Green space, social inequalities and neonatal mortality in France

Greenness on mortality of infant and under-5 child: A nationwide study in 147 Chinese cities

BACKGROUND

Higher greenness was associated with a lower risk of adult mortality. However, the effects of greenness on the mortality of infant and child under-5 have not been fully examined.

OBJECTIVES

The association of greenness on the infant mortality rate (IMR) and child under-5 mortality rate (U5MR) in 147 Chinese cities from 2009 to 2020 was evaluated.

METHODS

Average and maximum annual population-weighted greenness, IMR (per 1000 live births), and U5MR (per 1000 live births) in 147 cities from 2009 to 2020 were collected, and a longitudinal panel study was conducted. Greenness exposure was evaluated using satellite-derived data at a spatial resolution of 250 m ×250 m in urban regions, and linear mixed-effect models were applied to assess the associations between greenness and IMR or U5MR in China.

RESULTS

This national study showed that long-term exposure to greenness was associated with lower IMR and U5MR, respectively. Specifically, a 0.1 increase of Normalized Difference Vegetation Index (NDVI) in greenness was statistically significant with a decrease in IMR (-1.05 ‰, 95 % CI: -1.48, -0.63 ‰) and U5MR (-1.82 ‰, 95 % CI: -2.39, -1.25 ‰) in fully-adjusted model, respectively. In the stratified analyses, greenness effects on U5MR in the western (-2.33 ‰, 95 % CI: -3.43, -1.23 ‰) and central regions (-2.06 ‰, 95 % CI: -3.01, -1.10 ‰) were stronger than that in the eastern region (-0.86 ‰, 95 % CI: -1.66, -0.07 ‰).

CONCLUSIONS

This nationwide study indicated that exposure to higher greenness was associated with lower mortality rates in infant and child under-5 in China.

Effects of land cover and air pollution on the risk of preterm births

OBJECTIVE

To evaluate the association between gestational age and green areas, urban built areas, and the concentration of particulate matter 2.5 (PM2.5) in the city of São Paulo, analyzing the irregular distribution of these areas and pollution levels above the recommended level.

METHODS

The study population consisted of a cohort of live births from 2012, and data from the Live Birth Information System (Sinasc) of the city of São Paulo were used. Using satellite images and supervised classification, the distribution and quantity of green areas and built areas in the city of São Paulo was obtained, as well as the concentrations of PM2.5. Logistic regressions were used to obtain possible associations.

RESULTS

The results of the study show that a lower percentage of green areas is significantly associated with a higher chance of preterm births. A higher building density was positively associated with the odds ratio for preterm birth. We did not find any significant associations between air pollution (PM2.5) and preterm births.

CONCLUSIONS

The results of this study show that greener areas are less associated with preterm births when compared with less green areas.

Mapping high-risk clusters and identifying place-based risk factors of mental health burden in pregnancy

Purpose

Despite affecting up to 20% of women and being the leading cause of preventable deaths during the perinatal and postpartum period, maternal mental health conditions are chronically understudied. This study is the first to identify spatial patterns in perinatal mental health conditions, and relate these patterns to place-based social and environmental factors that drive cluster development.

Methods

We performed spatial clustering analysis of emergency department (ED) visits for perinatal mood and anxiety disorders (PMAD), severe mental illness (SMI), and maternal mental disorders of pregnancy (MDP) using the Poisson model in SatScan from 2016 to 2019 in North Carolina. Logistic regression was used to examine the association between patient and community-level factors and high-risk clusters.

Results

The most significant spatial clustering for all three outcomes was concentrated in smaller urban areas in the western, central piedmont, and coastal plains regions of the state, with odds ratios greater than 3 for some cluster locations. Individual factors (e.g., age, race, ethnicity) and contextual factors (e.g., racial and socioeconomic segregation, urbanity) were associated with high risk clusters.

Conclusions

Results provide important contextual and spatial information concerning at-risk populations with a high burden of maternal mental health disorders and can better inform targeted locations for the expansion of maternal mental health services.

Impact of cash transfer programs on birth and child growth outcomes: systematic review

To investigate the impact of cash transfer (CTs) on birth outcomes, including birth weight, low birth weight and prematurity, as well as child physical growth were included, as assessed by anthropometric indices in children under five years of age. Searching was performed using the PubMed/Medline, Embase, LILACS, Cochrane Library, Scopus and Web of Science databases. Quantitative observational, experimental and quasi-experimental. Eleven studies were included in the review. The majority (81.8%) were carried out in low-and middle-income countries and most involved conditional CTs (63.6%). Four were clinical trials and seven were observational studies. Conditional CTs were found to be associated with a reduction in height-for-age (-0.14; 95%CI -0.27, -0.02); (OR 0.85; 95%CI 0.77-0.94); (OR = 0.44; 95%CI 0.19-0.98), a significantly reduced chance of low weight-for-age (OR = 0.16; 95%CI -0.11-0.43), low weight-for-height (OR = -0.68; 95%CI -1.14, -0.21), and low weight-for-age (OR = 0.27; 95%CI 0.10; 0.71). Unconditional CTs were associated with reduced birth weight (RR = 0.71; 95%CI 0.63-0.81; p < 0.0001) and preterm births (RR = 0.76; 95%CI 0.69-0.84; p < 0.0001). Conditional CTs can positively influence birth outcomes and child growth.

Association between greenspace and cancer: evidence from a systematic review and meta-analysis of multiple large cohort studies

Cancer is a chronic disease that seriously endangers human health, and studies on its association with greenspace have been published. We aimed to systematically review the epidemiological evidence and obtain the best available evidence. PubMed, Web of Science, Embase, and Cochrane Library were used as search databases, the time limit was September 12, 2022, and the cited articles were manually supplemented. Two researchers independently performed literature screening and data extraction. We performed a meta-analysis of data using a normalized difference vegetation index (NDVI) as the greenspace measure, providing hazard ratio (HR) and corresponding 95% CI. After standardization of the data, we used a random effects model for pooling. We also assessed the risk of bias for each study and the quality of each evidence body. We identified 10,108 items and included 14 studies from 11 institutions in eight countries. All studies had a low risk of bias. Quantitative analysis of 13 studies found a beneficial association of greenspace with the mortality of lung cancer (pooled HR [95% CI]=0.965 [0.947, 0.983]) and prostate cancer (HR [95% CI]=0.939 [0.898, 0.980]) based on 0.1-unit NDVI increment and a potential beneficial association with the incidence of prostate, lung, and breast cancer. Greenspace had opposite associations with cancer mortality for urban and rural populations. Indirect comparisons did not find statistically significant differences in the effects of greenspace on different cancer outcomes. The evidence body assessment was considered to be "very low." This review indicated potential beneficial associations between greenspace for lung, prostate, and breast cancer outcomes. However, there was a lack of mediation analysis to explore the underlying mechanism of a causal association. Meanwhile, the interstudy heterogeneity was large. Therefore, future studies should consider more accurate exposure assessment and more comprehensive covariate coverage, while focusing on mediating analysis. PROSPERO: CRD42022361068.

[Social inequalities in under-five mortality: a systematic review]

OBJECTIVE

To identify the characteristics of the published studies on social inequalities in under-five mortality, their theoretical perspectives, axes of inequality, methods and results.

METHOD

We carried out a systematic literature review. We consulted four electronic databases and Google Scholar, for studies published between 2010 and 2018.

RESULTS

We analyzed 126 articles. In 62.7%, territory was studied as the axis of inequality, followed by socioeconomic determinants (27.8%). Neonatal, infant and under-five mortality was analyzed as an output in health in 19.0%, 49.2% and 32.3%, respectively. It predominated ecological (62.7%) and longitudinal (50.0%) studies. Significant reductions in mortality rates were found, however, the decline was not homogeneous among subpopulations.

CONCLUSIONS

The literature reports a marked decrease in under-five mortality; however, the gaps between different axes of inequality continue and in some cases they have increased. Gaps varied according to time, place, axis of inequality and type of mortality analyzed.

