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

Spatial distribution of delayed initiation of antenatal care visits and associated factors among reproductive age women in Ethiopia: spatial and multilevel analysis of 2019 mini-demographic and health survey

OBJECTIVES

This study aimed to assess the spatial distribution, wealth-related inequality and determinants for delayed initiation of antenatal care (ANC) visits among reproductive-age women in Ethiopia.

DESIGN

Cross-sectional study design.

SETTING

Ethiopia.

PARTICIPANTS

A total of 2924 reproductive-age women who had given birth in the 5 years preceding the survey.

OUTCOME MEASURE

Delayed initiation of ANC visits.

RESULTS

The magnitude of delayed initiation of ANC visits among reproductive-age women in Ethiopia was 62.63% (95% CI 60.86%, 64.37%). Women aged 35-49 (AOR=1.42; 95% CI 1.04, 1.94), being protestant religion followers (AOR=1.43; 95% CI 1.06, 1.94), being in higher wealth index (AOR=0.53; 95% CI 0.41, 0.69), living in rural residence (AOR=1.50; 95% CI 1.02, 2.19) and living in the metropolitan region (AOR=0.45; 95% CI 0.26, 0.77) were significantly associated with delayed initiation of ANC visit. Southern Nations Nationalities and Peoples Region (SNNPR), Somalia, Benishangul Gumuz, Southern Addis Ababa and Gambella regions were hot spot regions for delayed initiation of ANC visits. The SaTScan analysis result identified 107 primary clusters of delayed initiation of ANC visits located in regions of SNNPR, Gambella, Southern Addis Ababa, Eastern Oromia and Benishangul Gumuz.

CONCLUSIONS

Significant spatial clustering of delayed initiation of ANC visits was observed in Ethiopia. More than half of women had delayed initiation of ANC visits in Ethiopia. Women's age, religion, wealth index, residence and region were significant predictors of delayed initiation of ANC visits. There is a disproportional pro-poor distribution of delayed initiation of ANC visits in Ethiopia. Therefore, interventions should be designed in the hot spot areas where delayed initiation of ANC visits was high to enhance the timely initiation of ANC visits.

[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.

Air (ine)quality in the European Union

PURPOSE OF REVIEW

This paper presents an analytical review of recent research on social inequality caused or compounded by ambient air pollution in the European Union.

RECENT FINDINGS

While empirical studies have developed significantly both in the academic and institutional arena, they have largely focused on only one aspect: the exposure and sensitivity of individuals and groups to air pollution according to various criteria, documenting substantial and overlapping inequality. While EU policy should better address this proven impact inequality, research is also needed on new fronts of air (ine)quality (namely mental health impact and indoor air quality) as well as other types of ambient air inequality (such as inequality in responsibility and impact of air pollution mitigation policy).

An algorithm to identify residential mobility from electronic health-record data

BACKGROUND

Environmental, social and economic exposures can be inferred from address information recorded in an electronic health record. However, these data often contain administrative errors and misspellings. These issues make it challenging to determine whether a patient has moved, which is integral for accurate exposure assessment. We aim to develop an algorithm to identify residential mobility events and avoid exposure misclassification.

METHODS

At Penn Medicine, we obtained a cohort of 12 147 pregnant patients who delivered between 2013 and 2017. From this cohort, we identified 9959 pregnant patients with address information at both time of delivery and one year prior. We developed an algorithm entitled REMAP (Relocation Event Moving Algorithm for Patients) to identify residential mobility during pregnancy and compared it to using ZIP code differences alone. We assigned an area-deprivation exposure score to each address and assessed how residential mobility changed the deprivation scores.

RESULTS

To assess the accuracy of our REMAP algorithm, we manually reviewed 3362 addresses and found that REMAP was 95.7% accurate. In this large urban cohort, 41% of patients moved during pregnancy. REMAP outperformed the comparison of ZIP codes alone (82.9%). If residential mobility had not been taken into account, absolute area deprivation would have misclassified 39% of the patients. When setting a threshold of one quartile for misclassification, 24.4% of patients would have been misclassified.

CONCLUSIONS

Our study tackles an important characterization problem for exposures that are assigned based upon residential addresses. We demonstrate that methods using ZIP code alone are not adequate. REMAP allows address information from electronic health records to be used for accurate exposure assessment and the determination of residential mobility, giving researchers and policy makers more reliable information.

