City planning policies to support health and sustainability: an international comparison of policy indicators for 25 cities

[How to improve active mobility in São Paulo, Brazil? Survey with leaders of nongovernmental organizations and public and private sector managers]

This study aimed to describe a quantitative survey conducted with leaders to investigate effective and feasible actions that can be evaluated in computational models to inform policies to promote active mobility based in the city of São Paulo, Brazil. In 2022, an online survey was conducted during the Health Survey in São Paulo (Physical Activity and Environment study), which is monitored by representatives of nongovernmental organizations and public and private sector managers. A questionnaire was elaborated with three questions with 13 alternative answers about actions to promote walking and/or cycling. Leaders should select up to three alternatives based on their potential regarding: (1) effectiveness; (2) feasibility or ease of implementation; and (3) desire to verify tests in computational models to inform policies. The survey was answered by 18 leaders from 16 institutions, comprising 13 (72%) women and 12 (67%) representatives of the third sector, whose average age was 48 years and all had complete higher education. Reducing the speed of motor vehicles was the most cited option in all three questions. Other actions mentioned refer to controlling the traffic of vehicles in central areas, improving pedestrian safety, reducing the distances between homes and places of employment, conducting educational campaigns, and expanding and enhancing structures such as bicycle lanes and sidewalks. The results are relevant to support evidence-based decision-making in public management and to provide subsidies for the development of computational models with a view to promoting active mobility.

Spatial accessibility and inequality analysis of rabies-exposed patients to rabies post-exposure prophylaxis clinics in Guangzhou City, China

BACKGROUND

The incidence of rabies exposure is high and increasing in China, leading to an urgent demand of rabies post-exposure prophylaxis (PEP) clinics for the injured. However, the spatial accessibility and inequality of rabies-exposed patients to rabies PEP clinics is less known in China.

METHODS

Based on rabies exposure data, PEP clinic data, and resident travel origin-destination (OD) matrix data in Guangzhou City, China, we first described the incidence of rabies exposure in Guangzhou from 2020 to 2022. Then, the Gaussian two-step floating catchment area method (2SFCA) was used to analyze the spatial accessibility of rabies-exposed patients to rabies PEP clinics in Guangzhou, and the Gini coefficient and Moran's I statistics were utilized to evaluate the inequality and clustering of accessibility scores.

RESULTS

From 2020 to 2022, a total of 524,160 cases of rabies exposure were reported in Guangzhou, and the incidence showed a significant increasing trend, with an average annual incidence of 932.0/100,000. Spatial accessibility analysis revealed that the overall spatial accessibility scores for three scenarios (threshold of driving duration [d0] = 30 min, 45 min, and 60 min) were 0.30 (95% CI: 0.07, 0.87), 0.28 (95% CI: 0.11, 0.53) and 0.28 (95% CI: 0.14, 0.44), respectively. Conghua, Huangpu, Zengcheng and Nansha districts had the higher accessibility scores, while Haizhu, Liwan, and Yuexiu districts exhibited lower spatial accessibility scores. The Gini coefficient and Moran's I statistics showed that there were certain inequality and clustering in the accessibility to rabies PEP clinics in Guangzhou.

CONCLUSIONS

This study clarifies the heterogeneity of spatial accessibility to rabies PEP clinics, and provide valuable insights for resource allocation to achieve the WHO target of zero human dog-mediated rabies deaths by 2030.

The use of Virtual Reality (VR) to assess the impact of geographical environments on walking and cycling: a systematic literature review

BACKGROUND

Geographical environments influence people's active mobility behaviors, contributing to their physical and mental health. The use of Virtual Reality (VR) in experimental research can unveil new insights into the relationship between exposure to geographic environments and active mobility behaviors. This systematic review aims to (1) identify environmental attributes investigated in relation with walking and cycling, using VR, (2) assess their impacts on active mobility behaviors and attitudes, and (3) identify research gaps, strengths and limitations in VR-based experimental research.

METHODS

Articles published between January 2010 and February 2022 within five databases (PubMed, Scopus, EBSCO, IEEE Xplore, and Cochrane Library) were explored using three keywords and their synonyms: Virtual Reality, Active mobility behavior, and Geographical environments. Studies focusing on indoor environments, driving simulation, disease-specific groups, non-relevant disciplines (e.g. military, emergency evacuation), VR methodology/software optimization, and those with static participants' involvement were excluded. The full protocol is available from PROSPERO (ID = CRD42022308366).

RESULTS

Out of 3255 articles, 18 peer-reviewed papers met the selection criteria, mostly focusing on walking (83%). Most studies used head-mounted displays (94%) and relied on convenience sampling (72% below 100 participants). Both static (33%) and dynamic (45%) environmental attributes have been investigated, with only 22% of them simultaneously in the same virtual environment. Greenness and crowd density were the most frequent attributes, rather consistently associated with emotional states and movement behaviors. Few studies have taken into account participant's previous VR experience (33%) and cybersickness (39%) while both are likely to affect an individual's perception and behavior.

