{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T14:01:26Z","timestamp":1790776886694,"version":"4.1.0"},"reference-count":42,"publisher":"BMJ","issue":"9","license":[{"start":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T00:00:00Z","timestamp":1790726400000},"content-version":"unspecified","delay-in-days":29,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2026,8,21]]},"published-print":{"date-parts":[[2026,9]]},"abstract":"<jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>Access to nature has been associated with improved physical and mental health through multiple pathways, including stress reduction, physical activity promotion and reduced chronic disease risks. In contrast, urban areas lacking nature often expose residents to pollution, noise and heat. This study examines whether natural area availability is associated with morbidity.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>We conducted a cross-sectional study using 2023 outpatient billing data, with the Charlson Comorbidity Index (CCI) as a measure of morbidity. (Mixed) linear regression models were applied in ecological-regional (full sample) and individual (2.5% stratified random sample) designs to examine associations between CCI and three natural area indicators (semi-natural, forest and water) while controlling for sociodemographic, socioeconomic and infrastructural variables.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>Nationwide ambulatory claims data (secondary data analysis).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>Data from 72.7\u2009million individuals with statutory health insurance in Germany were used.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>In the ecological-regional analysis, higher proportions of semi-natural, forest and water areas per inhabitant were negatively associated with the average regional CCI, with coefficients of \u22120.433 (95% CI \u22120.723 to \u22120.143, p=0.004), \u22120.080 (95% CI \u22120.139 to \u22120.021, p=0.008) and \u22120.612 (95% CI \u22121.137 to \u22120.087, p=0.022). Multilevel analyses confirmed these associations at the individual level: an increase of one SD of semi-natural (\u22120.013, 95%\u2009CI \u22120.023 to \u22120.003, p=0.009), forest (\u22120.012, 95%\u2009CI \u22120.022 to \u22120.002, p=0.024) or water area (\u22120.011, 95%\u2009CI \u22120.021 to \u22120.001, p=0.032) was each associated with a lower CCI.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Regions with more natural areas were associated with lower morbidity. Green spaces may support better health. Equitable access to natural environments could promote population health.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2026-119383","type":"journal-article","created":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T13:36:53Z","timestamp":1790775413000},"page":"e119383","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Associations between natural area availability and morbidity: a cross-sectional study using health insurance billing data from Germany"],"prefix":"10.1136","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2565-0216","authenticated-orcid":false,"given":"Doreen","family":"M\u00fcller","sequence":"first","affiliation":[{"name":"Zentralinstitut f\u00fcr die kassen\u00e4rztliche Versorgung in der Bundesrepublik Deutschland, Berlin, Germany"},{"name":"Institute of Medical Sociology and Rehabilitation Science, Charite - Universitatsmedizin Berlin, Berlin, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zehra","family":"Durmus","sequence":"additional","affiliation":[{"name":"Zentralinstitut f\u00fcr die kassen\u00e4rztliche Versorgung in der Bundesrepublik Deutschland, Berlin, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Manas K","family":"Akmatov","sequence":"additional","affiliation":[{"name":"Zentralinstitut f\u00fcr die kassen\u00e4rztliche Versorgung in der Bundesrepublik Deutschland, Berlin, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Claudia","family":"Kohring","sequence":"additional","affiliation":[{"name":"Zentralinstitut