Social Vulnerability and Access of Local Medical Care During Hurricane Harvey: A Spatial Analysis

OBJECTIVES

When Hurricane Harvey struck the coastline of Texas in 2017, it caused 88 fatalities and over US $125 billion in damage, along with increased emergency department visits in Houston and in cities receiving hurricane evacuees, such as the Dallas-Fort Worth metroplex (DFW).This study explored demographic indicators of vulnerability for patients from the Hurricane Harvey impact area who sought medical care in Houston and in DFW. The objectives were to characterize the vulnerability of affected populations presenting locally, as well as those presenting away from home, and to determine whether more vulnerable communities were more likely to seek medical care locally or elsewhere.

METHODS

We used syndromic surveillance data alongside the Centers for Disease Control and Prevention Social Vulnerability Index to calculate the percentage of patients seeking care locally by zip code tabulation area. We used this variable to fit a spatial lag regression model, controlling for population density and flood extent.

RESULTS

Communities with more patients presenting for medical care locally were significantly clustered and tended to have greater socioeconomic vulnerability, lower household composition vulnerability, and more extensive flooding.

CONCLUSIONS

These findings suggest that populations remaining in place during a natural disaster event may have needs related to income, education, and employment, while evacuees may have more needs related to age, disability, and single-parent household status.

The role of prenatal social support in social inequalities with regard to maternal postpartum depression according to migrant status

BACKGROUND

An advantaged socioeconomic position (SEP) and satisfying social support during pregnancy (SSP) have been found to be protective factors of maternal postpartum depression (PDD). An advantaged SEP is also associated with satisfying SSP, making SSP a potential mediator of social inequalities in PPD. SEP, SSP and PPD are associated with migrant status. The aim of this study was to quantify the mediating role of SSP in social inequalities in PPD regarding mother's migrant status.

METHODS

A sub-sample of 15,000 mothers from the French nationally-representative ELFE cohort study was used for the present analyses. SEP was constructed as a latent variable measured with educational attainment, occupational grade, employment, financial difficulties and household income. SSP was characterized as perceived support from partner (good relation, satisfying support and paternal leave) and actual support from midwives (psychosocial risk factors assessment and antenatal education). Mediation analyses with multiple mediators, stratified by migrant status were conducted.

RESULTS

Study population included 76% of non-migrant women, 12% of second and 12% of first generation migrant. SEP was positively associated with support from partner, regardless of migrant status. Satisfying partner support was associated with a 8 (non-migrant women) to 11% (first generation migrant women) reduction in PPD score.

LIMITATIONS

History of depression was not reported.

CONCLUSIONS

Partner support could reduce social inequalities in PPD. This work supports the need of interventions, longitudinal and qualitative studies including fathers and adapted to women at risk of PPD to better understand the role of SSP in social inequalities in PPD.

Exploring geographical variations and inequalities in access to improved water and sanitation in Ethiopia: mapping and spatial analysis

Ensuring access to improved water and sanitation remains a public health challenge in Ethiopia. Exploring access to improved drinking-water supply and sanitation will help to track the progress towards achieving the Sustainable Development Goals. The aim of this study was to explore geographical variations and inequalities in access to improved drinking water and sanitation in Ethiopia. A total of 16,650 households from 643 enumeration areas of the recent Ethiopian Demographic and Health Survey 2016 data were extracted and included in the analysis. World Health Organization recommended definitions were used to measure indicators of improved drinking water and sanitation at enumeration areas. SaTScan™ software was used for spatial analysis using enumeration areas as centers for exploring geographical variations of improved water and sanitation. Absolute and relative inequalities were used to quantify regional inequalities in access to improved water and sanitation. Nationwide access to improved drinking water and sanitation in Ethiopia was 49.6% (95% CI: 48.4–50.7) and 6.3% (5.8–6.8), respectively, with large variations between and within regions (using the categories and definitions that were in effect for monitoring coverage in 2016). Access to improved drinking water ranged from 28.5% in Somali Region to 95.3% in Addis Ababa city whereas access to improved sanitation ranged from 1.7% in Amhara Region to 24% in Dire Dawa city. Households lacking access to improved water and sanitation were clustered in northern (Amhara Region) and southern (Southern Nations, Nationalities, and Peoples' Region) parts of Ethiopia. Most enumeration areas had very low level of access to improved drinking water and/or sanitation. This analysis demonstrated the existence of geographical variations and inequalities in access to improved drinking water and sanitation in Ethiopia. Therefore strategies to improve access for safe drinking water and sanitation should consider geographical variations and inequalities at a subnational scale.

