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

Exploring the nexus of urban form, transport, environment and health in large-scale urban studies: A state-of-the-art scoping review

BACKGROUND

As the world becomes increasingly urbanised, there is recognition that public and planetary health relies upon a ubiquitous transition to sustainable cities. Disentanglement of the complex pathways of urban design, environmental exposures, and health, and the magnitude of these associations, remains a challenge. A state-of-the-art account of large-scale urban health studies is required to shape future research priorities and equity- and evidence-informed policies.

OBJECTIVES

The purpose of this review was to synthesise evidence from large-scale urban studies focused on the interaction between urban form, transport, environmental exposures, and health. This review sought to determine common methodologies applied, limitations, and future opportunities for improved research practice.

METHODS

Based on a literature search, 2958 articles were reviewed that covered three themes of: urban form; urban environmental health; and urban indicators. Studies were prioritised for inclusion that analysed at least 90 cities to ensure broad geographic representation and generalisability. Of the initially identified studies, following expert consultation and exclusion criteria, 66 were included.

RESULTS

The complexity of the urban ecosystem on health was evidenced from the context dependent effects of urban form variables on environmental exposures and health. Compact city designs were generally advantageous for reducing harmful environmental exposure and promoting health, with some exceptions. Methodological heterogeneity was indicative of key urban research challenges; notable limitations included exposure and health data at varied spatial scales and resolutions, limited availability of local-level sociodemographic data, and the lack of consensus on robust methodologies that encompass best research practice.

CONCLUSION

Future urban environmental health research for evidence-informed urban planning and policies requires a multi-faceted approach. Advances in geospatial and AI-driven techniques and urban indicators offer promising developments; however, there remains a wider call for increased data availability at local-levels, transparent and robust methodologies of large-scale urban studies, and greater exploration of urban health vulnerabilities and inequities.

Urban environment and health: a cross-sectional multiregional project based on population health surveys in Spain (DAS-EP project) - study protocol

INTRODUCTION

The European Environment Agency estimates that 75% of the European population lives in cities. Despite the many advantages of city life, the risks and challenges to health arising from urbanisation need to be addressed in order to tackle the growing burden of disease and health inequalities in cities. This study, Urban environment and health: a cross-sectional multiregional project based on population health surveys in Spain (DAS-EP project), aims to investigate the complex association between the urban environmental exposures (UrbEEs) and health.

METHODS AND ANALYSIS

DAS-EP is a Spanish multiregional cross-sectional project that combines population health surveys (PHS) and geographical information systems (GIS) allowing to collect rich individual-level data from 17 000 adult citizens participating in the PHS conducted in the autonomous regions of the Basque Country, Andalusia, and the Valencian Community, and the city of Barcelona in the years 2021-2023. This study focuses on the population living in cities or metropolitan areas with more than 100 000 inhabitants. UrbEEs are described by objective estimates at participants' home addresses by GIS, and subjective indicators present in PHS. The health outcomes included in the PHS and selected for this study are self-perceived health (general and mental), prevalence of chronic mental disorders, health-related quality of life, consumption of medication for common mental disorders and sleep quality. We aim to further understand the direct and indirect effects between UrbEEs and health, as well as to estimate the impact at the population level, taking respondents' sociodemographic and socioeconomic characteristics, and lifestyle into consideration.

ETHICS AND DISSEMINATION

The study was approved by the regional Research Ethics Committee of the Basque Country (Ethics Committee for Research Involving Medicinal Products in the Basque Country; PI2022138), Andalusia (Biomedical Research Ethics Committee of the Province of Granada; 2078-N-22), Barcelona (CEIC-PSMar; 2022/10667) and the Valencian Community (Ethics Committee for Clinical Research of the Directorate General of Public Health and Center for Advanced Research in Public Health; 20221125/04). The results will be communicated to the general population, health professionals, and institutions through conferences, reports and scientific articles.

Urban green spaces and behavioral and cognitive development in children: A health impact assessment of the Barcelona "Eixos Verds" Plan (Green Axis Plan)

BACKGROUND

Urban environments lack natural features, while nature exposure in cities has been associated with health benefits, including children's neurodevelopment. Through extensive street greening, Barcelona's Eixos Verds (Green Axis) Plan enhances safety, environment, and climate resilience. We aimed to assess the Eixos Verds Plan's potential impact on children's behavioral and cognitive development due to the increased green space expected under the Eixos Verds implementation.

METHODS

We performed a quantitative health impact assessment for Barcelona children at census-tract level (n = 1068). We assessed the Eixos Verds Plan's impact by comparing baseline green space distribution with the proposed plan, translating it into percentage green area (%GA) and Normalized Difference Vegetation Index (NDVI). By combining these exposure metrics with child-specific risk estimates and population data, we estimated potential improvements in children's behavioral and cognitive development due to full Eixos Verds implementation.

RESULTS

With the full Eixos Verds implementation, citywide, %GA increased by 6.9% (IQR: 6.4%; range: 0-23.1%) and NDVI by 0.065 (IQR: 0.083; range: 0.000-0.194). Child behavioral and cognitive development outcomes are expected to improve compared to the baseline. Based on NDVI increases, children's Total Difficulties and Hyperactivity/Inattention scores, based on the Strengths and Difficulties Questionnaire (SDQ), are projected to decrease by 5% (95% CI: 0-15%) and 6% (95% CI: 0-17%). Working Memory and Superior Working Memory scores are expected to increase by 4% and 5%, respectively, based on the computerized n-back test, while the Inattentiveness score could be reduced by 1%, based on the computerized attentional test (ANT).

INTERPRETATION

Urban greening as planning tool can improve behavioral and cognitive development in city children. Methods and results of our study are applicable to many cities worldwide, and similar results for children of real-life urban greening interventions can be expected.