CONCLUSIONS

Future research should explore a broader range of environmental attributes, including static and dynamic ones, as well as a more complex integration of these attributes within a single experiment to mimic the effect of realistic environments on people's active mobility behaviors and attitudes. Larger and more diverse population samples are deemed required to improve result generalizability. Despite methodological challenges, VR emerges as a promising tool to disentangle the effect of complex environments on active mobility behaviors.

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.

A systematic review on the associations between the built environment and adult's physical activity in global tropical and subtropical climate regions

BACKGROUND

Physical inactivity is a major public health concern, exacerbated in countries with a (sub)tropical climate. The built environment can facilitate physical activity; however, current evidence is mainly from North American and European countries with activity-friendly climate conditions. This study explored associations between built environment features and physical activity in global tropical or subtropical dry or desert climate regions.

METHODS

A systematic review of four major databases (Web of Science, Scopus, PubMed, and SportDISCUS) was performed. To be included, studies had to investigate associations between perceived or objective built environment characteristics and adult's physical activity and had to be conducted in a location with (sub)tropical climate. Each investigated association was reported as one case and results were synthesized based upon perceived and objectively assessed environment characteristics as well as Western and non-Western countries. Study quality was evaluated using a tool designed for assessing studies on built environment and physical activity.

RESULTS

Eighty-four articles from 50 studies in 13 countries with a total of 2546 built environment-physical activity associations were included. Design (connectivity, walking/cycling infrastructure), desirability (aesthetics, safety), and destination accessibility were the built environment characteristics most frequently associated with physical activity across the domains active transport, recreational physical activity, total walking and cycling, and moderate-to-vigorous physical activity, particularly if multiple attributes were present at the same time. Very few studies assessed built environment attributes specifically relevant to physical activity in (sub)tropical climates. Most studies were conducted in Western countries, with results being largely comparable with non-Western countries. Findings were largely generalizable across gender and age groups. Results from natural experiments indicated that relocating to an activity-friendly neighborhood impacted sub-groups differently.

CONCLUSIONS

Built environment attributes, including destination accessibility, connectivity, walking and cycling infrastructure, safety, and aesthetics, are positively associated with physical activity in locations with (sub)tropical climate. However, few studies focus on built environment attributes specifically relevant in a hot climate, such as shade or indoor recreation options. Further, there is limited evidence from non-Western countries, where most of the urban population lives in (sub)tropical climates. Policy makers should focus on implementing activity-friendly environment attributes to create sustainable and climate-resilient cities.

More People, More Active, More Often for Heart Health - Taking Action on Physical Activity

Physical inactivity is a leading contributor to increased cardiovascular morbidity and mortality. Almost 500 million new cases of preventable noncommunicable diseases (NCDs) will occur globally between 2020 and 2030 due to physical inactivity, costing just over US$300 billion, or around US$ 27 billion annually (WHO 2022). Active adults can achieve a reduction of up to 35% in risk of death from cardiovascular disease. Physical activity also helps in moderating cardiovascular disease risk factors such as high blood pressure, unhealthy weight and type 2 diabetes. For people with cardiovascular disease, hypertension, type 2 diabetes and many cancers, physical activity is an established and evidence-based part of treatment and management. For children and young people, physical activity affords important health benefits. Physical activity can also achieve important cross-sector goals. Increased walking and cycling can reduce journeys by vehicles, air pollution, and traffic congestion and contribute to increased safety and liveability in cities.

The Urban Environment and Cardiometabolic Health

Urban environments contribute substantially to the rising burden of cardiometabolic diseases worldwide. Cities are complex adaptive systems that continually exchange resources, shaping exposures relevant to human health such as air pollution, noise, and chemical exposures. In addition, urban infrastructure and provisioning systems influence multiple domains of health risk, including behaviors, psychological stress, pollution, and nutrition through various pathways (eg, physical inactivity, air pollution, noise, heat stress, food systems, the availability of green space, and contaminant exposures). Beyond cardiometabolic health, city design may also affect climate change through energy and material consumption that share many of the same drivers with cardiometabolic diseases. Integrated spatial planning focusing on developing sustainable compact cities could simultaneously create heart-healthy and environmentally healthy city designs. This article reviews current evidence on the associations between the urban exposome (totality of exposures a person experiences, including environmental, occupational, lifestyle, social, and psychological factors) and cardiometabolic diseases within a systems science framework, and examines urban planning principles (eg, connectivity, density, diversity of land use, destination accessibility, and distance to transit). We highlight critical knowledge gaps regarding built-environment feature thresholds for optimizing cardiometabolic health outcomes. Last, we discuss emerging models and metrics to align urban development with the dual goals of mitigating cardiometabolic diseases while reducing climate change through cross-sector collaboration, governance, and community engagement. This review demonstrates that cities represent crucial settings for implementing policies and interventions to simultaneously tackle the global epidemics of cardiovascular disease and climate change.

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.