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.

Development of the Australian Cancer Atlas: spatial modelling, visualisation, and reporting of estimates

BACKGROUND

It is well known that the burden caused by cancer can vary geographically, which may relate to differences in health, economics or lifestyle. However, to date, there was no comprehensive picture of how the cancer burden, measured by cancer incidence and survival, varied by small geographical area across Australia.

METHODS

The Atlas consists of 2148 Statistical Areas level 2 across Australia defined by the Australian Statistical Geography Standard which provide the best compromise between small population and small area. Cancer burden was estimated for males, females, and persons separately, with 50 unique sex-specific (males, females, all persons) cancer types analysed. Incidence and relative survival were modelled with Bayesian spatial models using the Leroux prior which was carefully selected to provide adequate spatial smoothing while reflecting genuine geographic variation. Markov Chain Monte Carlo estimation was used because it facilitates quantifying the uncertainty of the posterior estimates numerically and visually.

RESULTS

The results of the statistical model and visualisation development were published through the release of the Australian Cancer Atlas ( https://atlas.cancer.org.au ) in September, 2018. The Australian Cancer Atlas provides the first freely available, digital, interactive picture of cancer incidence and survival at the small geographical level across Australia with a focus on incorporating uncertainty, while also providing the tools necessary for accurate estimation and appropriate interpretation and decision making.

CONCLUSIONS

The success of the Atlas will be measured by how widely it is used by key stakeholders to guide research and inform decision making. It is hoped that the Atlas and the methodology behind it motivates new research opportunities that lead to improvements in our understanding of the geographical patterns of cancer burden, possible causes or risk factors, and the reasons for differences in variation between cancer types, both within Australia and globally. Future versions of the Atlas are planned to include new data sources to include indicators such as cancer screening and treatment, and extensions to the statistical methods to incorporate changes in geographical patterns over time.

Social Inequalities in Exposure to Ambient Air Pollution: A Systematic Review in the WHO European Region

Ambient air pollution is a long-standing and significant public health issue. The aim of this review is to systematically examine the peer-reviewed evidence on social inequalities and ambient air pollution in the World Health Organization European Region. Articles published between 2010 and 2017 were analyzed in the review. In total 31 articles were included in the review. There is good evidence from ecological studies that higher deprivation indices and low economic position are usually linked with higher levels of pollutants such as particulate matter (particulate matter under 2.5 and 10 microns in diameter, PM_2.5, PM₁₀) and oxides of nitrogen (e.g., NO₂, and NO_x). There is also evidence that ethnic minorities experience a mixed exposure in comparison to the majority population being sometimes higher and sometimes lower depending on the ethnic minority under consideration. The studies using data at the individual level in this review are mainly focused on pregnant women or new mothers, in these studies deprivation and ethnicity are more likely to be linked to higher exposures of poor air quality. Therefore, there is evidence in this review that the burden of higher pollutants falls disproportionally on different social groups.

Elderly Health Inequality in China and its Determinants: A Geographical Perspective

Inter-regional health differences and apparent inequalities in China have recently received significant attention. By collecting health status data and individual socio-economic information from the 2015 fourth sampling survey of the elderly population in China (4th SSEP), this paper uses the geographical differentiation index to reveal the spatial differentiation of health inequality among Chinese provinces. We test the determinants of inequalities by multilevel regression models at the provincial and individual levels, and find three main conclusions: 1) There were significant health differences on an inter-provincial level. For example, provinces with a very good or good health rating formed a good health hot-spot region in the Yangtze River Delta, versus elderly people living in Gansu and Hainan provinces, who had a poor health status. 2) Nearly 2.4% of the health differences in the elderly population were caused by inter-provincial inequalities; access (or lack of access) to economic, medical and educational resources was the main reason for health inequalities. 3) At the individual level, inequalities in annual income served to deepen elderly health differences, and elderly living in less developed areas were more vulnerable to urban vs. rural-related health inequalities.

