Participatory quantitative health impact assessment of urban and transport planning in cities: A review and research needs

A scoping review on the association between early childhood caries and life on land: The Sustainable Development Goal 15

BACKGROUND

The Sustainable Development Goal 15 (SDG15) deals with protecting, restoring, and promoting the sustainable use of terrestrial ecosystems, sustainably managing forests, halting and reversing land degradation, combating desertification and halting biodiversity loss. The purpose of this scoping review was to map the current evidence on the association between SDG 15 and Early Childhood Caries (ECC).

METHODS

This scoping review was reported in accordance with the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) guidelines. Formal literature searches were conducted in PubMed, Web of Science, and Scopus in March 2023 using key search terms. Studies with the criteria (in English, with full text available, addressing component of life on land, focusing on dental caries in humans, with results that can be extrapolated to control ECC in children less than 6 years of age) were included. Retrieved papers were summarised and a conceptual framework developed regarding the postulated link between SDG15 and ECC.

RESULTS

Two publications met the inclusion criteria. Both publications were ecological studies relating environmental findings to aggregated health data at the area level. One study concluded that the eco-hydrogeological environment was associated with human health, including caries. The other reported that excessive calcium was associated with the presence of compounds increasing groundwater acidity that had an impact on human health, including caries. The two ecological studies were linked to SDG 15.1. It is also plausible that SDG 15.2 and SDG 15.3 may reduce the risk for food insecurity, unemployment, gender inequality, zoonotic infections, conflict and migration; while SDG 15.4 may improve access to medicinal plants such as anticariogenic chewing sticks and reduction in the consumption of cariogenic diets.

CONCLUSIONS

There are currently no studies to support an association between ECC and SDG15 although there are multiple plausible pathways for such an association that can be explored. There is also the possibility of synergistic actions between the elements of soil, water and air in ways that differentially affect the risk of ECC. Studies on the direct link between the SDG15 and ECC are needed. These studies will require the use of innovative research approaches.

Advocating for transportation equity: A critical examination of paratransit service reductions in St. Louis and its impact on health and community social participation

Social participation is associated with better health, quality of life, physical activity, and engagement in community living and is thus an emerging health priority. Transportation plays an important role in facilitating social participation. Our team recently reported in the Journal of Disability and Health that Missouri-dwelling adults aging with long-term physical disabilities who use paratransit services as their primary transportation mode are more likely to participate in social roles and activities outside the home compared to those who do not use paratransit. In March of 2023, the paratransit company Metro Call-A-Ride that serves St. Louis announced major scale backs to their coverage zones due in part to staffing shortages. This decision has been met with a formal complaint filed to the U.S. Department of Justice as well as protest from the St. Louis disability community and advocates. Thousands of individuals who relied on Call-A-Ride for their routine community outings-to work, grocery stores, or medical appointments, for example-have been affected by the cuts. In this commentary, we will summarize the media coverage this decision has received, including the perspectives of disability rights advocates and individuals who have been directly affected. We will then present an overview of our original research findings in the context of these recent events and a brief synthesis of existing literature on paratransit services in the U.S. The commentary will end with proposed policy, research, and programming solutions for St. Louis's Metro Call-A-Ride and public transportation at large.

Health equity in urban and rural settings: implementation of the place standard tool in Spain

The physical, social, and economic characteristics of neighborhoods and municipalities determine the health of their residents, shaping their behaviors and choices regarding health and well-being. Addressing local environmental inequalities requires an intersectoral, participatory, and equity-focused approach. Community participation plays a vital role by providing deeper insights into local contexts, integrating community knowledge and values into processes, and promoting healthier, fairer, and more equitable actions. In recent years, various tools have been developed to assess places and transform them into health-promoting settings. One such tool, the Place Standard Tool (PST), facilitates discussions on Social Determinants of Health grouped into 14 themes, serving as a starting point for local health interventions. In this study, that took place between August 2019 and February 2020, we described the resident's perceptions of two municipalities in the Valencian Community, Spain, using the validated Spanish version of the PST. A mixed-method convergent-parallel design was used to gain a holistic insight into residents' experiences concerning their physical, economic, and social environment. A total of 356 individuals from both municipalities participated in the study through discussion groups, structured interviews, and online survey. Descriptive analysis of the individual questionnaire answers was conducted, and differences between municipalities were explored. Qualitative thematic analysis was conducted on structured interviews and discussion groups. Quantitative and qualitative data were integrated to facilitate their comparison and identify areas of convergence or divergence in the findings. Overall, rural areas received more favorable evaluations compared to urban ones. Public Transport as well as Work and Local Economy were consistently rated the lowest across all groups and contexts, while Identity and Belonging received the highest ratings. In the urban area, additional negative ratings were observed for Traffic and Parking, Housing and Community, and Care and Maintenance. Conversely, Identity and Belonging, Natural Spaces, Streets and Spaces, Social Interaction, and Services emerged as the highest-rated themes overall. In the rural context, positive evaluations were given to Walking or Cycling, Traffic and Parking, Housing and Community, and Influence and Sense of Control. Significant differences (p < 0.01) between urban and rural settings were observed in dimensions related to mobility, spaces, housing, social interaction, and identity and belonging. Our study illustrated the capacity of the PST to identifying aspects within local settings that influence health, revealing both positive and challenging factors. Successful implementation requires appropriate territorial delineation, support from local authorities, and effective management of expectations. Furthermore, the tool facilitated community participation in decision-making about local environments, promoting equity by connecting institutional processes with citizen needs.

Toward Heart-Healthy and Sustainable Cities: A Policy Statement From the American Heart Association

Nearly 56% of the global population lives in cities, with this number expected to increase to 6.6 billion or >70% of the world's population by 2050. Given that cardiometabolic diseases are the leading causes of morbidity and mortality in people living in urban areas, transforming cities and urban provisioning systems (or urban systems) toward health, equity, and economic productivity can enable the dual attainment of climate and health goals. Seven urban provisioning systems that provide food, energy, mobility-connectivity, housing, green infrastructure, water management, and waste management lie at the core of human health, well-being, and sustainability. These provisioning systems transcend city boundaries (eg, demand for food, water, or energy is met by transboundary supply); thus, transforming the entire system is a larger construct than local urban environments. Poorly designed urban provisioning systems are starkly evident worldwide, resulting in unprecedented exposures to adverse cardiometabolic risk factors, including limited physical activity, lack of access to heart-healthy diets, and reduced access to greenery and beneficial social interactions. Transforming urban systems with a cardiometabolic health-first approach could be accomplished through integrated spatial planning, along with addressing current gaps in key urban provisioning systems. Such an approach will help mitigate undesirable environmental exposures and improve cardiovascular and metabolic health while improving planetary health. The purposes of this American Heart Association policy statement are to present a conceptual framework, summarize the evidence base, and outline policy principles for transforming key urban provisioning systems to heart-health and sustainability outcomes.

The methodology of quantitative risk assessment studies

Once an external factor has been deemed likely to influence human health and a dose response function is available, an assessment of its health impact or that of policies aimed at influencing this and possibly other factors in a specific population can be obtained through a quantitative risk assessment, or health impact assessment (HIA) study. The health impact is usually expressed as a number of disease cases or disability-adjusted life-years (DALYs) attributable to or expected from the exposure or policy. We review the methodology of quantitative risk assessment studies based on human data. The main steps of such studies include definition of counterfactual scenarios related to the exposure or policy, exposure(s) assessment, quantification of risks (usually relying on literature-based dose response functions), possibly economic assessment, followed by uncertainty analyses. We discuss issues and make recommendations relative to the accuracy and geographic scale at which factors are assessed, which can strongly influence the study results. If several factors are considered simultaneously, then correlation, mutual influences and possibly synergy between them should be taken into account. Gaps or issues in the methodology of quantitative risk assessment studies include 1) proposing a formal approach to the quantitative handling of the level of evidence regarding each exposure-health pair (essential to consider emerging factors); 2) contrasting risk assessment based on human dose-response functions with that relying on toxicological data; 3) clarification of terminology of health impact assessment and human-based risk assessment studies, which are actually very similar, and 4) other technical issues related to the simultaneous consideration of several factors, in particular when they are causally linked.

