Residential green space, air pollution, socioeconomic deprivation and cardiovascular medication sales in Belgium: A nationwide ecological study

Moderating effect of green space on relationship between atmospheric particulate matter and cardiovascular and cerebrovascular disease mortality in Ningxia, China

OBJECTIVE

This study explores the moderating effect of green space on the association between atmospheric particulate matter (PM) and cardiovascular and cerebrovascular disease (CCVD) mortality.

METHODS

Data on CCVD mortality, PM, meteorological factors, and the Normalized Difference Vegetation Index (NDVI) of green spaces in Ningxia from 2010 to 2020 were collected. A time-series generalized additive mixed-effect model (GAMM) was applied to analyze the exposure-response relationship between PM and CCVD mortality. The moderating effect of green spaces was examined using green space buffers of different radii (300 m, 500 m, 1000 m, and 2000 m) and density.

RESULTS

There were 150,356 CCVD deaths in Ningxia during the study period. The annual mean concentrations of PM2.5 and PM10 were 44.44 μg/m³ and 105.30 μg/m³, respectively, with an annual mean NDVI value of 0.25 within a 500 m radius buffer. An increase of 10 μg/m³ in PM2.5 and PM10 concentrations was significantly associated with an elevated risk of CCVD mortality, with the strongest excess risk (ER) observed at lag07 lag. The ER for PM2.5 was 1.43% (95% CI: 0.97%, 1.89%), and for PM10 was 0.55% (95% CI: 0.38%, 0.72%). The interaction analysis indicated that higher green space density could moderate the association between PM exposure and CCVD mortality risk. and as the green space buffer zone expanded, the interaction on CCVD mortality risk progressively strengthened. The independent moderation analysis indicated that an increase in green space buffer zone was associated with a reduced risk, and as green space density increased from Q1 to Q3, the ER for PM2.5-related CCVD mortality decreased from 1.56% to 0.6%, while the ER for PM10-related CCVD mortality decreased from 0.53% to 0.09%. In conclusion, atmospheric PM is associated with increased CCVD mortality risk, while larger green space buffers and higher green space density significantly moderated this association.

Urban green space, human heat perception and sleep quality: A repeated cross-sectional study

Urban heat poses significant challenges to public health, as exposure to high temperatures is associated to heat stress, resulting in heat strain, sleep deprivation, and cardiovascular morbidity and mortality. As the frequency of heat waves is increasing due to global warming, urban green spaces are often proposed as a nature-based solution to mitigate urban heat stress. This study investigated the impact of urban green space on perceived heat stress and sleep quality, using questionnaires and detailed land cover data. We surveyed 584 respondents during four heat and four control events in the summers of 2021 and 2022, assessing perceived heat stress, sleep quality, and mental health. Using structural equation models, this study analysed the influence of both tree cover and grass and shrub cover on perceived heat stress and sleep quality, while controlling for risk and vulnerability factors. The outcomes revealed that during heat events, enhanced tree cover was associated with reduced heat stress (B = -0.484, 95% CI [-0.693, -0.275], p = 0.001), while increased grass and shrub cover was associated with both reduced heat stress (B = -0.361 [-0.529, -0.193], p = 0.000) and improved sleep quality (B = -0. 241 [-0.399, -0.083], p = 0.003). Conversely, during control events, stress indicators were more strongly associated with individual vulnerability factors rather than surrounding green space. These results emphasize the importance of combining trees with lower vegetation in urban planning to mitigate heat-related stress and enhance sleep quality, thereby improving overall well-being during heat events.

Relationship between urban green space and mental health in older adults: mediating role of relative deprivation, physical activity, and social trust

Introduction

The importance of improving older adults' mental health is increasing worldwide with the rapid development of the aging process. Green space is an important part of the urban built environment, demonstrates a deep connection with the mental health of older adults, and its internal mechanisms have been widely studied. This study analyzed the influence of urban green spaces on the mental health of older adults via three factors: relative deprivation, physical activity, and social trust.

Methods

Based on the 2018 China Labor Dynamics Survey, a multi-level structural equation model was used to explore the mediating roles of relative deprivation, physical activity, social trust in urban green spaces, and the mental health of older adults.

Results

Urban green space was positively correlated with the mental health of older adults. Relative deprivation and physical activities played a mediating role between urban green space and the mental health of older adults.

Discussion

An increase in urban green spaces can help increase the number of older adults obtaining green space resources, and help them maintain good mental health. Secondly, older adults with a relatively homogeneous environment have more equal opportunities to obtain urban green space resources, which helps to reduce the comparison of older adults in access to green space resources and reduce the adverse impact of relative deprivation on their mental health. Additionally, increasing urban green spaces can encourage older adults to engage in physical activities and improve their mental health. Finally, we suggest improving the accessibility, fairness, and quality of green spaces, paying attention to the psychological needs of older adults, encouraging older adults to engage in physical activities in green spaces, and taking various measures to enhance the positive role of green space on the mental health of older adults.