Greenspace related to bipolar disorder in Taiwan: Quantitative benefits of saving DALY loss and increasing income

Scientific evidence reported that surrounding greenspace could promote better mental health. Considering bipolar disorder as the health outcome, this study aimed to investigate the association between greenspace and bipolar disorder in Taiwan and quantified the benefits of greenspace on bipolar disorder adjusted for the international greenspace availability standard. By examining datasets across 348 townships, two quantitative measures (i.e., disability-adjusted life year loss and income) were used to represent the benefits. The incidence rate of bipolar disorder was obtained from Taiwan's National Health Insurance Research Database. Normalized different vegetation index (NDVI) was measured as a proxy for the greenspace availability. A generalized additive mixed model coupled with a sensitivity test were applied to evaluate the statistical association. The prevented fraction for the population (PFP) was then applied to develop a scenario for quantifying benefit. The result showed a significant negative association between greenspace and bipolar disorder in Taiwan. Compared to low greenspace, areas with medium and high greenspace may reduce the bipolar risk by 21% (RR = 0.79; 95% CI = 0.76-0.83) and 51% (RR = 0.49; 95% CI = 0.45-0.53). Calculating benefits, we found that the development of a scenario by increasing greenspace adjusted for availability indicator in township categorized as low greenspace could save in DALY loss due to bipolar disorder up to10.97% and increase in income up to 11.04% from the current situation. Lastly, this was the first study in Asia-Pacific to apply a customized greenspace increment scenario to quantify the benefits to a particular health burden such as bipolar disorder.

An urban green space intervention with benefits for mental health: A health impact assessment of the Barcelona "Eixos Verds" Plan

BACKGROUND

Mental health disorders account for over 30% of the global burden of disease. There is a positive association between green space exposure and better mental health, and therefore urban greening can be an effective public health tool. Barcelona is a compact city with one of the highest population and traffic densities in Europe, with limited green spaces. Under the umbrella of the Superblock model, the Barcelona City council is implementing the Eixos Verds Plan for extensive street greening. We estimated the potential mental health benefits of this plan.

METHODS

We performed a quantitative health impact assessment at the Barcelona grid-cell level (n = 1,096). We compared the baseline green space situation (2015) with the proposed plan and translated the increase in green space into a) percentage of green area (%GA) and b) NDVI. We combined exposure data with Barcelona-specific mental health risk estimates, adult population (n = 1,235,375), and mental health data, and calculated preventable cases.

FINDINGS

Under the Eixos Verds Plan, we estimated an average increase of 5·67 %GA (range: 0·00% - 15·77%) and 0·059 NDVI (range: 0·000 - 0·312). We estimated that with the Eixos Verds Plan implementation, 31,353 (95%CI: 18,126-42,882) cases of self-perceived poor mental health (14·03% of total), 16,800 (95%CI: 6828-25,700) visits to mental health specialists (13·37% of total), 13,375 (95%CI: 6107-19,184) cases of antidepressant use (13·37% of total), and 9476 (95%CI: 802-16,391) cases of tranquilliser/ sedative use (8·11% of total) could be prevented annually, along corresponding to over 45 M € annual savings in mental health costs annually.

INTERPRETATION

Our results highlight the importance of urban greening as a public health tool to improve mental health in cities. Similar results for green interventions in other cities could be expected.

Cooling cities through urban green infrastructure: a health impact assessment of European cities

BACKGROUND

High ambient temperatures are associated with many health effects, including premature mortality. The combination of global warming due to climate change and the expansion of the global built environment mean that the intensification of urban heat islands (UHIs) is expected, accompanied by adverse effects on population health. Urban green infrastructure can reduce local temperatures. We aimed to estimate the mortality burden that could be attributed to UHIs and the mortality burden that would be prevented by increasing urban tree coverage in 93 European cities.

METHODS

We did a quantitative health impact assessment for summer (June 1-Aug 31), 2015, of the effect of UHIs on all-cause mortality for adults aged 20 years or older in 93 European cities. We also estimated the temperature reductions that would result from increasing tree coverage to 30% for each city and estimated the number of deaths that could be potentially prevented as a result. We did all analyses at a high-resolution grid-cell level (250 × 250 m). We propagated uncertainties in input analyses by using Monte Carlo simulations to obtain point estimates and 95% CIs. We also did sensitivity analyses to test the robustness of our estimates.

FINDINGS

The population-weighted mean city temperature increase due to UHI effects was 1·5°C (SD 0·5; range 0·5-3·0). Overall, 6700 (95% CI 5254-8162) premature deaths could be attributable to the effects of UHIs (corresponding to around 4·33% [95% CI 3·37-5·28] of all summer deaths). We estimated that increasing tree coverage to 30% would cool cities by a mean of 0·4°C (SD 0·2; range 0·0-1·3). We also estimated that 2644 (95% CI 2444-2824) premature deaths could be prevented by increasing city tree coverage to 30%, corresponding to 1·84% (1·69-1·97) of all summer deaths.

INTERPRETATION

Our results showed the deleterious effects of UHIs on mortality and highlighted the health benefits of increasing tree coverage to cool urban environments, which would also result in more sustainable and climate-resilient cities.

FUNDING

GoGreenRoutes, Spanish Ministry of Science and Innovation, Institute for Global Health, UK Medical Research Council, European Union's Horizon 2020 Project Exhaustion.

Effects of green spaces on alleviating mortality attributable to PM2.5 in China

Increasing research suggested that green spaces are associated with many health benefits, but evidence for the quantitative relationship between green spaces and mortality attributable to particulate matter with an aerodynamic diameter of 2.5 μm or less (PM_2.5) is limited. We collected disease-specific mortality and PM_2.5 data for a period of 4 years (2015-2018) along with green space data for an 8-year duration (2010-2017) in 31 provincial-level administrative regions of China. First, this study used the Integrated Exposure-Response model to estimate the mortality of four diseases attributable to PM_2.5, including chronic obstructive pulmonary diseases (COPD), lung cancer (LC), ischemic heart disease (IHD), and cerebrovascular disease (CBVD). Then we performed linear regression and mixed-effects model to investigate the counteracting effect of green spaces on death caused by PM_2.5 exposure. The differences in impacts among the Eastern, Central, and Western regions were explored using stratified analysis. The most significant results from linear regression analysis indicated that per 100 km² of green spaces increase, there was a decreased total mortality (10^-5) (COPD, LC, IHD, and CBVD) attributable to PM_2.5 by - 4.012 [95% confidence interval (CI): - 5.535, - 2.488], while the reduction by mixed-linear regression analysis was - 2.702/10⁵ (95% CI =  - 3.645, - 1.759). Of all hysteresis analyses, the effect estimates (β) at lag3 and lag4 were the largest. The effect of green spaces was more advantageous when targeting CBVD and the Eastern region. We found a negative correlation between green space exposure and mortality attributable to PM_2.5, which can provide further support for city planners, government personnel, and others to build a healthier city and achieve national health goals.