[City Planning, Urban Initiatives and Health]

Urban planning and public health are main fields of action when looking at urban development from a health perspective. In both fields of action, politics and administration as well as urban initiatives play a formative role. Action is oriented towards common overarching themes of sustainability, social justice and environmental justice. These commonalities are reflected in different memoranda. Despite the common basis of urban planning and health, there are areas of tension that are rooted, among other things, in different legal frameworks and logic of action. Against this complex background, recommendations are formulated for science, the funding landscape, practice as well as education and training in these areas.

Association between greenspace and cancer: evidence from a systematic review and meta-analysis of multiple large cohort studies

Cancer is a chronic disease that seriously endangers human health, and studies on its association with greenspace have been published. We aimed to systematically review the epidemiological evidence and obtain the best available evidence. PubMed, Web of Science, Embase, and Cochrane Library were used as search databases, the time limit was September 12, 2022, and the cited articles were manually supplemented. Two researchers independently performed literature screening and data extraction. We performed a meta-analysis of data using a normalized difference vegetation index (NDVI) as the greenspace measure, providing hazard ratio (HR) and corresponding 95% CI. After standardization of the data, we used a random effects model for pooling. We also assessed the risk of bias for each study and the quality of each evidence body. We identified 10,108 items and included 14 studies from 11 institutions in eight countries. All studies had a low risk of bias. Quantitative analysis of 13 studies found a beneficial association of greenspace with the mortality of lung cancer (pooled HR [95% CI]=0.965 [0.947, 0.983]) and prostate cancer (HR [95% CI]=0.939 [0.898, 0.980]) based on 0.1-unit NDVI increment and a potential beneficial association with the incidence of prostate, lung, and breast cancer. Greenspace had opposite associations with cancer mortality for urban and rural populations. Indirect comparisons did not find statistically significant differences in the effects of greenspace on different cancer outcomes. The evidence body assessment was considered to be "very low." This review indicated potential beneficial associations between greenspace for lung, prostate, and breast cancer outcomes. However, there was a lack of mediation analysis to explore the underlying mechanism of a causal association. Meanwhile, the interstudy heterogeneity was large. Therefore, future studies should consider more accurate exposure assessment and more comprehensive covariate coverage, while focusing on mediating analysis. PROSPERO: CRD42022361068.

Model Choice for Quantitative Health Impact Assessment and Modelling: An Expert Consultation and Narrative Literature Review

BACKGROUND

Health impact assessment (HIA) is a widely used process that aims to identify the health impacts, positive or negative, of a policy or intervention that is not necessarily placed in the health sector. Most HIAs are done prospectively and aim to forecast expected health impacts under assumed policy implementation. HIAs may quantitatively and/ or qualitatively assess health impacts, with this study focusing on the former. A variety of quantitative modelling methods exist that are used for forecasting health impacts, however, they differ in application area, data requirements, assumptions, risk modelling, complexities, limitations, strengths, and comprehensibility. We reviewed relevant models, so as to provide public health researchers with considerations for HIA model choice.

METHODS

Based on an HIA expert consultation, combined with a narrative literature review, we identified the most relevant models that can be used for health impact forecasting. We narratively and comparatively reviewed the models, according to their fields of application, their configuration and purposes, counterfactual scenarios, underlying assumptions, health risk modelling, limitations and strengths.

RESULTS

Seven relevant models for health impacts forecasting were identified, consisting of (i) comparative risk assessment (CRA), (ii) time series analysis (TSA), (iii) compartmental models (CMs), (iv) structural models (SMs), (v) agent-based models (ABMs), (vi) microsimulations (MS), and (vii) artificial intelligence (AI)/machine learning (ML). These models represent a variety in approaches and vary in the fields of HIA application, complexity and comprehensibility. We provide a set of criteria for HIA model choice. Researchers must consider that model input assumptions match the available data and parameter structures, the available resources, and that model outputs match the research question, meet expectations and are comprehensible to end-users.

CONCLUSION

The reviewed models have specific characteristics, related to available data and parameter structures, computational implementation, interpretation and comprehensibility, which the researcher should critically consider before HIA model choice.

Health impact assessment of local policies: methodology and tools

The aim of this work was to design some tools and a procedure for performing the Health Impact Assessment of municipal policies. A working group made up of municipal and public health specialists from the Valencian Community (Spain) was set up. After reviewing the tools used in other contexts, the Fem Salut? questionnaire for the simplified Health Impact Assessment of regional policies was adapted for use at the local level. A pilot study was carried out in six municipalities and local initiatives promoted by different sectors were analysed. Two workshops were held per municipality (with specialists and with citizens) and participatory techniques were used to identify the possible impacts on the social determinants of health, the population groups more particularly affected and the proposals for improvement. The feasibility of the methodology and the difficulties involved in carrying it out were discussed. A procedure was defined for the Health Impact Assessment of local initiatives in six steps: Describe (the municipality and the project), Extract (screening phase), Co-produce (participatory workshops), Integrate (the scientific evidence with the qualitative information obtained), Disseminate (to politicians, specialists and community) and Evaluate (direct and indirect results) (DECIDE). A guide was developed to facilitate its application at the local level along with two complementary tools (a questionnaire and worksheets). The technical group rated the process as simple and flexible, as well as being easy to adapt to the characteristics of the municipality and project. In addition to the cross-sectoral approach, the incorporation of citizen participation in the process is an important added value.

New urban models for more sustainable, liveable and healthier cities post covid19; reducing air pollution, noise and heat island effects and increasing green space and physical activity

Cities are centres of innovation and wealth creation, but also hotspots of air pollution and noise, heat island effects and lack of green space, which are all detrimental to human health. They are also hotspots of COVID19. COVID19 has led to a rethink of urban public space. Therefore, is it time to re-think our urban models and reduce the health burden? We provide a narrative meta-review around a number of cutting edge and visionary urban models that that may affect health and that have been reported over the past few years. New urban concepts such as the Superblocks, the low traffic neighbourhood, 15 Minute city, Car free city or a mixture of these that may go some way in reducing the health burden related to current urban and transport practices. They will reduce air pollution and noise, heat island effects and increase green space and physical activity levels. What is still lacking though is a thorough evaluation of the effectiveness and acceptability of the schemes and the impacts on not only health, but also liveability and sustainability, although they are expected to be positive. Finally, the COVID19 pandemic may accelerate these developments and stimulus funding like the EU Next Generation funding should be used to make these changes.

Premature Mortality of 2050 High Bike Use Scenarios in 17 Countries

BACKGROUND

Biking plays a significant role in urban mobility and has been suggested as a tool to promote public health. A recent study has proposed 2050 global biking scenarios based on large shifts from motorized vehicles to bikes. No previous studies have estimated the health impacts of global cycling scenarios, either future car-bike shift substitutions.

OBJECTIVES

We aimed to quantify changes in premature mortality of 2050 global biking scenarios in urban populations from 17 countries.

METHODS

Through a quantitative Health Impact Assessment, the mortality risks and benefits of replacing car trips by bike (mechanica bike and electric bike) in urban populations from 17 countries were estimated. Multiple bike scenarios were created based on current transport trends or large shifts from car trips to bike trips. We quantified the estimated change in the number of premature deaths (reduced or increased) concerning road traffic fatalities, air pollution, and physical activity. This study focuses on urban populations between 20 and 64 y old.