The economics of nature's healing touch: A systematic review and conceptual framework of green space, pharmaceutical prescriptions, and healthcare expenditure associations

Green spaces play a crucial role in promoting sustainable and healthy lives. Recent evidence shows that green space also may reduce the need for healthcare, prescription medications, and associated costs. This systematic review provides the first comprehensive assessment of the available literature examining green space exposure and its associations with healthcare prescriptions and expenditures. We applied Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines to search MEDLINE, Scopus, and Web of Science for observational studies published in English through May 6, 2023. A quality assessment of the included studies was conducted using the Office of Health Assessment and Translation (OHAT) tool, and the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) assessment was used to evaluate the overall quality of evidence. Our search retrieved 26 studies that met the inclusion criteria and were included in our review. Among these, 20 studies (77 % of the total) showed beneficial associations of green space exposure with healthcare prescriptions or expenditures. However, most studies had risks of bias, and the overall strength of evidence for both outcomes was limited. Based on our findings and related bodies of literature, we present a conceptual framework to explain the possible associations and complex mechanisms underlying green space and healthcare outcomes. The framework differs from existing green space and health models by including upstream factors related to healthcare access (i.e., rurality and socioeconomic status), which may flip the direction of associations. Additional research with lower risks of bias is necessary to validate this framework and better understand the potential for green space to reduce healthcare prescriptions and expenditures.

Cluster pattern analysis of environmental stressors and quantifying their impact on all-cause mortality in Belgium

Environmental stress represents an important burden on health and leads to a considerable number of diseases, hospitalisations, and excess mortality. Our study encompasses a representative sample size drawn from the Belgian population in 2016 (n = 11.26 million, with a focus on n = 11.15 million individuals). The analysis is conducted at the geographical level of statistical sectors, comprising a total of n = 19,794 sectors, with a subset of n = 18,681 sectors considered in the investigation. We integrated multiple parameters at the finest spatial level and constructed three categories of environmental stress through clustering: air pollution, noise stress and stress related to specific land-use types. We observed identifiable patterns in the spatial distribution of stressors within each cluster category. We assessed the relationship between age-standardized all-cause mortality rates (ASMR) and environmental stressors. Our research found that especially very high air pollution values in areas where traffic is the dominant local component of air pollution (ASMR + 14,8%, 95% CI: 10,4 - 19,4%) and presence of industrial land (ASMR + 14,7%, 95% CI: 9,4 - 20,2%) in the neighbourhood are associated with an increased ASMR. Cumulative exposure to multiple sources of unfavourable environmental stress (simultaneously high air pollution, high noise, presence of industrial land or proximity of primary/secondary roads and lack of green space) is associated with an increase in ASMR (ASMR + 26,9%, 95% CI: 17,1 - 36,5%).

Association of air pollution and green space with all-cause general practitioner and emergency room visits: A cross-sectional study of young people and adults living in Belgium

BACKGROUND

Residing in areas with lower levels of air pollution and higher green space is beneficial to physical and mental health. We investigated associations of PM2.5, tree cover and grass cover with in-hours and out-of-hours GP visits and ER visits, for young people and adults. We estimated potential cost savings of GP visits attributable to high PM2.5.

METHODS

We linked individual-level health insurance claims data of 315,123 young people (10-24 years) and 885,988 adults (25-64 years) with census tract-level PM2.5, tree cover and grass cover. Deploying negative binomial generalized linear mixed models, we estimated associations between quartile exposures and the three outcome measures.

RESULTS

For in-hours and out-of-hours GP visits, among young people as well as adults, statistically significant pairwise differences between quartiles suggested increasing beneficial effects with lower PM2.5. The same outcomes were statistically significantly less frequent in quartiles with highest tree cover (>30.00%) compared to quartiles with lower tree cover, but otherwise pairwise differences were not statistically significant. These associations largely persisted in rural and urban areas. Among adults living in urban areas lower grass cover was associated with increased in-hours GP visits and ER visits. Assuming causality, reducing PM2.5 levels to the lowest quartile (4.91-7.49 μg/m³), among adults, 195,964 in-hours and 74,042 out-of-hours GP visits could be avoided annually. Among young people, 27,457 in-hours and 22,423 out-of-hours GP visits could be avoided annually. Nationally, this amounts to an annual potential cost saving of €43 million (€5.7 million in out-of-pocket payments and €37.2 million in compulsory health insurance).

CONCLUSION

Higher ambient PM2.5 and lower tree cover show associations with higher non-urgent and urgent medical care utilization. These findings confirm the importance of reducing air pollution and fostering green zones, and that such policies may contribute positively to economic growth.

Street-view and traditional greenness metrics with adults' sitting time in high-density living in Hong Kong: Comparing associations, air pollution and noise roles, and population heterogeneity

BACKGROUND

Emerging evidence suggests neighborhood greenness is associated with physical activity; however, the sitting-specific associations with multi-source greenness metrics remain unclear, especially in high-density cities.

