title: Vulnerability to extreme heat by socio-demographic characteristics and area green space among the elderly in Michigan, 1990-2007.
abstract: OBJECTIVE
  We examined how individual and area socio-demographic characteristics independently modified the extreme heat (EH)-mortality association among elderly residents of 8 Michigan cities, May-September, 1990-2007.
  
  
  METHODS
  In a time-stratified case-crossover design, we regressed cause-specific mortality against EH (indicator for 4-day mean, minimum, maximum or apparent temperature above 97th or 99 th percentiles). We examined effect modification with interactions between EH and personal marital status, age, race, sex and education and ZIP-code percent "non-green space" (National Land Cover Dataset), age, race, income, education, living alone, and housing age (U.S. Census).
  
  
  RESULTS
  In models including multiple effect modifiers, the odds of cardiovascular mortality during EH (99 th percentile threshold) vs. non-EH were higher among non-married individuals (1.21, 95% CI=1.14-1.28 vs. 0.98, 95% CI=0.90-1.07 among married individuals) and individuals in ZIP codes with high (91%) non-green space (1.17, 95% CI=1.06-1.29 vs. 0.98, 95% CI=0.89-1.07 among individuals in ZIP codes with low (39%) non-green space). Results suggested that housing age may also be an effect modifier. For the EH-respiratory mortality association, the results were inconsistent between temperature metrics and percentile thresholds of EH but largely insignificant.
  
  
  CONCLUSIONS
  Green space, housing and social isolation may independently enhance elderly peoples' heat-related cardiovascular mortality vulnerability. Local adaptation efforts should target areas and populations at greater risk.
authors.affiliation: University of Michigan School of Public Health, Center for Social Epidemiology and Population Health, 2669 SPH Tower, 1415 Washington Heights, Ann Arbor, MI 48109-2029, USA; University of Michigan School of Public Health, Department of Environmental Health Sciences, 1415 Washington Heights, Ann Arbor, MI, 48109-2029, USA. Electronic address: gronlund@umich.edu.
authors.forename: Carina J
authors.initials: CJ
authors.lastname: Gronlund
authors.affiliation: University of Michigan School of Public Health, Department of Biostatistics, 1415 Washington Heights, Ann Arbor, MI 48109-2029, USA. Electronic address: berrocal@umich.edu.
authors.forename: Veronica J
authors.initials: VJ
authors.lastname: Berrocal
authors.affiliation: University of Michigan School of Public Health, Department of Environmental Health Sciences, 1415 Washington Heights, Ann Arbor, MI, 48109-2029, USA. Electronic address: jalonne@weact.org.
authors.forename: Jalonne L
authors.initials: JL
authors.lastname: White-Newsome
authors.affiliation: University of Michigan School of Public Health, Department of Environmental Health Sciences, 1415 Washington Heights, Ann Arbor, MI, 48109-2029, USA. Electronic address: kconlon@ucar.edu.
authors.forename: Kathryn C
authors.initials: KC
authors.lastname: Conlon
authors.affiliation: University of Michigan School of Public Health, Department of Environmental Health Sciences, 1415 Washington Heights, Ann Arbor, MI, 48109-2029, USA. Electronic address: marieo@umich.edu.
authors.forename: Marie S
authors.initials: MS
authors.lastname: O'Neill
mesh_terms: D002980:Climate; D018592:Cross-Over Studies; D003710:Demography; D004781:Environmental Exposure; D006358:Hot Temperature; D006801:Humans; D008824:Michigan; D008962:Models, Theoretical; D012923:Social Class
keywords: Green space; Heat wave; Mortality; Socio-demographic; Vulnerability