Rural-urban gradients and all-cause, cardiovascular and cancer mortality in Spain using individual data

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The literature reporting on rural-urban health status disparities remains inconclusive.

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We analyzed data from a longitudinal population-based study using individual observations.

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Our results show that the risks of all-cause and cancer mortality are greater in large cities than in other municipalities, with no clear urban-rural gradient.

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Not differences were found among territories in cardiovascular mortality.

Beyond green environments: Multi-scale difference in human exposure to greenspace in China

Greenspace exposure metrics can allow for comparisons of green space supply across time, space, and population groups, and for inferring patterns of variation in opportunities for people to enjoy the health and recreational benefits of nearby green environments. A better understanding of greenspace exposure differences across various spatial scales is a critical requirement for lessening environmental health disparities. However, existing studies are typically limited to a single city or across selected cities, which severely limits the use of results in measuring systemic national and regional scale differences that might need policy at above individual city planning level. To close this knowledge gap, our study aims to provide a holistic assessment of multi-scale greenspace exposure across provinces, cities, counties, towns, and land parcels for the whole of China. We mapped the nationwide fractional greenspace coverage at 10 m with Sentinel-2 satellite imagery, and then modeled population-weighted greenspace exposure to examine variation of greenspace exposure across scales. Our results show a prominent scaling effect of greenspace exposure across multi-scale administrative divisions in China, suggesting, as expected, an increase in heterogeneity with finer spatial scales. We also identify an asymmetric pattern of the difference between greenspace exposure and greenspace coverage, across a geo-demographic demarcation boundary (i.e., along the Heihe-Tengchong Line). In general, the greenspace coverage rate will overestimate more realistic human exposure to greenspace in East China while underestimating in West China. We further found that, in China, more recently urbanized areas have much better greenspace exposure than older urban areas. Our study provides a spatially explicit greenspace exposure metric for discovering multi-scale greenspace exposure difference, which will enhance governments' capacity to quantify environmental justice, detect vulnerable greenspace exposure risk hotspots, prioritize greenspace management at the supra-city scale, and monitor the balance between greenspace supply and demand.

The impact of urban environmental exposures on health: An assessment of the attributable mortality burden in Sao Paulo city, Brazil

BACKGROUND

Currently, more than half of the global population lives in cities. Contemporary urban planning practices result in environmental risk factors (e.g. air pollution, noise, lack of green space, excess heat) that put health and well-being of city dwellers at risk and contribute to chronic diseases and premature death. Despite a growing body of evidence on adverse health impacts related to current urban and transport planning practices, especially for cities in the Global North, not much is known about associated health impacts in South American cities. Therefore, we estimated the mortality burden attributable to breaching internationally-recommended or locally-preferable exposure levels of urban planning related environmental exposures in Sao Paulo, Brazil.

METHODS

We carried out a health impact assessment study, following the comparative risk assessment framework, to assess preventable mortality impacts of breaching exposure recommendations for air pollution, green spaces and temperature at the census tract (CT) level (n = 18,363). We also assessed the distribution thereof by socioeconomic vulnerability.

RESULTS

We estimated that annually 11,372 (95% CI: 7921; 15,910) attributable deaths could be prevented by complying with recommended exposure levels. The largest proportion of preventable mortality was due to breaching air pollution limits (i.e. 8409 attributable deaths), followed by insufficient green space (i.e. 2593), and excess heat (i.e. 370). Adverse health impacts were larger in CTs of lower socioeconomic vulnerability, due to demographic profile, traffic density and residential area configurations.

DISCUSSION

Not complying with the health limits for air pollution, green space and temperature exposures resulted in a considerable preventable mortality burden (i.e. 17% of total expected deaths) in Sao Paulo. This burden can be reduced by improving current urban and transport planning practices.

Methods for Evaluating Environmental Health Impacts at Different Stages of the Policy Process in Cities

PURPOSE OF REVIEW

Evaluating the environmental health impacts of urban policies is critical for developing and implementing policies that lead to more healthy and equitable cities. This article aims to (1) identify research questions commonly used when evaluating the health impacts of urban policies at different stages of the policy process, (2) describe commonly used methods, and (3) discuss challenges, opportunities, and future directions.

RECENT FINDINGS

In the diagnosis and design stages of the policy process, research questions aim to characterize environmental problems affecting human health and to estimate the potential impacts of new policies. Simulation methods using existing exposure-response information to estimate health impacts predominate at these stages of the policy process. In subsequent stages, e.g., during implementation, research questions aim to understand the actual policy impacts. Simulation methods or observational methods, which rely on experimental data gathered in the study area to assess the effectiveness of the policy, can be applied at these stages. Increasingly, novel techniques fuse both simulation and observational methods to enhance the robustness of impact evaluations assessing implemented policies. The policy process consists of interdependent stages, from inception to end, but most reviewed studies focus on single stages, neglecting the continuity of the policy life cycle. Studies assessing the health impacts of policies using a multi-stage approach are lacking. Most studies investigate intended impacts of policies; focusing also on unintended impacts may provide a more comprehensive evaluation of policies.