A Comprehensive Review on Social Inequalities and Pregnancy Outcome-Identification of Relevant Pathways and Mechanisms

Scientific literature tends to support the idea that the pregnancy and health status of fetuses and newborns can be affected by maternal, parental, and contextual characteristics. In addition, a growing body of evidence reports that social determinants, measured at individual and/or aggregated level(s), play a crucial role in fetal and newborn health. Numerous studies have found social factors (including maternal age and education, marital status, pregnancy intention, and socioeconomic status) to be linked to poor birth outcomes. Several have also suggested that beyond individual and contextual social characteristics, living environment and conditions (or "neighborhood") emerge as important determinants in health inequalities, particularly for pregnant women. Using a comprehensive review, we present a conceptual framework based on the work of both the Commission on Social Determinants of Health and the World Health Organization (WHO), aimed at describing the various pathways through which social characteristics can affect both pregnancy and fetal health, with a focus on the structural social determinants (such as socioeconomic and political context) that influence social position, as well as on intermediary determinants. We also suggest that social position may influence more specific intermediary health determinants; individuals may, on the basis of their social position, experience differences in environmental exposure and vulnerability to health-compromising living conditions. Our model highlights the fact that adverse birth outcomes, which inevitably lead to health inequity, may, in turn, affect the individual social position. In order to address both the inequalities that begin in utero and the disparities observed at birth, it is important for interventions to target various unhealthy behaviors and psychosocial conditions in early pregnancy. Health policy must, then, support: (i) midwifery availability and accessibility and (ii) enhanced multidisciplinary support for deprived pregnant women.

[Societal inequalities and the urban exposome: Social origins for different exposures]

Today, many epidemiological studies have proved the adverse health consequences of environmental exposure. For instance, air pollution exposure is recognized to be related with respiratory and cardiovascular diseases as well as adverse pregnancy outcomes. Noise nuisances are also known to increase cardiovascular diseases and to disturb the sleeping quality. Inversely, the access and availability of various resources, as parks, green spaces, and playgrounds positively affect health, psychological and physical well-being, and favorable health behaviors. In this present literature review, we will focus on the urban dimension of exposome, defined by Robinson et al. as the accumulation of all urban settings favorable or unfavorable to health, from the time of life in utero [1].

Urban green spaces and childhood leukemia incidence: A population-based case-control study in Madrid

BACKGROUND

Childhood leukemia is the most common childhood cancer. To date, few risk factors related to predisposition have been identified; therefore, new hypotheses should be considered.

OBJECTIVE

To explore the possible relationship of residential proximity to urban green spaces on childhood leukemia.

METHODS

We conducted a population-based case control study in the metropolitan area of Madrid from 2000 to 2015. It included 383 incident cases and 1935 controls, individually matched by birth year, sex and area of residence. Using the geographical coordinates of the participants' home residences, we built a proxy for exposure with four distances (250 m, 500 m, 750 m and 1 km) to urban parks (UPs) and urban wooded areas (UWAs). We employed logistic regression models to determinate the effect of them on childhood leukemia adjusting for environmental and socio-demographic covariates.

RESULTS

we found a reduction in childhood leukemia incidence at a distance of 250 m from UPs (OR = 0.78; 95%CI = 0.62-0.98), as well as a reduction of the incidence in the Q3 and Q4 quintiles for exposure to UWAs, in the 250 m and 500 m buffers respectively (Q3 (250 m): OR = 0.69; 95%CI = 0.48-1.00; and, Q4 (500 m): OR = 0.69; 95%CI = 0.48-0.99).

CONCLUSIONS

Our results suggest a possible association between lower incidence of childhood leukemia and proximity to different forms of urban green space. This study is a first approach to the possible urban green space effects on childhood leukemia so is necessary to continue studying this spaces taking into account more individual data and other environmental risk factors.

Green space and suicide mortality in Japan: An ecological study

Although numerous studies have investigated the effect of green space on mental health, as yet, little is known about the association between green space and suicide. To address this deficit, we conducted the first Japan-wide study of the relationship between green space and suicide mortality. Results from spatial analyses of municipality-level panel data for the 1975-2014 period that included 886,440 suicide deaths with a fixed-effect estimator showed that green space was associated with suicide mortality, and that this relationship was conditioned by the form of greenness, level of urbanity and demographic characteristics. In densely populated cities, park density (parks per 1000 of the population) was associated with reduced suicide mortality among females aged 18 and above and among males aged 18 to 39 and aged 65 and above. In small- and medium-sized cities, park coverage (% by area) was linked to fewer suicide deaths among middle-aged and older females (aged 40 and above). In contrast, in non-cities (rural areas), parks were not associated with suicide mortality whereas woodland coverage (% by area) was linked to reduced suicide deaths among middle-aged and older males (aged 40 and above). Our findings suggest that urban green space and rural forest coverage may have a protective effect against self-harming behavior. Future suicide prevention efforts should consider an increased greening of the residential environment in terms of both availability and accessibility, especially with better designs that accommodate population needs and local conditions.

Effects of residential greenness on clinical outcomes of patients with chronic kidney disease: a large-scale observation study

Background

As industrialization and urbanization are accelerating, the distribution of green areas is decreasing, particularly in developing countries. Since the 2000s, the effects of surrounding greenness on self-perceived health, including physical and mental health, longevity, and obesity have been reported. However, the effects of surrounding green space on chronic kidney disease are not well understood. Therefore, we investigated the impact of residential greenness on the mortality of chronic kidney disease patients and progression from chronic kidney disease to end-stage renal disease (ESRD).

Methods

Using a large-scale observational study, we recruited chronic kidney disease patients (n = 64,565; mean age, 54.0 years; 49.0% of male) who visited three Korean medical centers between January 2001 and December 2016. We investigated the hazard ratios of clinical outcomes per 0.1-point increment of exposure to greenness using various models.

Results

During the mean follow-up of 6.8 ± 4.6 years, 5,512 chronic kidney disease patients developed ESRD (8.5%) and 8,543 died (13.2%). In addition, a 0.1-point increase in greenness reduced all-cause mortality risk in chronic kidney disease and ESRD patients and progression of chronic kidney disease to ESRD in a fully adjusted model. The association between mortality in ESRD patients and the normalized difference vegetation index was negatively correlated in people aged >65 years, who had normal weight, were nonsmokers, and lived in a nonmetropolitan area.

Conclusion

Chronic kidney disease patients who live in areas with higher levels of greenness are at reduced risk of all-cause mortality and progression to ESRD.

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.

Geographical Pattern of COVID-19-Related Outcomes over the Pandemic Period in France: A Nationwide Socio-Environmental Study

BACKGROUND

Several studies have investigated the implication of air pollution and some social determinants on COVID-19-related outcomes, but none of them assessed the implication of spatial repartition of the socio-environmental determinants on geographic variations of COVID-19 related outcomes. Understanding spatial heterogeneity in relation to the socio-environmental determinant and COVID-19-related outcomes is central to target interventions toward a vulnerable population.

OBJECTIVES

To determine the spatial variability of COVID-19 related outcomes among the elderly in France at the department level. We also aimed to assess whether a geographic pattern of Covid-19 may be partially explained by spatial distribution of both long-term exposure to air pollution and deprived living conditions.

METHODS

This study considered four health events related to COVID-19 infection over the period of 18 March and 02 December 2020: (i) hospitalization, (ii) cases in intensive health care in the hospital, (iii) death in the hospital, and (iv) hospitalized patients recovered and returned back home. We used the percentage of household living in an overcrowding housing to characterize the living conditions and long-term exposure to NO2 to analyse the implication of air pollution. Using a spatial scan statistic approach, a Poisson cluster analysis method based on a likelihood ratio test and Monte Carlo replications was applied to identify high-risk clusters of a COVID-19-related outcome.

RESULT

our results revealed that all the outcomes related to COVID-19 infection investigated were not randomly distributed in France with a statistically significant cluster of high risk located in Eastern France of the hospitalization, cases in the intensive health care at the hospital, death in the hospital, and recovered and returned back home compared to the rest of France (relative risk, RR = 1.28, p-value = 0.001, RR = 3.05, p = 0.001, RR = 2.94, p = 0.001, RR = 2.51, p = 0.001, respectively). After adjustments for socio-environmental determinants, the crude cluster shifts according to different scenarios suggested that both the overcrowding housing level and long-term exposure to largely NO2 explain the spatial distribution of COVID-19-related outcomes.

CONCLUSIONS

Our findings suggest that the geographic pattern of COVID-19-related outcomes is largely explained by socio-spatial distribution of long-term exposure to NO2. However, to better understand spatial variations of COVID-19-related outcomes, it would be necessary to investigate and adjust it for other determinants. Thus, the current sanitary crisis reminds us of how unequal we all are in facing this disease.

