Health impact modelling of active travel visions for England and Wales using an Integrated Transport and Health Impact Modelling Tool (ITHIM)

An Analysis of the Health Effects of Physical Activity due to Active Travel Policies in Rennes, France

Background

Rennes, a midsize city in France, features many opportunities for active travel. City officials seek to increase walking and cycling by 2030 to improve public health. Physical inactivity, a leading risk factor for premature mortality around the globe, has been shown to be associated with many chronic diseases including heart disease, type 2 diabetes, and cancer.

Methods

Using the 2018 household travel survey of Rennes residents, we apply the Health-Oriented Transportation statistical model to assess health impacts associated with population-level rates of walking and cycling. We consider two proposed mobility and climate objectives which outline sustainable transportation goals by 2030. These include a shift in transportation mode share to increase walking and cycling trips, as well as a broad reduction in vehicle miles traveled (VMT) across the metropolitan area.

Results

Our regression analysis demonstrated that factors of household car access and inner-city residency were predictors of prevalence (observed one-day proportion engaging in walking or cycling), participation (weekly proportion), and intensity (mean individual physical activity achieved through walking/cycling) of active travel. Age and education were additionally associated with prevalence. The 2030 mobility objective (mode share: 9% cycle, 35% walk) was associated with a reduction of 1,051 DALYs (disability-adjusted life-years), translating to $73 million USD ($23-$177) in averted costs. The climate objective (10% reduction in VMT) was associated with a reduction of 369 DALYs when replaced entirely by walking and 714 DALYs with cycling, translating to $26 million ($8-$62) and $50 million ($15-$121) saved, respectively.

Conclusions

Rennes residents experience high participation in active travel, particularly those in the inner city. If residents achieve the city's active travel goals for 2030, there is potential for a large reduction in health burden and subsequent costs. Reaching these goals may require significant investment in transportation programming and infrastructure to improve active travel opportunities.

The untapped health and climate potential of cycling in France: a national assessment from individual travel data

Background

Promoting active modes of transportation such as cycling may generate important public health, economic, and climate mitigation benefits. We aim to assess the mortality and morbidity impacts of cycling in a country with relatively low levels of cycling, France, along with associated monetary benefits. We further assess the potential additional benefits of shifting a portion of short trips from cars to bikes, including projected greenhouse gas emissions savings.

Methods

Using individual data from a nationally representative mobility survey, we described the French 2019 cycling levels by age and sex. We conducted a burden of disease analysis to assess the incidence of five chronic diseases (breast cancer, colon cancer, cardiovascular diseases, dementia, and type-2 diabetes) and the number of deaths prevented by cycling, based on national incidence and mortality data and dose-response relationships from meta-analyses. We assessed the corresponding direct medical cost savings and the intangible costs prevented based on the value of a statistical life year. Lastly, based on individual simulations, we assessed the likely additional benefits of shifting 25% of short (<5 km) car trips to cycling.

Findings

The French adult (20-89 years) population was estimated to cycle on average 1 min 17 sec pers-1 day-1 in 2019, with important heterogeneity across sex and age. This yielded benefits of 1,919 (uncertainty interval, UI: 1,101-2,736) premature deaths and 5,963 (UI: 3,178-8,749) chronic disease cases prevented, with males reaping nearly 75% of these benefits. Direct medical costs prevented were estimated at €191 million (UI: 98-285) annually, while the corresponding intangible costs were nearly 25 times higher (€4.8 billion, UI: 3.0-6.5). We estimated that on average, €1.02 (UI: 0.59-1.62) of intangible costs were prevented for every km cycled. Shifting 25% of short car trips to cycling would yield approximatively a 2-fold increase in deaths prevented, while also generating important CO2 emissions reductions (0.257 MtCO2e, UI: 0.231-0.288).

Interpretation

In a country with a low- to moderate-cycling culture, cycling already generates important public health and health-related economic benefits. Further development of active transportation would increase these benefits while also contributing to climate change mitigation targets.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Benefits, risks, barriers, and facilitators to cycling: a narrative review

There is large potential to increase cycling participation worldwide. Participation in cycling is associated with lower risk of mortality from any cause, and incidence of cardiovascular disease and type 2 diabetes, as well as positive mental health and well-being. The largest potential for health gains likely to come from increasing participation amongst those who do not currently cycle regularly, rather than encouraging those who already cycle regularly to cycle more. Replacing car journeys with cycling can lead to reductions in air pollution emissions and lower pollutant exposure to the general population. Important gaps and uncertainties in the existing evidence base include: the extent to which the health benefits associated with cycling participation are fully causal due to the observational nature of much of the existing evidence base; the real-world economic cost-benefits of pragmatic interventions to increase cycling participation; and the most effective (combination of) approaches to increase cycling participation. To address these uncertainties, large-scale, long-term randomised controlled trials are needed to: evaluate the effectiveness, and cost-effectiveness, of (combinations of) intervention approaches to induce sustained long-term increases in cycling participation in terms of increases in numbers of people cycling regularly and number of cycling journeys undertaken, across a range of population demographic groups; establish the effects of such interventions on relevant outcomes related to health and wellbeing, economic productivity and wider societal impacts; and provide more robust quantification of potential harms of increasing cycling participation, such as collision risks.

The Health Economic Assessment Tool (HEAT) for walking and cycling - experiences from 10 years of application of a health impact assessment tool in policy and practice

Introduction

In recent years, walking and cycling have moved into the focus as promising approaches to achieve public health, sustainable transport, climate goals and better urban resilience. However, they are only realistic transport and activity options for a large proportion of the population when they are safe, inclusive and convenient. One way to increase their recognition in transport policy is the inclusion of health impacts of walking and cycling into transport economic appraisals.

Methods

The Health Economic Assessment Tool (HEAT) for walking and cycling calculates: if x people walk or cycle a distance of y on most days, what is the economic value of impacts on premature mortality, taking into account effects of physical activity, air pollution and road fatalities, as well as effects on carbon emissions. Different data sources were collated to examine how the HEAT in more than 10 years of existence, and to identify lessons learned and challenges.

Results

Since its launch in 2009, the HEAT has gained wide recognition as a user friendly, yet robust, evidence-based tool usable by academics, policymakers, and practitioners. Originally designed for use in Europe, it has since been expanded for global use.

Discussion

Challenges for a wider uptake of health-impact assessment (HIA) tools including active transport such as HEAT are the promotion and dissemination to local practitioners and policy makers also outside European and English-speaking regions and in low- and middle-income contexts, further increasing usability, and more generally the advancement of systematic data collection and impact quantification related to walking and cycling.

Validating the Perceived Active School Travel Enablers and Barriers-Parent (PASTEB-P) Questionnaire to Support Intervention Programming and Research

A child's ability to participate in active school travel (AST) is complicated by several factors. Of particular note are parental controls, which are informed by their perceptions of the local built and social environments, assessments of their child's skills, and convenience preferences, among other considerations. However, there is currently a lack of AST-specific scales that include validated parental perception measures related to such notable barriers and enablers, or those that tend to frame their AST decision-making processes. Framed within the social-ecological model of health behaviour, the aims of the present paper were thus threefold, specifically to (1) outline and test the construct validity of measures delineating parental perceptions of barriers and enablers to AST, (2) evaluate the reliability and consistency of the developed measures, and (3) connect these measures to develop broader constructs for use in the Perceived Active School Travel Enablers and Barriers-Parent (PASTEB-P) questionnaire. To achieve these aims, a mixed-methods approach featuring cognitive interviews and surveys, along with qualitative (thematic analysis) and quantitative (Cohen's Kappa, McDonald's Omega, and confirmatory factor analysis) analyses, was applied across two studies. The validation processes of the two studies resulted in the development of fifteen items comprising seven distinct constructs (barriers: AST Skills, Convenience, Road Safety, Social Safety, and Equipment Storage; enablers: Supportive Environment and Safe Environment) related to parental perceptions of AST. The developed PASTEB-P questionnaire can be used to inform and evaluate AST intervention programming and can be applied for AST research purposes.