RESULTS

We found that, among the urban populations (20-64 y old) of 17 countries, 205,424 annual premature deaths could be prevented if high bike-use scenarios are achieved by 2050 (assuming that 100% of bike trips replace car trips). If only 8% of bike trips replace car trips in a more conservative scenario, 18,589 annual premature deaths could be prevented by 2050 in the same population. In all the countries and scenarios, the mortality benefits related to bike use (rather than car use) outweighed the mortality risks.

DISCUSSION

We found that global biking policies may provide important mortality benefits in 2050. Current and future bike- vs. car-trip policies should be considered key public health interventions for a healthy urban design. https://doi.org/10.1289/EHP9073.

The Built Environment and Health in Low- and Middle-Income Countries: a Review on Quantitative Health Impact Assessments

PURPOSE OF REVIEW

Features and attributes of the built environment (BE) impact positively and negatively on health, especially in cities facing unprecedented urban population growth and mass motorization. A common approach to assess the health impacts of built environment is health impact assessment (HIA), but it is rarely used in low- and middle-income countries (LMICs) where urbanization rates are fastest. This article reviews selected HIA case studies from LMICs and reports the methods and tools used to support further implementation of quantitative HIAs in cities of LMICs.

RECENT FINDINGS

In total, 24 studies were reviewed across Algeria, Brazil, China, India, Iran, Kenya, Thailand, Turkey, and Mauritius. HIAs examine specific pathways through which the built environment acts: air pollution, noise, physical activity, and traffic injury. Few HIAs of BE addressed more than one exposure pathway at a time, and most studies focused on air pollution across the sectors of transport and energy. A wide number of tools were used to conduct exposure assessment, and different models were applied to assess health impacts of different exposures. Those HIAs rely on availability of local concentration data and often use models that have set exposure-response functions (ERFs). ERFs were not adapted to local populations except for HIAs conducted in China. HIAs of BE are being successfully conducted in LMICs with a variety of tools and datasets. Scaling and expanding quantitative health impact modeling in LMICs will require further study on data availability, adapted models/tools, low technical capacity, and low policy demand for evidence from modeling studies. As case studies with successful use of evidence from modeling emerge, the uptake of health impact modeling of BE is likely to increase in favor of people and planet.

Heart healthy cities: genetics loads the gun but the environment pulls the trigger

The world's population is estimated to reach 10 billion by 2050 and 75% of this population will live in cities. Two-third of the European population already live in urban areas and this proportion continues to grow. Between 60% and 80% of the global energy use is consumed by urban areas, with 70% of the greenhouse gas emissions produced within urban areas. The World Health Organization states that city planning is now recognized as a critical part of a comprehensive solution to tackle adverse health outcomes. In the present review, we address non-communicable diseases with a focus on cardiovascular disease and the urbanization process in relation to environmental risk exposures including noise, air pollution, temperature, and outdoor light. The present review reports why heat islands develop in urban areas, and how greening of cities can improve public health, and address climate concerns, sustainability, and liveability. In addition, we discuss urban planning, transport interventions, and novel technologies to assess external environmental exposures, e.g. using digital technologies, to promote heart healthy cities in the future. Lastly, we highlight new paradigms of integrative thinking such as the exposome and planetary health, challenging the one-exposure-one-health-outcome association and expand our understanding of the totality of human environmental exposures.

Narrative review of citizen science in environmental epidemiology: Setting the stage for co-created research projects in environmental epidemiology

Several citizen science (CS) initiatives have been adopted in environmental science to monitor air and noise pollution, and water quality related to civic concerns. Nevertheless, CS projects in environmental epidemiology remain scarce. This is because little attention has been paid to evaluate associations of environmental exposures with health effects directly. This narrative review aims to promote the understanding and application of CS in environmental epidemiology. There are many commonalities between CS and other participatory approaches in environmental epidemiology. Yet, CS can foster the democratization of scientific governance and enhance the sustainability of research projects more effectively than other existing participatory approaches. This is especially the case in projects where citizens are invited to participate, engage and become involved throughout all the phases of a research project (co-created projects). This paper identifies various challenges and opportunities specific to the implementation of co-created CS projects in environmental epidemiology. The development of more locally relevant research designs, using local knowledge, obtaining medical ethical clearance, and co-analysing the association between exposure and health, are examples of opportunities and challenges that require epidemiologists to go beyond the traditional research framework and include more outreach activities. Continued efforts, particularly the sharing of information about projects' collaborative processes, are needed to make CS a more concrete and cohesive approach in environmental epidemiology.

The perceptions and priorities of professionals in health and social welfare and city planning for creating a healthy living environment: a concept mapping study

BACKGROUND

It is helpful for collaboration if professionals from the field of health and social welfare and the field of city planning are aware of each other's concepts of what a healthy living environment entails and what its components are. This study examined perceptions about creating a healthy living environment of professionals from these two fields, as well as the differences between them.

METHODS

We recruited 95 professionals from Nijmegen, the Netherlands who worked in the fields of health, social welfare and city planning in governmental and non-governmental capacities. We used the concept mapping method to collect and analyse their thoughts on healthy living environments. Participants first submitted statements on this subject in a brainstorming session, using an online mapping tool. Then they sorted these statements and rated them on priorities and opportunities within urban planning processes.

RESULTS

During the brainstorm, 43 professionals generated 136 statements. After the elimination of duplicates, 92 statements were individually sorted by 32 professionals. Concept mapping software was used to create an overall map, in which the statements were sorted into ten clusters. Each of these clusters represented one of the main features of a healthy living environments. After 36 participants rated these statements, it emerged that professionals from both fields agreed on priorities and opportunities for the clusters 'Spatial quality' and 'Conducive to exercise'. Professionals also agreed on which three clusters had the fewest priorities and possibilities ('Promotes personal wellbeing', 'Encourages healthy choices', 'Conducive to social connections').

CONCLUSION

We found that professionals in health and social welfare and city planning have similar views concerning the most and least important features of a healthy living environment in urban planning process. This could indicate that the differences between the two fields may be more nuanced and specific than previously thought. This knowledge offers perspectives for professionals to strengthen their collaboration and to come to a joint result in urban planning projects.

Integrating health indicators into urban and transport planning: A narrative literature review and participatory process

Today, urban and transport planners face considerable challenges in designing and retrofitting cities that are prepared for increasing urban populations, and their service and mobility needs. When it comes to health-promoting urban and transport developments, there is also a lack of standardized, quantitative indicators to guide the integration of health components right from the outset, i.e. in the formal planning or zoning phase. We narratively reviewed the literature and organized stakeholder workshops to identify and tailor planning principles and indicators that can be linked to health outcomes. We defined four core planning objectives that previous authoritative studies have suggested to result in positive health outcomes among city dwellers, which are: I) development of compact cities, II) reduction of private motorized transport, III) promotion of active (i.e. walking and cycling) and public transport, IV) development of green and public open space. Built on the review and stakeholder consensus, we identified 10 urban and transport planning principles that work towards achieving the four core objectives thought to provide health benefits for European city dwellers. These 10 planning principles are: 1) land use mix, 2) street connectivity, 3) density, 4) motorized transport reductions, 5) walking, 6) cycling, 7) public transport, 8) multi-modality, 9) green and public open space, and 10) integration of all planning principles. A set of indicators was developed and tailored for each planning principle. The final output of this work is a checklist ready to be applied by urban and transport professionals to integrate health into urban and transport developments in urban environments right from the outset.

