exposure to urban residential greenness and markers of adiposity.

METHODS

A cohort of 5126 adults from five municipalities in Stockholm County was examined clinically at baseline (1992-1998) and follow-up (2002-2006) after on average nine years. Time-weighted average exposure to urban greenness was estimated by Normalized Difference Vegetation Index (NDVI) within 100 m, 250 m, and 500 m buffers around the residential addresses of each participant. Multiple linear and Poisson regression models were used to estimate associations between greenness and change in weight and waist circumference as well as risk of overweight, obesity and central obesity. Co-exposures to air pollution, traffic noise and distance to water were also examined.

RESULTS

In women, higher levels of residential greenness were associated with a reduced increase in waist circumference during follow-up (β = -0.11 cm/year, 95% CI -0.14; -0.08 per one interquartile range increase in NDVI) and decreased risk for central obesity (IRR = 0.88: 95% CI 0.79; 0.99) in the 500 m buffer. No associations were observed for men or with regard to weight development or the risk of developing overweight or obesity. Exposure to low NDVI levels in combination with high NO_x from road traffic and transportation noise as well as long distance to water rendered statistically significant increases in waist circumference in both sexes.

CONCLUSION

Higher long-term exposure to greenness was associated with a reduced increase in waist circumference and lower risk of central adiposity in women but not in men. In both sexes, low NDVI exposure in combination with other environmental risk factors appeared particularly harmful.

The impact of social capital, land use, air pollution and noise on individual morbidity in Dutch neighbourhoods

BACKGROUND

Both social and physical neighbourhood factors may affect residents' health, but few studies have considered the combination of several exposures in relation to individual health status.

AIM

To assess a range of different potentially relevant physical and social environmental characteristics in a sample of small neighbourhoods in the Netherlands, to study their mutual correlations and to explore associations with morbidity of residents using routinely collected general practitioners' (GPs') data.

METHODS

For 135 neighbourhoods in 43 Dutch municipalities, we could assess area-level social cohesion and collective efficacy using external questionnaire data, urbanisation, amount of greenspace and water areas, land use diversity, air pollution (particulate matter (PM) with a diameter <10 μm (PM₁₀), PM <2.5 μm (PM_2.5) and nitrogen dioxide (NO₂), and noise (from road traffic and from railways). Health data of the year 2013 from GPs were available for 4450 residents living in these 135 neighbourhoods, that were representative for the entire country. Morbidity of 10 relevant physical or mental health groupings was considered. Individual-level socio-economic information was obtained from Statistics Netherlands. Associations between neighbourhood exposures and individual morbidity were quantified using multilevel mixed effects logistic regression analyses, adjusted for sex, age (continuous), household income and socio-economic status (individual level) and municipality and neighbourhood (group level).

RESULTS

Most physical exposures were strongly correlated with degree of urbanisation. Social cohesion and collective efficacy tended to be higher in less urbanised municipalities. Degree of urbanisation was associated with higher morbidity of all disease groupings. A higher social cohesion at the municipal level coincided with a lower prevalence of depression, migraine/severe headache and Medically Unexplained Physical Symptoms (MUPS). An increase in both natural and agricultural greenspace in the neighbourhood was weakly associated with less morbidity for all conditions. A high land use diversity was consistently associated with lower morbidities, in particular among non-occupationally active individuals.

CONCLUSION

A high diversity in land use of neighbourhoods may be beneficial for physical and mental health of the inhabitants. If confirmed, this may be incorporated into urban planning, in particular regarding the diversity of greenspace.