The art of Patient and Public Involvement: exploring ways to research and reduce air pollution through art-based community workshops - a reflective paper

In this reflective paper we outline and discuss our art-based Patient and Public Involvement (PPI) approach.  This exercise held two broad objectives. Firstly, to assist policy makers in understanding the types of interventions communities will find acceptable to address the problem of poor air quality, and secondly, to ascertain community views about our research plans to explore the impact of the planned interventions on neighbourhoods.  We reflect on both our approach and the emergent conversations from the PPI activity.  Attendees contributed to the process and stressed the importance of not burdening poor neighbourhoods with costly charges as that would ameliorate one health problem but generate others as a consequence of additional financial burden.  Equally, they stressed the need to conduct research on matters which they could connect with such as the impact of clean air plans on young children and how information about air pollution is disseminated in their neighbourhoods as and when research findings emerge.  This paper offers a conceptual analysis of the art-based PPI method and uniquely draws a connection to the philosophical traditions of Ludwig Wittgenstein.  Specifically, we demonstrate how art is conducive to creating a dialogue which is specifically helpful for PPI purposes for both researchers and implementers, and conversely, why traditional conversational approaches may have fallen short of the adequacy mark in this regard.

Selected Research Issues of Urban Public Health

Health is created within the urban settings of people’s everyday lives. In this paper we define Urban Public Health and compile existing evidence regarding the spatial component of health and disease in urban environments. Although there is already a substantial body of single evidence on the links between urban environments and human health, focus is mostly on individual health behaviors. We look at Urban Public Health through a structural lens that addresses health conditions beyond individual health behaviors and identify not only health risks but also health resources associated with urban structures. Based on existing conceptual frameworks, we structured evidence in the following categories: (i) build and natural environment, (ii) social environment, (iii) governance and urban development. We focused our search to review articles and reviews of reviews for each of the keywords via database PubMed, Cochrane, and Google Scholar in order to cover the range of issues in urban environments. Our results show that linking findings from different disciplines and developing spatial thinking can overcome existing single evidence and make other correlations visible. Further research should use interdisciplinary approaches and focus on health resources and the transformation of urban structures rather than merely on health risks and behavior.

Impact of road traffic noise on annoyance and preventable mortality in European cities: A health impact assessment

BACKGROUND

Road traffic is the main source of environmental noise in European cities and one of the main environmental risks to health and wellbeing. In this study we aimed to provide an in-depth assessment of available road traffic noise data and to estimate population exposure and health impacts for cities in Europe.

METHODS

We conducted the analysis for 724 cities and 25 greater cities in 25 European countries. We retrieved road traffic strategic noise maps delivered under the Environmental Noise Directive (END) or available from local sources. We assessed noise exposure using the 24 h day-evening-night noise level indicator (L_den) starting at exposure levels of 55 dB L_den - based on data availability - for the adult population aged 20 and over (n = 123,966,346). For the adults exposed to noise levels above 55 dB L_den we estimated the health impacts of compliance with the World Health Organization (WHO) recommendation of 53 dB L_den. Two primary health outcomes were assessed: high noise annoyance and Ischemic Heart Disease (IHD), using mortality from IHD causes as indicator. Exposure Response Functions (ERFs) relating road traffic noise exposure to annoyance and IHD mortality were retrieved from the literature. Uncertainties in input parameters were propagated using Monte Carlo simulations to obtain point estimates and empirical 95% Confidence Intervals (CIs). Lastly, the noise maps were categorized as high, moderate and low quality following a qualitative approach.

RESULTS

Strategic noise map data was delivered in three distinct formats (i.e. raster, polygon or polyline) and had distinct noise ranges and levels of categorization. The majority of noise maps (i.e. 83.2%) were considered of moderate or low quality. Based on the data provided, almost 60 million adults were exposed to road traffic noise levels above 55 dB L_den, equating to a median of 42% (Interquartile Range (IQR): 31.8-64.8) of the adult population across the analysed cities. We estimated that approximately 11 million adults were highly annoyed by road traffic noise and that 3608 deaths from IHD (95% CI: 843-6266) could be prevented annually with compliance of the WHO recommendation. The proportion of highly annoyed adults by city had a median value of 7.6% (IQR: 5.6-11.8) across the analysed cities, while the number preventable deaths had a median of 2.2 deaths per 100,000 population (IQR: 1.4-3.1).

CONCLUSIONS

Based on the provided strategic noise maps a considerable number of adults in European cities are exposed to road traffic noise levels harmful for health. Efforts to standardize the strategic noise maps and to increase noise and disease data availability at the city level are needed. These would allow for a more accurate and comprehensive assessment of the health impacts and further help local governments to address the adverse health effects of road traffic noise.

Health impact assessment of transportation noise in two Estonian cities

Transportation noise is a growing public health concern worldwide, especially in urban areas, causing annoyance, sleep disturbance, cardiovascular diseases and other health effects. Recently, European Commission (EC) has developed a mutual methodology for assessing health impacts of transportation noise in European Union using strategic noise mapping. Applying this methodology, our aim was to quantify the health effects of road, rail and aircraft noise in two Estonian cities, Tallinn and Tartu. We also aimed to assess sensitivity of this methodology, while implementing lower threshold values and employing additional health outcomes. The proportion of highly annoyed residents due to road traffic noise was 11.6% in Tallinn, and 9.2% in Tartu; around 2.5% residents in both cities could have high sleeping disturbances. As exposure to railway and aircraft noise was relatively low in both cities, people with high annoyance and high sleep disturbance caused by railway and aircraft noise was below 1%. Ischemic heart disease (IHD) cases attributable to road traffic noise was estimated to be 122.6 in Tallinn and 21.5 in Tartu. Altogether transportation noise was estimated to cause 1807 disability adjusted life years (DALYs) in Tallinn and 370 DALYs in Tartu. The health costs were calculated as €126.5 and €25.9 million annually, respectively in the two cities. When we included higher number of health outcomes (stroke incidence, IHD deaths) and lowered exposure threshold by 5 dB, the annual burden of disease was doubled. As the latest epidemiological studies showed transportation noise having larger number of effects on lower noise levels, the results with the currently applied European Commission health impact assessment (HIA) methodology were rather conservative. Despite of uncertainties associated to applied methodology, transportation noise, especially road traffic noise, is an important environmental risk factor, that leads to considerable loss of healthy life years and causes large health costs in urban areas.