Why a New Research Agenda on Green Spaces and Health Is Needed in Latin America: Results of a Systematic Review

(1) Background: Increasing and improving green spaces have been suggested to enhance health and well-being through different mechanisms. Latin America is experiencing fast population and urbanization growth; with rising demand for interventions to improve public health and mitigate climate change. (2) Aim: This study aimed to review the epidemiological evidence on green spaces and health outcomes in Latin America. (3) Methods: A systematic literature review of green spaces and health outcomes was carried out for studies published in Latin America before 28 September 2020. A search strategy was designed to identify studies published in Medline via PubMed and LILACS. The search strategy included terms related to green spaces combined with keywords related to health and geographical location. No time limit for the publication was chosen. The search was limited to English, Spanish, Portuguese, and French published articles and humans’ studies. (4) Findings: This systematic review found 19 epidemiological studies in Latin America related to green spaces and health outcomes. Nine studies were conducted in Brazil, six in Mexico, three in Colombia, and one in Chile. In terms of study design, 14 were cross-sectional studies, 3 ecological, and 2 cohort studies. The population included among the studies ranged from 120 persons to 103 million. The green space definition used among studies was green density or proximity (eight studies), green presence (five studies), green spaces index (four studies), and green space visit (two studies). The health outcomes included were mental health (six studies), overweight and obesity (three studies), quality of life (three studies), mortality (two studies), cardiorespiratory disease (one study), disability (one study), falls (one study), and life expectancy (one study). Eleven studies found a positive association between green spaces and health, and eight studies found no association. (5) Conclusion: This systematic review identified 19 epidemiological studies associating green spaces and health outcomes in Latin America. Most of the evidence suggests a positive association between green spaces and health in the region. However, most of the evidence was supported by cross-sectional studies. Prioritizing longitudinal studies with harmonized exposure and outcome definitions and including vulnerable and susceptible populations is needed in the region.

A tool for assessing the climate change mitigation and health impacts of environmental policies: the Cities Rapid Assessment Framework for Transformation (CRAFT)

Background: A growing number of cities, including Greater London, have set ambitious targets, including detailed policies and implementation plans, to reach global goals on sustainability, health, and climate change. Here we present a tool for a rapid assessment of the magnitude of impact of specific policy initiatives to reach these targets. The decision-support tool simultaneously quantifies the environmental and health impacts of specified selected policies. Methods: The 'Cities Rapid Assessment Framework for Transformation (CRAFT)' tool was applied to Greater London. CRAFT quantifies the effects of ten environmental policies on changes in (1) greenhouse gas (GHG) emissions, (2) exposures to environmental hazards, (3) travel-related physical activity, and (4) mortality (the number of attributable deaths avoided in one typical year). Publicly available data and epidemiological evidence were used to make rapid quantitative estimates of these effects based on proportional reductions in GHG emissions and environmental exposures from current baseline levels and to compute the mortality impacts. Results: The CRAFT tool estimates that, of roughly 50,000 annual deaths in Greater London, the modelled hazards (PM 2.5 (from indoor and outdoor sources), outdoor NO 2, indoor radon, cold, overheating) and low travel-related physical activity are responsible for approximately 10,000 premature environment-related deaths. Implementing the selected polices could reduce the annual mortality number by about 20% (~1,900 deaths) by 2050. The majority of these deaths (1,700) may be avoided through increased uptake in active travel. Thus, out of ten environmental policies, the 'active travel' policy provides the greatest health benefit. Also, implementing the ten policies results in a GHG reduction of around 90%. Conclusions: The CRAFT tool quantifies the effects of city policies on reducing GHG emissions, decreasing environmental health hazards, and improving public health. The tool has potential value for policy makers through providing quantitative estimates of health impacts to support and prioritise policy options.

Barriers, Facilitating Factors, and Intersectoral Collaboration for Promoting Active Mobility for Healthy Aging-A Qualitative Study within Local Government in Germany

The promotion of walking and cycling to stay active and mobile offers great potential for healthy aging. Intersectoral collaboration for age-friendly urban planning is required in local government to realize this potential. Semi-structured interviews were conducted with the heads of planning and public health departments in city and district administrations of a Metropolitan Region in Germany to identify factors influencing action on the cross-cutting issue of active mobility for healthy aging. Although some administrations are working on the promotion of active mobility, they consider neither the needs of older people nor health effects. A lack of human resources and expertise, mainly due to the low priority placed on the issue, are described as the main barriers for further strategic collaboration. Furthermore, the public health sector often focuses on pathogens as the cause of morbidity and mortality, reducing their acceptance of responsibility for the topic. Facilitating factors include the establishment of new administrative structures, projects with rapid results that create awareness and credibility among citizens and politicians, additional staff with expertise in health promotion, and political commitment. In the future, new administrative structures for intersectoral collaboration are needed in order to consider various perspectives in complex developments, such as healthy aging, and to benefit from synergies.

How can we analyze environmental health resilience and vulnerability? A joint analysis with composite indices applied to the north of France

In environmental health, vulnerability reflecting the cumulative harmful constraints and nuisances to which populations are subjected and resilience defined as the capacity of a territory to cope with health inequalities have been little extensively investigated together with the same importance. Besides the diversity of factors involved, there is no consensual framework to develop composite indices, one recognized methodology to deal with a multifaceted issue. Therefore, this research aims to establish a new transferable approach to assess the spatial heterogeneity of territorial inequalities. This new strategy relies on the simultaneous evaluation of resilience and vulnerability and the joint analysis based on the cross-interpretation of the spatialized composite indices of resilience and vulnerability. A case study was conducted to demonstrate the feasibility of this methodology, using the municipality as a spatial unit of analysis within a region in the north of France. To provide the most holistic description possible of the 3817 studied municipalities, 50 variables related to the economic, environment, policy, health, services and social dimensions were used to develop the composite indices. The vulnerability Index has a median value of 0.151 with an IQR of [0.126-0.180] and the Resilience Index has a median value of 0.341 with an IQR of [0.273-0.401]. The joint analysis was conducted to classify each municipality among four defined typologies: 1687 municipalities (44.2%) belong to the "To monitor" category, 1646 (43.1%) to the "Resilient" category, 329 (8.6%) to the "Have resources" category and 155 (4.1%) to the "Territorial blackspot" category. The methodology herein may be a diagnostic tool to identify and prioritize municipalities that could benefit from the implementation of specifically tailored public health policies.

Premature mortality due to air pollution in European cities: a health impact assessment

BACKGROUND

Ambient air pollution is a major environmental cause of morbidity and mortality worldwide. Cities are generally hotspots for air pollution and disease. However, the exact extent of the health effects of air pollution at the city level is still largely unknown. We aimed to estimate the proportion of annual preventable deaths due to air pollution in almost 1000 cities in Europe.

METHODS

We did a quantitative health impact assessment for the year 2015 to estimate the effect of air pollution exposure (PM_2·5 and NO₂) on natural-cause mortality for adult residents (aged ≥20 years) in 969 cities and 47 greater cities in Europe. We retrieved the cities and greater cities from the Urban Audit 2018 dataset and did the analysis at a 250 m grid cell level for 2015 data based on the global human settlement layer residential population. We estimated the annual premature mortality burden preventable if the WHO recommended values (ie, 10 μg/m³ for PM_2·5 and 40 μg/m³ for NO₂) were achieved and if air pollution concentrations were reduced to the lowest values measured in 2015 in European cities (ie, 3·7 μg/m³ for PM_2·5 and 3·5 μg/m³ for NO₂). We clustered and ranked the cities on the basis of population and age-standardised mortality burden associated with air pollution exposure. In addition, we did several uncertainty and sensitivity analyses to test the robustness of our estimates.