Cities and mental health: The role of the built environment, and environmental and lifestyle factors in Barcelona

Built environment characteristics and related environmental exposures and behaviors have been, separately, implicated in the development of poor mental health. However, it is unclear how these factors act together in relation to mental health. We studied these factors simultaneously to evaluate the impact of the built environment, and the mediating role of environmental exposures and physical activity, on mental health, while also studying moderation by sex, age, and length of residence. We used a cross-sectional population-based sample of 3145 individuals aged 15-97 years from Barcelona, Spain. Time spent walking and mental health status were assessed with validated questionnaires, administered through a face-to-face interview. We characterized the built environment (e.g., building, population and intersection density and green space), road traffic noise, and ambient air pollution at the residential level using land cover maps, remote sensing, noise maps and land use regression models. Adjusted regression models accounting for spatial clustering were analyzed to study associations between built environment attributes and mental health, and mediation and moderation effects. Density attributes were directly or indirectly, through air pollution and less consistently through walking, associated with poor mental health. Green space indicators were associated with lower prevalence of poor mental health, partly through lower air pollution exposure and more walking. In some cases, these associations differed by sex, age or length of residence. Non-linear associations of density indicators with environmental exposures, and of particulate matter with poor mental health indicated threshold effects. We conclude that living in dense areas with high air pollution concentrations was associated with poor mental health. On the other hand, green areas with lower air pollution concentrations were protective against poor mental health. Greater urban density might benefit health, but might only do so when air pollution concentrations are low.

Associations of the 'weekend warrior' physical activity pattern with all-cause, cardiovascular disease and cancer mortality: the Mexico City Prospective Study

OBJECTIVES

The objective was to investigate the benefits of the 'weekend warrior' physical activity pattern in Latin America, where many people take part in high levels of non-exercise physical activity.

METHODS

Participants in the Mexico City Prospective Study were surveyed from 1998 to 2004 and resurveyed from 2015 to 2019. Those who exercised up to once or twice per week were termed weekend warriors. Those who exercised more often were termed regularly active. Analyses were adjusted for potential confounders.

RESULTS

The main analysis included 26 006 deaths in 154 882 adults (67% female) aged 52±13 years followed for 18±4 years (mean±SD). Compared with those who reported no exercise, the HR (95% CI) was 0.88 (0.83 to 0.93) in the weekend warriors and 0.88 (0.84 to 0.91) in the regularly active. Similar results were observed for cardiovascular disease and cancer mortality, but associations were weaker. Stratified analyses showed that substantial reductions in all-cause mortality risk only occurred when the duration of exercise sessions was at least 30-60 min. The repeated-measures analysis included 843 deaths in 10 023 adults followed for 20±2 years. Compared with being inactive or becoming inactive, the HR was 0.86 (95% CI 0.65 to 1.12) when being a weekend warrior or becoming a weekend warrior and 0.85 (95% CI 0.70 to 1.03) when being regularly active or becoming regularly active.

CONCLUSIONS

This is the first prospective study to investigate the benefits of the weekend warrior physical activity pattern in Latin America. The results suggest that even busy adults could benefit from taking part in one or two sessions of exercise per week.

A cohort study examining individual factors influencing cycling as a transportation mode in São Paulo, Brazil

The aim of this study is to explore the relationship between individual-level factors and cycling for transportation in a cohort of participants living in São Paulo city, Brazil. The same participants (n = 1,431 adults) were interviewed in 2014/2015 (Wave 1) and 2020/2021 (Wave 2) as part of the 'São Paulo Health Survey-ISA: Physical Activity and Environment'. For the longitudinal transport cycling binary outcome, participants who reported cycling at both time-points and those who were cycling at Wave 2 only were coded as a positive longitudinal pattern for cycling. Those who were not cycling at either Waves, and those who were cycling at Wave 1 only, were grouped into a negative pattern for cycling. The relationship between the longitudinal patterns for transport cycling and sociodemographics, health characteristics, and behaviors at Wave 1 were tested using bivariate analysis, and the significant individual-level factors were then examined in a multivariable binary logistic regression model. The odds of being classified in the positive cycling pattern were lower for women [OR = 0.09; 95 % CI = 0.04---0.19], and higher for persons aged 30 - 39 [OR = 3.25; 95 % CI = 1.38---7.66], those who owned a bicycle [OR = 2.00; 95 % CI = 1.13---3.54], and those who engaged in ≥ 120 min/week of transport walking [OR = 2.07; 95 % CI = 1.24---3.47] or leisure-time physical activity [OR = 1.77; 95 % CI = 1.02---3.06]. Cycling interventions and promotion should target women, the mid-aged and involve facilitating bicycle access. Advocacy for physical activity interventions is needed to influence transport cycling.

Public Open Spaces and Leisure-Time Walking: A Longitudinal Study With Brazilian People in the COVID-19 Pandemic

AIM

To examine whether changes in public open spaces (POS) were associated with leisure-time walking (LTW) between 2014 and 2021.

METHODS

The sample comprised a prospective cohort of individuals living in São Paulo City, Brazil. The baseline sample was collected in 2014/2015 (4042 people aged 12 y or older) and the second wave in 2020/2021 (1431 people aged 18 y or older, 35.4% of total). Changes in POS scores in 500-m network buffers were based on household address, including positive or negative maintenance and increases or decreases in parks, public squares, and bike paths between 2015 and 2020. The International Physical Activity Questionnaire was used to evaluate LTW in the baseline and second wave. To examine the association of LTW with changes in POS, we used multilevel models in 4 levels: health administration areas, census tracts, individuals, and observations of individuals. The exposure was the POS tertiles, and the outcome was LTW.