Residential greenness and birth outcomes: A systematic review and meta-analysis of observational studies

BACKGROUND

The amount of natural vegetation surrounding homes (residential greenness) has been proposed as a mitigation measure to buffer the adverse health effects of urban living, associated with promoting health and wellbeing including birth outcomes. This study aimed to systematically review the epidemiological evidence on the association of residential greenness with birth outcomes and quantitatively provide summary effect estimates of the current literature.

METHODS

We extensively searched epidemiological studies related to residential greenness and birth outcomes in three electronic databases (EMBASE, Web of Science, and PubMed) using terms related to residential greenness and birth outcomes before July 10, 2020. Summary effect estimates of residential greenness on birth outcomes including SGA (small for gestational age), PTB (preterm birth), LBW (low birth weight), and birth weight were calculated for each 0.1 unit increase in residential greenness exposure, as well as comparing the highest to the lowest categories using random-effects meta-analyses. We assessed the risk of bias of each individual study, and the overall quality of the body of evidence and level of evidence for each exposure-outcome were also evaluated.

RESULTS

The initial search identified 161 studies, of which 29 studies were finally included. Meta-analysis for continuous exposure suggested that an increase in residential greenness, measured by NDVI (normalized difference vegetation index) with different buffer sizes, was generally associated with higher birth weights ranging from 7.99 g [95% confidence interval (CI) = 4.29-11.70] to 15.35 g (95% CI = 11.41-19.29) and lower odds of LBW ranging from 0.79 (95% CI = 0.65-0.96) to 0.93 (95% CI = 0.86-1.00), but associations between residential greenness and PTB or SGA were not significant. When introducing the exposure as high versus low categories, similar results were found. The overall evidence for each exposure-outcome combination was considered to be of "moderate" certainty.

CONCLUSIONS

This study indicated a potential positive association between residential greenness and several birth outcomes. However, because of the moderate to high between-study heterogeneity, further studies with better adjustment of covariates, improved residential greenness assessment in a longitudinal approach throughout pregnancy rather than a cross-sectional approach at time of delivery, and accounting thoroughly for socioeconomic status, are warranted to replicate these findings as well as to explore in greater detail in their implications.

Residential proximity to green space and preeclampsia in California

Background

We investigated whether residing near more green space might reduce the risk of preeclampsia.

Methods

Participants were women who delivered a live, singleton birth between 1998 and 2011 in eight counties of the San Joaquin Valley in California. There were 7276 cases of preeclampsia divided into mild, severe, or superimposed on preexisting hypertension. Controls were 197,345 women who did not have a hypertensive disorder and delivered between 37 and 41 weeks. Green space was estimated from satellite data using Normalized Difference Vegetation Index (NDVI), an index calculated from surface reflectance at the visible and near-infrared wavelengths. Values closer to 1 denote a higher density of green vegetation. Average NDVI was calculated within a 50 m, 100 m, and 500 m buffer around each woman's residence. Odds ratios and 95% confidence intervals were estimated comparing the lowest and highest quartiles of mean NDVI to the interquartile range comparing each preeclampsia phenotype, divided into early (20-31 weeks) and late (32-36 weeks) preterm birth, to full-term controls.

Results

We observed an inverse association in the 500 m buffer for women in the top quartile of NDVI and a positive association for women in the lowest quartile of NDVI for women with superimposed preeclampsia. There were no associations in the 50 and 100 m buffers.

Conclusion

Within a 500 m buffer, more green space was inversely associated with superimposed preeclampsia. Future work should explore the mechanism by which green space may protect against preeclampsia.

Green space and early childhood development: a systematic review

Background The urban environment presents significant health challenges for children, such as discouraging physical exercise and increasing exposure to air pollution, excessive noise and higher temperatures. Reducing exposures to these negative environmental factors can have great benefits on a child's well-being and lower their risk of developing chronic diseases later in life. There is increasing evidence that suggests that the presence of urban green space can offer benefits to human health and well-being. While studies have reported the impact green space exposure has on the individual health outcomes of children, few have paid attention to the link between green space and the child's development. This review aims to synthesise the evidence of the effect green space exposure has on early childhood development. Objectives To explore the relationship between green space and early childhood development. Methods An online search was conducted using pre-identified keywords related to green space and early childhood development using search engines such as PubMed, MEDLINE, Web of Science, MeSH and PsycINFO. Peer-reviewed papers published in the past 10 years were included in this review. Papers were selected, extracted, analysed and interpreted based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results Fifty-one papers were identified, of which 28 were excluded due to duplications or irrelevance, yielding a total of 23 papers to be reviewed. Articles were categorised based on reported outcomes: perinatal health, physical health, psychological health and respiratory health. An increase in green space during pregnancy was associated with increased birth weight and a decreased risk for low birth weight (LBW). Further, higher greenness exposure during childhood was associated with increased levels of physical activity and a lower risk of obesity and neurodevelopmental issues such as inattentiveness. While green space exposure was negatively associated with wheezing and bronchitis in some cohorts, certain plant species increase asthmatic symptoms during childhood, indicating that plant species type is an important determinant. Conclusion The extant literature on green space exposure and early childhood development is small. Regardless, the existing research provides promising insights into the benefits of green space exposure on children's health and well-being in an ever-increasing urban world. Further research is needed on the causal relationships between both quantity and quality of green space to early childhood development.

Small-Area Factors and Their Impact on Low Birth Weight-Results of a Birth Cohort Study in Bielefeld, Germany

Introduction: The location of residence is a factor possibly contributing to social inequalities and emerging evidence indicates that it already affects perinatal development. The underlying pathways remain unknown; theory-based and hypothesis-driven analyses are lacking. To address these challenges, we aim to establish to what extent small-area characteristics contribute to low birth weight (LBW), independently of individual characteristics. First, we select small-area characteristics based on a conceptual model and measure them. Then, we empirically analyse the impact of these characteristics on LBW. Material and methods: Individual data were provided by the birth cohort study "Health of infants and children in Bielefeld/Germany." The sample consists of 892 eligible women and their infants distributed over 80 statistical districts in Bielefeld. Small-area data were obtained from local noise maps, emission inventory, Google Street View and civil registries. A linear multilevel analysis with a two-level structure (individuals nested within statistical districts) was conducted. Results: The effects of the selected small-area characteristics on LBW are small to non-existent, no significant effects are detected. The differences in proportion of LBW based on marginal effects are small, ranging from zero to 1.1%. Newborns from less aesthetic and subjectively perceived unsafe neighbourhoods tend to have higher proportions of LBW. Discussion: We could not find evidence for negative effects of small-area factors on LBW, but our study confirms that obtaining adequate sample size, reliable measure of exposure and using available data for operationalisation of the small-area context represent the core challenges in this field of research.

A Systematic Review and Meta-Analysis of Associations between Green and Blue Spaces and Birth Outcomes

Previous studies suggest that green and blue spaces may promote several health outcomes including birth outcomes. However, no synthesis of previous work has specifically asked policy-relevant questions of how much and what type is needed in every neighborhood to elicit these benefits at the population level. A systematic review and meta-analyses were conducted to synthesize thirty-seven studies on the association between residential green and blue spaces and pregnancy outcomes. Meta-analyses were performed for birth weight (BW), small for gestational age (SGA), low birth weight (LBW) and preterm birth (PTB). Increase in residential greenness was statistically significantly associated with higher BW [β = 0.001, 95%CI: (<0.001, 0.002)] and lower odds of SGA [OR = 0.95, 95%CI: (0.92, 0.97)]. Associations between green space and LBW and PTB were as hypothesized but not statistically significant. Associations between blue spaces and pregnancy outcomes were not evident. No study explicitly examined questions of threshold, though some evidence of nonlinearity indicated that moderate amounts of green space may support more favorable pregnancy outcomes. Policy-relevant green and blue space exposures involving theory-driven thresholds warrant testing to ensure future investments in urban greening promote healthier pregnancy outcomes.