OBJECTIVES

This cross-sectional study examined: 1) the associations of street-view greenness (SVG) and traditional greenness metrics (i.e., Normalized Difference Vegetable Index (NDVI) and park density) with sitting time; 2) the potential moderating/mediating roles of objective/perceived air pollution and perceived roadside noise; and 3) how the associations vary by demographics and socioeconomic status.

METHODS

Interview survey data of 1977 adults in Hong Kong from 2014 and 2015 was linked to environmental data. Using an object-based image classification algorithm, SVG was derived from Google Street View images, capturing human-viewed street-level greenery. NDVI was derived from Landsat 8 satellite images using the normalized difference between the near-infrared and red bands. Park density was calculated by point density. In the main analyses including regressions, parallel mediation, interaction, and stratified models, the environmental metrics were measured within a 1000-m Euclidean buffer of residence.

RESULTS

SVG and park density were negatively associated with sitting time after adjusting for covariates including physical activity while NDVI was not significantly associated with sitting time, and results were robust with 800-1800 m Euclidean and 1400-1800 m network distance. Greenness-sitting associations were not moderated/mediated by perceived air pollution/roadside noise while SVG-sitting associations were moderated by objective NO₂, O₃, and PM_2.5 and mediated by O₃. SVG-sitting associations differed by age, having under-school-aged children, birthplace, education, and occupation type while associations between traditional greenness metrics and prolonged sitting showed no significant population heterogeneity.

CONCLUSIONS

SVG appears to be more accurate in estimating exposure than traditional metrics to reflect greenness-sitting associations, objective air pollution moderating and mediating roles, and population heterogeneity, which emphasizes the importance of street-level greenness planning for health promotion in terms of reducing sitting time.

How do territorial characteristics affect spatial inequalities in the risk of coronary heart disease?

BACKGROUND

Cardiovascular diseases remain the leading cause of death and disabilities worldwide, with coronary heart diseases being the most frequently diagnosed. Their multifactorial etiology involves individual, behavioral and territorial determinants, and thus requires the implementation of multidimensional approaches to assess links between territorial characteristics and the incidence of coronary heart diseases.

CONTEXT AND OBJECTIVES

This study was carried out in a densely populated area located in the north of France with multiple sources of pollutants. The aim of this research was therefore to establish complex territorial profiles that have been characterized by the standardized incidence, thereby identifying the influences of determinants that can be related to a beneficial or a deleterious effect on cardiovascular health.

METHODS

Forty-four variables related to economic, social, health, environment and services dimensions with an established or suspected impact on cardiovascular health were used to describe the multidimensional characteristics involved in cardiovascular health.

RESULTS

Three complex territorial profiles have been highlighted and characterized by the standardized incidence rate (SIR) of coronary heart diseases after adjustment for age and gender. Profile 1 was characterized by an SIR of 0.895 (sd: 0.143) and a higher number of determinants that revealed favorable territorial conditions. Profiles 2 and 3 were characterized by SIRs of respectively 1.225 (sd: 0.242) and 1.119 (sd: 0.273). Territorial characteristics among these profiles of over-incidence were nevertheless dissimilar. Profile 2 revealed higher deprivation, lower vegetation and lower atmospheric pollution, while profile 3 displayed a rather privileged population with contrasted territorial conditions.

CONCLUSION

This methodology permitted the characterization of the multidimensional determinants involved in cardiovascular health, whether they have a negative or a positive impact, and could provide stakeholders with a diagnostic tool to implement contextualized public health policies to prevent coronary heart diseases.

Does the quality of street greenspace matter? Examining the associations between multiple greenspace exposures and chronic health conditions of urban residents in a rapidly urbanising Chinese city

BACKGROUND

Numerous studies have demonstrated that greenspace(GS) exposure is associated with health improvements in individuals with hypertension and diabetes. However, studies examining the associations between multiple GS exposures and chronic health conditions in developing countries are limited.

METHODS

Geospatial data and spatial analysis were employed to objectively measure the total neighbourhood vegetative cover (mean value of normalised difference vegetation index [NDVI] within specific buffer zone) and proximity to park-based GS (network distance from home to the entrance of park-based GS). Street view imagery and machine learning techniques were used to measure the subjective perceptions of street GS quality. A multiple linear regression model was applied to examine the associations between multiple GS exposures and the prevalence of hypertension and diabetes in neighbourhoods located in Qingdao, China.