The Impact of Transport on Population Health and Health Equity for Māori in Aotearoa New Zealand: A Prospective Burden of Disease Study

Background: The land transport system influences health via a range of pathways. This study aimed to quantify the amount and distribution of health loss caused by the current land transport system in Aotearoa New Zealand (NZ) through the pathways of road injury, air pollution and physical inactivity. Methods: We used an existing multi-state life table model to estimate the long-term health impacts (in health-adjusted life years (HALYs)) and changes in health system costs of removing road injury and transport related air pollution and increasing physical activity to recommended levels through active transport. Health equity implications were estimated using relative changes in HALYs and life expectancy for Māori and non-Māori. Results: If the NZ resident population alive in 2011 was exposed to no further air pollution from transport, had no road traffic injuries and achieved at least the recommended weekly amount of physical activity through walking and cycling from 2011 onwards, 1.28 (95% UI: 1.11–1.5) million HALYs would be gained and $7.7 (95% UI: 10.2 to 5.6) billion (2011 NZ Dollars) would be saved from the health system over the lifetime of this cohort. Māori would likely gain more healthy years per capita than non-Māori, which would translate to small but important reductions (2–3%) in the present gaps in life expectancy. Conclusion: The current transport system in NZ, like many other car-dominated transport systems, has substantial negative impacts on health, at a similar level to the effects of tobacco and obesity. Transport contributes to health inequity, as Māori bear greater shares of the negative health impacts. Creating a healthier transport system would bring substantial benefits for health, society and the economy.

People's desire to be in nature and how they experience it are partially heritable

Nature experiences have been linked to mental and physical health. Despite the importance of understanding what determines individual variation in nature experience, the role of genes has been overlooked. Here, using a twin design (TwinsUK, number of individuals = 2,306), we investigate the genetic and environmental contributions to a person's nature orientation, opportunity (living in less urbanized areas), and different dimensions of nature experience (frequency and duration of public nature space visits and frequency and duration of garden visits). We estimate moderate heritability of nature orientation (46%) and nature experiences (48% for frequency of public nature space visits, 34% for frequency of garden visits, and 38% for duration of garden visits) and show their genetic components partially overlap. We also find that the environmental influences on nature experiences are moderated by the level of urbanization of the home district. Our study demonstrates genetic contributions to individuals' nature experiences, opening a new dimension for the study of human-nature interactions.

Study protocol of the European Urban Burden of Disease Project: a health impact assessment study

INTRODUCTION

Cities have long been known to be society's predominant engine of innovation and wealth creation, yet they are also hotspots of pollution and disease partly due to current urban and transport practices. The aim of the European Urban Burden of Disease project is to evaluate the health burden and its determinants related to current and future potential urban and transport planning practices and related exposures in European cities and make this evidence available for policy and decision making for healthy and sustainable futures.

METHODS AND ANALYSIS

Drawing on an established comparative risk assessment methodology (ie, Urban and Transport Planning Health Impact Assessment) tool), in nearly 1000 European cities we will (1) quantify the health impacts of current urban and transport planning related exposures (eg, air pollution, noise, excess heat, lack of green space) (2) and evaluate the relationship between current levels of exposure, health impacts and city characteristics (eg, size, density, design, mobility) (3) rank and compare the cities based on exposure levels and the health impacts, (4) in a number of selected cities assess in-depth the linkages between urban and transport planning, environment, physical activity and health, and model the health impacts of alternative and realistic urban and transport planning scenarios, and, finally, (5) construct a healthy city index and set up an effective knowledge translation hub to generate impact in society and policy.

ETHICS AND DISSEMINATION

All data to be used in the project are publicly available data and do not need ethics approval. We will request consent for personal data on opinions and views and create data agreements for those providing information on current and future urban and transport planning scenarios.For dissemination and to generate impact, we will create a knowledge translation hub with information tailored to various stakeholders.

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.

Do we know enough to quantify the impact of urban green spaces on mortality? An analysis of the current knowledge

OBJECTIVES

The addition of green spaces (GS) in cities is perceived as an efficient solution to combat climate change and biodiversity loss while also improving human health. Quantitative health impact assessment (QHIA) is a powerful tool to assess the health benefits of GS and support policy-making decisions. In France, a preliminary analysis of the literature led to the decision of developing guidance for QHIA applied to GS and mortality. This paper focuses on the choice of exposure-response functions (ERF) for those QHIA.

STUDY DESIGN

Literature review and analysis of the key steps of QHIA.

METHODS

Articles providing ERF for all-cause, cardiovascular and respiratory mortality in relation to GS were identified through a literature review and ranked based on a quality score. ERF from the articles with the highest scores was pooled in meta-analyses.

RESULTS

In total, 13 ERF were selected for all-cause mortality, 10 for cardiovascular mortality and 5 for respiratory mortality. Meta-risk for a 0.1 increase in the normalised differential vegetation index were, 0.96 (95% confidence interval [CI] 0.94; 0.97), 0.98 (95% CI 0.96; 0.99) and 0.97 (95% CI 0.92; 1.02) for all-cause, cardiovascular and respiratory mortality, respectively.

CONCLUSIONS

While current knowledge makes it possible to use QHIA on GS and mortality, interdisciplinary research is still needed to clarify the shape of the relationship and its temporality and to assess exposure in a meaningful way for decision-making.

Green space and mortality in European cities: a health impact assessment study

BACKGROUND

Natural outdoor environments including green spaces play an important role in preserving population health and wellbeing in cities, but the number of deaths that could be prevented by increasing green space in European cities is not known. We aimed to estimate the number of natural-cause deaths among adult residents that could be prevented in cities in 31 European countries, if the WHO recommendation for universal access to green space was achieved.

METHODS

In this health impact assessment study we focused on adult residents (aged ≥20 years; n=169 134 322) in 978 cities and 49 greater cities, in 31 European countries. We used two green space proxies: normalised difference vegetation index (NDVI), and percentage of green area (%GA). The exposure was estimated at a fine grid-cell level (250 m × 250 m) and the preventable mortality burden for 2015 was estimated at the local city-level.