FINDINGS

Compliance with WHO air pollution guidelines could prevent 51 213 (95% CI 34 036-68 682) deaths per year for PM_2·5 exposure and 900 (0-2476) deaths per year for NO₂ exposure. The reduction of air pollution to the lowest measured concentrations could prevent 124 729 (83 332-166 535) deaths per year for PM_2·5 exposure and 79 435 (0-215 165) deaths per year for NO₂ exposure. A great variability in the preventable mortality burden was observed by city, ranging from 0 to 202 deaths per 100 000 population for PM_2·5 and from 0 to 73 deaths for NO₂ per 100 000 population when the lowest measured concentrations were considered. The highest PM_2·5 mortality burden was estimated for cities in the Po Valley (northern Italy), Poland, and Czech Republic. The highest NO₂ mortality burden was estimated for large cities and capital cities in western and southern Europe. Sensitivity analyses showed that the results were particularly sensitive to the choice of the exposure response function, but less so to the choice of baseline mortality values and exposure assessment method.

INTERPRETATION

A considerable proportion of premature deaths in European cities could be avoided annually by lowering air pollution concentrations, particularly below WHO guidelines. The mortality burden varied considerably between European cities, indicating where policy actions are more urgently needed to reduce air pollution and achieve sustainable, liveable, and healthy communities. Current guidelines should be revised and air pollution concentrations should be reduced further to achieve greater protection of health in cities.

FUNDING

Spanish Ministry of Science and Innovation, Internal ISGlobal fund.

Lessons from an International Initiative to Set and Share Good Practice on Human Health in Environmental Impact Assessment

Environmental Impact Assessment (EIA) is applied to infrastructure and other large projects. The European Union EIA Directive (2011/92/EU as amended by 2014/52/EU) requires EIAs to consider the effects that a project might have on human health. The International Association for Impact Assessment and the European Public Health Association prepared a reference paper on public health in EIA to enable the health sector to contribute to this international requirement. We present lessons from this joint action. We review literature on policy analysis, impact assessment and Health Impact Assessment (HIA). We use findings from this review and from the consultation on the reference paper to consider how population and human health should be defined; how the health sector can participate in the EIA process; the relationship between EIA and HIA; what counts as evidence; when an effect should be considered ‘likely’ and ‘significant’; how changes in health should be reported; the risks from a business-as-usual coverage of human health in EIA; and finally competencies for conducting an assessment of human health. This article is relevant for health authorities seeking to ensure that infrastructure, and other aspects of development, are not deleterious to, but indeed improve, human health.

A tool for assessing the climate change mitigation and health impacts of environmental policies: the Cities Rapid Assessment Framework for Transformation (CRAFT)

Background: A growing number of cities, including Greater London, have set ambitious targets, including detailed policies and implementation plans, to reach global goals on sustainability, health, and climate change. Here we present a tool for a rapid assessment of the magnitude of impact of specific policy initiatives to reach these targets. The decision-support tool simultaneously quantifies the environmental and health impacts of specified selected policies. Methods: The 'Cities Rapid Assessment Framework for Transformation (CRAFT)' tool was applied to Greater London. CRAFT quantifies the effects of ten environmental policies on changes in (1) greenhouse gas (GHG) emissions, (2) exposures to environmental hazards, (3) travel-related physical activity, and (4) mortality (the number of attributable deaths avoided in one typical year). Publicly available data and epidemiological evidence were used to make rapid quantitative estimates of these effects based on proportional reductions in GHG emissions and environmental exposures from current baseline levels and to compute the mortality impacts. Results: The CRAFT tool estimates that, of roughly 50,000 annual deaths in Greater London, the modelled hazards (PM 2.5 (from indoor and outdoor sources), outdoor NO 2, indoor radon, cold, overheating) and low travel-related physical activity are responsible for approximately 10,000 premature environment-related deaths. Implementing the selected polices could reduce the annual mortality number by about 20% (~1,900 deaths) by 2050. The majority of these deaths (1,700) may be avoided through increased uptake in active travel. Thus, out of ten environmental policies, the 'active travel' policy provides the greatest health benefit. Also, implementing the ten policies results in a GHG reduction of around 90%. Conclusions: The CRAFT tool quantifies the effects of city policies on reducing GHG emissions, decreasing environmental health hazards, and improving public health. The tool has potential value for policy makers through providing quantitative estimates of health impacts to support and prioritise policy options.

Participatory quantitative health impact assessment of urban transport planning: A case study from Eastern Africa

BACKGROUND

High rates of motorization in urban areas of Africa have adverse effects on public health. Transport-related mortality will increase as a result of inadequate transport infrastructure, air pollution and sedentary lifestyles. Health Impact Assessments (HIAs) have proven to be a successful tool to predict and mitigate negative health impact of urban transport planning policies, programmes or projects. Yet, there is a gap of evidence on transport and health in African countries. The aim of this study is assessing the health impacts of transport scenarios in Port Louis (city of 119,018 inhabitants in Mauritius) using a full chain participatory HIA model.

METHODS

We estimated health and economic impacts associated to transport scenarios with qualitative data and quantitative comparative risk assessment methods. The health impact modeling was based on differences between the baseline and three transport scenarios (worse, good, ideal), estimating the averted deaths per year and economic outcomes by assessing health determinants of air pollution (AP), traffic deaths and physical activity (PA). Data on air pollution and traffic fatalities were obtained from public data sources. Data used to construct scenarios, establish baseline travel mode shares and physical activity were collected through (a) open-ended individual interviews (IDIs) with 14 stakeholders (b) closed-ended survey questions to 600 citizens and (c) 2 focus group discussions (FGDs) with the same 14 stakeholders from (a).

RESULTS

In Port Louis, the worse-case transport scenario (doubling in car trips and a reduction in walking, motorcycle, and public transport), resulted in a total increment of 3.28 premature deaths per year. The good-case scenario (reducing car trips by half and increasing walking, motorcycle, and public transport trips) resulted in a total increment of 0.79 premature deaths per year. The ideal-case scenario (reduction in car and motorcycle trips and an increase in walking and public transport trips) resulted in a total reduction of 13.72 premature deaths per year. We estimated USD 23 millions of economic benefits related to mortality if the ideal-case was achieved.

CONCLUSION

Participatory HIA shows that implementing transport policies aiming for less than an ideal situation may not be adequate or sufficient to avoid negative transport-related mortality in Mauritius. Urban transport planning is an opportunity to encourage physical activity in rapidly urbanizing settings of Africa. Transport policies should aim to restrict all forms of private motorized vehicles and promote active and public transport to support public health. We highly recommend the use of participatory approaches in quantitative HIA to ensure context specificity and policy relevance.

Framework for Participatory Quantitative Health Impact Assessment in Low- and Middle-Income Countries

Background: Conducting health impact assessments (HIAs) is a growing practice in various organizations and countries, yet scholarly interest in HIAs has primarily focused on the synergies between exposure and health outcomes. This limits our understanding of what factors influence HIAs and the uptake of their outcomes. This paper presents a framework for conducting participatory quantitative HIA (PQHIA) in low- and middle-income countries (LMICs), including integrating the outcomes back into society after an HIA is conducted. The study responds to the question: what are the different components of a participatory quantitative model that can influence HIA implementation in LMICs? Methods: To build the framework, we used a case study from a PQHIA fieldwork model developed in Port Louis (Mauritius). To explore thinking on the participatory components of the framework, we extract and analyze data from ethnographic material including fieldnotes, interviews, focus group discussions and feedback exercises with 14 stakeholders from the same case study. We confirm the validity of the ethnographic data using five quality criteria: credibility, transferability, dependability, confirmability, and authenticity. We build the PQHIA framework connecting the main HIA steps with factors influencing HIAs. Results: The final framework depicts the five standard HIA stages and summarizes participatory activities and outcomes. It also reflects key factors influencing PQHIA practice and uptake of HIA outcomes: costs for participation, HIA knowledge and interest of stakeholders, social responsibility of policymakers, existing policies, data availability, citizen participation, multi-level stakeholder engagement and multisectoral coordination. The framework suggests that factors necessary to complete a participatory HIA are the same needed to re-integrate HIA results back into the society. There are three different areas that can act as facilitators to PQHIAs: good governance, evidence-based policy making, and access to resources. Conclusions: The framework has several implications for research and practice. It underlines the importance of applying participatory approaches critically while providing a blueprint for methods to engage local stakeholders. Participatory approaches in quantitative HIAs are complex and demand a nuanced understanding of the context. Therefore, the political and cultural contexts in which HIA is conducted will define how the framework is applied. Finally, the framework underlines that participation in HIA does not need to be expensive or time consuming for the assessor or the participant. Yet, participatory quantitative models need to be contextually developed and integrated if they are to provide health benefits and be beneficial for the participants. This integration can be facilitated by investing in opportunities that fuel good governance and evidence-based policy making.