Walkability and urban built environments-a systematic review of health impact assessments (HIA)

BACKGROUND

Urban environments are important determinants of human health. The term walkability summarizes features of the urban built environment that promote walking and other types of physical activity. While the beneficial effects of active and public transport have been well established, the health impact of other features of walkability are less well documented.

METHODS

We conducted a systematic review of health impact assessments (HIAs) of walkability. Studies were identified through PUBMED and Science Direct, from two German websites related to urban health and reference tracking. Finally, 40 studies were included in the present review. We applied qualitative thematic analysis to summarize the major results from these studies.

RESULTS

Most of the HIAs (n = 31) reported the improvement of health or health behaviour resulting from an investigated project or policy. However, three HIAs reported a lack of improvement or even a decrease of health status. In parallel, 13 HIAs reported a gain in economic value, whereas one reported a lack or loss of economic effects. Moreover, three HIAs reported on social effects and six HIAs gave additional recommendations for policies or the implementation of projects or HIAs.

CONCLUSIONS

Most HIAs investigate the impact of increasing active or public transport. Other features of walkability are less well studied. With few exceptions, HIAs document beneficial impacts of improving walkability on a variety of health outcomes, including reductions of mortality and non-communicable diseases.

Impact on mortality of pathways to net zero greenhouse gas emissions in England and Wales: a multisectoral modelling study

BACKGROUND

The UK is legally committed to reduce its greenhouse gas emissions to net zero by 2050. We aimed to understand the potential impact on population health of two pathways for achieving this target through the integrated effects of six actions in four sectors.

METHODS

In this multisectoral modelling study we assessed the impact on population health in England and Wales of six policy actions relating to electricity generation, transport, home energy, active travel, and diets relative to a baseline scenario in which climate actions, exposures, and behaviours were held constant at 2020 levels under two scenarios: the UK Climate Change Committee's Balanced Pathway of technological and behavioural measures; and its Widespread Engagement Pathway, which assumes more substantial changes to consumer behaviours. We quantified the impacts of each policy action on mortality using a life table comprising all exposures, behaviours, and health outcomes in a single model.

FINDINGS

Both scenarios are predicted to result in substantial reductions in mortality by 2050. The Widespread Engagement Pathway achieves a slightly greater reduction in outdoor fine particulate matter air pollution of 3·2 μg/m3 (33%) and, under assumptions of appropriate ventilation, a greater improvement in indoor air pollution (a decrease in indoor-generated fine particulate matter from 9·4 μg/m3 to 4·6 μg/m3) and winter temperatures (increasing from 17·8°C to 18·1°C), as well as appreciably greater changes in levels of active travel (27% increase in metabolic equivalent hours per week of walking and cycling) by 2050. Additionally, the greater reduction in red meat consumption (50% compared with 35% under the Balanced Pathway) by 2050 results in greater consumption of fruits (17-18 g/day), vegetables (22-23 g/day), and legumes (5-7 g/day). Combined actions under the Balanced Pathway result in more than 2 million cumulative life-years gained over 2021-50; the estimated gain under the Widespread Engagement Pathway is greater, corresponding to nearly 2·5 million life-years gained by 2050 and 13·7 million life-years gained by 2100.

INTERPRETATION

Reaching net zero greenhouse gas emissions is likely to lead to substantial benefits for public health in England and Wales, with the cumulative net benefits being correspondingly greater with a pathway that entails faster and more ambitious changes, especially in physical activity and diets.

FUNDING

National Institute for Health Research and the Wellcome Trust.

A theory-based model of cumulative activity

Energy expenditure can be used to examine the health of individuals and the impact of environmental factors on physical activity. One of the more common ways to quantify energy expenditure is to process accelerometer data into some unit of measurement for this expenditure, such as Actigraph activity counts, and bin those measures into physical activity levels. However, accepted thresholds can vary between demographics, and some units of energy measurements do not currently have agreed upon thresholds. We present an approach which computes unique thresholds for each individual, using piecewise exponential functions to model the characteristics of their overall physical activity patterns corresponding to well established sedentary, light, moderate and vigorous activity levels from the literature. Models are fit using existing piecewise fitting techniques and software. Most participants’ activity intensity profile is exceptionally well modeled as piecewise exponential decay. Using this model, we find emergent groupings of participant behavior and categorize individuals into non-vigorous, consistent, moderately active, or extremely active activity intensity profiles. In the supplemental materials, we demonstrate that the parameters of the model correlate with demographics of age, household size, and level of education, inform behavior change under COVID lockdown, and are reasonably robust to signal frequency.

Disparities in Activity and Traffic Fatalities by Race/Ethnicity

INTRODUCTION

Traffic fatalities remain a major public health challenge despite progress made during recent decades. This study develops exposure-based estimates of fatalities per mile traveled for pedestrians, cyclists, and light-duty vehicle occupants and describes disparities by race/ethnicity, including a subanalysis of fatality rates during darkness and in urban areas.

METHODS

Estimates of person-miles traveled by mode and race/ethnicity group were derived from the 2017 National Household Travel Survey using replicate weights. Three-year average (2016‒2018) traffic fatalities were measured by mode and race/ethnicity group with the U.S. Fatality Analysis Reporting System. Fatality rates per mile traveled and CIs were calculated for each subgroup as well as separately for trips occurring during darkness and in urban areas. Analysis was conducted in 2021‒2022.

RESULTS

Exposure to traffic fatality differs by race/ethnicity group and by mode, indicating that adjustment for differential exposure is needed when estimating disparities. The authors find that fatality rates per 100 million miles traveled are systematically higher for Black and Hispanic Americans for all modes and notably higher for vulnerable modes (e.g., Black Americans died at more than 4 times the rate for White Americans while cycling, 33.71 [95% CI: 21.84, 73.83] compared with 7.53 [95% CI: 6.64, 8.69], and more than 2 times the rate while walking, 40.92 [95% CI: 36.58, 46.44] compared with 18.77 [95% CI: 17.30, 20.51]). Previous estimates that do not adjust for differential exposure may underestimate disparities by race/ethnicity. Observed disparities remained when considering only urban areas and appear to be exacerbated during darkness.

CONCLUSIONS

Traffic fatalities are a substantial and preventable public health challenge in America. Black and Hispanic Americans have higher traffic fatality rates per mile traveled than White Americans across the transportation system, requiring urgent attention.

Health benefits from cleaner vehicles and increased active transportation in Seattle, Washington

BACKGROUND

Climate mitigation policies that focus on the transportation sector yield near-term health co-benefits that could motivate policy action.

OBJECTIVE

We quantified CO₂ emission reductions as well as the air pollution and health benefits of urban transportation policies promoting electric vehicles (EV) and walking and bicycling in Seattle, Washington.