FINDINGS

For 2015 we found that meeting the WHO recommendation of access to green space could prevent 42 968 (95% CI 32 296-64 177) deaths annually using the NDVI proxy (ie, 20% [95% CI 15-30] of deaths per 100 000 inhabitants-year), which represents 2·3% (95% CI 1·7-3·4) of the total natural-cause mortality and 245 (95% CI 184-366) years of life lost per 100 000 inhabitants-year. For the %GA proxy 17 947 (95%CI 0-35 747) deaths could be prevented annually. For %GA the number of attributable deaths were half of that of the NDVI and results were non-significant due to the exposure response function considered. The distribution of NDVI and %GA varied between cities and was not equally distributed within cities. Among European capitals, Athens, Brussels, Budapest, Copenhagen, and Riga showed some of the highest mortality burdens due to the lack of green space. The main source of uncertainty for our results was the choice of the age-structures of the population for the NDVI analysis, and exposure-response function for the %GA analysis.

INTERPRETATION

A large number of premature deaths in European cities could be prevented by increasing exposure to green space, while contributing to sustainable, liveable and healthy cities.

FUNDING

GoGreenRoutes, Internal ISGlobal fund, and the United States Department of Agriculture Forest Service.

High-Resolution Modeling and Apportionment of Diesel-Related Contributions to Black Carbon Concentrations

Exposure to diesel-related air pollution, which includes black carbon (BC) as a major component of the particulate matter emitted in engine exhaust, is a known human health hazard. The resulting health burden falls heavily on vulnerable communities located close to major sources including highways, rail yards, and ports. Determination of source contributions to the overall pollution burden is challenging due to collinearity in the exhaust composition profiles for relevant sources including heavy-duty diesel trucks, railroad locomotives, cargo-handling equipment, and marine engines. Additionally, the impact of each source depends not just on the magnitude of emissions but on its location relative to receptors as well as on meteorology. We modeled source-resolved BC concentrations in West Oakland, California, at a high (150 m) spatial resolution using the Weather Research and Forecasting model. The ability of the model to predict hourly and 24 h average BC concentrations is evaluated for a 100-day period in summer 2017 when BC was measured at 100 sites within the community. We find that a community monitoring site is representative of population-weighted average BC exposure in the community. Major contributing sources to BC in West Oakland include on-road diesel trucks (44 ± 5%) and three off-road diesel sources: ocean-going vessels (19 ± 1%), railroad locomotives (16 ± 2%), and harbor craft such as tugboats and ferries (11 ± 1%).

Children of Smoking and Non-Smoking Households' Perceptions of Physical Activity, Cardiorespiratory Fitness, and Exercise

Previous research has shown secondhand tobacco smoke to be detrimental to children’s health. This qualitative study aimed to explore children from low socioeconomic status (SES) families and their reasons for being physically active, attitudes towards physical activity (PA), fitness and exercise, perceived barriers and facilitators to PA, self-perceptions of fitness and physical ability, and how these differ for children from smoking and non-smoking households. A total of 38 children (9–11 years; 50% female; 42% smoking households) from the deprived areas of North West England participated in focus groups (n = 8), which were analysed by utilizing thematic analysis. The findings support hypothesised mediators of PA in children including self-efficacy, enjoyment, perceived benefit, and social support. Fewer than a quarter of all children were aware of the PA guidelines with varying explanations, while the majority of children perceived their own fitness to be high. Variances also emerged between important barriers (e.g., sedentary behaviour and environmental factors) and facilitators (e.g., psychological factors and PA opportunity) for children from smoking and non-smoking households. This unique study provided a voice to children from low SES and smoking households and these child perspectives could be used to create relevant and effective strategies for interventions to improve PA, fitness, and health.

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.

Green Space and Health Equity: A Systematic Review on the Potential of Green Space to Reduce Health Disparities

Disadvantaged groups worldwide, such as low-income and racially/ethnically minoritized people, experience worse health outcomes than more privileged groups, including wealthier and white people. Such health disparities are a major public health issue in several countries around the world. In this systematic review, we examine whether green space shows stronger associations with physical health for disadvantaged groups than for privileged groups. We hypothesize that disadvantaged groups have stronger protective effects from green space because of their greater dependency on proximate green space, as they tend to lack access to other health-promoting resources. We use the preferred reporting items for systematic reviews and meta-analyses (PRISMA) method and search five databases (CINAHL, Cochrane, PubMed, Scopus, and Web of Science) to look for articles that examine whether socioeconomic status (SES) or race/ethnicity modify the green space-health associations. Based on this search, we identify 90 articles meeting our inclusion criteria. We find lower-SES people show more beneficial effects than affluent people, particularly when concerning public green spaces/parks rather than green land covers/greenness. Studies in Europe show stronger protective effects for lower-SES people versus higher-SES people than do studies in North America. We find no notable differences in the protective effects of green space between racial/ethnic groups. Collectively, these results suggest green space might be a tool to advance health equity and provide ways forward for urban planners, parks managers, and public health professionals to address health disparities.

Assessing the Distribution of Air Pollution Health Risks within Cities: A Neighborhood-Scale Analysis Leveraging High-Resolution Data Sets in the Bay Area, California

BACKGROUND

Air pollution-attributable disease burdens reported at global, country, state, or county levels mask potential smaller-scale geographic heterogeneity driven by variation in pollution levels and disease rates. Capturing within-city variation in air pollution health impacts is now possible with high-resolution pollutant concentrations.

OBJECTIVES

We quantified neighborhood-level variation in air pollution health risks, comparing results from highly spatially resolved pollutant and disease rate data sets available for the Bay Area, California.

METHODS

We estimated mortality and morbidity attributable to nitrogen dioxide (NO2), black carbon (BC), and fine particulate matter [PM ≤2.5μm in aerodynamic diameter (PM2.5)] using epidemiologically derived health impact functions. We compared geographic distributions of pollution-attributable risk estimates using concentrations from a) mobile monitoring of NO2 and BC; and b) models predicting annual NO2, BC and PM2.5 concentrations from land-use variables and satellite observations. We also compared results using county vs. census block group (CBG) disease rates.