Health Impacts from Ambient Particle Exposure in Southern Sweden

A health impact assessment (HIA) is an important tool for making informed decisions regarding the design and evaluation of environmental interventions. In this study, we performed a quantitative HIA for the population of Scania (1,247,993), the southernmost county in Sweden, in 2016. The impact of annual mean concentrations of particulate matter with an aerodynamic diameter <2.5 µm (PM_2.5), modeled at their home residences for the year 2011, on mortality, asthma, dementia, autism spectrum disorders, preeclampsia and low birth weight (LBW) was explored. Concentration–response (C-R) functions were taken from epidemiological studies reporting meta-analyses when available, and otherwise from single epidemiological studies. The average level of PM_2.5 experienced by the study population was 11.88 µg/m³. The PM_2.5 exposure was estimated to cause 9–11% of cases of LBW and 6% of deaths from natural causes. Locally produced PM_2.5 alone contributed to 2–9% of the cases of diseases and disorders investigated. Reducing concentrations to a maximum of 10 µg/m³ would, according to our estimations, reduce mortality by 3% and reduce cases of LBW by 2%. Further analyses of separate emission sources’ distinct effects were also presented. Reduction of air pollution levels in the study area would, as expected, have a substantial effect on both mortality and adverse health outcomes. Reductions should be aimed for by local authorities and on national and even international levels.

Urban and transport planning pathways to carbon neutral, liveable and healthy cities; A review of the current evidence

INTRODUCTION

Half the world population lives in cities and this is likely to increase to 70% over the next 20 years. Suboptimal urban and transport planning has led to e.g. high levels of air pollution and noise, heat island effects and lack of green space and physical activity and thereby an increase in morbidity and premature mortality. How can better urban and transport planning improve public health?

METHODS

A narrative meta-review around a number of cutting edge and visionary studies and practices on how to improve public health through better urban and transport planning reported in the literature and from meetings over the past few years.

RESULTS

We describe the latest quantitative evidence of how cities can become healthier through better urban and transport planning. It focuses and provides evidence for important interventions, policies and actions that can improve public health, including the need for land use changes, reduce car dependency and move towards public and active transportation, greening of cities, visioning, citizen involvement, collaboration, leadership and investment and systemic approaches. Health impact assessment studies have recently provided new powerful quantitative evidence on how to make cities healthier and will be used as examples. At the same time these measures make also our cities more sustainable (i.e. carbon neutral) and liveable creating multiple benefits.

CONCLUSION

Better urban and transport planning can lead to carbon neutral, more liveable and healthier cities, particularly through land use changes, a move from private motorised transportation to public and active transportation and greening of cities.

Through Internet and Friends: Translation of Air Pollution Research in Malmö Municipality, Sweden

Air pollution is estimated to cause more than 7000 deaths annually in Sweden alone. To reduce the impact of air pollution and to plan and build sustainable cities, it is vital that research is translated into efficient decisions and practice. However, how do civil servants in a municipality access research results? How do they normally find relevant information, and what obstacles are there to accessing and applying research results? As part of the collaborative and transdisciplinary research project Air Pollution Research in Local Environmental Planning (ARIEL), these questions were explored through interviews and seminars with civil servants within the Malmö Municipality Environmental Office. We found that the civil servants generally have proficiency in processing research results, but often do not use such results as part of their everyday decision making and practices. Instead, the data and measurements used are mostly produced case-by-case within the municipal sector itself. Information about best practices is also collected via a number of knowledge access practices, involving the Internet or social networks within other municipalities. Lack of time, paywalls, and the insufficient applicability of research hinder the dissemination of up-to-date results. This slows down the process whereby research, funded by tax-money, can be put to best practice in the effort to create healthy and sustainable cities.

Burden of disease from transportation noise and motor vehicle crashes: Analysis of data from Houston, Texas

BACKGROUND

Transportation systems have an essential role in satisfying individuals' needs for mobility and accessibility. Yet, they have been linked to several adverse health impacts, with a large, but modifiable, burden of disease. Among the several transportation-related health risk factors, this study focused on transportation-related noise as an emerging exposure whose burden of disease remains partially recognized. We compared premature deaths potentially attributable to transportation-related noise with deaths from motor vehicle crashes, a well-researched and widely recognized transportation risk factor.

METHOD

We employed a standard burden of disease assessment framework to quantify premature cardiovascular diseases mortality attributable to transportation-related (road and aviation) noise at the census tract level (n = 592) in Houston, Texas. The results were compared to motor vehicle crash fatalities, which are routinely observed and collected in the study area. We also investigated the distribution of premature deaths across the city and explored the relationship between household median income and premature deaths attributable to transportation-related noise.

RESULTS

We estimated 302 (95% CI: 185-427) premature deaths (adults 30-75 years old) attributable to transportation-related noise in Houston, compared to 330 fatalities from motor vehicle crashes (adults younger than 75 years old). Transportation-related noise and motor vehicle crashes were responsible for 1.7% and 1.9% of all-cause premature deaths in Houston, respectively. Households with lower median income had a higher risk of adverse exposure and premature deaths potentially attributable to transportation-related noise. A larger number of premature deaths was associated with living in the central business district and the vicinity of highways and airports.

CONCLUSION

This study highlighted the significant contribution of transportation-related noise and motor vehicle crashes to premature deaths in the city of Houston. The analogy between the estimated premature deaths attributable to transportation-related noise and motor vehicle crashes showed that the health impacts of transportation-related noise were as significant as motor vehicle crashes. The estimated premature death rate attributable to transportation-related noise was also comparable to the death rate caused by suicide, influenza, or pneumonia in the US. There is an urgent need for imposing policies to reduce transportation noise emissions and human exposures and to equip health impact assessment tools with a noise burden of disease analysis function.

Urban health: an example of a "health in all policies" approach in the context of SDGs implementation

BACKGROUND

Cities are an important driving force to implement the Sustainable Development Goals (SDGs) and the New Urban Agenda. The SDGs provide an operational framework to consider urbanization globally, while providing local mechanisms for action and careful attention to closing the gaps in the distribution of health gains. While health and well-being are explicitly addressed in SDG 3, health is also present as a pre condition of SDG 11, that aims at inclusive, safe, resilient and sustainable cities. Health in All Policies (HiAP) is an approach to public policy across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts in order to improve population health and health equity. HiAP is key for local decision-making processes in the context of urban policies to promote public health interventions aimed at achieving SDG targets. HiAPs relies heavily on the use of scientific evidence and evaluation tools, such as health impact assessments (HIAs). HIAs may include city-level quantitative burden of disease, health economic assessments, and citizen and other stakeholders' involvement to inform the integration of health recommendations in urban policies. The Barcelona Institute for Global Health (ISGlobal)'s Urban Planning, Environment and Health Initiative provides an example of a successful model of translating scientific evidence into policy and practice with regards to sustainable and healthy urban development. The experiences collected through ISGlobal's participation implementing HIAs in several cities worldwide as a way to promote HiAP are the basis for this analysis.

