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Peer-reviewedCC BYAnnals of Global Health

The Role of Greenness in Heat‑Related Mortality: A Systematic Review and Meta‑Analysis

  • Ana Perez‑Moreno1
  • Maria Martinez‑Andres2
  • Blanca Notario‑Pacheco3
  • Irene Marcilla‑Toribio2
  • Shkelzen Cekrezi4
  • Lidia Lucas‑de la Cruz5
  • Antonio Miguel Caraballo‑Betancort6
  • Bruno Bizzozero‑Peroni7
7 affiliations
  1. 1Health and Social Research Center, Universidad de Castilla‑La Mancha‑Campus de Cuenca, 16071, Cuenca; Research Group Health, Gender, and Social Determinants, Universidad de Castilla‑La Mancha‑Campus de Cuenca, 16071, Cuenca; Research Group Health, Gender, and Social Determinants, Instituto de Investigación Sanitaria de Castilla‑La Mancha (IDISCAM)
  2. 2Health and Social Research Center, Universidad de Castilla‑La Mancha‑Campus de Cuenca, 16071, Cuenca; Research Group Health, Gender, and Social Determinants, Instituto de Investigación Sanitaria de Castilla‑La Mancha (IDISCAM); Faculty of Nursing of Albacete, Universidad de Castilla‑La Mancha‑Campus de Albacete, 02071, Albacete
  3. 3Health and Social Research Center, Universidad de Castilla‑La Mancha‑Campus de Cuenca, 16071, Cuenca; Research Group Health, Gender, and Social Determinants, Universidad de Castilla‑La Mancha‑Campus de Cuenca, 16071, Cuenca; Faculty of Nursing of Cuenca, Universidad de Castilla‑La Mancha‑Campus de Cuenca, 16071, Cuenca
  4. 4Health and Social Research Center, Universidad de Castilla‑La Mancha‑Campus de Cuenca, 16071, Cuenca; Research Group Health, Gender, and Social Determinants, Instituto de Investigación Sanitaria de Castilla‑La Mancha (IDISCAM)
  5. 5Health and Social Research Center, Universidad de Castilla‑La Mancha‑Campus de Cuenca, 16071, Cuenca; Research Group Health, Gender, and Social Determinants, Instituto de Investigación Sanitaria de Castilla‑La Mancha (IDISCAM); Faculty of Nursing of Cuenca, Universidad de Castilla‑La Mancha‑Campus de Cuenca, 16071, Cuenca
  6. 6Health and Social Research Center, Universidad de Castilla‑La Mancha‑Campus de Cuenca, 16071, Cuenca; Research Group Health, Gender, and Social Determinants, Universidad de Castilla‑La Mancha‑Campus de Cuenca, 16071, Cuenca
  7. 7Health and Social Research Center, Universidad de Castilla‑La Mancha‑Campus de Cuenca, 16071, Cuenca, Spain; Higher Institute of Physical Education, Universidad de la República, 20000, Maldonado, Uruguay; Department of Neurobiology, Care Sciences and Society, Aging Research Center, Karolinska Institutet and Stockholm University, 17165, Stockholm
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Abstract

Background: Rising temperatures and the frequency of heat waves are challenges that have an impact on the health and mortality of populations. A high level of greenness is emerging as a strategy to mitigate the effects of extreme heat. Objective: To assess whether higher levels of greenness are associated with reduced mortality compared with lower greenness during periods of extreme heat. Methods: In this systematic review and meta‑analysis, we searched MEDLINE, SCOPUS, WEB OF SCIENCE, CINHAL, Environment Complete, and GreenFILE. Observational studies were included. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated via a random‑effects model. Results: The systematic review and meta‑analysis included 11 articles. These cover data from China, France, Germany, Jordan, Switzerland, and the USA, as well as a global analysis covering 24 countries. The meta‑analysis suggested that heat waves significantly increased mortality in areas with the lowest greenness (RR = 1.33; 95% CI: 1.15–1.55; I2 = 99.4%) and in areas with the highest greenness (RR = 1.18; 95% CI: 1.03–1.36; I2 = 97.9%). The pooled ratio of RR (RoR) indicated that the association was significantly stronger in low‑greenness areas than in high‑greenness areas (RoR = 1.11; 95% CI: 1.06–1.15; I2 = 90.5%), indicating that the heat–mortality association was 11% stronger in low‑greenness areas. The pooled associations varied descriptively across subgroup analyses, although no statistically significant differences were observed between geographical regions or study settings. Conclusion: Higher temperatures were associated with increased mortality in both low‑ and high‑greenness areas; however, the heat–mortality association was 11% stronger in low‑greenness areas. These findings suggest that greater greenness may attenuate vulnerability to extreme heat, although the limited evidence base and considerable between‑study heterogeneity warrant cautious interpretation.