RESULTS

The model explained 29.8% and 28.2% of the prevalence of hypertension and diabetes, respectively. The results suggested that: 1) the total vegetative cover of the neighbourhood was inversely correlated with the prevalence of hypertension (β = -0.272, p = 0.013, 95% confidence interval (CI): [-1.332, -0.162]) and diabetes (β = -0.230, p = 0.037, 95% CI: [-0.720, -0.008]). 2) The street GS quality was negatively correlated with the prevalence of hypertension (β = -0.303, p = 0.007, 95% CI: [-2.981, -0.491]) and diabetes (β = -0.309, p = 0.006, 95% CI: [-1.839, -0.314]). 3) Proximity to park-based GS and the prevalence of hypertension and diabetes mellitus were not significantly correlated.

CONCLUSIONS

This study used subjective and objective methods to comprehensively assess the greenspace exposure from overhead to eye level, from quantity, proximity to quality. The results demonstrated the beneficial relationships between street GS quality, total vegetative cover, and chronic health in a rapidly urbanising Chinese city. Furthermore. the effect of street GS quality was more pronounced in potentially mitigating chronic health problems, and improving the quality of street GS might be an efficient and effective intervention pathway for addressing chronic health issues in densely populated cities.

Changing trends in the air pollution-related disease burden from 1990 to 2019 and its predicted level in 25 years

In the twenty-first century, exposure to air pollution has become a threat to human health worldwide due to industrial development. Timely, comprehensive, and reliable assessment and prediction of disease burden can help mitigate the health hazards of air pollution. This study conducted a two-stage analysis. First, we reported the air pollution-related disease burden globally and for different subgroups like socio-demographic index (SDI), sex, and age. We analyzed the trend of the disease burden from 1990 to 2019. In addition, we explored whether and how some national indicators modified the disease burden. Second, we predicted the number and the age-standardized rates of death and disability-adjusted life years (DALYs) attributable to air pollution from 2020 to 2044 by the autoregressive integrated moving average (ARIMA) model and exponential smoothing model. The age-period-cohort (APC) model in the maximum likelihood framework and the Bayesian APC model integrated nested Laplace approximations (INLAs) were further applied to perform sensitivity analysis. In 2019, air pollution accounted for 11.62% of death and 0.84% of DALY worldwide. The corresponding age-standardized rate was 85.62 (95% uncertainty interval (UI): 75.71, 96.07) and 2791.08 (95% UI: 2468.81, 3141.39) per 100,000 population. From 1990 to 2019, the number of death attributable to air pollution remained stable, and the number of DALY exhibited a downward trend. The corresponding age-standardized rates both declined. In some countries with larger population densities, higher proportions of elders, and lower proportions of females, the disease burden attributable to air pollution was lower. The predicted results showed that the number of air pollution-related death and DALY would increase. This study comprehensively assessed and predicted the air pollution-related disease burden worldwide. The results indicated that the disease burden would remain very serious in the future. Hence, some relevant policies should be developed to prevent and manage air pollution.

Relationship between Built-Up Environment, Air Pollution, Activity Frequency and Prevalence of Hypertension-An Empirical Analysis from the Main City of Lanzhou

In the process of promoting the strategy of a healthy China, the built environment, as a carrier of human activities, can effectively influence the health level of residents in the light of its functional types. Based on the POI data of four main urban areas in Lanzhou, this paper classifies the built environment in terms of function into four types. The association between different types of built environments and the prevalence of hypertension was investigated by using the community as the study scale, and activity frequency, air pollution and green space were used as mediating variables to investigate whether they could mediate the relationship between built environments and hypertension. The results indicate that communities with a high concentration of commercial service facilities, road and traffic facilities and industrial facilities have a relatively high prevalence of hypertension. By determining the direct, indirect and overall effects of different functional types of built environment on the prevalence of hypertension, it was learned that the construction of public management and service facilities can effectively mitigate the negative effects of hypertension in the surrounding residents. The results of the study contribute to the rational planning of the structure of the built environment, which is beneficial for optimizing the urban structure and preventing and controlling chronic diseases such as hypertension.

Residential green space and mental health-related prescription medication sales: An ecological study in Belgium

BACKGROUND

Residential green space has been associated with mental health benefits, but how such associations vary with green space types is insufficiently known.

OBJECTIVE

We aimed to investigate associations between types and quantities of green space and sales of mood disorder medication in Belgium.

METHODS

We used aggregated sales data of psycholeptics and psychoanaleptics prescribed to adults from 2006 to 2014. Generalized mixed effects models were used to investigate associations between relative covers of woodland, low-green, grassland, and garden, and average annual medication sales. Models were adjusted for socio-economic background variables, urban-rural differences, and administrative region, and included random effects of latitude and longitude.

RESULTS

Urban census tracts were associated with 9-10% higher medication sales. In nationwide models, a 10% increase in relative cover of woodland, garden, and grass was associated with a 1-2% decrease in medication sales. The same association was found for low green but only for men. In stratified models, a 10% increase in relative cover of any green space type in urban census tracts was associated with a decrease of medication sales by 1-3%. In rural census tracts, no protective associations between green space and mood disorder medication sales were observed, with the exception of relative woodland cover for women (-1%), and low green was associated with higher medication sales (+6-7%).