f\u00fcr die kassen\u00e4rztliche Versorgung in der Bundesrepublik Deutschland, Berlin, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jakob","family":"Holstiege","sequence":"additional","affiliation":[{"name":"Zentralinstitut f\u00fcr die kassen\u00e4rztliche Versorgung in der Bundesrepublik Deutschland, Berlin, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Johannes","family":"Hagelskamp","sequence":"additional","affiliation":[{"name":"Zentralinstitut f\u00fcr die kassen\u00e4rztliche Versorgung in der Bundesrepublik Deutschland, Berlin, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8991-9966","authenticated-orcid":false,"given":"Julie Lorraine","family":"O\u2019Sullivan","sequence":"additional","affiliation":[{"name":"Institute of Medical Sociology and Rehabilitation Science, Charite - Universitatsmedizin Berlin, Berlin, Germany"},{"name":"Einstein Center Population Diversity, Berlin, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,9,30]]},"reference":[{"key":"2026093006352084000_16.9.e119383.1","doi-asserted-by":"crossref","DOI":"10.3389\/phrs.2024.1606863","article-title":"Greenspaces and Health: Scoping Review of studies in Europe","volume":"45","author":"Banwell","year":"2024","journal-title":"Public Health Rev"},{"key":"2026093006352084000_16.9.e119383.2","doi-asserted-by":"crossref","first-page":"720","DOI":"10.1007\/s00103-018-2744-9","article-title":"[Contribution of natural spaces to human health and wellbeing]","volume":"61","author":"Cla\u00dfen","year":"2018","journal-title":"Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz"},{"key":"2026093006352084000_16.9.e119383.3","unstructured":"Hornberg C , Beyer R , Cla\u00dfen T , et al . Stadtnatur f\u00f6rdert die Gesundheit. In: Kowarik I , Bartz R , Brenck M , eds. \u00d6kosyst. Stadt \u2013 Gesundh. Sch\u00fctz. Leb. Erh\u00f6hen. Berlin; Leipzig, 2016: 98\u2013124."},{"key":"2026093006352084000_16.9.e119383.4","doi-asserted-by":"publisher","DOI":"10.1016\/j.envres.2018.06.030"},{"key":"2026093006352084000_16.9.e119383.5","doi-asserted-by":"crossref","first-page":"100051","DOI":"10.1016\/j.geomat.2025.100051","article-title":"Urban green spaces and mental wellbeing: a methodology for measuring structural characteristics of individual-level green space exposure and its associations with wellbeing","volume":"77","author":"Neuner","year":"2025","journal-title":"Geomatica"},{"key":"2026093006352084000_16.9.e119383.6","doi-asserted-by":"crossref","DOI":"10.3390\/ijerph182111028","article-title":"Green Space Quality and Health: A Systematic Review","volume":"18","author":"Nguyen","year":"2021","journal-title":"Int J Environ Res Public Health"},{"key":"2026093006352084000_16.9.e119383.7","first-page":"8","article-title":"Built environment and health: a systematic review of studies in Germany","volume":"40","author":"Schulz","year":"2018","journal-title":"J Public Health (Oxf)"},{"key":"2026093006352084000_16.9.e119383.8","doi-asserted-by":"publisher","DOI":"10.1515\/reveh-2019-0046"},{"key":"2026093006352084000_16.9.e119383.9","doi-asserted-by":"crossref","first-page":"e718","DOI":"10.1016\/S2542-5196(21)00229-1","article-title":"Green space and mortality in European cities: a health impact assessment study","volume":"5","author":"Barboza","year":"2021","journal-title":"Lancet Planet Health"},{"key":"2026093006352084000_16.9.e119383.10","doi-asserted-by":"crossref","DOI":"10.1097\/EE9.0000000000000372","article-title":"Urban greenspace under a changing climate: Benefit or harm for allergies and respiratory health?","volume":"9","author":"Zhao","year":"2025","journal-title":"Environ Epidemiol"},{"key":"2026093006352084000_16.9.e119383.11","doi-asserted-by":"crossref","DOI":"10.3390\/ijerph18052563","article-title":"Green Space and Health Equity: A Systematic Review on the Potential of Green Space to Reduce Health Disparities","volume":"18","author":"Rigolon","year":"2021","journal-title":"Int J Environ Res Public