Greenness-air pollution-physical activity-hypertension association among middle-aged and older adults: Evidence from urban and rural China

Background: Although some evidence suggests that residential greenness may prevent hypertension in urban areas, limited attention has been paid to urban-rural disparities in the association of greenness with hypertension in rapidly urbanizing developing countries. Objectives: The current study investigated the association between the amount of neighbourhood greenness and hypertension among middle and older aged people in Chinese urban and rural areas. It further examined whether PM2.5 (particulate matter <= 2.5 mu m in aerodynamic diameter) concentrations, physical activity, and body mass index (BMI) mediated the association of greenness with hypertension. Methods: We used data from 11 486 adults aged 50 years or above within the first wave of the Study on Global Ageing and Adult Health in China during 2007-2010. Hypertension was assessed by criterion-based measures of blood pressure. Residential greenness was characterized by satellite-derived Normalized Difference Vegetation Index. We employed multilevel generalized structural equation models to estimate the association between neighbourhood greenness and hypertension in urban and rural areas. Serial mediation models have been performed to test potential pathways linking greenness to hypertension. Results: In rural areas, a greater amount of residential greenness was directly associated with a decrease in the odds of hypertension (odds ratio = 0.51, 95% confidence interval 0.29-0.89). No direct association was observed in urban areas (odds ratio = 1.33, 95% confidence interval 0.94-1.89). Serial mediation models showed that the association of greenness with hypertension was completely mediated by PM2.5 concentrations in urban areas, while the association of greenness with hypertension was only partially mediated by PM2.5 concentrations and serial PM2.5 concentrations-physical activity path in rural areas. There was no evidence that physical activity, air pollution-BMI path, air pollution-physical activity-BMI path, and physical activity-BMI path mediated the association in both urban and rural areas. Conclusions: Higher neighbourhood greenness was directly associated with a lower prevalence of hypertension among middle and older aged adults in rural China but not in urban areas. The association of greenness with hypertension was completely mediated by air pollution (without any mediation effect of physical activity and BMI) in urban areas. In contrast, the association was partly mediated by air pollution, physical activity, and other unobservables in rural areas. Further longitudinal studies are warranted to prove a cause-and-effect association, which may help policymakers and practitioners to conduce effective interventions to prevent and control the prevalence of hypertension and the attendant disease burden.