Associations of ambient temperature exposure during pregnancy with the risk of miscarriage and the modification effects of greenness in Guangdong, China

Miscarriage is one of the commonest complications of pregnancy. Although previous studies suggested that environmental factors were important causes of miscarriage, evidence is still inadequate. Here, we examined the association of maternal exposure to temperature with the risk of miscarriage and further assessed the modifying effects of surrounding residential greenness. A case-control study was conducted at a large hospital in Guangzhou, China. All participants' information was extracted from hospital records. An inverse distance weighted method was used to estimate the temperature exposure at each residential address, where the greenness was measured by Normalized Difference Vegetation Index (NDVI). A logistic regression model was applied to estimate the association of temperature exposure with the risk of miscarriage. A total of 2044 cases of miscarriage and 2285 controls were included in the present study. We observed a generally non-linear positive relationship between temperature exposure and the risk of miscarriage. More pronounced effects of high temperatures vs. low temperatures were found during the two months prior to hospitalization than in other periods. The odds ratio (OR) of 29.4 °C (95th centile) compared with 15 °C during the first month prior to hospitalization was 1.480 (95% CI: 1.021-2.145). Smaller effects of temperatures were seen on the risk of miscarriage among participants with moderately great surrounding greenness compared with those with less greenness. We concluded that maternal exposure to moderately high temperature during pregnancy may increase the risk of miscarriage, but the modifying effects of greenness on these associations need to be further tested in future studies.

Effects of greenspace morphology on mortality at the neighbourhood level: a cross-sectional ecological study

BACKGROUND

The association between urban greenspace and mortality risk is well known, but less is known about how the spatial arrangement of greenspace affects population health. We aimed to investigate the relation between urban greenspace distribution and mortality risk.

METHODS

We did a cross-sectional study in Philadelphia, PA, USA, using high-resolution landcover data for 2008 from the Pennsylvania Spatial Data Access database. We calculated landscape metrics to measure the greenness, fragmentation, connectedness, aggregation, and shape of greenspace, including and omitting green areas 83·6 m² or smaller, using Geographical Information System and spatial pattern analysis programs. We analysed all-cause and cause-specific mortality (related to heart disease, chronic lower respiratory diseases, and neoplasms) recorded in 2006 for 369 census tracts (small geographical areas with a population of 2500-8000 people). We did negative binomial regression and principal component analyses to assess associations between landscape spatial metrics and mortality, controlling for geographical, demographic, and socioeconomic factors.

FINDINGS

A 1% increase in the percentage of greenspace was predicted to reduce all-cause mortality by 0·419% (95% CI 0·050-0·777), with no effect on cause-specific mortality. All-cause mortality was negatively associated with the area of greenspace. A 1 m² increase in the mean area of greenspace led to a 0·011% (95% CI 0·004-0·018) fall in all-cause mortality and a 0·019% (0·007-0·032) decrease in cardiac mortality; considering only green areas larger than 83·6 m² would contribute to a 0·002% (95% CI 0·001-0·003) decrease in all-cause mortality and a 0·003% (0·001-0·006) reduction in cardiac deaths. Census tracts with more connected, aggregated, coherent, and complex shape greenspaces had a lower risk of all-cause and cause-specific mortality. The negative association between articulated landscape parcels and all-cause mortality varied with age and education, such that the relation was stronger for census tracts with a higher percentage of older and less well-educated adults.

INTERPRETATION

A significant modest association exists between the spatial distribution of greenspace in cities and mortality risk. The overall amount of greenspace alone is probably failing to capture significant variance in local health outcomes and, thus, environment-based health planning should consider the shape, form, and function of greenspace.

FUNDING

None.

Green spaces and mortality: a systematic review and meta-analysis of cohort studies

BACKGROUND

Green spaces have been proposed to be a health determinant, improving health and wellbeing through different mechanisms. We aimed to systematically review the epidemiological evidence from longitudinal studies that have investigated green spaces and their association with all-cause mortality. We aimed to evaluate this evidence with a meta-analysis, to determine exposure-response functions for future quantitative health impact assessments.

METHODS

We did a systematic review and meta-analysis of cohort studies on green spaces and all-cause mortality. We searched for studies published and indexed in MEDLINE before Aug 20, 2019, which we complemented with an additional search of cited literature. We included studies if their design was longitudinal; the exposure of interest was measured green space; the endpoint of interest was all-cause mortality; they provided a risk estimate (ie, a hazard ratio [HR]) and the corresponding 95% CI for the association between green space exposure and all-cause mortality; and they used normalised difference vegetation index (NDVI) as their green space exposure definition. Two investigators (DR-R and DP-L) independently screened the full-text articles for inclusion. We used a random-effects model to obtain pooled HRs. This study is registered with PROSPERO, CRD42018090315.

FINDINGS

We identified 9298 studies in MEDLINE and 13 studies that were reported in the literature but not indexed in MEDLINE, of which 9234 (99%) studies were excluded after screening the titles and abstracts and 68 (88%) of 77 remaining studies were excluded after assessment of the full texts. We included nine (12%) studies in our quantitative evaluation, which comprised 8 324 652 individuals from seven countries. Seven (78%) of the nine studies found a significant inverse relationship between an increase in surrounding greenness per 0·1 NDVI in a buffer zone of 500 m or less and the risk of all-cause mortality, but two studies found no association. The pooled HR for all-cause mortality per increment of 0·1 NDVI within a buffer of 500 m or less of a participant's residence was 0·96 (95% CI 0·94-0·97; I², 95%).

INTERPRETATION

We found evidence of an inverse association between surrounding greenness and all-cause mortality. Interventions to increase and manage green spaces should therefore be considered as a strategic public health intervention.

FUNDING

World Health Organization.

Assessing the impact of rising child poverty on the unprecedented rise in infant mortality in England, 2000-2017: time trend analysis

OBJECTIVE

To determine whether there were inequalities in the sustained rise in infant mortality in England in recent years and the contribution of rising child poverty to these trends.

DESIGN

This is an analysis of trends in infant mortality in local authorities grouped into five categories (quintiles) based on their level of income deprivation. Fixed-effects regression models were used to quantify the association between regional changes in child poverty and regional changes in infant mortality.

SETTING

324 English local authorities in 9 English government office regions.

PARTICIPANTS

Live-born children under 1 year of age.

MAIN OUTCOME MEASURE

Infant mortality rate, defined as the number of deaths in children under 1 year of age per 100 000 live births in the same year.

RESULTS

The sustained and unprecedented rise in infant mortality in England from 2014 to 2017 was not experienced evenly across the population. In the most deprived local authorities, the previously declining trend in infant mortality reversed and mortality rose, leading to an additional 24 infant deaths per 100 000 live births per year (95% CI 6 to 42), relative to the previous trend. There was no significant change from the pre-existing trend in the most affluent local authorities. As a result, inequalities in infant mortality increased, with the gap between the most and the least deprived local authority areas widening by 52 deaths per 100 000 births (95% CI 36 to 68). Overall from 2014 to 2017, there were a total of 572 excess infant deaths (95% CI 200 to 944) compared with what would have been expected based on historical trends. We estimated that each 1% increase in child poverty was significantly associated with an extra 5.8 infant deaths per 100 000 live births (95% CI 2.4 to 9.2). The findings suggest that about a third of the increases in infant mortality between 2014 and 2017 can be attributed to rising child poverty (172 deaths, 95% CI 74 to 266).

CONCLUSION

This study provides evidence that the unprecedented rise in infant mortality disproportionately affected the poorest areas of the country, leaving the more affluent areas unaffected. Our analysis also linked the recent increase in infant mortality in England with rising child poverty, suggesting that about a third of the increase in infant mortality from 2014 to 2017 may be attributed to rising child poverty.

Relationships between greenness and low birth weight: Investigating the interaction and mediation effects of air pollution

BACKGROUND

Associations between residential greenness and improved birth weight have been increasingly reported, but underlying mechanisms and interactions with other environmental exposures are still unclear.

OBJECTIVES

To study the relationships between low birth weight (LBW, <2500 g), residential greenness, and the potential influence of air pollution in these relationships (interaction and mediation) in California, over the period 2001-2008.

METHODS

Residential greenness around maternal homes was characterized using the Normalized Difference Vegetation Index (NDVI). Complementary indicators of air pollution exposure reflected its main components. Birth weight and maternal characteristics were obtained from birth certificate records. In this case-cohort study, associations between greenness and LBW were investigated using multi-level Poisson regression with random effect at the hospital level. We investigated potential interaction of greenness and air pollutants on both additive and multiplicative scales. Mediation analyses were conducted to estimate the potential contribution of local variations in air pollutant concentrations associated with greenness on LBW risk.