Health"},{"key":"2026093006352084000_16.9.e119383.12","doi-asserted-by":"crossref","first-page":"1291","DOI":"10.1007\/s00103-025-04142-1","article-title":"[Health inequalities in a health system with two full insurance schemes?: Secondary analyses of the microcensus survey among insured persons of the statutory and private health insurance in Germany]","volume":"68","author":"Hollederer","year":"2025","journal-title":"Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz"},{"key":"2026093006352084000_16.9.e119383.13","doi-asserted-by":"publisher","DOI":"10.1016\/0021-9681(87)90171-8"},{"key":"2026093006352084000_16.9.e119383.14","doi-asserted-by":"publisher","DOI":"10.1097\/01.mlr.0000182534.19832.83"},{"key":"2026093006352084000_16.9.e119383.15","doi-asserted-by":"publisher","DOI":"10.1159\/000521288"},{"key":"2026093006352084000_16.9.e119383.16","unstructured":"Bundesinstitut f\u00fcr Bau-, Stadt- und Raumforschung (BBSR), Bonn . Laufende raumbeobachtung des bbsr - inkar."},{"key":"2026093006352084000_16.9.e119383.17","unstructured":"KBV - Gesundheitsdaten - Zahlen, Trends und Analysen. Available: https:\/\/www.kbv.de\/infothek\/zahlen-und-fakten\/gesundheitsdaten [Accessed 31 Jul 2025]."},{"key":"2026093006352084000_16.9.e119383.18","doi-asserted-by":"publisher","DOI":"10.1016\/j.saa.2021.120652"},{"key":"2026093006352084000_16.9.e119383.19","doi-asserted-by":"publisher","DOI":"10.21105\/joss.03139"},{"key":"2026093006352084000_16.9.e119383.20","doi-asserted-by":"publisher","DOI":"10.1016\/j.jclinepi.2007.11.008"},{"key":"2026093006352084000_16.9.e119383.21","doi-asserted-by":"crossref","first-page":"218","DOI":"10.1038\/s41370-022-00468-z","article-title":"Investigation on urban greenspace in relation to sociodemographic factors and health inequity based on different greenspace metrics in 3 US urban communities","volume":"33","author":"Heo","year":"2023","journal-title":"J Expo Sci Environ Epidemiol"},{"key":"2026093006352084000_16.9.e119383.22","doi-asserted-by":"publisher","DOI":"10.1136\/jech-2024-222485"},{"key":"2026093006352084000_16.9.e119383.23","doi-asserted-by":"publisher","DOI":"10.1136\/jech-2022-219111"},{"key":"2026093006352084000_16.9.e119383.24","doi-asserted-by":"crossref","DOI":"10.1186\/s12942-015-0009-5","article-title":"Beyond greenspace: an ecological study of population general health and indicators of natural environment type and quality","volume":"14","author":"Wheeler","year":"2015","journal-title":"Int J Health Geogr"},{"key":"2026093006352084000_16.9.e119383.25","doi-asserted-by":"publisher","DOI":"10.1016\/j.healthplace.2012.01.006"},{"key":"2026093006352084000_16.9.e119383.26","doi-asserted-by":"crossref","first-page":"105173","DOI":"10.1016\/j.envint.2019.105173","article-title":"Exploring mechanisms underlying the relationship between the natural outdoor environment and health and well-being - Results from the PHENOTYPE project","volume":"134","author":"Kruize","year":"2020","journal-title":"Environ Int"},{"key":"2026093006352084000_16.9.e119383.27","doi-asserted-by":"crossref","first-page":"176","DOI":"10.1016\/j.envint.2017.08.012","article-title":"More than clean air and tranquillity: Residential green is independently associated with decreasing mortality","volume":"108","author":"Vienneau","year":"2017","journal-title":"Environ Int"},{"key":"2026093006352084000_16.9.e119383.28","doi-asserted-by":"publisher","DOI":"10.1016\/S0272-4944(05)80184-7"},{"key":"2026093006352084000_16.9.e119383.29","doi-asserted-by":"crossref","DOI":"10.3389\/fpsyg.2024.1402885","article-title":"Benefits for emotional regulation of contact with nature: a systematic review","volume":"15","author":"R\u00edos-Rodr\u00edguez","year":"2024","journal-title":"Front Psychol"},{"key":"2026093006352084000_16.9.e119383.30","doi-asserted-by":"crossref","first-page":"102514","DOI":"10.1016\/j.ctim.2020.102514","article-title":"Effect of nature exposure on perceived and physiologic stress: A systematic review","volume":"53","author":"Shuda","year":"2020","journal-title":"Complement Ther