Social Justice: Disparities in Average Earnings across Portuguese Municipalities

An ever-ongoing discussion these days involves the disparities in monthly earnings across different genders, geographical locations, levels of education, economic sectors, and skills and careers, with various economic and social consequences. In fact, in a framework such as that in which we live in nowadays (with pertinent concerns about economic and social convergences across several indicators), investigating these disparities would be interesting in order to complement the basis that is considered for the design of social policies. There are few studies considering the approaches here developed for this topic. The objective of this study is to analyse the disparities in the average monthly earnings received by employees across Portuguese mainland municipalities over the period 2004–2012, considering as additional analysis criteria geographical location, gender, levels of qualification, levels of education, economic sectors, professional activities, and further qualifications. For this both a cluster and factor analysis were considered to better identify municipalities with similar characteristics and correlations among variables. The results show that the disparities in the monthly average earnings between the Portuguese municipalities are related to three indexes associated with gender, qualifications, and chosen professions. The findings presented are specific to the Portuguese framework; however, the approaches developed in this study may be applied in other contexts to explore the dynamics related with the topic of social justice.

Social Inequalities in Environmental Resources of Green and Blue Spaces: A Review of Evidence in the WHO European Region

Residential green and blue spaces and their potential health benefits have received increasing attention in the context of environmental health inequalities, because an unequal social distribution of these resources may contribute to inequalities in health outcomes. This systematic review synthesised evidence of environmental inequalities, focusing on availability and accessibility measures of green and blue spaces. Studies in the World Health Organisation (WHO) European Region published between 2010 and 2017 were considered for the review. In total, 14 studies were identified, where most of them (n = 12) analysed inequalities of green spaces. The majority had an ecological study design that mostly applied deprivation indices on the small area level, whereas cross-sectional studies on the individual level mostly applied single social measures. Ecological studies consistently showed that deprived areas had lower green space availability than more affluent areas, whereas mixed associations were found for single social dimensions in cross-sectional studies on the individual level. In order to gain more insights into how various social dimensions are linked to the distribution of environmental resources within the WHO European Region, more studies are needed that apply comparable methods and study designs for analysing social inequalities in environmental resources.

Does the regional deprivation impact the spatial accessibility to dental care services?

The aim of the present study was to assess the regional deprivation and individual factors that influence how far a person will travel to access dental care. Using data from the Korea Health Panel (2008 to 2011), we selected a group of 4,256 subjects and geocoded their homes and dental hospitals/clinics. Using the road network analysis, we calculated the distance traveled by the subjects for dental care. We used the generalized estimating equation (GEE) for repeated data analysis and included an interaction term between regional deprivation and individual income to determine the effects of the two factors on the choice of a dental hospital/clinic. When the regional deprivation index was divided into three quarters (high, middle, and low), urban areas had higher"high" and "low" levels of deprivation, and rural areas had relatively higher middle level of deprivation. GEE regression showed that the level of education, regional deprivation level, and income all affected the distance traveled to dental clinics. The regional deprivation level had a higher association than income with the travel distance. At the same income level, subjects who lived in the least deprived areas were more likely to travel longer distances than subjects living in the most deprived areas. Regarding the distribution of dental hospitals/clinics, incentive based dental polices for either dental providers or patients are needed that will assure the delivery of dental care despite spatial inequality.

The Urban Exposome during Pregnancy and Its Socioeconomic Determinants

BACKGROUND

The urban exposome is the set of environmental factors that are experienced in the outdoor urban environment and that may influence child development.

OBJECTIVE

The authors' goal was to describe the urban exposome among European pregnant women and understand its socioeconomic determinants.

METHODS

Using geographic information systems, remote sensing and spatio-temporal modeling we estimated exposure during pregnancy to 28 environmental indicators in almost 30,000 women from six population-based birth cohorts, in nine urban areas from across Europe. Exposures included meteorological factors, air pollutants, traffic noise, traffic indicators, natural space, the built environment, public transport, facilities, and walkability. Socioeconomic position (SEP), assessed at both the area and individual level, was related to the exposome through an exposome-wide association study and principal component (PC) analysis.