AIM

The aim of this article is threefold: to understand the links between social determinants of health, environmental exposures, behaviour, health outcomes and urban policies within the SDGs, following a HiAP rationale; to review and analyze the key elements of a HiAP approach as an accelerator of the SDGs in the context of urban and transport planning; and to describe lessons learnt from practical implementation of HIAs in cities across Europe, Africa and Latin-America.

METHODS

We create a comprehensive, urban health related SDGs conceptual framework, by linking already described urban health dimensions to existing SDGs, targets and indicators. We discuss, taking into account the necessary conditions and steps to conduct HiAP, the main barriers and opportunities within the SDGs framework. We conclude by reviewing HIAs in a number of cities worldwide (based on the experiences collected by co-authors of this publication), including city-level quantitative burden of disease and health economic assessments, as practical tools to inform the integration of health recommendations in urban policies.

RESULTS

A conceptual framework linking SDGs and urban and transportplanning, environmental exposures, behaviour and health outcomes, following a HiAP rationale, is designed. We found at least 38 SDG targets relevant to urban health, corresponding to 15 SDGs, while 4 important aspects contained in our proposed framework were not present in the SDGs (physical activity, noise, quality of life or social capital). Thus, a more comprehensive HiAP vision within the SDGs could be beneficial. Our analysis confirmed that the SDGs framework provides an opportunity to formulate and implement policies with a HiAP approach. Three important aspects are highlighted: 1) the importance of the intersectoral work and health equity as a cross-cutting issue in sustainable development endeavors; 2) policy coherence, health governance, and stakeholders' participation as key issues; and 3) the need for high quality data. HIAs are a practical tool to implement HiAP. Opportunities and barriers related to the political, legal and health governance context, the capacity to inform policies in other sectors, the involvement of different stakeholders, and the availability of quality data are discussed based on our experience. Quantitative assessments can provide powerful data such as: estimates of annual preventable morbidity and disability-adjusted life-years (DALYs) under compliance with international exposure recommendations for physical activity, exposure to air pollution, noise, heat, and access to green spaces; the associated economic impacts in health care costs per year; and the number of preventable premature deaths when improvements in urban and transport planning are implemented. This information has been used to support the design of policies that promote cycling, walking, public, zero and low-emitting modes of transport, and the provision of urban greening or healthy public open spaces in Barcelona (e.g. Urban Mobility, Green Infrastructure and Biodiversity Plans, or the Superblocks's model), the Bus Rapid Transit and Open Streets initiatives in several Latin American cities or targeted SDGs assessments in Morocco.

CONCLUSIONS

By applying tools such as HIA, HiAP can be implemented to inform and improve transport and urban planning to achieve the 2030 SDG Agenda. Such a framework could be potentially used in cities worldwide, including those of less developed regions or countries. Data availability, taking into account equity issues, strenghtening the communication between experts, decision makers and citizens, and the involvement of all major stakeholders are crucial elements for the HiAP approach to translate knowledge into SDG implementation.

Green spaces and mortality: a systematic review and meta-analysis of cohort studies

BACKGROUND

Green spaces have been proposed to be a health determinant, improving health and wellbeing through different mechanisms. We aimed to systematically review the epidemiological evidence from longitudinal studies that have investigated green spaces and their association with all-cause mortality. We aimed to evaluate this evidence with a meta-analysis, to determine exposure-response functions for future quantitative health impact assessments.

METHODS

We did a systematic review and meta-analysis of cohort studies on green spaces and all-cause mortality. We searched for studies published and indexed in MEDLINE before Aug 20, 2019, which we complemented with an additional search of cited literature. We included studies if their design was longitudinal; the exposure of interest was measured green space; the endpoint of interest was all-cause mortality; they provided a risk estimate (ie, a hazard ratio [HR]) and the corresponding 95% CI for the association between green space exposure and all-cause mortality; and they used normalised difference vegetation index (NDVI) as their green space exposure definition. Two investigators (DR-R and DP-L) independently screened the full-text articles for inclusion. We used a random-effects model to obtain pooled HRs. This study is registered with PROSPERO, CRD42018090315.

FINDINGS

We identified 9298 studies in MEDLINE and 13 studies that were reported in the literature but not indexed in MEDLINE, of which 9234 (99%) studies were excluded after screening the titles and abstracts and 68 (88%) of 77 remaining studies were excluded after assessment of the full texts. We included nine (12%) studies in our quantitative evaluation, which comprised 8 324 652 individuals from seven countries. Seven (78%) of the nine studies found a significant inverse relationship between an increase in surrounding greenness per 0·1 NDVI in a buffer zone of 500 m or less and the risk of all-cause mortality, but two studies found no association. The pooled HR for all-cause mortality per increment of 0·1 NDVI within a buffer of 500 m or less of a participant's residence was 0·96 (95% CI 0·94-0·97; I², 95%).

INTERPRETATION

We found evidence of an inverse association between surrounding greenness and all-cause mortality. Interventions to increase and manage green spaces should therefore be considered as a strategic public health intervention.

FUNDING

World Health Organization.

Systematic Literature Review of Health Impact Assessments in Low and Middle-Income Countries

Health Impact Assessments (HIAs) motivate effective measures for safeguarding public health. There is consensus that HIAs in low and middle-income countries (LMICs) are lacking, but no study systematically focuses on those that have been successfully conducted across all regions of the world, nor do they highlight factors that may enable or hinder their implementation. Our objectives are to (1) systematically review, geographically map, and characterize HIA activity in LMICs; and (2) apply a process evaluation method to identify factors which are important to improve HIA implementation in LMICs. A systematic review of peer-reviewed HIAs in 156 LMICs was performed in Scopus, Medline, Web of Science, Sociological abstracts, and LILACs (Latin American and Caribbean Health Sciences) databases. The search used PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and covered HIAs across all type of interventions, topics, and health outcomes. HIAs were included if they reported a clear intervention and health outcome to be assessed. No time restriction was applied, and grey literature was not included. The eligible studies were subjected to six process evaluation criteria. The search yielded 3178 hits and 57 studies were retained. HIAs were conducted in 26 out of 156 countries. There was an unequal distribution of HIAs across regions and within LMICs countries. The leading topics of HIA in LMICs were air pollution, development projects, and urban transport planning. Most of the HIAs reported quantitative approaches (72%), focused on air pollution (46%), appraised policies (60%), and were conducted at the city level (36%). The process evaluation showed important variations in the way HIAs have been conducted and low uniformity in the reporting of six criteria. No study reported the time, money, and staff used to perform HIAs. Only 12% of HIAs were based on participatory approaches; 92% of HIAs considered multiple outcomes; and 61% of HIAs provided recommendations and fostered cross-national collaboration. The limited transparency in process, weak participation, and inconsistent delivery of recommendations were potential limitations to HIA implementation in low and middle-income countries. Scaling and improving HIA implementation in low and middle-income countries in the upcoming years will depend on expanding geographically by increasing HIA governance, adapting models and tools in quantitative methods, and adopting better reporting practices.