RESULTS

Estimated pollution-attributable deaths per 100,000 people at the 100-m grid-cell level ranged across the Bay Area by a factor of 38, 4, and 5 for NO2 [mean=30 (95% CI: 9, 50)], BC [mean=2 (95% CI: 1, 2)], and PM2.5, [mean=49 (95% CI: 33, 64)]. Applying concentrations from mobile monitoring and land-use regression (LUR) models in Oakland neighborhoods yielded similar spatial patterns of estimated grid-cell-level NO2-attributable mortality rates. Mobile monitoring concentrations captured more heterogeneity [mobile monitoring mean=64 (95% CI: 19, 107) deaths per 100,000 people; LUR mean=101 (95% CI: 30, 167)]. Using CBG-level disease rates instead of county-level disease rates resulted in 15% larger attributable mortality rates for both NO2 and PM2.5, with more spatial heterogeneity at the grid-cell-level [NO2 CBG mean=41 deaths per 100,000 people (95% CI: 12, 68); NO2 county mean=38 (95% CI: 11, 64); PM2.5 CBG mean=59 (95% CI: 40, 77); and PM2.5 county mean=55 (95% CI: 37, 71)].

DISCUSSION

Air pollutant-attributable health burdens varied substantially between neighborhoods, driven by spatial variation in pollutant concentrations and disease rates. https://doi.org/10.1289/EHP7679.

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.

Health equity and burden of childhood asthma - related to air pollution in Barcelona

BACKGROUND

Air pollution is one of the major health risk factors in urban populations. Air pollution has been associated with asthma in children. Air pollution has also been suggested to be distributed unequally within the cities, something that can lead to urban health inequalities.

AIM

We aimed to estimate the number of childhood asthma cases attributable to three main air pollutants; Nitrogen dioxide (NO2), Particulate Matter (PM 2.5), and Black Carbon (BC) in the city of Barcelona, Spain. We also aimed to describe the distribution of those impacts depending on the social deprivation index in Barcelona.

METHODS

We estimated the number of childhood asthma cases in Barcelona by applying a quantitative Health Impact Assessment (HIA) approach. Air pollution (NO2, PM2.5, and BC) exposure assessment was estimated using a land-use regression model. Two scenarios were assessed and compared the current levels of air pollution with 1) achieving the World Health Organization (WHO) guideline on exposure levels for NO2 and PM2.5 (scenario 1); and 2) achieving the minimum reported levels in a previously published meta-analysis (scenario 2), from where we also obtained the exposure-response functions. The relative risk and population attributable fraction (PAF) for each scenario and pollutant were estimated. Using the asthma incidence rate in Spain the expected number of asthma cases in Barcelona attributable to NO2, PM2.5, and BC for each scenario was estimated.

RESULTS

The annual average levels of NO2, PM2.5, and BC at census levels were 56 μg/m³, 17.11 μg/m^3, and 2.88 μg/m³, respectively. The number of asthma cases attributable to NO2 and PM2.5 (percentage of total cases) estimated in scenario 1 was 454 (18%) and 478 (19%) respectively. For scenario 2, the estimated number of cases attributable to NO2, PM2.5, and BC were 1230 (48%), 992 (39%) and 789 (31%) respectively. Although NO2 and BC showed differences between asthma cases and areas with different deprivation index, only BC differences were statistically significant between less and more deprived areas.

CONCLUSIONS

This study estimated that up to 1230 (48%) of asthma cases in Barcelona could be attributable to air pollution each year. This study also found that in Barcelona, less socially deprived groups could be more affected by asthma-related to air pollution than those more socially deprived.

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.

Is a liveable city a healthy city? Health impacts of urban and transport planning in Vienna, Austria

Each year, The Economist Intelligence Unit (EIU) computes the Global Liveability Index and determines the most liveable cities around the world. Vienna, Austria, was ranked by the EIU as the most liveable city worldwide in 2018 and 2019. However, the relationship between a liveable as well as healthy and environmentally-just city has not been previously explored. To explore whether the most liveable city is also a healthy and environmentally-just one, we estimated the premature mortality burden related to non-compliance with international exposure level recommendations for physical activity (PA), air pollution (PM_2.5 and NO₂), road traffic noise, green space and heat for Vienna, as well as its distribution by socioeconomic status (SES). We applied the Urban and TranspOrt Planning Health Impact Assessment (UTOPHIA) methodology and estimated the annual mortality, life expectancy (LE) and economic impact of non-compliance with exposure guidelines for the Viennese adult population ≥ 20 years. We compared current with recommended exposure levels, quantified the association between exposures and mortality and calculated attributable health impact fractions. Eight percent of premature mortality (i.e. 1239 deaths, 95% CI: 679-1784) was estimated to be attributable to non-compliance with the recommended exposure levels. Seventy-six percent of the attributable premature mortality was due to PM_2.5 exposure and insufficient PA. Non-compliance also resulted in an average of 199 days of LE lost for the adult population (95% CI: 111-280) and an economic impact of 4.6 (95% CI: 2.5-6.7) billion 2015€ annually. Overall, residents of lower SES neighbourhoods faced higher risk of premature mortality due to higher exposure to NO₂, road traffic noise, heat and less green space. Despite high liveability standards according to EIU definition, a considerable premature mortality burden was attributable to non-compliance with exposure recommendations, and socioeconomic inequalities were estimated. Although the exposure attributable mortality burden was lower than in other European cities and local Viennese policies favour the reduction of motorized traffic, alongside the promotion of active and public transport and urban greening, there is room for further alignment of liveability, environmental health and justice objectives.