Impacts of Individual Daily Greenspace Exposure on Health Based on Individual Activity Space and Structural Equation Modeling

Previous studies on the effects of greenspace exposure on health are largely based on static contextual units, such as residential neighborhoods, and other administrative units. They tend to ignore the spatiotemporal dynamics of individual daily greenspace exposure and the mediating effects of specific activity type (such as physical activity). Therefore, this study examines individual daily greenspace exposure while taking into account people’s daily mobility and the mediating role of physical activity between greenspace exposure and health. Specifically, using survey data collected in Guangzhou, China, and high-resolution remote sensing images, individual activity space for a weekday is delineated and used to measure participants’ daily greenspace exposure. Structural equation modeling is then applied to analyze the direct effects of individual daily greenspace exposure on health and its indirect effects through the mediating variable of physical activity. The results show that daily greenspace exposure directly influences individual health and also indirectly affects participants’ health status through physical activity. With respect to the total effects, daily greenspace exposure helps improve participants’ mental health and contributes to promoting their social health. It also helps improve participants’ physical health, although to a lesser extent. In general, the higher the daily greenspace exposure, the higher the physical activity level and the better the overall health (including physical, mental, and social health).

More green space is related to less antidepressant prescription rates in the Netherlands: A Bayesian geoadditive quantile regression approach

BACKGROUND

Exposure to green space seems to be beneficial for self-reported mental health. In this study we used an objective health indicator, namely antidepressant prescription rates. Current studies rely exclusively upon mean regression models assuming linear associations. It is, however, plausible that the presence of green space is non-linearly related with different quantiles of the outcome antidepressant prescription rates. These restrictions may contribute to inconsistent findings.

OBJECTIVE

Our aim was: a) to assess antidepressant prescription rates in relation to green space, and b) to analyze how the relationship varies non-linearly across different quantiles of antidepressant prescription rates.

METHODS

We used cross-sectional data for the year 2014 at a municipality level in the Netherlands. Ecological Bayesian geoadditive quantile regressions were fitted for the 15%, 50%, and 85% quantiles to estimate green space-prescription rate correlations, controlling for physical activity levels, socio-demographics, urbanicity, etc. RESULTS: The results suggested that green space was overall inversely and non-linearly associated with antidepressant prescription rates. More important, the associations differed across the quantiles, although the variation was modest. Significant non-linearities were apparent: The associations were slightly positive in the lower quantile and strongly negative in the upper one.

CONCLUSION

Our findings imply that an increased availability of green space within a municipality may contribute to a reduction in the number of antidepressant prescriptions dispensed. Green space is thus a central health and community asset, whilst a minimum level of 28% needs to be established for health gains. The highest effectiveness occurred at a municipality surface percentage higher than 79%. This inverse dose-dependent relation has important implications for setting future community-level health and planning policies.

Overweight modifies the association between long-term ambient air pollution and prehypertension in Chinese adults: the 33 Communities Chinese Health Study

BACKGROUND

Research regarding the interaction of ambient air pollution and overweight on prehypertension is scarce. We aimed to test whether overweight modifies the association between long-term exposure to ambient air pollution and prehypertension in Chinese adults.

METHODS

A total of 16,188 Chinese adults, aged 18-74 years old, from 33 communities in 3 Northeastern Chinese cities were evaluated. Three-year average levels of particles with an aerodynamic diameter ≤ 10 μm (PM₁₀), sulfur dioxides (SO₂), nitrogen dioxides (NO₂), and ozone (O₃) were calculated at monitoring stations. Generalized additive models and 2-level regression analyses were applied.

RESULTS

We observed significant interactions between air pollutants and overweight on prehypertension and blood pressure. The associations of PM₁₀, SO₂, NO₂, and O₃ with prehypertension were significant among overweight participants (Prevalence Rate Ratios (PRRs) per interquartile range (IQR) of air pollutants: 1.14-1.20), but not among normal weight participants (PRRs: 0.98-1.04). PM₁₀, SO₂, and O₃ were significantly associated with systolic blood pressure (SBP), and the magnitudes of these associations were higher among overweight adults (increases in SBP per IQR of air pollutants: 1.82-4.53 mmHg) than those among normal weight adults (increases in SBP: 0.42-0.61 mmHg). For diastolic blood pressure (DBP), significant associations were mainly observed in overweight participants (increases in DBP: 0.80-1.63 mmHg). Further stratified analyses showed that all these interactions were stronger in women, the older, and participants living in areas with lower income levels or higher population density.

CONCLUSIONS

Being overweight may enhance the effects of ambient air pollution on prehypertension and blood pressure in Chinese adults.