RESULTS

In total 72,632 LBW cases were included. A reduction of LBW risk was associated with an increase in NDVI (adjusted risk ratio per inter-quartile range in NDVI: 0.963; 95% confidence interval: 0.947; 0.978). We observed no interaction between NDVI and air pollution on LBW risk. The estimated mediating effect of fine particulate matter in the impact of greenness on LBW was 12%.

CONCLUSION

This large study confirms that residential greenness is associated with a reduced risk of LBW and suggests that greenness might benefit to LBW partly through a local reduction in air pollution.

Greenspace and Infant Mortality in Philadelphia, PA

Despite mounting evidence that urban greenspace protects against mortality in adults, few studies have explored the relationship between greenspace and death among infants. Here, we describe results from an analysis of associations between greenness and infant mortality in Philadelphia, PA. We used images of the normalized difference vegetation index (NDVI), derived from processed satellite data, to estimate greenness density in each census tract. We linked these data with census tract level counts of total infant mortality cases (n = 963) and births (n = 113,610) in years 2010-2014, and used Bayesian spatial areal unit, conditional autoregressive models to estimate associations between greenness and infant mortality. The models included a set of random effects to account for spatial autocorrelation between neighboring census tracts. Infant mortality counts were modeled using a Poisson distribution, and the logarithm of total births in each census tract was specified as the offset term. The following variables were included as potential confounders and effect modifiers: percentage non-Hispanic black, percentage living below the poverty line, an indicator of housing quality, and population density. In adjusted models, the rate of infant mortality was 27% higher in less green compared to more green tracts (95% CI 1.02-1.59). These results contribute further evidence that greenspace may be a health promoting environmental asset.

A sibling study of whether maternal exposure to different types of natural space is related to birthweight

Background

Birthweight is an important determinant of health across the life course. Maternal exposure to natural space has been linked to higher birthweight, but stronger evidence of a causal link is needed. We use a quasi-experimental sibling study design to investigate if change in the mother’s exposure to natural space between births was related to birthweight, in urban Scotland.

Methods

Amount (% area) of total natural space, total accessible (public) natural space, parks, woodlands and open water within 100 m of the mother’s postcode was calculated for eligible births (n = 40 194; 1991–2010) in the Scottish Longitudinal Study (a semi-random 5.3% sample of the Scottish population). Associations between natural space and birthweight were estimated, using ordinary least squares and fixed effects models.

Results

Birthweight was associated with the total amount of natural space around the mother’s home (+8.2 g for interquartile range increase), but was unrelated to specific types of natural space. This whole-sample relationship disappeared in the sibling analysis, indicating residual confounding. The sibling models showed effects for total natural space with births to women who already had children (+20.1 g), and to those with an intermediate level of education (+14.1 g).

Conclusions

The importance of total natural space for birthweight suggests that benefits can be experienced near to as well as within natural space. Ensuring expectant mothers have good access to high quality neighbourhood natural space has the potential to improve the infant’s start in life, and consequently their health trajectory over the life course.

Premature Adult Death and Equity Impact of a Reduction of NO₂, PM10, and PM2.5 Levels in Paris-A Health Impact Assessment Study Conducted at the Census Block Level

Background: To support environmental policies aiming to tackle air pollution, quantitative health impact assessments (HIAs) stand out as one of the best decision-making tools. However, no risk assessment studies have quantified or mapped the health and equity impact of air pollution reduction at a small spatial scale. Objectives: We developed a small-area analysis of the impact of air pollution on "premature" death among an adult population over 30 years of age to quantify and map the health and equity impact related to a reduction of air pollution. Methods: All-cause mortality data of an adult population (>30 years) from January 2004 to December 2009 were geocoded at the residential census block level in Paris. Each census block was assigned socioeconomic deprivation levels and annual average ambient concentrations of NO₂, PM₁₀, and PM_2.5. HIAs were used to estimate, at a small-area level, the number of "premature" deaths associated with a hypothetical reduction of NO₂, PM₁₀, and PM_2.5 exposure. In total, considering global dose response function for the three pollutants and socioeconomic deprivation specific dose response function, nine HIAs were performed for NO₂ and six and four HIAs for PM10 and PM2.5, respectively. Finally, a clustering approach was used to quantify how the number of "premature" deaths could vary according to deprivation level. Results: The number of deaths attributable to NO₂, PM₁₀, and PM_2.5 exposure were equal to 4301, 3209, and 2662 deaths, respectively. The most deprived census blocks always appeared as one of the groups most impacted by air pollution. Our findings showed that "premature" deaths attributable to NO₂ were not randomly distributed over the study area, with a cluster of excess "premature" deaths located in the northeastern area of Paris. Discussion: This study showed the importance of stratifying an environmental burden of disease study on the socioeconomic level, in order to take into consideration the modifier effect of socioeconomic status on the air pollution-mortality relationship. In addition, we demonstrated the value of spatial analysis to guide decision-making. This shows the need for tools to support priority-setting and to guide policymakers in their choice of environmental initiatives that would maximize health gains and reduce social inequalities in health.

Mean and variance of greenness and pregnancy outcomes in Tel Aviv during 2000–14: longitudinal and cross-sectional approaches

Background

Natural environments may have beneficial impacts on pregnancy outcomes. However, longitudinal evidence is limited and the associations with variance in surrounding greenness is unknown. Our objective was to evaluate these associations among 73 221 live births in Tel Aviv, Israel.

Methods

Longitudinal exposure to mean of greenness during pregnancy and trimesters were calculated using satellite-based Moderate Resolution Imaging Spectroradiometer (MODIS) Normalised Difference Vegetation Index (NDVI) data. In addition, exposure to mean and variation of NDVI from high-resolution satellite and percentage of tree cover [Vegetation Continuous Fields (VCF)] at 300-m buffer were evaluated in a cross-sectional approach. Generalized linear models were used to estimate the crude and adjusted associations. We explore the possible mediating role of ambient exposures and distance to ‘outdoor gyms’ located in parks.

Results

Crude beneficial associations between exposure to higher mean NDVI during pregnancy and pregnancy outcomes were observed [for birthweight, 3rd/1st tertile exposure increased the mean by 25.5 g, 95% confidence intervals (CIs): 15.4, 35.5] and decreased the odds of low birthweight, small for gestational age, preterm deliveries (PTD) and very PTD. Adjustment for individual and neighbourhood-level markers of socio-economic status (SES) attenuated all the associations. Strongest associations were observed during the first and second trimesters. Cross-sectional associations for mean greenness were similar with narrower CIs, and associations with NDVI were stronger than with tree cover and stronger for mean compared with variance of greenness. Associations were consistent for term births, different buffer sizes and for further adjustment to maternal education. Stronger associations were observed for lowest SES. Distance to ‘outdoor gyms’ and variance of greenness had the largest estimates of mediation.

Conclusion

This study adds to the limited information on when exposure to greenness is most beneficial, on the association with variance of greenness and the possible pathways. These observations require confirmation in other populations.

Using a Clustering Approach to Investigate Socio-Environmental Inequality in Preterm Birth-A Study Conducted at Fine Spatial Scale in Paris (France)

Background & Objectives: Today, to support public policies aiming to tackle environmental and health inequality, identification and monitoring of the spatial pattern of adverse birth outcomes are crucial. Spatial identification of the more vulnerable population to air pollution may orient health interventions. In this context, the objective of this study is to investigate the geographical distribution of the risk of preterm birth (PTB, gestational age ≤36 weeks) at the census block level in in city of Paris, France. We also aimed to assess the implication of neighborhood characteristics including air pollution and socio-economic deprivation. Material & Methods: Newborn health data are available from the first birth certificate registered by the Maternal and Child Care department of Paris. All PTB from January 2008 to December 2011 were geocoded at the mother residential census block. Each census block was assigned a socioeconomic deprivation level and annual average ambient concentrations of NO₂. A spatial clustering approach was used to investigate the spatial distribution of PTB. Results: Our results highlight that PTB is non-randomly spatially distributed, with a cluster of high risk in the northeastern area of Paris (RR = 1.15; p = 0.06). After adjustment for socio-economic deprivation and NO₂ concentrations, this cluster becomes not statistically significant or shifts suggesting that these characteristics explain the spatial distribution of PTB; further, their combination shows an interaction in comparison with SES or NO₂ levels alone. Conclusions: Our results may inform the decision makers about the areas where public health efforts should be strengthened to tackle the risk of PTB and to choose the most appropriate and specific community-oriented health interventions.