METHODS

We compared a business-as-usual scenario projected to 2035 with intervention scenarios in which 35% of gasoline vehicles were switched to EV, and 50% of car trips less than 8 kilometers were replaced by walking or bicycling. We modeled changes in primary traffic-generated oxides of nitrogen (NO_x) and fine particulate matter (PM_2.5) as well as walking and bicycling activity, CO₂ emissions from traffic, and fatal traffic injuries due to the transportation policy scenarios. We estimated the impacts of these changes on annual cases of asthma and premature mortality in the Seattle population.

RESULTS

Increasing the use of EV, walking, and bicycling is estimated to reduce CO₂ emissions by 744 tons/year (30%) and lower annual average concentrations of primary traffic-generated NO_x and PM_2.5 by 0.32 ppb (13%) and 0.08 μg/m³ (19%), respectively. In Seattle, the lower air pollutant concentrations, greater active transportation, and lower fatal traffic injuries would prevent 13 (95% CI: -1, 28), 49 (95% CI: 19, 71), and 5 (95% CI: 0, 14) premature deaths per year, respectively and 20 (95% CI: 8, 27) cases of asthma per year.

SIGNIFICANCE

Moving towards cleaner vehicles and active transportation can reduce CO₂ emissions, improve air quality, and population health. The resulting public health benefits provide important motivation for urban climate action plans.

IMPACT STATEMENT

Using key components of the health impact assessment framework, we quantify the environmental and health benefits of urban transportation policy scenarios that promote electric vehicle use and replace short car trips with walking and bicycling as compared with a business as usual scenario in 2035. Our findings demonstrate that transportation scenarios promoting cleaner vehicles and active transportation can reduce CO₂ emissions, improve air quality, and increase physical activity levels, resulting in significant public health benefits.

A comparison of the World Health Organisation's HEAT model results using a non-linear physical activity dose response function with results from the existing tool

Introduction: The WHO-Europe’s Health Economic Assessment Tool is a tool used to estimate the costs and benefits of changes in walking and cycling. Due to data limitations the tool’s physical activity module assumes a linear dose response relationship be-tween physical activity and mortality. Methods: This study estimates baseline population physical activity distributions for 44 countries included in the HEAT. It then compares, for three different scenarios, the results generated by the current method, using a linear dose-response relationship, with results generated using a non-linear dose-response relationship. Results: The study finds that estimated deaths averted are relatively higher (lower) using the non-linear effect in countries with less (more) active populations. This difference is largest for interventions which affect the activity levels of the least active the most. Since more active populations, e.g. in Eastern Europe, also tend to have lower Value of a Statistical Life estimates the net monetary benefit estimated by the scenarios are much higher in western-Europe than eastern-Europe. Conclusions: Using a non-linear dose response function results in materially different estimates where populations are particularly inactive or particularly active. Estimating base-line distributions is possible with limited additional data requirements, although the method has yet to be validated. Given the significant role of the physical activity module within the HEAT tool it is likely that in the evaluation of many interventions the monetary benefit estimates will be sensitive to the choice of the physical activity dose response function.

Barriers and Enablers for Integrating Public Health Cobenefits in Urban Climate Policy

Urban climate policy offers a significant opportunity to promote improved public health. The evidence around climate and health cobenefits is growing but has yet to translate into widespread integrated policies. This article presents two systematic reviews: first, looking at quantified cobenefits of urban climate policies, where transportation, land use, and buildings emerge as the most studied sectors; and second, looking at review papers exploring the barriers and enablers for integrating these health cobenefits into urban policies. The latter reveals wide agreement concerning the need to improve the evidence base for cobenefits and consensus about the need for greater political will and leadership on this issue. Systems thinking may offer a way forward to help embrace complexity and integrate health cobenefits into decision making. Knowledge coproduction to bring stakeholders together and advance policy-relevant research for urban health will also be required. Action is needed to bring these two important policy agendas together.

A guide to value of information methods for prioritising research in health impact modelling

Health impact simulation models are used to predict how a proposed policy or scenario will affect population health outcomes. These models represent the typically-complex systems that describe how the scenarios affect exposures to risk factors for disease or injury (e.g. air pollution or physical inactivity), and how these risk factors are related to measures of population health (e.g. expected survival). These models are informed by multiple sources of data, and are subject to multiple sources of uncertainty. We want to describe which sources of uncertainty contribute most to uncertainty about the estimate or decision arising from the model. Furthermore, we want to decide where further research should be focused to obtain further data to reduce this uncertainty, and what form that research might take. This article presents a tutorial in the use of Value of Information methods for uncertainty analysis and research prioritisation in health impact simulation models. These methods are based on Bayesian decision-theoretic principles, and quantify the expected benefits from further information of different kinds. The expected value of partial perfect information about a parameter measures sensitivity of a decision or estimate to uncertainty about that parameter. The expected value of sample information represents the expected benefit from a specific proposed study to get better information about the parameter. The methods are applicable both to situationswhere the model is used to make a decision between alternative policies, and situations where the model is simply used to estimate a quantity (such as expected gains in survival under a scenario). This paper explains how to calculate and interpret the expected value of information in the context of a simple model describing the health impacts of air pollution from motorised transport. We provide a general-purpose R package and full code to reproduce the example analyses.

Health impacts of changes in travel patterns in Greater Accra Metropolitan Area, Ghana

BACKGROUND

Health impact assessments of alternative travel patterns are urgently needed to inform transport and urban planning in African cities, but none exists so far.

OBJECTIVE

To quantify the health impacts of changes in travel patterns in the Greater Accra Metropolitan Area, Ghana.

METHODS

We estimated changes to population exposures to physical activity, air pollution, and road traffic fatality risk and consequent health burden (deaths and years of life lost prematurely - YLL) in response to changes in transportation patterns. Five scenarios were defined in collaboration with international and local partners and stakeholders to reflect potential local policy actions.

RESULTS

Swapping bus and walking trips for car trips can lead to more than 400 extra deaths and 20,500 YLL per year than travel patterns observed in 2009. If part of the rise in motorisation is from motorcycles, we estimated an additional nearly 370 deaths and over 18,500 YLL per year. Mitigating the rise in motorisation by swapping long trips by car or taxi to bus trips is the most beneficial for health, averting more than 600 premature deaths and over 31,500 YLL per year. Without significant improvements in road safety, reduction of short motorised trips in favour of cycling and walking had no significant net health benefits as non-communicable diseases deaths and YLL benefits were offset by increases in road traffic deaths. In all scenarios, road traffic fatalities were the largest contributor to changes in deaths and YLL.

CONCLUSIONS

Rising motorisation, particularly from motorcycles, can cause significant increase in health burden in the Greater Accra Metropolitan Area. Mitigating rising motorisation by improving public transport would benefit population health. Tackling road injury risk to ensure safe walking and cycling is a top priority. In the short term, this will save lives from injury. Longer term it will help halt the likely fall in physical activity.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Health, environmental and distributional impacts of cycling uptake: The model underlying the Propensity to Cycle tool for England and Wales

INTRODUCTION

The Propensity to Cycle Tool (PCT) is a widely used free, open source and publicly available tool for modelling cycling uptake and corresponding health and carbon impacts in England and Wales. In this paper we present the methods for our new individual-level modelling representing all commuters in England and Wales.

METHODS

Scenario commuter cycling potential in the PCT is modelled as a function of route distance and hilliness between home and work. Our new individual-level approach has allowed us to create an additional "Near Market" scenario where age, gender, ethnicity, car ownership and area level deprivation also affect an individual's likelihood of switching to cycling. For this and other scenarios, we calculate the carbon benefits of cycling uptake based on the trip distance and previous mode, while health benefits are additionally affected by hilliness and baseline average mortality risk. This allows the estimation of how health and carbon benefits differ by demographic group as well as by scenario.