Cyclists’ Multiple Environmental Urban Exposures—Comparing Subjective and Objective Measurements

Citizens in urban areas are exposed to multiple environmental stressors like noise, heat, and air pollution, with impact on human health. There is a great deal of evidence that connects human health, objective environmental exposure, and place of residence. However, little is known about subjective and objective multiple personal exposures while being mobile. To address this research gap, this paper presents results from a mixed-methods exploratory study with cyclists in the City of Leipzig, Germany. In the summer of 2017, cyclists (n = 66) wore a unique combination of sensors that measured particle number counts (PNC), noise, humidity, temperature, geolocation, and the subjective perception of each exposure on everyday routes for one week (n = 730). A smartphone application was developed to question participants about their perception of subjective exposure. The data were analyzed with three aims: (i) to compare the multiple exposure profiles of the cyclists, (ii) to contrast the objective data and subjective individual perception, and (iii) to examine the role of route decision-making and awareness of health impacts for healthier route choices. The results indicate distinct differences between the exposure profiles of cyclists. Over 80% of the cyclists underestimated their exposure to noise and air pollution. Except for heat, no significant associations between the objective and subjective data were found. This reveals an exposure awareness gap that needs to be considered in urban health planning and risk communication. It is argued that knowledge about health impacts and route characteristics plays a crucial role in decision-making about route choices. The paper concludes with suggestions to harness smart sensing for exposure mitigation and research in health geography.

Socioeconomic inequalities in urban and transport planning related exposures and mortality: A health impact assessment study for Bradford, UK

BACKGROUND

Cities have unique geographic, environmental and sociocultural characteristics that influence the health status of their citizens. Identification and modification of these characteristics may help to promote healthier cities.

OBJECTIVE

We estimated premature mortality impacts of breaching international exposure guidelines for physical activity (PA), air pollution, noise and access to green space for Bradford (UK) adult residents (n = 393,091).

METHODS

We applied the Urban and TranspOrt Planning Health Impact Assessment (UTOPHIA) methodology and estimated mortality, life expectancy (LE) and economic impacts of non-compliance with recommended exposure levels. We also investigated the distribution of the mortality burden among the population, focusing on socioeconomic position (SEP) as defined by deprivation status and ethnicity.

RESULTS

We estimated that annually almost 10% of premature mortality (i.e. 375 deaths, 95% CI: 276-474) in Bradford is attributable to non-compliance with recommended exposure levels. Non-compliance was also estimated to result in over 300 days of LE lost (95% CI: 238-432), which translated in economic losses of over £50,000 per person (95% CI: 38,518-69,991). 90% of the premature mortality impact resulted from insufficient PA performance. Air and noise pollution and the lack of green space had smaller impacts (i.e. 48 deaths). Residents of lower SEP neighborhoods had the highest risks for adverse exposure and premature death. A larger number of deaths (i.e. 253 and 145, respectively) could be prevented by reducing air and noise pollution levels well below the guidelines.

DISCUSSION

Current urban and transport planning related exposures result in a considerable health burden that is unequally distributed among the Bradford population. Improvements in urban and transport planning practices including the reduction of motor traffic and the promotion of active transport together with greening of the district, particularly in areas of lower SEP, are promising strategies to increase PA performance and reduce harmful environmental exposures.

[Impact of the Air Quality on Health - Analysis of the activity of a SAMU-Center 15 in Paris area - the IQUASS Study]

INTRODUCTION

The atmospheric pollution is a growing public health problem. The highly urbanized regions such as Paris area seem particularly exposed. However, the overall health impact is poorly documented.

OBJECTIVE

To investigate the influence of air quality degradation on the demand for primary care.

METHOD

Site: medical dispatching center SAMU 93-Center 15. Related population: 1.6 million inhabitants.

DATA

daily number of medical regulation records (DRM) and daily air quality index (AQI) using the Airparif^® database from January 2014 to February 2017. The AQI is classified into five levels. Level 4 corresponds to the threshold of information and recommendations to reduce certain sources of polluting emissions and level 5 to the alert threshold setting up measures of restriction or suspension of the activities contributing to the pollution including vehicles circulation.

RESULTS

The analysis covered 1134 consecutive days and a total of 639,576 DRM. Average daily DRM number: 564 (507-643). IQA≥4 for 56 (5%) days and≥5 for 4 (0.4%) days. The number of DRM was very closely correlated with the IQA (R²=0.91); the daily median varied from 502 (494-621) for an IQA of level 1 to 650 (540-704) for an IQA≥4.

CONCLUSION

Degradation of air quality was significantly correlated with demand for primary care. The environmental alert is also a health alert. The impact was major (DRM +30%) considering all pathologies, all the pollutants on a departmental scale.

Full-chain health impact assessment of traffic-related air pollution and childhood asthma

BACKGROUND

Asthma is the most common chronic disease in children. Traffic-related air pollution (TRAP) may be an important exposure contributing to its development. In the UK, Bradford is a deprived city suffering from childhood asthma rates higher than national and regional averages and TRAP is of particular concern to the local communities.

AIMS

We estimated the burden of childhood asthma attributable to air pollution and specifically TRAP in Bradford. Air pollution exposures were estimated using a newly developed full-chain exposure assessment model and an existing land-use regression model (LUR).

METHODS

We estimated childhood population exposure to NO_x and, by conversion, NO₂ at the smallest census area level using a newly developed full-chain model knitting together distinct traffic (SATURN), vehicle emission (COPERT) and atmospheric dispersion (ADMS-Urban) models. We compared these estimates with measurements and estimates from ESCAPE's LUR model. Using the UK incidence rate for childhood asthma, meta-analytical exposure-response functions, and estimates from the two exposure models, we estimated annual number of asthma cases attributable to NO₂ and NO_x in Bradford, and annual number of asthma cases specifically attributable to traffic.

RESULTS

The annual average census tract levels of NO₂ and NO_x estimated using the full-chain model were 15.41 and 25.68 μg/m³, respectively. On average, 2.75 μg/m³ NO₂ and 4.59 μg/m³ NO_x were specifically contributed by traffic, without minor roads and cold starts. The annual average census tract levels of NO₂ and NO_x estimated using the LUR model were 21.93 and 35.60 μg/m³, respectively. The results indicated that up to 687 (or 38% of all) annual childhood asthma cases in Bradford may be attributable to air pollution. Up to 109 cases (6%) and 219 cases (12%) may be specifically attributable to TRAP, with and without minor roads and cold starts, respectively.

CONCLUSIONS

This is the first study undertaking full-chain health impact assessment of TRAP and childhood asthma in a disadvantaged population with public concern about TRAP. It further adds to scarce literature exploring the impact of different exposure assessments. In conservative estimates, air pollution and TRAP are estimated to cause a large, but largely preventable, childhood asthma burden. Future progress with childhood asthma requires a move beyond the prevalent disease control-based approach toward asthma prevention.

A conceptual study on the formulation of a permeable reactive pavement with activated carbon additives for controlling the fate of non-point source environmental organic contaminants

To take advantage of the road pavement network where non-point source (NPS) pollution such as benzene, toluene, ethyl-benzene, and xylene (BTEX) from vehicle traffic exhaust via wet and dry atmospheric deposition occurs, the asphalt pavement may be used as a media to control the NPS pollution. An experiment to prepare an adsorptive porous reactive pavement (PRP) was initiated to explore the potential to reduce environmental NPS vehicle pollution. The PRP was prepared and studied as follows: various activated carbons (AC) were initially screened to determine if they were suitable as an additive in the porous asphalt mixture; various mixtures of a selected AC were incorporated with the design of porous asphalt concrete (PAC) to produce PRP, and the PRP formulations were tested to ensure that they comply with the required specifications; qualified specimens were subsequently tested to determine their adsorption capacity for BTEX in aqueous solution, as compared to conventional PAC. The PRP08 and PRP16 samples, named for the design formulations of 0.8% and 1.6% of AC (by wt. in the formulation), exhibited low asphalt drain-down and low abrasion loss and also met all regulated specifications. The BTEX adsorption capacity measurements of PRP08 and PRP16 were 33-46%, 36-51%, 20-22%, and 6-8% respectively, higher than those obtained from PACs. Based on the test results, PRPs showed good physical performance and adsorption and may be considered as a potential method for controlling the transport of NPS vehicle pollutants.