RESULTS

Changes in LTW prevalence were observed in both periods and according to POS tertiles distributions. When adjusted for time (baseline/second wave), gender, education, and age, the highest POS tertile was significantly associated with a high likelihood for LTW (odds ratio = 1.44; 95% confidence interval, 1.03-2.02).

CONCLUSION

The results showed that people in São Paulo who lived within 500-m buffers with the highest access to POS were more likely to practice LTW between 2014/2015 and 2020/2021. These results have important implications for policies that were implemented in 2014, including the New Master Plan to contribute to São Paulo's good ranking among healthy cities.

Advancing urban green and blue space contributions to public health

Urban green and blue spaces (UGBS) have the potential to improve public health and wellbeing, address health inequities, and provide co-benefits for the environment, economy, and society. To achieve these ambitions, researchers should engage with communities, practitioners, and policy makers in a virtuous circle of research, policy, implementation, and active citizenship using the principles of co-design, co-implementation, co-evaluation, and co-translation. This Viewpoint provides an integrated perspective on the challenges that hinder the delivery of health-enhancing UGBS and recommendations to address them. Our recommendations include: strengthening the evidence beyond cross-sectional research designs, strengthening the evidence base on UGBS intervention approaches, evaluating the effects on diverse population groups and communities, addressing inequities in the distribution and quality of UGBS, accelerating research on blue space, providing evidence for environmental effects, incorporating co-design approaches, developing innovative modelling methods, fostering whole-system evidence, harnessing political drivers, creating collaborations for sustainable UGBS action, and advancing evidence in low-income and middle-income countries. The full potential of UGBS as public health, social, economic, and environmental assets is yet to be realised. Acting on the research and translation recommendations will aid in addressing these challenges in collaboration with research, policy, practice, and communities.

Effects of an urban cable car intervention on physical activity: the TrUST natural experiment in Bogotá, Colombia

BACKGROUND

Cable cars are part of the transport system in several cities in Latin America, but no evaluations of their effects on physical activity are available. TransMiCable is the first cable car in Bogotá, Colombia, and the wider intervention includes renovated parks and playgrounds. We assessed the effects of TransMiCable and the wider intervention on physical activity.

METHODS

The Urban Transformations and Health natural experiment was a prospective quasi-experimental study conducted from Feb 1, 2018, to Dec 18, 2018 (baseline, pre-intervention) and from July 2, 2019, to March 15, 2020 (post-intervention follow-up) in the TransMiCable intervention area (Ciudad Bolívar settlement) and a control area without TransMiCable (San Cristóbal settlement). A multistage strategy was used to sample households in each area, with one adult (aged ≥18 years) per household invited to participate. Eligible participants had lived in the intervention or control areas for at least 2 years and were not planning to move within the next 2 years. Physical activity was assessed among participants in the intervention and control areas before and after the inauguration of TransMiCable in Ciudad Bolívar with the International Physical Activity Questionnaire (long form) and with wearable accelerometers. Complete cases (those with baseline and follow-up data) were included in analyses. Respondents were classed as being physically active if they met 2020 WHO guidelines (≥150 min per week of moderate activity, ≥75 min per week of vigorous activity, or equivalent combinations); and accelerometery data were classified with the Freedson cut-points for adults. Data were also gathered in zonal parks (area ≥10 000 m2) and neighbourhood parks (area <10 000 m2) in the intervention and control areas by direct observation with the System for Observing Play and Recreation in Communities, to assess levels of physical activity before and after the TransMiCable intervention. Multilevel regression models were used to assess changes in physical activity associated with the TransMiCable intervention.

FINDINGS

Physical activity questionnaires were completed by 2052 adult participants (1289 [62·8%] women and 763 [37·2%] men; mean age 43·5 years [SD 17·7]) before the inauguration of TransMiCable. After the inauguration, the follow-up (final) questionnaire sample comprised 825 adults in the intervention group and 854 in the control group, including 357 adults in the intervention group and 334 in the control group with valid accelerometery data. 334 (40·5%) of 825 participants in the intervention group reported levels of physical activity that met the 2020 WHO guidelines during walking for transport before the intervention, and 426 (51·6%) afterwards (change 11·1 percentage points [95% CI 6·4 to 15·9]). A similar change was observed in the control group (change 8·0 percentage points [3·4 to 12·5]; adjusted odds ratio [OR] for the time-by-group interaction, intervention vs control group: 1·1 [95% CI 0·8 to 1·5], p=0·38). Time spent doing moderate-to-vigorous physical activity, measured with accelerometers, did not change in the intervention group after the inauguration of TransMiCable (change -0·8 min per day [-4·6 to 3·0]) and did not change compared with the control group (adjusted β for the time-by-group interaction: 1·4 min per day [95% CI -2·0 to 4·9], p=0·41). Moderate-to-vigorous physical activity was 52·1 min per day (SD 24·7) before and 59·4 min per day (35·2) after the inauguration of TransMiCable in new regular users who reported using TransMiCable during mandatory trips for work or education (n=32; change 7·3 min per day [-22·5 to 7·9]). After the intervention, an increase in the proportion of male individuals engaging in moderate or vigorous physical activity was observed in a renovated zonal park (adjusted OR for the time-by-group interaction, intervention vs control park: 2·7 [1·1 to 6·8], p=0·033). Female users of a renovated neighbourhood park were less likely to become engaged in moderate or vigorous physical activity than female users of the control area neighbourhood park (adjusted OR for the time-by-group interaction: 0·4 [0·1 to 0·6], p=0·019).