RESULTS

While cycle commuting in England and Wales is demographically skewed towards men and white people, women and people from ethnic minorities have greater cycling potential based on route distance and hilliness. Benefits from cycling uptake are distributed differently again. For example, while increasing female cycling mode share is good for equity, each additional female cyclist generates a smaller average health and carbon benefit than a male cyclist. This is based on women's lower baseline mortality risk, shorter commute travel distances, and lower propensity to commute by car than men.

CONCLUSION

We have demonstrated a new approach to modelling that allows for more sophisticated and nuanced assessment of cycling uptake and subsequent benefits, under different scenarios. Health and carbon are increasingly incorporated into appraisal of active travel schemes, valuing important outcomes. However, especially with better representation of demographic factors, this can act as a barrier to equity goals.

Crisis care: tackling the climate and ecological emergency

The climate crisis is a health crisis; it demands the urgent attention and action of healthcare professionals and organisations. In this issue of the BJPsych Bulletin, we consider what the destructive effects of the climate and ecological crisis entail for the mental health of populations, and what the response of psychiatrists, both individual and collective, must be. We also highlight the opportunities and benefits a more sustainable and preventative approach could offer individuals, communities and the planet.

Forecasting Diabetes Cases Prevented and Cost Savings Associated with Population Increases of Walking in the Greater Toronto and Hamilton Area, Canada

Promoting adequate levels of physical activity in the population is important for diabetes prevention. However, the scale needed to achieve tangible population benefits is unclear. We aimed to estimate the public health impact of increases in walking as a means of diabetes prevention and health care cost savings attributable to diabetes. We applied the validated Diabetes Population Risk Tool (DPoRT) to the 2015/16 Canadian Community Health Survey for adults aged 18–64, living in the Greater Toronto and Hamilton area, Ontario, Canada. DPoRT was used to generate three population-level scenarios involving increases in walking among individuals with low physical activity levels, low daily step counts and high dependency on non-active forms of travel, compared to a baseline scenario (no change in walking rates). We estimated number of diabetes cases prevented and health care costs saved in each scenario compared with the baseline. Each of the three scenarios predicted a considerable reduction in diabetes and related health care cost savings. In order of impact, the largest population benefits were predicted from targeting populations with low physical activity levels, low daily step counts, and non active transport use. Population increases of walking by 25 min each week was predicted to prevent up to 10.4 thousand diabetes cases and generate CAD 74.4 million in health care cost savings in 10 years. Diabetes reductions and cost savings were projected to be higher if increases of 150 min of walking per week could be achieved at the population-level (up to 54.3 thousand diabetes cases prevented and CAD 386.9 million in health care cost savings). Policy, programming, and community designs that achieve modest increases in population walking could translate to meaningful reductions in the diabetes burden and cost savings to the health care system.

Speeding in the city of Xalapa, Mexico: Prevalence and associated factors

OBJECTIVE

To estimate the prevalence of speeding in the city of Xalapa, Veracruz, in Mexico and to identify factors potentially associated to this risk behavior.

METHODS

A cross-sectional study was conducted on December 2019 in Xalapa, Veracruz. Speed measurement was conducted in a random sample of 10% of all the main roads in the urban area (n = 12). Observations were conducted over the course of one week at different times spending no more than 1.5 h in each site at a time. All vehicles circulating in each observation site during the data collection were included in the sample. Characteristics of drivers, vehicles and the environment were also collected and analyzed, using logistic regression analysis and a multiple ordinal regression model to identify factors associated to speeding and more serious violations of speed limits.

RESULTS

Average speed of the 3,390 vehicles observed was 50.97 km/h. Prevalence of speeding was 65.66% (95%-CI: 64.04-67.26%); 26.96% (95%-CI: 25.47-28.49) exceeded the speed limit by 50%. Speeding and more serious violations of speed limits were more frequent in light vehicles, residential zones and during weekends. More serious violations of speed limits were also more frequent on smaller roads, where speed limit were lower and during morning hours.

CONCLUSIONS

The great majority of vehicles transgress speed limits in Xalapa, Veracruz. Our results support the urgent need to implement speed control measures in the city. Changes in road infrastructure design, as well as promoting a comprehensive speeding legislation (with adequate speed limits and correctly enforced) aimed at reducing exposure to this key risk factor are recommended. As evaluation of road safety interventions is key, our data could be used as a baseline to evaluate the effects and impact of future interventions implemented in this Mexican city.

Using health impact assessment (HIA) to understand the wider health and well-being implications of policy decisions: the COVID-19 'staying at home and social distancing policy' in Wales

BACKGROUND

Health Impact Assessment (HIA) is promoted as a decision-informing tool by public health and governmental agencies. HIA is beneficial when carried out as part of policy development but is also valuable as a methodology when a policy is being implemented to identify and understand the wider health and well-being impacts of policy decisions, particularly when a decision needs to be taken rapidly to protect the population. This paper focusses on a HIA of the 'Staying at Home and Social Distancing Policy' or 'lockdown' in response to the COVID-19 pandemic in Wales conducted by the Welsh national public health institute. It describes the process and findings, captures the learning and discusses how the process has been used to better understand the wider health and well-being impacts of policy decisions beyond direct health harm. It also examines the role of public health institutes in promoting and using HIA.

METHODS

A HIA was conducted following a standard HIA five step process. A literature review was undertaken alongside 15 qualitative semi-structured interviews with key stakeholders, and relevant health and demographic data were collated. The results were triangulated and analysed to form a holistic assessment of the policy decision and its impacts.

RESULTS

A wide range of major health and well-being impacts of the lockdown in Wales were identified across the determinants of health, which included positive and negative social, economic, environmental and mental well-being impacts beyond the impact on direct health. Populations affected included children and young people, those on low incomes and women as well as those whose health has been directly impacted by COVID-19 such as older people. The work highlighted the benefit that HIA can bring in emphasizing impacts which can inform policy and shared learning with others.

CONCLUSION

HIA is a largely underused tool to understand the impact of policy and political decisions, particularly when a decision has been taken at speed. This case study highlights how HIA provide evidence and information for advocacy and further work by public health institutes, health agencies and policy makers.

The price of precision: trade-offs between usability and validity in the World Health Organization Health Economic Assessment Tool for walking and cycling

OBJECTIVES

The widely used World Health Organization (WHO) Health Economic Assessment Tool (HEAT) for walking and cycling quantifies health impacts in terms of premature deaths avoided or caused as a result of changes in active transport. This article attempts to assess the effect of incorporating 'life-years' as an impact measure to increase the precision of the model and assess the effect on the tool's usability.

STUDY DESIGN

This article is a methods paper, using simulation to estimate the effect of a methodological change to the HEAT 4.2 physical activity module.

METHODS

We use the widely used WHO HEAT for walking and cycling as a case study. HEAT currently quantifies health impacts in terms of premature deaths avoided or caused as a result of changes in active transport. We assess the effect of incorporating "duration of life gained" as an impact measure to increase the precision of the model without substantially affecting usability or increasing data requirements.

RESULTS

Compared with the existing tool (HEAT version 4.2), which values premature deaths avoided, estimates derived by valuing life-years gained are more sensitive to the age of the population affected by an intervention, with results for older and younger age groups being markedly different between the two methods. This is likely to improve the precision of the tool, especially where it is applied to interventions that affect age groups differentially. The life-years method requires additional background data (obtained and used in this analysis) and minimal additional user inputs; however, this may also make the tool harder to explain to users.