CONCLUSIONS

Taken together, these results suggest that living in green environments may be beneficial for adult mental health. Woodland exposure seemed the most beneficial, but the amount of green space was more important than the type. Results underline the importance of conserving green space in our living environment, for the conservation of biodiversity and for human health.

The association of specific industry-related air pollution with occurrence of chronic diseases: A register-based study

Air pollution may contribute to onset and progression of chronic diseases such as cardiovascular and respiratory diseases. Most studies have focused on the contribution of traffic-related exposure to PM₁₀ or PM_2.5. Our aim was to investigate the association of different components of industry-related air pollution on the occurrence of chronic diseases. A register-based repeated cross-sectional study was conducted among 89,714 subjects (2012) with 536,599 annual observations (2012-2017) living in the vicinity of a large industrial area in the Netherlands. Information from the dispensed medication registration was linked with a dispersion model to characterize annual individual-level exposure of all subjects at place of residence. Associations between annual exposure (concentration and duration) to particulate matter (PM₁₀), nitrogen oxides (NO_X), sulphur dioxide (SO₂), and volatile organic compounds (VOC) with annual dispensed medication for cardiovascular diseases, respiratory diseases, diabetes mellitus, and inflammatory conditions were investigated by multivariate logistic regression analysis with generalized estimating equations (GEE) while controlling for confounders. Exposure to PM₁₀ and to NO_X (per μg/m³) were significantly associated with medication for cardiovascular diseases (OR 1.06, 95CI% 1.06-1.06 and OR 1.01, 95%CI 1.01-1.01 respectively). Exposures to PM₁₀ and SO₂ (per μg/m³) were significantly associated with medication for inflammatory conditions (OR 1.05, 95%CI 1.00-1.09 and OR 1.07, 95%CI 1.01-1.14 respectively). Exposure to SO₂ was inversely associated with respiratory diseases (OR 0.91, 95%CI 0.86-0.97). Except for inflammatory conditions, exposure duration (years) was significantly associated with the other three chronic diseases (OR varying from 1.01 to 1.03). This study indicates that specific air pollution components caused by industry may contribute to the occurrence of cardiovascular diseases, respiratory diseases, diabetes mellitus, and inflammatory conditions.

Beneficial Use Impairments, Degradation of Aesthetics, and Human Health: A Review

In environmental programs and blue/green space development, improving aesthetics is a common goal. There is broad interest in understanding the relationship between ecologically sound environments that people find aesthetically pleasing and human health. However, to date, few studies have adequately assessed this relationship, and no summaries or reviews of this line of research exist. Therefore, we undertook a systematic literature review to determine the state of science and identify critical needs to advance the field. Keywords identified from both aesthetics and loss of habitat literature were searched in PubMed and Web of Science databases. After full text screening, 19 studies were included in the review. Most of these studies examined some measure of greenspace/bluespace, primarily proximity. Only one study investigated the impacts of making space quality changes on a health metric. The studies identified for this review continue to support links between green space and various metrics of health, with additional evidence for blue space benefits on health. No studies to date adequately address questions surrounding the beneficial use impairment degradation of aesthetics and how improving either environmental quality (remediation) or ecological health (restoration) efforts have impacted the health of those communities.

Long-term exposure to objective and perceived residential greenness and diabetes mortality: A census-based cohort study

BACKGROUND

Residing close to green spaces might reduce diabetes mellitus (DM) risk; however, evidence for diabetes mortality is limited. Moreover, individual and neighbourhood social factors may determine DM risk. Exposure to green spaces may also depend on socioeconomic position (SEP). This study examined the associations between residential greenness and diabetes-related mortality, and the role of the social environment in these associations.

METHODS

We used the 2001 Belgian census linked to mortality register data for the period 2001-2014. We included individuals aged 40-79 years old and residing in the five largest Belgian urban areas at baseline. Exposure to residential greenness was assessed with surrounding greenness using the Normalized Difference Vegetation Index (NDVI) within 500-m of residence (objective indicator), and perceived neighbourhood greenness (subjective indicator). We conducted mixed-effects Cox proportional hazards models to obtain hazard ratios (HR) for diabetes-related mortality per interquartile range (IQR) increments of residential greenness. We assessed effect modification by social factors through stratification.

RESULTS

From 2,309,236 individuals included at baseline, 1.2% died from DM during follow-up. Both residential greenness indicators were inversely associated with diabetes-related mortality after adjustment for individual social factors. After controlling for neighbourhood SEP, the beneficial association with surrounding greenness disappeared [HR 1.02 (95%CI:0.99,1.06)], but persisted with perceived neighbourhood greenness [HR 0.93 (95%CI:0.91,0.95)]. After stratification the inverse associations with perceived neighbourhood greenness were strongest for women, the lowest educated, and individuals residing in least deprived neighbourhoods.