INTERPRETATION

It is encouraging that walking for transport remained high in the TransMiCable intervention area when the use of private motorised transport had increased elsewhere in Bogotá. In low-income urban areas, where transport-related walking is a necessity, transport interventions should be focused on efforts to maintain participation in active travel while improving conditions under which it occurs.

FUNDING

Wellcome Trust (as part of the Urban Health in Latin America project); Bogotá Urban Planning Department; Ministry of Science, Technology, and Innovation of Colombia; Universidad de Los Andes; Fundación Santa Fe de Bogotá; and Universidad del Norte.

TRANSLATION

For the Spanish translation of the abstract see Supplementary Materials section.

Built environment and schizophrenia re-hospitalization risk in China: A cohort study

BACKGROUND

Built environment exposure, characterized by ubiquity and changeability, has the potential to be the prospective target of public health policy. However, little research has been conducted to explore its impact on schizophrenia. This study aimed to investigate the association between built environmentand and schizophrenia rehospitalization by simultaneously considering substantial built environmental exposures.

METHODS

We recruited eligible schizophrenia patients from Hefei, Anhui Province, China between 2017 and 2019. The main outcome for this study was the time interval until the first recurrent hospital admission occurred within one year after discharge. For each included subject, we estimated the built environment exposures, including population density, walkability, land use mix, green and blue space, public transportation accessibility and road traffic indicator. Lasso (Least Absolute Shrinkage and Selection Operator) analysis was used to select the key variables. Multivariable Cox regression model was applied to obtain hazard ratio (HR) and its corresponding 95% confidence intervals (CI). Further, we also evaluated the joint effects of built environment characteristics on rehospitalization for schizophrenia by Quantile g-computation model.

RESULTS

A total of 1564 hospitalized schizophrenia patients were enrolled, with 347 patients (22.2%) had a rehospitalization within one-year after discharge. Multivariable Cox regression analysis indicated that the re-hospitalization rate for schizophrenia would be higher in areas with a high population density (HR: 1.10, 95%CI: 1.04-1.16). Nonetheless, compared to the reference (Q1), participants who lived in a neighborhood with the highest walkability and NDVI (Normalized Difference Vegetation Index) (Q4) had a 76% and 47% lower risk of re-hospitalization within one year (HR:0.24, 95%CI: 0.13-0.45; and 0.53, 95%CI:0.32-0.85), respectively. Moreover, quantile-based g-computation analyses revealed that increased walkability and green space significantly eliminated the adverse effects of population density increases on schizophrenia patients, with a HR ratio of 0.61 (95%CI:0.48,0.79) per one quartile change at the same time.

CONCLUSION

Our study provides scientific evidence for the significant role of built environment in schizophrenia rehospitalization, suggesting that optimizing the built environment is required in designing and building a healthy city.

What are the lessons from COVID-19 for creating healthy, sustainable, resilient future cities?

The COVID-19 pandemic has disrupted lives and the economy, reminding the global community of the devastating health and economic impacts of uncontrolled infectious disease. It has affected how and where people live, work, shop, and play, and exposed our cities' vulnerabilities, leading to calls for a health lens to be applied in designing, approving, and evaluating city plans. Socioeconomic, spatial and health inequities have been amplified, particularly for those living in inadequate or poorly designed housing, neighbourhoods, and cities. Hence, city mayors have committed to 'build back better' with all daily living amenities within a 15-min walking or cycling trip. Designed well, these cities have the potential to be healthier, more sustainable, equitable, and resilient. Yet their delivery requires a rethink of city planning. Drawing on lessons from the COVID-19 pandemic, we argue that to reduce the risk of future pandemics, we must mitigate climate change, limit urban expansion, and use nature-based solutions to protect natural habitats and biodiversity. We then explore how healthy, sustainable, and resilient 15-minute cities could be planned to reduce emissions and ensure our cities are more resilient in the event of future crises. Given that higher density housing underpins the success of 15-minute cities, we also examine how to create more resilient housing stock, through well-implemented health-supportive apartment design standards. Finally, we argue that to achieve all this, cross-sector leadership and investment will be vital.

Local government policy to facilitate healthy and sustainable diets and the broader policy hierarchy: insights from Milan Urban Food Policy Pact cities

BACKGROUND

Local government authorities are well positioned to change the way food is produced and consumed through the implementation of integrated food policies. By facilitating the uptake of healthy and sustainable diet-related practices, integrated local government food policy can trigger change throughout the food supply chain. This study aimed to provide insights as to how the policy hierarchy surrounding local governments may be influencing local government's capacity to create integrated food policy.