CONCLUSIONS

Methodological improvements in the precision of widely used tools, such as the HEAT, may also inadvertently reduce their practical usability. It is therefore important to consider the overall impact on the tool's value to stakeholders and explore ways of mitigating potential reductions in usability.

Overall health impacts of a potential increase in cycle commuting in Stockholm, Sweden

AIMS

To estimate the overall health impact of transferring commuting trips from car to bicycle.

METHODS

In this study registry information on the location of home and work for residents in Stockholm County was used to obtain the shortest travel route on a network of bicycle paths and roads. Current modes of travel to work were based on travel survey data. The relation between duration of cycling and distance cycled was established as a basis for selecting the number of individuals that normally would drive a car to work, but have a distance to work that they could bicycle within 30 minutes. The change in traffic flows was estimated by a transport model (LuTrans) and effects on road traffic injuries and fatalities were estimated by using national hospital injury data. Effects on air pollution concentrations were modelled using dispersion models.

RESULTS

Within the scenario, 111,000 commuters would shift from car to bicycle. On average the increased physical activity reduced the one-year mortality risk by 12% among the additional bicyclists. Including the number of years lost due to morbidity, the total number of disability adjusted life-years gained was 696. The amount of disability adjusted life-years gained in the general population due to reduced air pollution exposure was 471. The number of disability adjusted life-years lost by traffic injuries was 176. Also including air pollution effects among bicyclists, the net benefit was 939 disability adjusted life-years per year.

CONCLUSIONS

Large health benefits were estimated by transferring commuting by car to bicycle.

Is mode of transport to work associated with mortality in the working-age population? Repeated census-cohort studies in New Zealand, 1996, 2001 and 2006

BACKGROUND

Increasing active transport is proposed as a means to address both health and environmental issues. However, the associations between specific modes, such as cycling, walking and public transport, and health outcomes remain unclear. We examined the association between mode of travel to work and mortality.

METHODS

Cohort studies of the entire New Zealand working population were created using 1996, 2001 and 2006 censuses linked to mortality data. Mode of travel to work was that reported on census day, and causes of death examined were ischaemic heart disease and injury. Main analyses were Poisson regression models adjusted for socio-demographics. Sensitivity analyses included: additional adjustment for smoking in the 1996 and 2006 cohorts, and bias analysis about non-differential misclassification of cycling vs car use.

RESULTS

Walking (5%) and cycling (3%) to work were uncommon. Compared with people reporting using motor vehicles to travel to work, those cycling had a reduced all-cause mortality (ACM) in the socio-demographic adjusted models RR 0.87 (0.77-0.98). Those walking (0.97, 0.90-1.04) and taking public transport (0.96, 0.88-1.05) had no substantive difference in ACM. No mode of transport was associated with detectable statistically significant reductions in cause-specific mortality. Sensitivity analyses found weaker associations when adjusting for smoking and stronger associations correcting for likely non-differential misclassification of cycling.

CONCLUSIONS

This large cohort study supports an association between cycling to work and reduced ACM, but found no association for walking or public-transport use and imprecise cause-specific mortality patterns.

Potential for reduced premature mortality by current and increased bicycle commuting: a health impact assessment using registry data on home and work addresses in Stockholm, Sweden

Objectives

The study aims to make use of individual data to estimate the impact on premature mortality due to both existing commuter bicycling and the potential impact due to increased physical activity through shifting transport mode from car commuting to bicycling.

Methods

Using registry data on home and work addresses for the population of Stockholm County the shortest bicycling route on a network of bicycle paths and roads was retrieved. Travel survey data were used to establish current modes of commuting. The relation between duration of bicycling and distance bicycled within the general population in 2015 was established as a basis for identifying individuals that currently drive a car to work but were estimated to have the physical capacity to bicycle to work within 30 min. Within this mode-shift scenario from car-to-bike the duration of bicycling per week was estimated, both among current and potential bicycle commuters. The health impact assessment (HIA) on mortality due to bicycle commuting physical activity was estimated using the same relative risk as within the WHO Health Economic Assessment Tool.

Results

The current number of bicycle commuters were 53 000, and the scenario estimated an additional 111 000. Their mean bicycle distances were 4.5 and 3.4 km, respectively. On average these respective amounts of physical activity reduced the yearly mortality by 16% and 12%, resulting in 11.3 and 16.2 fewer preterm deaths per year.

Conclusion

The HIA of transferring commuting by car to bicycle estimated large health benefits due to increased physical activity.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Potential Effects on Travelers' Air Pollution Exposure and Associated Mortality Estimated for a Mode Shift from Car to Bicycle Commuting

This study aims to use dispersion-modeled concentrations of nitrogen oxides (NOx) and black carbon (BC) to estimate bicyclist exposures along a network of roads and bicycle paths. Such modeling was also performed in a scenario with increased bicycling. Accumulated concentrations between home and work were thereafter calculated for both bicyclists and drivers of cars. A transport model was used to estimate traffic volumes and current commuting preferences in Stockholm County. The study used individuals’ home and work addresses, their age, sex, and an empirical model estimate of their expected physical capacity in order to establish realistic bicycle travel distances. If car commuters with estimated physical capacity to bicycle to their workplace within 30 min changed their mode of transport to bicycle, >110,000 additional bicyclists would be achieved. Time-weighted mean concentrations along paths were, among current bicyclists, reduced from 25.8 to 24.2 μg/m³ for NOx and 1.14 to 1.08 μg/m³ for BC. Among the additional bicyclists, the yearly mean NOx dose from commuting increased from 0.08 to 1.03 μg/m³. This would be expected to yearly cause 0.10 fewer deaths for current bicycling levels and 1.7 more deaths for additional bicycling. This increased air pollution impact is much smaller than the decrease in the total population.

Health and climate benefits of Electric Vehicle Deployment in the Greater Toronto and Hamilton Area

This study presents the results of an integrated model developed to evaluate the environmental and health impacts of Electric Vehicle (EV) deployment in a large metropolitan area. The model combines a high-resolution chemical transport model with an emission inventory established with detailed transportation and power plant information, as well as a framework to characterize and monetize the health impacts. Our study is set in the Greater Toronto and Hamilton Area (GTHA) in Canada with bounding scenarios for 25% and 100% EV penetration rates. Our results indicate that even with the worst-case assumptions for EV electricity supply (100% natural gas), vehicle electrification can deliver substantial health benefits in the GTHA, equivalent to reductions of about 50 and 260 premature deaths per year for 25% and 100% EV penetration, compared to the base case scenario. If EVs are charged with renewable energy sources only, then electrifying all passenger vehicles can prevent 330 premature deaths per year, which is equivalent to $3.8 Billion (2016$CAD) in social benefits. When the benefit of EV deployment is normalized per vehicle, it is higher than most incentives provided by the government, indicating that EV incentives can generate high social benefits.

