Effect modification of greenness on temperature-mortality relationship among older adults: A case-crossover study in China.

Journal Article (Journal Article)


Climate change exacerbates temperature-related mortality, but effects may vary by geographic characteristics. We hypothesize that higher greenness may mitigate temperature-related mortality, and that the effect may vary in different areas.


We examined how mortality among older adults in China was associated with temperature for 2000-2014, and how geolocation and residential greenness may modulate this association.


We used health data from the China Longitudinal Healthy Longevity Survey (CLHLS), and meteorological data from the Global Surface Summary of Day (GSOD) product by National Climate Data Center. We used a case-crossover study design with distributed nonlinear modeling to estimate mortality risks in relation to temperature, and stratified analysis by quartile of greenness. Greenness was estimated by Normalized Difference Vegetation Index (NDVI) from remote-sensed imagery. In addition to the national analysis, we also assessed three provinces (Jiangsu, Guangdong, and Liaoning) to examine differences by climatic regions.


Extreme temperatures had a significant association with higher mortality, with regional differences. Findings from the national analysis suggest that individuals in the lowest quartile of greenness exposure had a ratio of relative risks (RRR) of 1.38 (0.79, 2.42) for mortality risk on extreme hot days at the 95th percentile compared to those at the 50th percentile, compared to those in the highest quartile, which means those residing in the lowest quartile of greenness had a 38% higher RR than those residing in the highest quartile of greenness, where RR refers to the risk of mortality on days at the 95th percentile of temperature compared to days at the 50th percentile. The RRR for the highest to lowest quartiles of greenness for mortality risk on extreme cold days at the 5th percentile compared to the 50th percentile was 2.08 (0.12, 36.2). In Jiangsu and Guangdong provinces, both the heat effects and cold effects were the lowest in the highest greenness quartile, and the results in Liaoning province were not statistically significant, indicating different regional effects of greenness on modulating the temperature-mortality relationship.


We elucidated one pathway through which greenness benefits health by decreasing impact from extreme high temperatures. The effects of greenness differed by climatic regions. Policymakers should consider vegetation in the context of climate change and health.

Full Text

Duke Authors

Cited Authors

  • Qiu, C; Ji, JS; Bell, ML

Published Date

  • June 2021

Published In

Volume / Issue

  • 197 /

Start / End Page

  • 111112 -

PubMed ID

  • 33838131

Pubmed Central ID

  • PMC8343965

Electronic International Standard Serial Number (EISSN)

  • 1096-0953

International Standard Serial Number (ISSN)

  • 0013-9351

Digital Object Identifier (DOI)

  • 10.1016/j.envres.2021.111112


  • eng