METHODS

Content analysis was conducted on local government food policies (n = 36) from signatory cities of the Milan Urban Food Policy Pact were mapped to seven global regions. A set of 13 predetermined healthy and sustainable diet-related practices, organized into three categories: "where to source food", "what to eat" and "how to eat", was used to assess the level of integration of each local government food policy. Additional policies from the broader policy hierarchy that were mentioned in each local government food policy were sourced and then screened for relevancy, charted according to their level of administration (local, national, global region, international) and analysed to consider which diet-related practice(s) each broader policy was likely to promote.

RESULTS

Analysis revealed three key insights: (i) local government food policies across all included global regions (n = 4) mostly promoted practices in the "where to source food" category, (ii) local government food policies across all global regions referred to policies from higher levels of administration (local, national, global region and international) which tended to also promote practices in the "where to source food" category and (iii) regarding the level of integration, local government food policies in Europe and Central Asia targeted the highest number of diet-related practices.

CONCLUSIONS

The level of integration of food policy at national, global region and international levels may be influencing that of local governments. Further research is required to understand why local government food policies are referring to some relevant policies and not others, and to determine whether a greater focus on the diet-related practices of "what to eat" and "how to eat" in policies from higher levels of government would support local governments to also prioritize these practices in their food policies.

Examining Place-Based Neighborhood Factors in a Multisite Peer-Led Healthy Lifestyle Effectiveness Trial for People with Serious Mental Illness

People with severe mental illness (SMI) experience significantly higher obesity-related comorbidities and premature mortality rates than healthy populations. The physical and social characteristics of neighborhoods where people with SMI reside can play an important role in promoting or hindering healthy eating and physical activity. However, this is seldom considered when designing and testing health behavior interventions for these populations. This study used baseline data from an obesity control trial for low-income, minority people with SMI to demonstrate the utility of assessing neighborhood- and city-level place-based factors within the context of lifestyle interventions. GIS was used to create a zip-code-level social and built environment geodatabase in New York City and Philadelphia, where the trial occurred. Chi-square and t-tests were used to assess differences in the spatial distribution of health-related built and social environment characteristics between and within cities and diet and physical activity outcomes. All types of neighborhood characteristics showed significant environmental differences between and within cities. Several neighborhood characteristics were associated with participants' baseline healthy eating and physical activity behaviors, emphasizing that place-based factors may moderate lifestyle interventions for SMI patients. Future behavioral interventions targeting place-dependent behaviors should be powered and designed to assess potential moderation by place-based factors.

Premature mortality attributable to NO2 exposure in cities and the role of built environment: A global analysis

BACKGROUND

Environmental risks accumulate in cities, including polluted air and health disparities, but these risks can be reduced through scientific city planning. The purpose of this study was to investigate the global burden of premature mortality attributable to NO₂ exposure in urban areas and the role of the built environment in this regard.

METHODS

An approach based on health impact assessment was used to estimate the premature mortality burdens associated with NO₂ exposure in 13,169 urban areas around the world using globally gridded NO₂ and population estimates, baseline mortality, and epidemiologically derived exposure-response functions. We used the most recent WHO recommended value (i.e.,10 μg/m³) as a counterfactual concentration. Finally, the relationship between the characteristics of the built environment at the city level and the burden of NO₂-related mortality was evaluated.

RESULTS

Worldwide, 549,715(95%CI: 276204-815,023) cases of death attributable to NO₂ exposure in urban areas could be prevented if compliance with the latest WHO guideline, accounting for 2.7 % (95%CI:1.4 %-4.0 %) of total mortalities in 2019. Across cities around the world, the age-standardized mortality rate (per 100,000 people) attributable to NO₂ exposure ranged from 51.3 (95%CI:25.8-76.0) in Central Asia to 3.4(95%CI: 1.7-5.1) in Oceania. Although there was a significant decrease in premature mortality attributable to NO₂ exposure globally, considerable regional heterogeneity exists, with cities in Central Asia and Andean Latin America in particular exhibiting an upward trend. Further, we discovered a positive association between population density and street connectivity with mortality attributable to NO₂. While the increase in green and blue space were significantly associated with a lower NO₂-associated mortality.

CONCLUSION

The findings of this study provided a comprehensive understanding of the premature mortality burden due to NO₂ in cities throughout the world and the role that urban planning policies can play in reducing the health burden associated with air pollution.

The Built Environment and Population Physical Activity: Methods for Mapping the Relevant Laws

BACKGROUND

The development of policies that promote and enable physical activity (PA) is a global health priority. Laws are an important policy instrument that can enable enduring beneficial outcomes for individuals, organizations, and environments through multiple mechanisms. This article presents a systematic process for mapping laws relevant to PA, which can be used to understand the role of laws as a powerful PA policy lever.

METHODS

Building on methods used in public health law research, we developed a protocol for scientific mapping of laws influencing the built environment for PA in Australia. The MonQcle online legal research platform was used for data coding, analysis, and presentation.