Mapping the co-benefits of climate change action to issues of public concern in the UK: a narrative review

To avoid a 1·5°C rise in global temperatures above preindustrial levels, the next phase of reductions in greenhouse gas emissions will need to be comparatively rapid. Linking the co-benefits of climate action to wider issues that the public are concerned about can help decision makers to prioritise decarbonisation options that increase the chance of public support for such changes, while ensuring that a just transition is delivered. We identified key issues of concern to the UK public by use of Ipsos MORI public opinion data from 2007 to 2020 and used these data to guide a narrative review of academic and grey literature on the co-benefits of climate change action for the UK. Correspondence with civil servants, third sector organisations, and relevant academics allowed us to identify omissions and to ensure policy relevance of the recommendations. This evidence-based Review of the various co-benefits of climate change action for the UK identifies four main areas: health and the National Health Service; security; economy and unemployment; and poverty, housing, and inequality. Associated trade-offs are also discussed. City-level and regional-level governments are particularly well placed to incorporate co-benefits into their decision making because it is at this scale that co-benefits most clearly manifest, and where interventions can have the most immediate effects.

What Is the Best Practice Method for Quantifying the Health and Economic Benefits of Active Transport?

The aim of this study was to identify a best practice method to cost the health benefits of active transport for use in infrastructure planning in New South Wales, Australia. We systematically reviewed the international literature covering the concept areas of active transport and cost and health benefits. Original publications describing a method to cost the health benefits of active transport, published in 2000–2019 were included. Studies meeting the inclusion criteria were assessed against criteria identified in interviews with key government stakeholders. A total of 2993 studies were identified, 53 were assessed for eligibility, and 19 were included in the review. The most commonly studied active transport modes were cycling (n = 8) and walking and cycling (n = 6). Exposures considered were physical activity, road transport related injuries and air pollution. The most often applied economic evaluation method was cost benefit analysis (n = 8), and costs were commonly calculated by monetising health outcomes. Based on evaluation of models against the criteria, a Multistate Life Table model was recommended as the best method currently available. There is strong and increasing interest in quantifying and costing the health benefits of active transport internationally. Incorporating health-related economic benefits into existing regulatory processes such as cost benefit analyses could provide an effective way to encourage the non-health sector to include health impacts in infrastructure measures.

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.

Suburb-level changes for active transport to meet the SDGs: Causal theory and a New Zealand case study

The 2030 Agenda for Sustainable Development and its Sustainable Development Goals (SDGs) represent a historic global linking of health, equity and environmental sustainability. Accumulated evidence suggests that improving urban neighbourhoods to make them safer and more attractive for walking and cycling can accelerate progress towards the SDGs. The pathways to change are complex, non-linear and involve multiple pathways and multiple SDG outcomes, yet the SDG goals are often considered in isolation. Further, there have been few studies of environmental interventions for healthier transport that foreground equity. The aim of this paper is to describe and demonstrate practically how integrated interventions for placemaking and active transport can contribute to a wide range of SDG targets. First, we take an evidence-based approach to describing how such interventions are connected to targets within the SDGs. Second, we propose a complex causal theory of the pathways to change and the inter-relationships between SDGs. Third, we show, with concrete examples, how a case study project in Auckland, New Zealand illustrates these pathways, contributing to achieving the SDG targets, including barriers and challenges. We find that by addressing Goal 11 in particular ways that focus on equity (Goal 10), eight of the other goals can also be advanced. Our causal theory describes one balancing and 12 reinforcing patterns of behaviour that link interventions improvements to neighbourhoods with ten of the SDGs in a complex system. Our case study demonstrates that it is possible to successfully put this causal theory into practice through interventions, but these require strong partnerships between researchers, public health practitioners, policy-makers and communities, long-term evaluation and addressing both physical and social environments.

How does mode of travel affect risks posed to other road users? An analysis of English road fatality data, incorporating gender and road type

Background

Most analysis of road injuries examines the risk experienced by people using different modes of transport, for instance, pedestrian fatalities per-head or per-km. A small but growing field analyses the impact that the use of different transport modes has on other road users, for instance, injuries to others per-km driven.

Methods

This paper moves the analysis of risk posed to others forward by comparing six different vehicular modes, separating road types (major vs minor roads in urban vs rural settings). The comparison of risk posed by men and women for all these modes is also novel.

Results

Per-vehicle kilometre, buses and lorries pose much the highest risk to others, while cycles pose the lowest. Motorcycles pose a substantially higher per-km risk to others than cars. The fatality risk posed by cars or vans to ORUs per km is higher in rural areas. Risk posed is generally higher on major roads, although not in the case of lorries, suggesting a link to higher speeds. Men pose higher per-km risk to others than women for all modes except buses, as well as being over-represented among users of the most dangerous vehicles.

Conclusions

Future research should examine more settings, adjust for spatial and temporal confounders, or examine how infrastructure or route characteristics affect risk posed to others. Although for most victims the other vehicle involved is a car, results suggest policy-makers should also seek to reduce disproportionate risks posed by the more dangerous vehicles, for instance, by discouraging motorcycling. Finally, given higher risk posed to others by men across five of six modes analysed, policy-makers should consider how to reduce persistent large gender imbalances in jobs involving driving.

Health benefits of policies to reduce carbon emissions

James Milner and colleagues argue that carefully considered policies to lower carbon emissions can also improve health, and we should use these benefits to push for strong climate action

Health economic assessment of a shift to active transport

Active transportation (walking or cycling) as a substitute for car trips still represents a small percentage of all daily travels in many European cities. This study aimed to estimate the health and economic co-benefits for the adult population of modal shift from driving to active travel in urban environments. Three scenarios were modelled for the case study, the city of Porto, Portugal, by comparing travel patterns of 2013 to hypothetical scenarios of modal shifts from driving to active transport, namely: i) SC1 - conservative scenario, with a change of 5% from driving to cycling and 10% from driving to walking; ii) SC2 - moderate scenario, with a shift of 10% and 15%, respectively; and iii) SC3 - optimistic scenario, with a shift of 15% and 20%, respectively. The mortality risk reduction for five health outcomes (colon and breast cancers, diabetes, ischemic heart disease, cerebrovascular disease) was assessed, including an estimation of traffic injury and air pollution exposure risks. Results were presented in Disability-Adjusted Life Years (DALYs) avoided. Economic valuation for each scenario was performed using a Willingness-to-Pay approach for morbimortality and a Cost of Illness approach for 2013 hospitalizations and work absenteeism. Significant health benefits were found in all modelled scenarios, ranging from 1657 (16%) to 2881 (28%) DALYs avoided. Total costs averted ranged from €3894 to €6769 million through the scenarios. Cardio and cerebrovascular diseases mortality presented the largest benefit, accounting for about 3/4 of all avoidable DALYs in all scenarios. Reductions in CO₂ and PM₁₀ emissions were calculated, showing a decrease from 31.6 to 73.7 kt of CO₂ and 7 to 16 t for PM₁₀, respectively. A modal shift towards active transportation could lead to significant health and economic benefits, indicating that the evaluation of health impacts should be included in the analysis of active transport interventions.

Quantifying the handprint-Footprint balance into a single score: The example of pharmaceuticals

Life Cycle Assessment typically focuses on the footprint of products and services, expressed on three Areas of Protection (AoP): Human Health, Ecosystems and Resources. While the handprint is often expressed qualitatively, quantified handprints have recently been compared directly to the footprint concerning one AoP: Human Health. We propose to take this one step further by simultaneously comparing the quantified handprint and footprint on all AoPs through normalization and weighting of the results towards a single score. We discuss two example cases of a pharmaceutical treatment: mebendazole to treat soil-transmitted helminthiases and paliperidone palmitate to treat schizophrenia. Each time, treatment is compared to 'no treatment'. The footprint of health care is compared to the handprint of improved patient health. The handprint and footprint were normalized separately. To include sensitivity in the normalization step we applied four sets of external normalization factors for both handprint (Global Burden of Disease) and footprint (ReCiPe and PROSUITE). At the weighting step we applied 26 sets of panel weighting factors from three sources. We propose the Relative Sustainability Benefit Rate (RSBR) as a new metric to quantify the relative difference in combined handprint and footprint single score between two alternatives. When only considering the footprint, the first case study is associated with an increased single score burden of treatment compared to 'no treatment', while in the second case study treatment reduces the single score burden by 41.1% compared to 'no treatment'. Also including the handprint provided new insights for the first case study, now showing a decrease of 56.4% in single score burden for treatment compared to 'no treatment'. For the second case study the reduction of single score burden was confirmed as the handprint burden was also decreased because of treatment by 9.9%, reinforcing the findings.