Med"},{"key":"2026093006352084000_16.9.e119383.31","doi-asserted-by":"crossref","first-page":"401","DOI":"10.1111\/jrh.12295","article-title":"Urban-Rural Differences in Aerobic Physical Activity, Muscle Strengthening Exercise, and Screen-Time Sedentary Behavior","volume":"34","author":"Robertson","year":"2018","journal-title":"J Rural Health"},{"key":"2026093006352084000_16.9.e119383.32","doi-asserted-by":"crossref","first-page":"161","DOI":"10.15585\/mmwr.mm7105a1","article-title":"Self-Rated Physical Health Among Working-Aged Adults Along the Rural-Urban Continuum - United States, 2021","volume":"71","author":"Rhubart","year":"2022","journal-title":"MMWR Morb Mortal Wkly Rep"},{"key":"2026093006352084000_16.9.e119383.33","doi-asserted-by":"publisher","DOI":"10.1002\/sim.2370"},{"key":"2026093006352084000_16.9.e119383.34","doi-asserted-by":"publisher","DOI":"10.1136\/jech.50.3.366"},{"key":"2026093006352084000_16.9.e119383.35","doi-asserted-by":"crossref","DOI":"10.1016\/j.heliyon.2023.e15377","article-title":"Systematic population-wide ecological analysis of regional variability in disease prevalence","volume":"9","author":"Lo Sardo","year":"2023","journal-title":"Heliyon"},{"key":"2026093006352084000_16.9.e119383.36","doi-asserted-by":"crossref","first-page":"e351","DOI":"10.1016\/S2468-2667(21)00094-3","article-title":"Neighbourhood characteristics and health: advancing research and practice","volume":"6","author":"Lowe","year":"2021","journal-title":"Lancet Public Health"},{"key":"2026093006352084000_16.9.e119383.37","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0123456","article-title":"Interactive and independent associations between the socioeconomic and objective built environment on the neighbourhood level and individual health: a systematic review of multilevel studies","volume":"10","author":"Sch\u00fcle","year":"2015","journal-title":"PLoS One"},{"key":"2026093006352084000_16.9.e119383.38","doi-asserted-by":"publisher","DOI":"10.1068\/a35111"},{"key":"2026093006352084000_16.9.e119383.39","doi-asserted-by":"crossref","first-page":"126316","DOI":"10.1016\/j.envpol.2025.126316","article-title":"Inequalities in residential green space and trajectory of cardiometabolic multimorbidity: Different associations by sex and socioeconomic status","volume":"375","author":"Yang","year":"2025","journal-title":"Environ Pollut"},{"key":"2026093006352084000_16.9.e119383.40","doi-asserted-by":"crossref","first-page":"109799","DOI":"10.1016\/j.envint.2025.109799","article-title":"Neighborhood green space and psychological distress: a longitudinal study of socioeconomic disparities in mental health outcomes","volume":"204","author":"Galera","year":"2025","journal-title":"Environ Int"},{"key":"2026093006352084000_16.9.e119383.41","doi-asserted-by":"crossref","DOI":"10.1007\/s40520-025-03052-1","article-title":"Urban health inequities and healthy longevity: traditional and emerging risk factors across the cities and policy implications","volume":"37","author":"Cacciatore","year":"2025","journal-title":"Aging Clin Exp Res"},{"key":"2026093006352084000_16.9.e119383.42","doi-asserted-by":"crossref","DOI":"10.1038\/s41598-025-19621-3","article-title":"Impact of primary, specialist, and hospital care data on disease frequency estimates in older adults in Sweden","volume":"15","author":"Schmidt-Mende","year":"2025","journal-title":"Sci Rep"}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2026-119383","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T13:36:57Z","timestamp":1790775417000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2026-119383"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9]]},"references-count":42,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2026,9,30]]},"published-print":{"date-parts":[[2026,9]]}},"alternative-id":["10.1136\/bmjopen-2026-119383"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2026-119383","relation":{},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"value":"2044-6055","type":"print"},{"value":"2044-6055","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9]]}}}