RESULTS

Mean±standard deviation (SD) NO2 levels ranged from 13.6±5.1 μg/m3 (in Heraklion, Crete) to 43.2±11 μg/m3 (in Sabadell, Spain), mean±SD walkability score ranged from 0.22±0.04 (Kaunas, Lithuania) to 0.32±0.07 (Valencia, Spain) and mean±SD Normalized Difference Vegetation Index ranged from 0.21±0.05 in Heraklion to 0.51±0.1 in Oslo, Norway. Four PCs explained more than half of variation in the urban exposome. There was considerable heterogeneity in social patterning of the urban exposome across cities. For example, high-SEP (based on family education) women lived in greener, less noisy, and less polluted areas in Bradford, UK (0.39 higher PC1 score, 95% confidence interval (CI): 0.31, 0.47), but the reverse was observed in Oslo (-0.57 PC1 score, 95% CI: -0.73, -0.41). For most cities, effects were stronger when SEP was assessed at the area level: In Bradford, women living in high SEP areas had a 1.34 higher average PC1 score (95% CI: 1.21, 1.48).

CONCLUSIONS

The urban exposome showed considerable variability across Europe. Pregnant women of low SEP were exposed to higher levels of environmental hazards in some cities, but not others, which may contribute to inequities in child health and development. https://doi.org/10.1289/EHP2862.

Geographic variation in health insurance benefits in Qianjiang District, China: a cross-sectional study

BACKGROUND

Health insurance contributes to reducing the economic burden of disease and improving access to healthcare. In 2016, the Chinese government announced the integration of the New Cooperative Medical Scheme (NCMS) and Urban Resident Basic Medical Insurance (URBMI) to reduce system segmentation. Nevertheless, it was unclear whether there would be any geographic variation in health insurance benefits if the two types of insurance were integrated. The aim of this study was to identify the potential geographic variation in health insurance benefits and the related contributing factors.

METHODS

This cross-sectional study was carried out in Qianjiang District, where the NCMS and URBMI were integrated into Urban and Rural Resident Basic Medical Insurance Scheme (URRBMI) in 2010. All beneficiaries under the URRBMI were hospitalized at least once in 2013, totaling 445,254 persons and 65,877 person-times, were included in this study. Town-level data on health insurance benefits, healthcare utilization, and socioeconomic and geographical characteristics were collected through health insurance system, self-report questionnaires, and the 2014 Statistical Yearbook of Qianjiang District. A simplified Theil index at town level was calculated to measure geographic variation in health insurance benefits. Colored maps were created to visualize the variation in geographic distribution of benefits. The effects of healthcare utilization and socioeconomic and geographical characteristics on geographic variation in health insurance benefits were estimated with a multiple linear regression analysis.

RESULTS

Different Theil index values were calculated for different towns, and the Theil index values for compensation by person-times and amount were 2.5028 and 1.8394 in primary healthcare institutions and 1.1466 and 0.9204 in secondary healthcare institutions. Healthcare-seeking behavior and economic factors were positively associated with health insurance benefits in compensation by person-times significantly, meanwhile, geographical accessibility and economic factors had positive effects (p < 0.05).

CONCLUSIONS

The geographic variation in health insurance benefits widely existed in Qianjiang District and the distribution of health insurance benefits for insured inpatients in primary healthcare institutions was distinctly different from that in secondary healthcare institutions. When combining the NRCM and URMIS in China, the geographical accessibility, healthcare-seeking behavior and economic factors required significant attention.

Assessment of spatial variation in breast cancer-specific mortality using Louisiana SEER data

BACKGROUND

Previous studies suggest spatial differences in mortality for many types of cancer, including breast cancer. Identifying explanations for these spatial differences results in a better understanding of what leads to longer survival time.

METHODS

We used a Bayesian accelerated failure time model with spatial frailty terms to investigate potential spatial differences in breast cancer mortality following breast cancer diagnosis using 2000-2013 Louisiana SEER data.

RESULTS

There are meaningful spatial differences in breast cancer mortality across the parishes of Louisiana, even after adjusting for known demographic and clinical risk factors. For example, the average survival time of a woman diagnosed in Orleans parish was 1.51 times longer than that of a woman diagnosed in Terrebonne parish. Additionally, there is evidence to suggest shorter survival times in lower income parishes along the Red and Mississippi Rivers, as well as parishes with lower socioeconomic status, less access to care and fresh food, worse quality of care, and more workers in certain industries.

CONCLUSION

The addition of spatial frailties to account for an individual's geographic location is useful when analyzing breast cancer mortality data. Our findings suggest that survival following breast cancer diagnosis could potentially be improved if socioeconomic status differences were addressed, healthcare improved in quality and became more accessible, and certain industrial situations were improved for individuals diagnosed in parishes identified as having shorter average survival times.

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.