CONCLUSIONS

Our findings suggest that an overall positive perception of neighbourhood green spaces reduces independently the risk of diabetes-related mortality, regardless of the neighbourhood social environment. Nevertheless, neighbourhood SEP may be a strong confounder in the associations between diabetes-related mortality and greenness indicators derived from satellite images. Perception factors not captured by objective measurements of green spaces are potentially relevant in the association with DM, especially among disadvantaged groups.

Residential Exposure to Urban Trees and Medication Sales for Mood Disorders and Cardiovascular Disease in Brussels, Belgium: An Ecological Study

BACKGROUND

The available evidence for positive associations between urban trees and human health is mixed, partly because the assessment of exposure to trees is often imprecise because of, for instance, exclusion of trees in private areas and the lack of three-dimensional (3D) exposure indicators (e.g., crown volume).

OBJECTIVES

We aimed to quantify all trees and relevant 3D structural traits in Brussels (Belgium) and to investigate associations between the number of trees, tree traits, and sales of medication commonly prescribed for mood disorders and cardiovascular disease.

METHODS

We developed a workflow to automatically isolate all individual trees from airborne light detection and ranging (LiDAR) data collected in 2012. Trait data were subsequently extracted for 309,757 trees in 604 census tracts. We used the average annual age-standardized rate of medication sales in Brussels for the period 2006 to 2014, calculated from reimbursement information on medication prescribed to adults (19-64 years of age). The medication sales data were provided by sex at the census tract level. Generalized log-linear models were used to investigate associations between the number of trees, the crown volume, tree structural variation, and medication sales. Models were run separately for mood disorder and cardiovascular medication and for men and women. All models were adjusted for indicators of area-level socioeconomic status.

RESULTS

Single-factor models showed that higher stem densities and higher crown volumes are both associated with lower medication sales, but opposing associations emerged in multifactor models. Higher crown volume [an increase by one interquartile range (IQR) of 1.4×104 m³/ha] was associated with 34% lower mood disorder medication sales [women, β=-0.341 (95% CI: -0.379, -0.303); men, β=-0.340 (95% CI: -0.378, -0.303)] and with 21-25% lower cardiovascular medication sales [women, β=-0.214 (95% CI: -0.246, -0.182); men, β=-0.252 (95% CI: -0.285, -0.219)]. Conversely, a higher stem density (an increase by one IQR of 21.8 trees/ha) was associated with 28-32% higher mood disorder medication sales [women, β=0.322 (95% CI: 0.284, 0.361); men, β=0.281 (95% CI: 0.243, 0.319)] and with 20-24% higher cardiovascular medication sales [women, β=0.202 (95% CI: 0.169, 0.236); men, β=0.240 (95% CI: 0.206, 0.273)].

DISCUSSION

We found a trade-off between the number of trees and the crown volumes of those trees for human health benefits in an urban environment. Our results demonstrate that conserving large trees in urban environments may not only support conservation of biodiversity but also human health. https://doi.org/10.1289/EHP9924.

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.

Associations of combined exposures to ambient temperature, air pollution, and green space with hypertension in rural areas of Anhui Province, China: A cross-sectional study

Hypertension (HTN) was a major preventable cause of cardiovascular disease (CVD), contributing to a huge disease burden. Ambient temperature, air pollution and green space were important influencing factors of HTN, and few studies have assessed the effects and interactions of ambient temperature, air pollution and green space on HTN in rural areas. In this study, we selected 8400 individuals randomly in rural areas of Anhui Province by a multi-stage stratified cluster sampling. A total of 8383 individuals were included in the final analysis. We collected particulate pollutants and meteorological data from the local air quality monitoring stations and National Center for Meteorological Science from January 1 to December 31, 2020, respectively. The normalized differential vegetation index (NDVI) of Anhui Province in 2020 was produced and processed by remote sensing inversion on the basis of medium resolution satellite images. The average annual mean exposure concentrations of air pollution, meteorological factors, and NDVI were calculated for each individual based on the geocoded residential address. HTN was defined according the Chinese Guidelines for Prevention and Treatment of HTN. The effects and interactions of ambient temperature, air pollution and green space on HTN were evaluated by generalized linear model and interaction model, respectively. In this study, the prevalence of HTN was 24.14%. The adjusted odd ratio of HTN for each 1 μg/m³ increasing in PM_2.5 and PM₁₀, 1 °C of ambient temperature, and 0.1 of NDVI were:1.276 (1.013, 1.043), 1.012 (1.006, 1.018), 0.862 (0.862, 0.981) and 0.669 (0.611, 0.733), respectively. The results showed that air pollutants were positively correlated with HTN, while ambient temperature and green space were negatively correlated with HTN. Meanwhile, the negative associations of green space on HTN could decrease with the increasing concentrations of air pollution, but increase with the rising of ambient temperature.

