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The role of natural outdoor environment on COVID-19 mortality and hospitalisations among older community-dwellers in the pre-vaccination period : the Register RELOC-AGE cohort study in Sweden

Bhebhe, Mthabisi Anele ; Nilsson, Anton LU ; Björk, Jonas LU orcid ; Iwarsson, Susanne LU and Gefenaite, Giedre LU orcid (2025) In BMC Public Health
Abstract

BACKGROUND: Most COVID-19-related deaths and hospitalisations occurred among older people. Natural outdoor environments influence health outcomes, but the evidence of their effect on COVID-19 outcomes among older adults is limited. This study aimed to investigate associations between residential natural outdoor environment and COVID-19-related deaths or hospitalisations among community dwellers aged 59 years or older, and whether income and education moderated these associations.

METHODS: The current study is part of the Register RELCOC-AGE cohort and included ≥ 59-year-old community-dwellers (N = 299,219) in Scania, Sweden. The main exposure was the Perceived Sensory Dimension Score (PSD-score), an aggregated area-level score... (More)

BACKGROUND: Most COVID-19-related deaths and hospitalisations occurred among older people. Natural outdoor environments influence health outcomes, but the evidence of their effect on COVID-19 outcomes among older adults is limited. This study aimed to investigate associations between residential natural outdoor environment and COVID-19-related deaths or hospitalisations among community dwellers aged 59 years or older, and whether income and education moderated these associations.

METHODS: The current study is part of the Register RELCOC-AGE cohort and included ≥ 59-year-old community-dwellers (N = 299,219) in Scania, Sweden. The main exposure was the Perceived Sensory Dimension Score (PSD-score), an aggregated area-level score indicating the presence of residential natural outdoor environment, measured between 2008 and 2019, grouped into low, intermediate, and high PSD-score. COVID-19 deaths and hospitalisations were assessed from 1 January to 31 December 2020. Hazard ratios (HRs) were estimated using Cox proportional hazard regression, and moderation by income or education was assessed using interaction terms. Models were adjusted for demographic and socioeconomic characteristics, population density and comorbidities.

RESULTS: The adjusted HRs for COVID-19 deaths and hospitalisations among intermediate- as compared to low PSD-score residents- were 0.90 (95% CI: 0.71-1.15) and 0.88 (95% CI: 0.77-1.01), respectively. Among high PSD-score residents, adjusted HRs were 0.88 (95% CI: 0.62-1.24) and 0.92 (95% CI: 0.76-1.12) for COVID-19 deaths and hospitalisations, respectively. No evidence of moderation of associations by income and education was found.

CONCLUSION: A protective effect from residential natural outdoor environment on COVID-19 hospitalisation and death was suggested, but statistical uncertainty was substantial and the evidence thus inconclusive. Future investigations across diverse populations could shed more light on the role of residential living environments in mitigating the consequences of epidemics and pandemics.

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author
; ; ; and
organization
publishing date
type
Contribution to journal
publication status
epub
subject
in
BMC Public Health
publisher
BioMed Central (BMC)
external identifiers
  • pmid:41354920
ISSN
1471-2458
DOI
10.1186/s12889-025-25515-w
project
Sustainable outdoor living environments – systematic interdisciplinary studies of health effects and impact on social inequalities
RELOC-AGE: How do housing choices and relocation matter for active and healthy ageing?
How can living environments buffer the consequences of prolonged social isolation during the COVID-19 pandemic?
Improved preparedness for future pandemics and other health crises through large-scale disease surveillance
language
English
LU publication?
yes
additional info
© 2025. The Author(s).
id
f0796f89-1723-40a4-9b89-b7f1f8183eb0
date added to LUP
2025-12-10 09:27:20
date last changed
2025-12-12 12:12:05
@article{f0796f89-1723-40a4-9b89-b7f1f8183eb0,
  abstract     = {{<p>BACKGROUND: Most COVID-19-related deaths and hospitalisations occurred among older people. Natural outdoor environments influence health outcomes, but the evidence of their effect on COVID-19 outcomes among older adults is limited. This study aimed to investigate associations between residential natural outdoor environment and COVID-19-related deaths or hospitalisations among community dwellers aged 59 years or older, and whether income and education moderated these associations.</p><p>METHODS: The current study is part of the Register RELCOC-AGE cohort and included ≥ 59-year-old community-dwellers (N = 299,219) in Scania, Sweden. The main exposure was the Perceived Sensory Dimension Score (PSD-score), an aggregated area-level score indicating the presence of residential natural outdoor environment, measured between 2008 and 2019, grouped into low, intermediate, and high PSD-score. COVID-19 deaths and hospitalisations were assessed from 1 January to 31 December 2020. Hazard ratios (HRs) were estimated using Cox proportional hazard regression, and moderation by income or education was assessed using interaction terms. Models were adjusted for demographic and socioeconomic characteristics, population density and comorbidities.</p><p>RESULTS: The adjusted HRs for COVID-19 deaths and hospitalisations among intermediate- as compared to low PSD-score residents- were 0.90 (95% CI: 0.71-1.15) and 0.88 (95% CI: 0.77-1.01), respectively. Among high PSD-score residents, adjusted HRs were 0.88 (95% CI: 0.62-1.24) and 0.92 (95% CI: 0.76-1.12) for COVID-19 deaths and hospitalisations, respectively. No evidence of moderation of associations by income and education was found.</p><p>CONCLUSION: A protective effect from residential natural outdoor environment on COVID-19 hospitalisation and death was suggested, but statistical uncertainty was substantial and the evidence thus inconclusive. Future investigations across diverse populations could shed more light on the role of residential living environments in mitigating the consequences of epidemics and pandemics.</p>}},
  author       = {{Bhebhe, Mthabisi Anele and Nilsson, Anton and Björk, Jonas and Iwarsson, Susanne and Gefenaite, Giedre}},
  issn         = {{1471-2458}},
  language     = {{eng}},
  month        = {{12}},
  publisher    = {{BioMed Central (BMC)}},
  series       = {{BMC Public Health}},
  title        = {{The role of natural outdoor environment on COVID-19 mortality and hospitalisations among older community-dwellers in the pre-vaccination period : the Register RELOC-AGE cohort study in Sweden}},
  url          = {{http://dx.doi.org/10.1186/s12889-025-25515-w}},
  doi          = {{10.1186/s12889-025-25515-w}},
  year         = {{2025}},
}