Exposure to unsafe mobility: Traveling in the cargo area of pickup trucks in three Mexican cities

Objective: To estimate the prevalence of pickup trucks transporting people in the cargo area and to identify factors associated to this behavior in three Mexican cities.Methods: Eight rounds of roadside observations of randomly selected pickup trucks were conducted from August 2012 to November 2014 in three Mexican cities: Guadalajara-Zapopan, León and Cuernavaca.Results: Overall, 4.03% of the 4,611 pickup trucks observed were transporting people in the cargo area (95% CI: 3.48 - 4.64%). This implies that a total of 427 passengers were traveling unsafely in the cargo area of pickup trucks; of all them 22.01% were children and 82.20% were male. Prevalence of exposure to this risky behavior was higher in León (5.77%, 95% CI: 4.73 - 6.97%) than in Cuernavaca (3.73%, 95% CI: 2.49 - 5.35%) and Guadalajara-Zapopan (2.70%, 95% CI: 2.05 - 3.48%). According to this data, exposure to this risk factor has decreased in time. Male drivers, not using seatbelt correctly carried passengers in the cargo area more frequently.Conclusions: Results support the importance of improving and enforcing current legislation and evaluating strategies directed to prevent exposure to this risky behavior with the potential of contributing to lowering the high burden that road traffic injuries imposed in Mexican public health.

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.

A Transport Policy Whose Injury Impacts May Go Unnoticed: More Walking, Cycling and Use of Public Transport

It is an objective of transport policy in many countries and cities to promote walking, cycling and the use of public transport. This policy seeks to improve public health and reduce emissions contributing to global warming. It is, however, very likely that more walking, cycling and use of public transport will be associated with an increase in traffic injury. Moreover, it is likely that most of this increase will go unnoticed and not be recorded in official road accident statistics. Official statistics on traffic injury are known to be very incomplete as far as injuries to pedestrians, cyclists and public transport passengers are concerned. This incompleteness is a problem when assessing health impacts of more walking, cycling and travel by public transport. In this paper, studies made in the city of Oslo, Norway (population 700,000) are used to develop numerical examples showing how the estimated real and recorded number of injuries may change when 10% of person km of travel performed by car are transferred to walking, cycling or public transport. It is shown that not more than about 2% of the estimated change in the actual number of injured road users will be recorded by official statistics on traffic injury.

Health economic assessment of a scenario to promote bicycling as active transport in Stockholm, Sweden

OBJECTIVES

To conduct a health economic evaluation of a proposed investment in urban bicycle infrastructure in Stockholm County, Sweden.

DESIGN

A cost-effectiveness analysis is undertaken from a healthcare perspective. Investment costs over a 50-year life cycle are offset by averted healthcare costs and compared with estimated long-term impacts on morbidity, quantified in disability-adjusted life years (DALYs). The results are re-calculated under different assumptions to model the effects of uncertainty.

SETTING

The Municipality of Stockholm (population 2.27 million) committed funds for bicycle path infrastructure with the aim of achieving a 15% increase in the number of bicycle commuters by 2030. This work is based on a previously constructed scenario, in which individual registry data on home and work address and a transport model allocation to different modes of transport identified 111 487 individuals with the physical capacity to bicycle to work within 30 min but that currently drive a car to work.

RESULTS

Morbidity impacts and healthcare costs attributed to increased physical activity, change in air pollution exposure and accident risk are quantified under the scenario. The largest reduction in healthcare costs is attributed to increased physical activity and the second largest to reduced air pollution exposure among the population of Greater Stockholm. The expected net benefit from the investment is 8.7% of the 2017 Stockholm County healthcare budget, and 3.7% after discounting. The economic evaluation estimates that the intervention is cost-effective and each DALY averted gives a surplus of €9933. The results remained robust under varied assumptions pertaining to reduced numbers of additional bicycle commuters.

CONCLUSION

Investing in urban infrastructure to increase bicycling as active transport is cost-effective from a healthcare sector perspective.

Potential of active transport to improve health, reduce healthcare costs, and reduce greenhouse gas emissions: A modelling study

Background

Physical inactivity contributes substantively to disease burden, especially in highly car dependent countries such as New Zealand (NZ). We aimed to quantify the future health gain, health-sector cost-savings, and change in greenhouse gas emissions that could be achieved by switching short vehicle trips to walking and cycling in New Zealand.

Methods

We used unit-level survey data to estimate changes in physical activity, distance travelled by mode, and air pollution for: (a) switching car trips under 1km to walking and (b) switching car trips under 5km to a mix of walking and cycling. We modelled uptake levels of 25%, 50%, and 100%, and assumed changes in transport behaviour were permanent. We then used multi-state life table modelling to quantify health impacts as quality adjusted life years (QALYs) gained and changes in health system costs over the rest of the life course of the NZ population alive in 2011 (n = 4.4 million), with 3% discounting.

Findings

The modelled scenarios resulted in health gains between 1.61 (95% uncertainty interval (UI) 1.35 to 1.89) and 25.43 (UI 20.20 to 30.58) QALYs/1000 people, with total QALYs up to 112,020 (UI 88,969 to 134,725) over the remaining lifespan. Healthcare cost savings ranged between NZ$127million (UI $101m to 157m) and NZ$2.1billion (UI $1.6b to 2.6b). Greenhouse gas emissions were reduced by up to 194kgCO₂e/year, though changes in emissions were not significant under the walking scenario.

Conclusions

Substantial health gains and healthcare cost savings could be achieved by switching short car trips to walking and cycling. Implementing infrastructural improvements and interventions to encourage walking and cycling is likely to be a cost-effective way to improve population health, and may also reduce greenhouse gas emissions.

Redefining the Use of Big Data in Urban Health for Increased Liveability in Smart Cities

Policy decisions and urban governance are being influenced by an emergence of data from internet of things (IoT), which forms the backbone of Smart Cities, giving rise to Big Data which is processed and analyzed by Artificial Intelligence models at speeds unknown to mankind decades ago. This is providing new ways of understanding how well cities perform, both in terms of economics as well as in health. However, even though cities have been increasingly digitalized, accelerated by the concept of Smart Cities, the exploration of urban health has been limited by the interpretation of sensor data from IoT devices, omitting the inclusion of data from human anatomy and the emergence of biological data in various forms. This paper advances the need for expanding the concept of Big Data beyond infrastructure to include that of urban health through human anatomy; thus, providing a more cohesive set of data, which can lead to a better knowledge as to the relationship of people with the city and how this pertains to the thematic of urban health. Coupling both data forms will be key in supplementing the contemporary notion of Big Data for the pursuit of more contextualized, resilient, and sustainable Smart Cities, rendering more liveable fabrics, as outlined in the Sustainable Development Goal (SDG) 11 and the New Urban Agenda.