Greenspace, Inflammation, Cardiovascular Health, and Cancer: A Review and Conceptual Framework for Greenspace in Cardio-Oncology Research

Cardiovascular disease (CVD) is a leading cause of global morbidity and mortality. Cancer survivors have significantly elevated risk of poor cardiovascular (CV) health outcomes due to close co-morbid linkages and shared risk factors between CVD and cancer, as well as adverse effects of cancer treatment-related cardiotoxicity. CVD and cancer-related outcomes are exacerbated by increased risk of inflammation. Results from different pharmacological interventions aimed at reducing inflammation and risk of major adverse cardiovascular events (MACEs) have been largely mixed to date. Greenspaces have been shown to reduce inflammation and have been associated with CV health benefits, including reduced CVD behavioral risk factors and overall improvement in CV outcomes. Greenspace may, thus, serve to alleviate the CVD burden among cancer survivors. To understand pathways through which greenspace can prevent or reduce adverse CV outcomes among cancer survivors, we review the state of knowledge on associations among inflammation, CVD, cancer, and existing pharmacological interventions. We then discuss greenspace benefits for CV health from ecological to multilevel studies and a few existing experimental studies. Furthermore, we review the relationship between greenspace and inflammation, and we highlight forest bathing in Asian-based studies while presenting existing research gaps in the US literature. Then, we use the socioecological model of health to present an expanded conceptual framework to help fill this US literature gap. Lastly, we present a way forward, including implications for translational science and a brief discussion on necessities for virtual nature and/or exposure to nature images due to the increasing human-nature disconnect; we also offer guidance for greenspace research in cardio-oncology to improve CV health outcomes among cancer survivors.

Residential greenness attenuated associations of long-term exposure to air pollution with biomarkers of advanced fibrosis

Long-term exposure to air pollutants and residential greenness related to advanced fibrosis have been sparsely studied in low- and middle-income countries. A total of 29883 participants were selected from a cross-sectional survey of the Henan Rural Cohort. Concentrations of air pollutants (particulate matter with an aerodynamic diameter ≤ 1.0 μm (PM1), ≤ 2.5 μm (PM2.5), ≤ 10 μm (PM10) and nitrogen dioxide (NO2)) for participants were predicted by using a spatiotemporal model. Residential greenness of each participant was indicated by Enhanced Vegetation Index (EVI) and Normalized Difference Vegetation Index (NDVI). Independent and joint associations of air pollutants and residential greenness indices with prevalent advanced fibrosis reflected by fibrosis-4 score (FIB4), aspartate-to-platelet-ratio index (APRI) and ALT/AST ratio were analyzed by generalized linear mixed models and their interactive effect on prevalent advanced fibrosis were visualized by using the interplot method. Long-term exposure to PM1, PM2.5, PM10 and NO2 were positively related to FIB4 or APRI as well as prevalent intermediate-high advanced fibrosis; EVI was negatively related to FIB4 or APRI as well as prevalent intermediate-high advanced fibrosis. Negative associations of residential greenness indices (EVI or NDVI) with prevalent advanced fibrosis were decreased as increased air pollutants (PM1, PM2.5, PM10 or NO2) (P < 0.05 for all). This study indicated that residential greenness may partially attenuate negative effect of long-term exposure to air pollutants related to increased prevalent intermediate-high advanced fibrosis, implying that residential greenness may be an effective strategy to reduce the burden of prevalent hepatic fibrosis and its related disease in association with exposure high levels of air pollutants. The Henan Rural Cohort study has been registered at Chinese Clinical Trial Register (Registration number: ChiCTR-OOC-15006699, http://www.chictr.org.cn/showproj.aspx?proj=11375 ).

Forecasting PM2.5 concentration using artificial neural network and its health effects in Ahvaz, Iran

The main objective of the present study was to predict the associated health endpoint of PM_2.5 using an artificial neural network (ANN). The neural network used in this work contains a hidden layer with 27 neurons, an input layer with 8 parameters, and an output layer. First, the artificial neural network was implemented with 80% of data for training then with 90% of data for training. The value of R for the data validation of these two networks was 0.80 and 0.83 respectively. The World Health Organization AirQ ⁺ software was utilized for assessing Health effects of PM_2.5 levels. The mean PM_2.5 over the 9-year study period was 63.27(μg/m³), about six times higher than the WHO guideline. However, the PM_2.5 concentration in the last year decreased by about 25% compared to the first year, which is statistically significant (P-value = 0.0048). This reduced pollutant concentration led to a decrease in the number of deaths from 1785 in 2008 to 1059 in 2016. Moreover, a positive correlation was found between PM_2.5 concentration and temperature and wind speed. Considering the importance of predicting PM_2.5 concentration for accurate and timely decisions as well as the accuracy of the artificial neural network used in this study, the artificial neural network can be utilized as an effective instrument to reduce health and economic effects.

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).