RESULTS

We describe the 10 key stages of legal mapping that we applied to examine state and territory laws that influence walking and cycling in Australia.

CONCLUSIONS

Law is a neglected element of policy research for PA. There is a need for accessible legal data to drive the design, investment, and implementation of legal interventions to improve population PA. Legal mapping is a first step toward evaluation of such laws for PA. This paper provides a practical case study and guidance for the 10 stages in legal mapping of laws that influence the built environment for PA.

Street Experiments and COVID-19: Challenges, Responses and Systemic Change

Cities have introduced street experiments, among others, in order to cope with the urgent health challenges caused by the COVID-19 pandemic. They are primarily intended to allow people to move safely in urban spaces according to physical distancing requirements. It has been suggested that street experiments have the potential to not only respond to pressing needs, but to also trigger systemic change in mobility. This paper explores urban case studies and demonstrates how pandemic-induced street experiments provide a solution to specific challenges to mobility and public space. There are, however, issues concerning equity and citizen participation. Finally, we find that pandemic-induced street experiments have a higher acceptance among the public and authorities, a more permanent character and a greater embeddedness in long-term planning agendas. The paper concludes that the pandemic stimulated the introduction of street experiments and fostered their potential to enable systemic change in urban mobility.

Mapping and analysis of laws influencing built environments for walking and cycling in Australia

BACKGROUND

Physical inactivity is a significant public health concern, with limited signs of improvement despite a global commitment to achieving the World Health Organization's target of 15% reduction by 2030. A systems approach is required to tackle this issue, involving the creation of environments that are conducive to physical activity. Laws represent an important tool for regulating the built environment for physical activity, are a mechanism for systems change, and have the capacity to reorient the goals and rules of a system. However, they are understudied and potentially underutilised for physical activity. Scientific legal mapping is a first step towards understanding how laws could impact the built environment to facilitate greater population physical activity.

METHOD

We conducted a legal assessment of state and territory laws in Australia, to systematically characterise how they address built environment considerations with specific relevance to walking and cycling. An interdisciplinary team of researchers with public health, law and urban planning expertise was formed to complete the multistage process. Key steps included a systematic search of laws using a combination of original legal research, consultation of secondary sources, and review and verification by an urban planning expert; development of a coding scheme; and completion of coding and quality control procedures.

RESULTS

Most jurisdictions in Australia do not currently embed objectives in primary legislation that would promote physical activity and support an integrated approach to land use and transport planning that encourages active and sustainable lifestyles. Only two jurisdictions addressed the large majority of evidence-based standards that promote active living. Of the standards addressed in law, few fully met evidence-based recommendations. While most jurisdictions legislated responsibility for enforcement of planning law, few legislated obligations for monitoring implementation.

CONCLUSION

Increasing physical activity is a systems issue, requiring actions across multiple sectors. An in-depth examination of the legal environment is an important step towards understanding and influencing the existing physical activity system, why it may not be generating desired outcomes, and potential opportunities for improvement. Our findings reveal opportunities where laws could be strengthened to promote more active environments. Updating this dataset periodically will generate longitudinal data that could be used to evaluate the impact of these laws on the built environment and physical activity behaviours.

An analytical model for spatial developing of sports places and spaces

Purpose

In terms of the use of sports places and spaces, per capita is a determining parameter for the status and perspective of the future. Although there are many uses for the per capita indicator in sports places, there are no consistent scientific and methodological methods for calculating it. Therefore, this study aims to provide an analytical model to determine the per capita index of sports places and spaces.

Design/methodology/approach

One of the matters that can be considered as the basic information required to develop and construct sports facilities is determination of per capita, which can be used as the most vital information to plan and develop this type of urban utilities. In the history of contemporary urbanization, the use of the per capita concept is one of Reinhard Laumeister’s innovations, a founder of modern urban engineering in Germany, hence, the use of per capita was triggered in 1876, almost 133 years ago.

Findings

The underlying information of the research in two spatial and descriptive sections was analyzed in the geographic information systems (GIS) software. After the division and network distribution of the boundary by the Thiessen Networks analytic function in the Arc GIS, per capita of each polygon was separately calculated using the presented formula and the population of the related blocks

Originality/value

Finally, with the qualitative per capita achieved in the previous stage, the study area was classified based on the need for the development of indoor pools to three, privileged, semi-privileged and deprived spectrums.

How Does Community-Based Housing Foster Social Participation in Older Adults: Importance of Well-Designed Common Space, Proximity to Resources, Flexible Rules and Policies, and Benevolent Communities

As supporting active and healthy aging calls for different community-based housing alternatives, integrated knowledge of their impacts on older adults' social participation is required. This study aimed to explore how community-based housing fostered social participation in older adults. A scoping review was used to systematically identify relevant studies according to 32 keywords in 8 electronic databases. Published during 2000-2021, the 46 studies were carried out in North America, Europe, Oceania, and Asia, documenting older adults' social participation in six community-based housing models. Targeting different clienteles, these models mainly promote older adults' social participation by providing: 1) accessible common space in a design favorable to social interactions; 2) proximity to resources; 3) flexible rules and policies that facilitate residents' interactions with not only co-residents but community neighbors; and 4) benevolent communities. These results highlight the interactions between the physical and social environments; they suggest the importance of building benevolent communities as well as of sharing resources among residences and local communities to create a supportive living and neighborhood environment for active and healthy aging. Future studies should further explore the role of different stakeholders in developing benevolent communities by considering the dynamics between the person and the environment.