Residential green space and birth outcomes in a coastal setting

BACKGROUND

Residential green space may improve birth outcomes, with prior studies reporting higher birthweight among infants of women living in greener areas. However, results from studies evaluating associations between green space and preterm birth have been mixed. Further, the potential influence of residential proximity to water, or 'blue space', on health has not previously been evaluated.

OBJECTIVES

To evaluate associations between green and blue space and birth outcomes in a coastal area of the northeastern United States.

METHODS

Using residential surrounding greenness (measured by Normalized Difference Vegetation Index [NDVI]) and proximity to recreational facilities, coastline, and freshwater as measures of green and blue space, we examined associations with preterm birth (PTB), term birthweight, and term small for gestational age (SGA) among 61,640 births in Rhode Island. We evaluated incremental adjustment for socioeconomic and environmental metrics.

RESULTS

In models adjusted for individual - and neighborhood-level markers of socioeconomic status (SES), an interquartile range (IQR) increase in NDVI was associated with a 12% higher (95% CI: 4, 20%) odds of PTB and, conversely, living within 500 m of a recreational facility was associated with a 7% lower (95% CI: 1, 13%) odds of PTB. These associations were eliminated after further adjustment for town of residence. NDVI was associated with higher birthweight (7.4 g, 95% CI: 0.4-14.4 g) and lower odds of SGA (OR = 0.92, 95% CI: 0.87-0.98) when adjusted for individual-level markers of SES, but not when further adjusted for neighborhood SES or town. Living within 500 m of a freshwater body was associated with a higher birthweight of 10.1 g (95% CI: 2.0, 18.2) in fully adjusted models.

CONCLUSIONS

Findings from this study do not support the hypothesis that residential green space is associated with reduced risk of preterm birth or higher birthweight after adjustment for individual and contextual socioeconomic factors, but variation in results with incremental adjustment raises questions about the optimal degree of control for confounding by markers of SES. We found that living near a freshwater body was associated with higher birthweight. This result is novel and bears further investigation in other settings and populations.

Do Individual and Neighborhood Characteristics Influence Perceived Air Quality?

Background: Despite improvements, air pollution still remains a major public health issue. Numerous epidemiological studies have demonstrated the adverse health effects of air pollution exposure based on modeled measures, but only a few have considered the health impact of perceived air quality. Improving our knowledge of individual perceptions is crucial to defining targeted actions and promoting appropriate intervention measures. Our objective is to investigate the relationship between subjective and objective measures of air pollution and to focus on how individual characteristics combined with the neighborhood socioeconomic deprivation index, measured at a fine spatial scale, may or may not alter this relationship. Materials and Methods: The subjective measures of air quality reported by a sample of Lyon residents were collected via an individual questionnaire. The objective measures of air pollution were modeled by the local air quality monitoring network of the Rhône-Alpes region at census block level. We used a socioeconomic deprivation index to capture the different socioeconomic dimensions at census block level. The statistical analysis was structured in two steps: (1) identification of individual determinants of the subjective measures of air quality using multiple correspondence analysis followed by hierarchical clustering; (2) identification of individual and contextual characteristics that may alter the relationship between the objective and subjective measures of air pollution. Results: Among the youngest and the middle aged population (ages 30 to 59), consistent results between level of satisfaction, perceived air quality and objective measures of air pollution were found whatever the individual characteristics of the population. It is less clear among the oldest population: globally no significant difference between the NO₂ concentrations and the level of satisfaction was observed. Conclusions: We found a significant relationship between the subjective and objective measures of air pollution in many population sub-groups with different combinations of individual characteristics. The relationship is less clear among the oldest population, which confirms previous findings. Our finding highlights that age combined with low level of education and unemployment, or women or health problems as well as the neighborhood deprivation index influence the level of air quality satisfaction.

The health benefits of nature-based solutions to urbanization challenges for children and the elderly - A systematic review

Urban green and blue spaces promote health by offering areas for physical activity, stress relief, and social interaction, which may be considered as cultural ecosystem services. They also provide a number of regulating ecosystem services that can be regarded as nature-based solutions to mitigate impacts from urbanization-induced challenges. Urban trees and other vegetation provide cooling through shade and evapotranspiration, which reduce the impact of the urban heat island on hot summer days. Urban vegetation may improve air quality by removing air pollutants. Open areas in cities, such as parks, gardens, playgrounds and cemeteries, are unsealed spaces that also improve infiltration during extreme precipitation events providing water regulating functions. All these services have the potential to improve the health of urban residents, particularly of specific vulnerable groups such as children and the elderly. The aim of this paper is to provide an overview of the current state of evidence on the relationship between the health of children and the elderly and urban green and blue spaces that can account as nature-based solutions to urbanization-induced challenges. We discuss potential confounding factors and refer to the different green space metrics used to identify associations to health. From the results, we cannot conclude on a universal protective health effect of urban green and blue spaces for children and the elderly. While the association trend is positive, the results remain inconclusive, context dependent and are partly overridden by socioeconomic confounders. However, the research area is consistently increasing, and we advance important prospects for future research on urban green and blue spaces in the face of global challenges such as urbanization.

Racial disparity in infant mortality

In the United States, African-American infants have significantly higher mortality than white infants. Previous work has identified associations between individual socioeconomic factors and select community-level factors. In this review, the authors look beyond traditional risk factors for infant mortality and examine the social context of race in this country, in an effort to understand African-American women's long-standing birth outcome disadvantage. In the process, recent insights are highlighted concerning neighborhood-level factors such as crime, segregation, built environment, and institutional racism, other likely causes for the poor outcomes of African-American infants in this country compared with infants in most other industrialized nations.

Green Streets: Urban Green and Birth Outcomes

Recent scholarship points to a protective association between green space and birth outcomes as well a positive relationship between blue space and wellbeing. We add to this body of literature by exploring the relationship between expectant mothers' exposure to green and blue spaces and adverse birth outcomes in New York City. The Normalized Difference Vegetation Index (NDVI), the NYC Street Tree Census, and access to major green spaces served as measures of greenness, while proximity to waterfront areas represented access to blue space. Associations between these factors and adverse birth outcomes, including preterm birth, term birthweight, term low birthweight, and small for gestational age, were evaluated via mixed-effects linear and logistic regression models. The analyses were conducted separately for women living in deprived neighborhoods to test for differential effects on mothers in these areas. The results indicate that women in deprived neighborhoods suffer from higher rates adverse birth outcomes and lower levels of residential greenness. In adjusted models, a significant inverse association between nearby street trees and the odds of preterm birth was found for all women. However, we did not identify a consistent significant relationship between adverse birth outcomes and NDVI, access to major green spaces, or waterfront access when individual covariates were taken into account.

Developing a data-driven spatial approach to assessment of neighbourhood influences on the spatial distribution of myocardial infarction

BACKGROUND

There is a growing understanding of the role played by 'neighbourhood' in influencing health status. Various neighbourhood characteristics-such as socioeconomic environment, availability of amenities, and social cohesion, may be combined-and this could contribute to rising health inequalities. This study aims to combine a data-driven approach with clustering analysis techniques, to investigate neighbourhood characteristics that may explain the geographical distribution of the onset of myocardial infarction (MI) risk.

METHODS

All MI events in patients aged 35-74 years occurring in the Strasbourg metropolitan area (SMA), from January 1, 2000 to December 31, 2007 were obtained from the Bas-Rhin coronary heart disease register. All cases were geocoded to the census block for the residential address. Each areal unit, characterized by contextual neighbourhood profile, included socioeconomic environment, availability of amenities (including leisure centres, libraries and parks, and transport) and psychosocial environment as well as specific annual rates standardized (per 100,000 inhabitants). A spatial scan statistic implemented in SaTScan was then used to identify statistically significant spatial clusters of high and low risk of MI.

RESULT

MI incidence was non-randomly spatially distributed, with a cluster of high risk of MI in the northern part of the SMA [relative risk (RR) = 1.70, p = 0.001] and a cluster of low risk of MI located in the first and second periphery of SMA (RR 0.04, p value  =  0.001). Our findings suggest that the location of low MI risk is characterized by a high socioeconomic level and a low level of access to various amenities; conversely, the location of high MI risk is characterized by a high level of socioeconomic deprivation-despite the fact that inhabitants have good access to the local recreational and leisure infrastructure.