New Approaches to Identifying and Reducing the Global Burden of Disease From Pollution

Pollution from multiple sources causes significant disease and death worldwide. Some sources are legacy, such as heavy metals accumulated in soils, and some are current, such as particulate matter. Because the global burden of disease from pollution is so high, it is important to identify legacy and current sources and to develop and implement effective techniques to reduce human exposure. But many limitations exist in our understanding of the distribution and transport processes of pollutants themselves, as well as the complicated overprint of human behavior and susceptibility. New approaches are being developed to identify and eliminate pollution in multiple environments. Community-scale detection of geogenic arsenic and fluoride in Bangladesh is helping to map the distribution of these harmful elements in drinking water. Biosensors such as bees and their honey are being used to measure heavy metal contamination in cities such as Vancouver and Sydney. Drone-based remote sensors are being used to map metal hot spots in soils from former mining regions in Zambia and Mozambique. The explosion of low-cost air monitors has allowed researchers to build dense air quality sensing networks to capture ephemeral and local releases of harmful materials, building on other developments in personal exposure sensing. And citizen science is helping communities without adequate resources measure their own environments and in this way gain agency in controlling local pollution exposure sources and/or alerting authorities to environmental hazards. The future of GeoHealth will depend on building on these developments and others to protect a growing population from multiple pollution exposure risks.

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.

Burden of Disease Assessment of Ambient Air Pollution and Premature Mortality in Urban Areas: The Role of Socioeconomic Status and Transportation

With recent rapid urbanization, sustainable development is required to prevent health risks associated with adverse environmental exposures from the unsustainable development of cities. Ambient air pollution is the greatest environmental risk factor for human health and is responsible for considerable levels of mortality worldwide. Burden of disease assessment (BoD) of air pollution in and across cities, and how these estimates vary according to socioeconomic status and exposure to road traffic, can help city planners and health practitioners to mitigate adverse exposures and promote public health. In this study, we quantified the health impacts of air pollution exposure (PM2.5 and NO2) at the census tract level in Houston, Texas, employing a standard BoD assessment framework to estimate the premature deaths (adults 30 to 78 years old) attributable to PM2.5 and NO2. We found that 631 (95% CI: 366-809) premature deaths were attributable to PM2.5 in Houston, and 159 (95% CI: 0-609) were attributable to NO2, in 2010. Complying with the World Health Organization air quality guidelines (annual mean: 10 μg/m3 for PM2.5) and the US National Ambient Air Quality standard (annual mean: 12 μg/m3 for PM2.5) could save 82 (95% CI: 42-95) and 8 (95% CI: 6-10) lives in Houston, respectively. PM2.5 was responsible for 7.3% of all-cause premature deaths in Houston, in 2010, which is higher than the death rate associated with diabetes mellites, Alzheimer's disease, or motor vehicle crashes in the US. Households with lower income had a higher risk of adverse exposure and attributable premature deaths. We also showed a positive relationship between health impacts attributable to air pollution and road traffic passing through census tracts, which was more prominent for NO2.

Autonomous Vehicles and Public Health

Autonomous vehicles (AVs) have the potential to shape urban life and significantly modify travel behaviors. "Autonomous technology" means technology that can drive a vehicle without active physical control or monitoring by a human operator. The first AV fleets are already in service in US cities. AVs offer a variety of automation, vehicle ownership, and vehicle use options. AVs could increase some health risks (such as air pollution, noise, and sedentarism); however, if proper regulated, AVs will likely reduce morbidity and mortality from motor vehicle crashes and may help reshape cities to promote healthy urban environments. Healthy models of AV use include fully electric vehicles in a system of ridesharing and ridesplitting. Public health will benefit if proper policies and regulatory frameworks are implemented before the complete introduction of AVs into the market.

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.

Connecting Air Pollution Exposure to Socioeconomic Status: A Cross-Sectional Study on Environmental Injustice among Pregnant Women in Scania, Sweden

Environmental injustice, characterized by lower socioeconomic status (SES) persons being subjected to higher air pollution concentrations, was explored among pregnant women in Scania, Sweden. Understanding if the general reduction of air pollution recorded is enjoyed by all SES groups could illuminate existing inequalities and inform policy development. "Maternal Air Pollution in Southern Sweden", an epidemiological database, contains data for 48,777 pregnancies in Scanian hospital catchment areas and includes births from 1999-2009. SES predictors considered included education level, household disposable income, and birth country. A Gaussian dispersion model was used to model women's average NO_X and PM_2.5 exposure at home residence over the pregnancy period. Total concentrations were dichotomized into emission levels below/above respective Swedish Environmental Protection Agency (EPA) Clean Air objectives. The data were analyzed using binary logistic regression. A sensitivity analysis facilitated the investigation of associations' variation over time. Lower-SES women born outside Sweden were disproportionately exposed to higher pollutant concentrations. Odds of exposure to NO_X above Swedish EPA objectives reduced over time, especially for low-SES persons. Environmental injustice exists in Scania, but it lessened with declining overall air pollution levels, implying that continued air quality improvement could help protect vulnerable populations and further reduce environmental inequalities.

Urban aerobiological risk mapping of ornamental trees using a new index based on LiDAR and Kriging: A case study of plane trees

Ornamental trees bring benefits for human health, including reducing urban pollution. However, some species, such as plane trees (Platanus sp.), produce allergenic pollen. Consequently, urban maps are a valuable tool for allergic patients and allergists, but they often fail to include variables that contribute to the "building downwash effect", such as the width and shape of streets and the height of buildings. Other factors that directly influence pollen dispersion (slopes and other geographical features) also have not traditionally been discussed. The LiDAR (Laser Imaging Detection and Ranging) technique enables one to consider these variables with high accuracy. This work proposes an Aerobiological Index to create Risk maps for Ornamental Trees (AIROT) and the establishment of potential areas of risk of exposure to Platanus pollen. LiDAR data from five urban areas were used to create the DEM and DSM (Digital Elevation and Surface Models) needed to perform further analysis. GIS software was used to map the points for each city and to create risk maps by Kriging, with stable (3 cases) and exponential function (2 cases) as the optimal models. In short, the AIROT index was a useful tool to map possible biological risks in cities. Since AIROT allows each city to consider its own characteristics, including geographical specifications, by using remote sensing and geostatistics techniques, the establishment of risk maps and healthy itineraries is valuable for allergic patients, allergists, architects and urban planners. This new aerobiological index provides a new decision-making tool related to urban planning and allergenicity assessment.

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.