Health Benefits of Physical Activity Related to an Urban Riverside Regeneration

The promotion of physical activity through better urban design is one pathway by which health and well-being improvements can be achieved. This study aimed to quantify health and health-related economic impacts associated with physical activity in an urban riverside park regeneration project in Barcelona, Spain. We used data from Barcelona local authorities and meta-analysis assessing physical activity and health outcomes to develop and apply the “Blue Active Tool”. We estimated park user health impacts in terms of all-cause mortality, morbidity (ischemic heart disease; ischemic stroke; type 2 diabetes; cancers of the colon and breast; and dementia), disability-adjusted life years (DALYs) and health-related economic impacts. We estimated that 5753 adult users visited the riverside park daily and performed different types of physical activity (walking for leisure or to/from work, cycling, and running). Related to the physical activity conducted on the riverside park, we estimated an annual reduction of 7.3 deaths (95% CI: 5.4; 10.2), and 6.2 cases of diseases (95% CI: 2.0; 11.6). This corresponds to 11.9 DALYs (95% CI: 3.4; 20.5) and an annual health-economic impact of 23.4 million euros (95% CI: 17.2 million; 32.8 million). The urban regeneration intervention of this riverside park provides health and health-related economic benefits to the population using the infrastructure.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

DISCUSSION

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

Development of the Impacts of Cycling Tool (ICT): A modelling study and web tool for evaluating health and environmental impacts of cycling uptake

BACKGROUND

A modal shift to cycling has the potential to reduce greenhouse gas emissions and provide health co-benefits. Methods, models, and tools are needed to estimate the potential for cycling uptake and communicate to policy makers the range of impacts this would have.

METHODS AND FINDINGS

The Impacts of Cycling Tool (ICT) is an open source model with a web interface for visualising travel patterns and comparing the impacts of different scenarios of cycling uptake. It is currently applied to England. The ICT allows users to visualise individual and trip-level data from the English National Travel Survey (NTS), 2004-2014 sample, 132,000 adults. It models scenarios in which there is an increase in the proportion of the population who cycle regularly, using a distance-based propensity approach to model which trips would be cycled. From this, the model estimates likely impact on travel patterns, health, and greenhouse gas emissions. Estimates of nonoccupational physical activity are generated by fusing the NTS with the English Active People Survey (APS, 2013-2014, 559,515 adults) to create a synthetic population. Under 'equity' scenarios, we investigate what would happen if cycling levels increased equally among all age and gender categories, as opposed to in proportion to the profile of current cyclists. Under electric assist bike (pedelecs or 'e-bike') scenarios, the probability of cycling longer trips increases, based on the e-bike data from the Netherlands, 2013-2014 Dutch Travel Survey (50,868 adults).Outcomes are presented across domains including transport (trip duration and trips by mode), health (physical activity levels, years of life lost), and car transport-related CO2 emissions. Results can be visualised for the whole population and various subpopulations (region, age, gender, and ethnicity). The tool is available at www.pct.bike/ict. If the proportion of the English population who cycle regularly increased from 4.8% to 25%, then there would be notable reductions in car miles and passenger related CO2 emissions (2.2%) and health benefits (2.1% reduction in years of life lost due to premature mortality). If the new cyclists had access to e-bikes, then mortality reductions would be similar, while the reduction in car miles and CO2 emissions would be larger (2.7%). If take-up of cycling occurred equally by gender and age (under 80 years), then health benefits would be marginally greater (2.2%) but reduction in CO2 slightly smaller (1.8%). The study is limited by the quality and comparability of the input data (including reliance on self-report behaviours). As with all modelling studies, many assumptions are required and potentially important pathways excluded (e.g. injury, air pollution, and noise pollution).

CONCLUSION

This study demonstrates a generalisable approach for using travel survey data to model scenarios of cycling uptake that can be applied to a wide range of settings. The use of individual-level data allows investigation of a wide range of outcomes, and variation across subgroups. Future work should investigate the sensitivity of results to assumptions and omissions, and if this varies across setting.

Climate change, urban health, and the promotion of health equity

Jerald Fagliano and Ana Diez Roux discuss the challenges of climate change in an urban environment, but also opportunities for healthier lifestyles and green spaces.

A Cost Benefit Analysis of an Active Travel Intervention with Health and Carbon Emission Reduction Benefits

Active travel (walking and cycling) is beneficial for people’s health and has many co-benefits, such as reducing motor vehicle congestion and pollution in urban areas. There have been few robust evaluations of active travel, and very few studies have valued health and emissions outcomes. The ACTIVE before-and-after quasi-experimental study estimated the net benefits of health and other outcomes from New Zealand’s Model Communities Programme using an empirical analysis comparing two intervention cities with two control cities. The Programme funded investment in cycle paths, other walking and cycling facilities, cycle parking, ‘shared spaces’, media campaigns and events, such as ‘Share the Road’, and cycle-skills training. Using the modified Integrated Transport and Health Impacts Model, the Programme’s net economic benefits were estimated from the changes in use of active travel modes. Annual benefits for health in the intervention cities were estimated at 34.4 disability-adjusted life years (DALYs) and two lives saved due to reductions in cardiac disease, diabetes, cancer, and respiratory disease. Reductions in transport-related carbon emissions were also estimated and valued. Using a discount rate of 3.5%, the estimated benefit/cost ratio was 11:1 and was robust to sensitivity testing. It is concluded that when concerted investment is made in active travel in a city, there is likely to be a measurable, positive return on investment.

Evaluating Health Co-Benefits of Climate Change Mitigation in Urban Mobility

There is growing recognition that implementation of low-carbon policies in urban passenger transport has near-term health co-benefits through increased physical activity and improved air quality. Nevertheless, co-benefits and related cost reductions are often not taken into account in decision processes, likely because they are not easy to capture. In an interdisciplinary multi-model approach we address this gap, investigating the co-benefits resulting from increased physical activity and improved air quality due to climate mitigation policies for three urban areas. Additionally we take a (macro-)economic perspective, since that is the ultimate interest of policy-makers. Methodologically, we link a transport modelling tool, a transport emission model, an emission dispersion model, a health model and a macroeconomic Computable General Equilibrium (CGE) model to analyze three climate change mitigation scenarios. We show that higher levels of physical exercise and reduced exposure to pollutants due to mitigation measures substantially decrease morbidity and mortality. Expenditures are mainly born by the public sector but are mostly offset by the emerging co-benefits. Our macroeconomic results indicate a strong positive welfare effect, yet with slightly negative GDP and employment effects. We conclude that considering economic co-benefits of climate change mitigation policies in urban mobility can be put forward as a forceful argument for policy makers to take action.

Urban Form, Air Pollution, and Health

PURPOSE OF REVIEW

Urban form can impact air pollution and public health. We reviewed health-related articles that assessed (1) the relationships among urban form, air pollution, and health as well as (2) aspects of the urban environment (i.e., green space, noise, physical activity) that may modify those relationships.

RECENT FINDINGS

Simulation and empirical studies demonstrate an association between compact growth, improved regional air quality, and health. Most studies are cross-sectional and focus on connections between transportation emissions and land use. The physical and mental health impacts of green space, public spaces that promote physical activity, and noise are well-studied aspects of the urban environment and there is evidence that these factors may modify the relationship between air pollution and health. Urban form can support efforts to design clean, health-promoting cities. More work is needed to operationalize specific strategies and to elucidate the causal pathways connecting various aspects of health.