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Cite

BibTeXRIS
BibTeX
@article{perezmoreno2026role,
  title = {{The Role of Greenness in Heat‑Related Mortality: A Systematic Review and Meta‑Analysis}},
  author = {Ana Perez‑Moreno and Maria Martinez‑Andres and Blanca Notario‑Pacheco and Irene Marcilla‑Toribio and Shkelzen Cekrezi and Lidia Lucas‑de la Cruz and Antonio Miguel Caraballo‑Betancort and Bruno Bizzozero‑Peroni},
  journal = {Annals of Global Health},
  year = {2026},
  month = sep,
  doi = {10.5334/aogh.5216},
  url = {https://doi.org/10.5334/aogh.5216},
  note = {CC BY},
}
RIS
TY  - JOUR
TI  - The Role of Greenness in Heat‑Related Mortality: A Systematic Review and Meta‑Analysis
AU  - Ana Perez‑Moreno
AU  - Maria Martinez‑Andres
AU  - Blanca Notario‑Pacheco
AU  - Irene Marcilla‑Toribio
AU  - Shkelzen Cekrezi
AU  - Lidia Lucas‑de la Cruz
AU  - Antonio Miguel Caraballo‑Betancort
AU  - Bruno Bizzozero‑Peroni
PY  - 2026
DA  - 2026/09/01
JO  - Annals of Global Health
DO  - 10.5334/aogh.5216
UR  - https://doi.org/10.5334/aogh.5216
AB  - Background: Rising temperatures and the frequency of heat waves are challenges that have an impact on the health and mortality of populations. A high level of greenness is emerging as a strategy to mitigate the effects of extreme heat. Objective: To assess whether higher levels of greenness are associated with reduced mortality compared with lower greenness during periods of extreme heat. Methods: In this systematic review and meta‑analysis, we searched MEDLINE, SCOPUS, WEB OF SCIENCE, CINHAL, Environment Complete, and GreenFILE. Observational studies were included. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated via a random‑effects model. Results: The systematic review and meta‑analysis included 11 articles. These cover data from China, France, Germany, Jordan, Switzerland, and the USA, as well as a global analysis covering 24 countries. The meta‑analysis suggested that heat waves significantly increased mortality in areas with the lowest greenness (RR = 1.33; 95% CI: 1.15–1.55; I2 = 99.4%) and in areas with the highest greenness (RR = 1.18; 95% CI: 1.03–1.36; I2 = 97.9%). The pooled ratio of RR (RoR) indicated that the association was significantly stronger in low‑greenness areas than in high‑greenness areas (RoR = 1.11; 95% CI: 1.06–1.15; I2 = 90.5%), indicating that the heat–mortality association was 11% stronger in low‑greenness areas. The pooled associations varied descriptively across subgroup analyses, although no statistically significant differences were observed between geographical regions or study settings. Conclusion: Higher temperatures were associated with increased mortality in both low‑ and high‑greenness areas; however, the heat–mortality association was 11% stronger in low‑greenness areas. These findings suggest that greater greenness may attenuate vulnerability to extreme heat, although the limited evidence base and considerable between‑study heterogeneity warrant cautious interpretation.
SN  - 2214-9996
ER  -