Residential green space and medication sales for childhood asthma: A longitudinal ecological study in Belgium

BACKGROUND

Living in green environments has been associated with various health benefits, but the evidence for positive effects on respiratory health in children is ambiguous.

OBJECTIVE

To investigate if residential exposure to different types of green space is associated with childhood asthma prevalence in Belgium.

METHODS

Asthma prevalence was estimated from sales data of reimbursed medication for obstructive airway disease (OAD) prescribed to children between 2010 and 2014, aggregated at census tract level (n = 1872) by sex and age group (6-12 and 13-18 years). Generalized log-linear mixed effects models with repeated measures were used to estimate effects of relative covers of forest, grassland and garden in the census tract of the residence on OAD medication sales. Models were adjusted for air pollution (PM₁₀), housing quality and administrative region.

RESULTS

Consistent associations between OAD medication sales and relative covers of grassland and garden were observed (unadjusted parameter estimates per IQR increase of relative cover, range across four strata: grassland, β = 0.15-0.17; garden, β = 0.13-0.17). The associations remained significant after adjusting for housing quality and chronic air pollution (adjusted parameter estimates per IQR increase of relative cover, range across four strata: grassland, β = 0.10-0.14; garden, β = 0.07-0.09). There was no association between OAD medication sales and forest cover.

CONCLUSIONS

Based on aggregated data, we found that living in close proximity to areas with high grass cover (grasslands, but also residential gardens) may negatively impact child respiratory health. Potential allergic and non-allergic mechanisms that underlie this association include elevated exposure to grass pollen and fungi and reduced exposure to environmental biodiversity. Reducing the dominance of grass in public and private green space might be beneficial to reduce the childhood asthma burden and may simultaneously improve the ecological value of urban green space.

Analytical approaches to testing pathways linking greenspace to health: A scoping review of the empirical literature

BACKGROUND

Inadequate translation from theoretical to statistical models of the greenspace - health relationship may lead to incorrect conclusions about the importance of some pathways, which in turn may reduce the effectiveness of public health interventions involving urban greening. In this scoping review we aimed to: (1) summarize the general characteristics of approaches to intervening variable inference (mediation analysis) employed in epidemiological research in the field; (2) identify potential threats to the validity of findings; and (3) propose recommendations for planning, conducting, and reporting mediation analyses.

METHODS

We conducted a scoping review, searching PubMed, Scopus, and Web of Science for peer-reviewed epidemiological studies published by December 31, 2019. The list of potential studies was continuously updated through other sources until March 2020. Narrative presentation of the results was coupled with descriptive summary of study characteristics.

RESULTS

We found 106 studies, most of which were cross-sectional in design. Most studies only had a spatial measure of greenspace. Mental health/well-being was the most commonly studied outcome, and physical activity and air pollution were the most commonly tested intervening variables. Most studies only conducted single mediation analysis, even when multiple potentially intertwined mediators were measured. The analytical approaches used were causal steps, difference-of-coefficients, product-of-coefficients, counterfactual framework, and structural equation modelling (SEM). Bootstrapping was the most commonly used method to construct the 95% CI of the indirect effect. The product-of-coefficients method and SEM as used to investigate serial mediation components were more likely to yield findings of indirect effect. In some cases, the causal steps approach thwarted tests of indirect effect, even though both links in an indirect effect were supported. In most studies, sensitivity analyses and proper methodological discussion of the modelling approach were missing.

CONCLUSIONS

We found a persistent pattern of suboptimal conduct and reporting of mediation analysis in epidemiological studies investigating pathways linking greenspace to health; however, recent years have seen improvements in these respects. Better planning, conduct, and reporting of mediation analyses are warranted.

Applying landscape metrics and structural equation modeling to predict the effect of urban green space on air pollution and respiratory mortality in Tehran

Green space and its spatial formation are important elements of public welfare in urban environments and green ecosystems in big cities largely contribute to the mental and physical health of citizens. Tehran is Iran's biggest and most polluted city and air pollution in this city causes loss of human lives due to respiratory diseases. The effect of green area has been less studied in former researches in Tehran, and the reducing effects of green landscape on the mortality of respiratory diseases have not yet been evaluated. To measure the effects of green area landscape patterns (fragmentation, area-edge, shape, and aggregation) on public health, the current study evaluated the pathways and effects of green space on air pollution and the mortality of respiratory diseases using structural equation modeling approach and the partial least squares method. The results of the study indicated green space has a significant mitigating effect on air pollution and mortality of respiratory diseases and also air pollution has a meaningful increasing effect on mortality due to respiratory diseases in Tehran. The most important latent variable in green space is class area that indicates more area of green space is correlated with less mortality of respiratory diseases. The most important indicator of air pollution was the PM_2.5 that needs to be considered and controlled by urban policymakers. Accordingly, maximizing the green area and its cohesion and minimizing fragmentation and green patch edge can contribute to a reduction in air pollution and consequently lower mortality of citizens.