CONCLUSION

Our data-driven approach highlights how the different contextual dimensions were inter-combined in the SMA. Our spatial approach allowed us to identify the neighbourhood characteristics of inhabitants living within a cluster of high versus low MI risk. Therefore, spatial data-driven analyses of routinely-collected data georeferenced by various sources may serve to guide policymakers in defining and promoting targeted actions at fine spatial level.

Residential greenness: current perspectives on its impact on maternal health and pregnancy outcomes

Recent research in environmental epidemiology has attempted to estimate the effects of exposure to nature, often operationalized as vegetation, on health. Although many analyses have focused on vegetation or greenness with regard to physical activity and weight status, an incipient area of interest concerns maternal health and birth outcomes. This paper reviews 14 studies that examined the association between greenness and maternal or infant health. Most studies were cross-sectional and conducted in birth cohorts. Several studies found evidence for positive associations between greenness and birth weight and maternal peripartum depression. Few studies found evidence for an association between greenness and gestational age or other birth outcomes, or between greenness and preeclampsia or gestational diabetes. Several assessed effect modification by individual or area-level socioeconomic status and found that effects were stronger among those of lower socioeconomic status. Few studies conducted mediation analyses of any kind. Future research should include more diverse birth outcomes and focus on maternal health (especially mental health) and capitalize on richer exposure information during pregnancy rather than cross-sectional assessment at birth.

Transforming Life: A Broad View of the Developmental Origins of Health and Disease Concept from an Ecological Justice Perspective

The influential scientist Rene J. Dubos (1901–1982) conducted groundbreaking studies concerning early-life environmental exposures (e.g., diet, social interactions, commensal microbiota, housing conditions) and adult disease. However, Dubos looked beyond the scientific focus on disease, arguing that “mere survival is not enough”. He defined mental health as fulfilling human potential, and expressed concerns about urbanization occurring in tandem with disappearing access to natural environments (and elements found within them); thus modernity could interfere with health via “missing exposures”. With the advantage of emerging research involving green space, the microbiome, biodiversity and positive psychology, we discuss ecological justice in the dysbiosphere and the forces—financial inequity, voids in public policy, marketing and otherwise—that interfere with the fundamental rights of children to thrive in a healthy urban ecosystem and learn respect for the natural environment. We emphasize health within the developmental origins of health and disease (DOHaD) rubric and suggest that greater focus on positive exposures might uncover mechanisms of resiliency that contribute to maximizing human potential. We will entrain our perspective to socioeconomic disadvantage in developed nations and what we have described as “grey space”; this is a mental as much as a physical environment, a space that serves to insidiously reinforce unhealthy behavior, compromise positive psychological outlook and, ultimately, trans-generational health. It is a dwelling place that cannot be fixed with encephalobiotics or the drug-class known as psychobiotics.

Health Impact Assessment of Urban Development Project

Background:

Health impact assessment (HIA) has emerged to identify those activities and policies likely to have major impacts on the health of a population.

Method:

In this research, qualitative method was applied to identifying health determinants that urban man made lake affect on them, formatting and weighing the hierarchy of the factors, calculating AHP, and Technique for Order Preference by Similarity to Ideal Solution (TOPSIS) method for decide and ranking alternatives.

Results:

According to the results of the study, from the structural determinants point of view, the most positive effect of man-made lake was on Recreational services by 89.5% and the most negative one was on housing. According to intermediary determinants and general average, the most positive effect of lake was on physical activity and quality of air by 88.9% and the most negative one was on noise pollution by 46.7%. Ultimately, considering the positive and negative effects of lake between constructing and not constructing the lake option, the construction option was selected.

Conclusion:

There is substantial potential to improve public health by bringing decision makers’ attention to the health consequences of their actions; city councilpersons, zoning commissioners, and other decision makers typically have little background in health.

Use of geographic indicators of healthcare, environment and socioeconomic factors to characterize environmental health disparities

BACKGROUND

An environmental health inequality is a major public health concern in Europe. However just few studies take into account a large set of characteristics to analyze this problematic. The aim of this study was to identify and describe how socioeconomic, health accessibility and exposure factors accumulate and interact in small areas in a French urban context, to assess environmental health inequalities related to infant and neonatal mortality.

METHODS

Environmental indicators on deprivation index, proximity to high-traffic roads, green space, and healthcare accessibility were created using the Geographical Information System. Cases were collected from death certificates in the city hall of each municipality in the Nice metropolitan area. Using the parental addresses, cases were geocoded to their census block of residence. A classification using a Multiple Component Analysis following by a Hierarchical Clustering allow us to characterize the census blocks in terms of level of socioeconomic, environmental and accessibility to healthcare, which are very diverse definition by nature. Relation between infant and neonatal mortality rate and the three environmental patterns which categorize the census blocks after the classification was performed using a standard Poisson regression model for count data after checking the assumption of dispersion.

RESULTS

Based on geographic indicators, three environmental patterns were identified. We found environmental inequalities and social health inequalities in Nice metropolitan area. Moreover these inequalities are counterbalance by the close proximity of deprived census blocks to healthcare facilities related to mother and newborn. So therefore we demonstrate no environmental health inequalities related to infant and neonatal mortality.

CONCLUSION

Examination of patterns of social, environmental and in relation with healthcare access is useful to identify census blocks with needs and their effects on health. Similar analyzes could be implemented and considered in other cities or related to other birth outcomes.

The need for, and value of, a spatial scan statistical tool for tackling social health inequalities

Today, one important challenge in developed countries is health inequalities. Research conducted in public health policy issues supply little evidence for effective interventions aiming to improve population health and to reduce health inequalities. There is a need for a powerful tool to support priority setting and guide policy makers in their choice of health interventions, and that maximizes social welfare. This paper proposes to divert a spatial tool based on Kulldorff's scan method to investigate social inequalities in health. This commentary argues that this spatial approach can be a useful tool to tackle social inequalities in health by guiding policy makers at three levels: (i) supporting priority setting and planning a targeted intervention; (ii) choosing actions or interventions which will be performed for the whole population, but with a scale and intensity proportionate to need; and (iii) assessing health equity of public interventions.

Influence of Socio-Economic Inequalities on Access to Renal Transplantation and Survival of Patients with End-Stage Renal Disease

Background

Public and scientific concerns about the social gradient of end-stage renal disease and access to renal replacement therapies are increasing. This study investigated the influence of social inequalities on the (i) access to renal transplant waiting list, (ii) access to renal transplantation and (iii) patients’ survival.

Methods

All incident adult patients with end-stage renal disease who lived in Bretagne, a French region, and started dialysis during the 2004–2009 period were geocoded in census-blocks. To each census-block was assigned a level of neighborhood deprivation and a degree of urbanization. Cox proportional hazards models were used to identify factors associated with each study outcome.

Results

Patients living in neighborhoods with low level of deprivation had more chance to be placed on the waiting list and less risk of death (HR = 1.40 95%CI: [1.1–1.7]; HR = 0.82 95%CI: [0.7–0.98]), but this association did not remain after adjustment for the patients’ clinical features. The likelihood of receiving renal transplantation after being waitlisted was not associated with neighborhood deprivation in univariate and multivariate analyses.

Conclusions

In a mixed rural and urban French region, patients living in deprived or advantaged neighborhoods had the same chance to be placed on the waiting list and to undergo renal transplantation. They also showed the same mortality risk, when their clinical features were taken into account.

Greenness and Birth Outcomes in a Range of Pennsylvania Communities

Living in communities with more vegetation during pregnancy has been associated with higher birth weights, but fewer studies have evaluated other birth outcomes, and only one has been conducted in the Eastern United States, in regions with a broad range, including high levels, of greenness. We evaluated associations between prenatal residential greenness and birth outcomes (term birth weight, small for gestational age, preterm birth, and low 5 min Apgar score) across a range of community types using electronic health record data from 2006–2013 from the Geisinger Health System in Pennsylvania. We assigned greenness based on mother’s geocoded address using the normalized difference vegetation index from satellite imagery. We used propensity scores to restrict the study population to comparable groups among those living in green vs. less-green areas. Analyses were adjusted for demographic, clinical, and environmental covariates, and stratified by community type (city, borough, and township). In cities, higher greenness (tertiles 2–3 vs. 1) was protective for both preterm (OR = 0.78, 95% CI: 0.61–0.99) and small for gestational age birth (OR = 0.73, 95% CI: 0.58–0.97), but not birth weight or Apgar score. We did not observe associations between greenness and birth outcomes in adjusted models in boroughs or townships. These results add to the evidence that greener cities might be healthier cities.