Patterns of Physical Activity and Sedentary Behavior During the COVID-19 Pandemic in the Thai 2021 National Health Survey

BACKGROUND

Understanding patterns of physical activity and sedentary behavior is essential, but evidence from low- and middle-income countries remains limited. This study aimed to investigate the prevalence of physical activity and sedentary behavior in the Thai population; their sociodemographic correlates; and the contribution of specific domains to total physical activity.

METHODS

We analyzed data from the 2021 Health Behavior Survey, a nationally representative survey, conducted by the Thailand National Statistical Office during the COVID-19 pandemic. Physical activity and sedentary behavior were assessed using the Global Physical Activity Questionnaire. "Sufficiently active" was defined according to the World Health Organization guidelines. "Highly sedentary" was defined as sitting ≥7 hours per day. The contribution of work, transport, and recreational physical activity was determined as the proportion of total physical activity. Multivariable logistic regression was conducted to determine the correlates of being sufficiently active and being highly sedentary.

RESULTS

Of the total study population (N = 78,717), 71.9% were sufficiently active, whereas 75.8% were highly sedentary. Females, having a labor-intensive work, and living in Bangkok had a higher likelihood of being sufficiently active. Those with higher education and income levels, and living in Bangkok and the Central region had a greater likelihood of being highly sedentary. The work domain contributed the highest proportion toward physical activity (82.1%), followed by the recreation (10.0%) and transport domains (7.9%).

CONCLUSIONS

Policies should focus on promoting transport and recreational physical activity and activity that can break up sedentary behavior among adults because when countries become technologically advanced, physical activity at work declines.

Determining thresholds for spatial urban design and transport features that support walking to create healthy and sustainable cities: findings from the IPEN Adult study

An essential characteristic of a healthy and sustainable city is a physically active population. Effective policies for healthy and sustainable cities require evidence-informed quantitative targets. We aimed to identify the minimum thresholds for urban design and transport features associated with two physical activity criteria: at least 80% probability of engaging in any walking for transport and WHO's target of at least 15% relative reduction in insufficient physical activity through walking. The International Physical Activity and the Environment Network Adult (known as IPEN) study (N=11 615; 14 cities across ten countries) provided data on local urban design and transport features linked to walking. Associations of these features with the probability of engaging in any walking for transport and sufficient physical activity (≥150 min/week) by walking were estimated, and thresholds associated with the physical activity criteria were determined. Curvilinear associations of population, street intersection, and public transport densities with walking were found. Neighbourhoods exceeding around 5700 people per km², 100 intersections per km², and 25 public transport stops per km² were associated with meeting one or both physical activity criteria. Shorter distances to the nearest park were associated with more physical activity. We use the results to suggest specific target values for each feature as benchmarks for progression towards creating healthy and sustainable cities.

Using open data and open-source software to develop spatial indicators of urban design and transport features for achieving healthy and sustainable cities

Benchmarking and monitoring of urban design and transport features is crucial to achieving local and international health and sustainability goals. However, most urban indicator frameworks use coarse spatial scales that either only allow between-city comparisons, or require expensive, technical, local spatial analyses for within-city comparisons. This study developed a reusable, open-source urban indicator computational framework using open data to enable consistent local and global comparative analyses. We show this framework by calculating spatial indicators-for 25 diverse cities in 19 countries-of urban design and transport features that support health and sustainability. We link these indicators to cities' policy contexts, and identify populations living above and below critical thresholds for physical activity through walking. Efforts to broaden participation in crowdsourcing data and to calculate globally consistent indicators are essential for planning evidence-informed urban interventions, monitoring policy effects, and learning lessons from peer cities to achieve health, equity, and sustainability goals.

What next? Expanding our view of city planning and global health, and implementing and monitoring evidence-informed policy

This Series on urban design, transport, and health aimed to facilitate development of a global system of health-related policy and spatial indicators to assess achievements and deficiencies in urban and transport policies and features. This final paper in the Series summarises key findings, considers what to do next, and outlines urgent key actions. Our study of 25 cities in 19 countries found that, despite many well intentioned policies, few cities had measurable standards and policy targets to achieve healthy and sustainable cities. Available standards and targets were often insufficient to promote health and wellbeing, and health-supportive urban design and transport features were often inadequate or inequitably distributed. City planning decisions affect human and planetary health and amplify city vulnerabilities, as the COVID-19 pandemic has highlighted. Hence, we offer an expanded framework of pathways through which city planning affects health, incorporating 11 integrated urban system policies and 11 integrated urban and transport interventions addressing current and emerging issues. Our call to action recommends widespread uptake and further development of our methods and open-source tools to create upstream policy and spatial indicators to benchmark and track progress; unmask spatial inequities; inform interventions and investments; and accelerate transitions to net zero, healthy, and sustainable cities.