The association between green space and depressive symptoms in pregnant women: moderating roles of socioeconomic status and physical activity

BACKGROUND

The current study explored the association between green space and depression in a deprived, multiethnic sample of pregnant women, and examined moderating and mediating variables.

METHOD

7547 women recruited to the 'Born in Bradford' cohort completed a questionnaire during pregnancy. A binary measure of depressive symptoms was calculated using a validated survey. Two green space measures were used: quintiles of residential greenness calculated using the normalised difference vegetation index for three neighbourhood sizes (100, 300 and 500 m buffer zones around participant addresses); access to major green spaces estimated as straight line distance between participant address and nearest green space (>0.5 hectares). Logistic regression analyses examined relationships between green space and depressive symptoms, controlling for ethnicity, demographics, socioeconomic status (SES) and health behaviours. Multiplicative interactions explored variations by ethnic group, SES or activity levels. Mediation analysis assessed indirect effects via physical activity.

RESULTS

Pregnant women in the greener quintiles were 18-23% less likely to report depressive symptoms than those in the least green quintile (for within 100 m of green space buffer zone). The green space-depressive symptoms association was significant for women with lower education or who were active. Physical activity partially mediated the association of green space, but explained only a small portion of the direct effect.

CONCLUSIONS

Higher residential greenness was associated with a reduced likelihood of depressive symptoms. Associations may be stronger for more disadvantaged groups and for those who are already physically active. Improving green space is a promising intervention to reduce risk of depression in disadvantaged groups.

Residential green spaces and mortality: A systematic review

BACKGROUND

A number of studies have associated natural outdoor environments with reduced mortality but there is no systematic review synthesizing the evidence.

OBJECTIVES

We aimed to systematically review the available evidence on the association between long-term exposure to residential green and blue spaces and mortality in adults, and make recommendations for further research. As a secondary aim, we also conducted meta-analyses to explore the magnitude of and heterogeneity in the risk estimates.

METHODS

Following the PRISMA statement guidelines for reporting systematic reviews and meta-analysis, two independent reviewers searched studies using keywords related to natural outdoor environments and mortality.

DISCUSSION

Our review identified twelve eligible studies conducted in North America, Europe, and Oceania with study populations ranging from 1645 up to more than 43 million individuals. These studies are heterogeneous in design, study population, green space assessment and covariate data.We found that the majority of studies show a reduction of the risk of cardiovascular disease (CVD) mortality in areas with higher residential greenness. Evidence of a reduction of all-cause mortality is more limited, and no benefits of residential greenness on lung cancer mortality are observed. There were no studies on blue spaces.

CONCLUSIONS

This review supports the hypothesis that living in areas with higher amounts of green spaces reduces mortality, mainly CVD. Further studies such as cohort studies with more and better covariate data, improved green space assessment and accounting well for socioeconomic status are needed to provide further and more complete evidence, as well as studies evaluating the benefits of blue spaces.

A Review of the Health Benefits of Greenness

Researchers are increasingly exploring how neighborhood greenness, or vegetation, may affect health behaviors and outcomes. Greenness may influence health by promoting physical activity and social contact; decreasing stress; and mitigating air pollution, noise, and heat exposure. Greenness is generally measured using satellite-based vegetation indices or land-use databases linked to participants' addresses. In this review, we found fairly strong evidence for a positive association between greenness and physical activity, and a less consistent negative association between greenness and body weight. Research suggests greenness is protective against adverse mental health outcomes, cardiovascular disease, and mortality, though most studies were limited by cross-sectional or ecological design. There is consistent evidence that greenness exposure during pregnancy is positively associated with birth weight, though findings for other birth outcomes are less conclusive. Future research should follow subjects prospectively, differentiate between greenness quantity and quality, and identify mediators and effect modifiers of greenness-health associations.

Data analysis techniques: a tool for cumulative exposure assessment

Everyone is subject to environmental exposures from various sources, with negative health impacts (air, water and soil contamination, noise, etc.or with positive effects (e.g. green space). Studies considering such complex environmental settings in a global manner are rare. We propose to use statistical factor and cluster analyses to create a composite exposure index with a data-driven approach, in view to assess the environmental burden experienced by populations. We illustrate this approach in a large French metropolitan area. The study was carried out in the Great Lyon area (France, 1.2 M inhabitants) at the census Block Group (BG) scale. We used as environmental indicators ambient air NO2 annual concentrations, noise levels and proximity to green spaces, to industrial plants, to polluted sites and to road traffic. They were synthesized using Multiple Factor Analysis (MFA), a data-driven technique without a priori modeling, followed by a Hierarchical Clustering to create BG classes. The first components of the MFA explained, respectively, 30, 14, 11 and 9% of the total variance. Clustering in five classes group: (1) a particular type of large BGs without population; (2) BGs of green residential areas, with less negative exposures than average; (3) BGs of residential areas near midtown; (4) BGs close to industries; and (5) midtown urban BGs, with higher negative exposures than average and less green spaces. Other numbers of classes were tested in order to assess a variety of clustering. We present an approach using statistical factor and cluster analyses techniques, which seem overlooked to assess cumulative exposure in complex environmental settings. Although it cannot be applied directly for risk or health effect assessment, the resulting index can help to identify hot spots of cumulative exposure, to prioritize urban policies or to compare the environmental burden across study areas in an epidemiological framework.

Spatial distribution of end-stage renal disease (ESRD) and social inequalities in mixed urban and rural areas: a study in the Bretagne administrative region of France

Background

Several studies have investigated the implication of biological and environmental factors on geographic variations of end-stage renal disease (ESRD) incidence at large area scales, but none of them assessed the implication of neighbourhood characteristics (healthcare supply, socio-economic level and urbanization degree) on spatial repartition of ESRD. We evaluated the spatial implications of adjustment for neighbourhood characteristics on the spatial distribution of ESRD incidence at the smallest geographic unit in France.

Methods

All adult patients living in Bretagne and beginning renal replacement therapy during the 2004–09 period were included. Their residential address was geocoded at the census block level. Each census block was characterized by socio-economic deprivation index, healthcare supply and rural/urban typology. Using a spatial scan statistic, we examined whether there were significant clusters of high risk of ESRD incidence.

Results

The ESRD incidence was non-randomly spatially distributed, with a cluster of high risk in the western Bretagne region (relative risk, RR = 1.28, P-value = 0.0003). Adjustment for sex, age and neighbourhood characteristics induced cluster shifts. After these adjustments, a significant cluster (P = 0.013) persisted.

Conclusions

Our spatial analysis of ESRD incidence at a fine scale, across a mixed rural/urban area, indicated that, beyond age and sex, neighbourhood characteristics explained a great part of spatial distribution of ESRD incidence. However, to better understand spatial variation of ESRD incidence, it would be necessary to research and adjust for other determinants of ESRD.

Green spaces and adverse pregnancy outcomes

OBJECTIVE

The objective of this study was to evaluate the associations between proximity to green spaces and surrounding greenness and pregnancy outcomes, such as birth weight, low birth weight (LBW), very LBW (VLBW), gestational age, preterm deliveries (PTD) and very PTD (VPTD).

METHODS

This study was based on 39,132 singleton live births from a registry birth cohort in Tel Aviv, Israel, during 2000-2006. Surrounding greenness was defined as the average of satellite-based Normalised Difference Vegetation Index (NDVI) in 250 m buffers and proximity to major green spaces was defined as residence within a buffer of 300 m from boundaries of a major green space (5000 m(2)), based on data constructed from OpenStreetMap. Linear regression (for birth weight and gestational age) and logistic regressions models (for LBW, VLBW, PTD and VPTD) were used with adjustment for relevant covariates.

RESULTS

An increase in 1 interquartile range greenness was associated with a statistically significant increase in birth weight (19.2 g 95% CI 13.3 to 25.1) and decreased risk of LBW (OR 0.84, 95% CI 0.78 to 0.90). Results for VLBW were in the same direction but were not statistically significant. In general, no associations were found for gestational age, PTD and VPTD. The findings were consistent with different buffer and green space sizes and stronger associations were observed among those of lower socioeconomic status.

CONCLUSIONS

This study confirms the results of a few previous studies demonstrating an association between maternal proximity to green spaces and birth weight. Further investigation is needed into the associations with VLBW and VPTD, which has never been studied before.