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.

Non-occupational physical activity and risk of cardiovascular disease, cancer and mortality outcomes: a dose-response meta-analysis of large prospective studies.

OBJECTIVE: To estimate the dose-response associations between non-occupational physical activity and several chronic disease and mortality outcomes in the general adult population. DESIGN: Systematic review and cohort-level dose-response meta-analysis. DATA SOURCES: PubMed, Scopus, Web of Science and reference lists of published studies. ELIGIBILITY CRITERIA: Prospective cohort studies with (1) general population samples >10 000 adults, (2) ≥3 physical activity categories, and (3) risk measures and CIs for all-cause mortality or incident total cardiovascular disease, coronary heart disease, stroke, heart failure, total cancer and site-specific cancers (head and neck, myeloid leukaemia, myeloma, gastric cardia, lung, liver, endometrium, colon, breast, bladder, rectum, oesophagus, prostate, kidney). RESULTS: 196 articles were included, covering 94 cohorts with >30 million participants. The evidence base was largest for all-cause mortality (50 separate results; 163 415 543 person-years, 811 616 events), and incidence of cardiovascular disease (37 results; 28 884 209 person-years, 74 757 events) and cancer (31 results; 35 500 867 person-years, 185 870 events). In general, higher activity levels were associated with lower risk of all outcomes. Differences in risk were greater between 0 and 8.75 marginal metabolic equivalent of task-hours per week (mMET-hours/week) (equivalent to the recommended 150 min/week of moderate-to-vigorous aerobic physical activity), with smaller marginal differences in risk above this level to 17.5 mMET-hours/week, beyond which additional differences were small and uncertain. Associations were stronger for all-cause (relative risk (RR) at 8.75 mMET-hours/week: 0.69, 95% CI 0.65 to 0.73) and cardiovascular disease (RR at 8.75 mMET-hours/week: 0.71, 95% CI 0.66 to 0.77) mortality than for cancer mortality (RR at 8.75 mMET-hours/week: 0.85, 95% CI 0.81 to 0.89). If all insufficiently active individuals had achieved 8.75 mMET-hours/week, 15.7% (95% CI 13.1 to 18.2) of all premature deaths would have been averted. CONCLUSIONS: Inverse non-linear dose-response associations suggest substantial protection against a range of chronic disease outcomes from small increases in non-occupational physical activity in inactive adults. PROSPERO registration number CRD42018095481.

Towards a global framework for transport, health and health equity.

This study derives a generalised global framework for transport, health and health equity, based on a synthesis of 94 urban transport and health frameworks. The framework emphasises factors related to health equity, which are generally ignored in existing conceptual frameworks on the relationship between transport and health. While some factors such as travel behaviour were included in most reviewed frameworks, climate change and other macro-level factors were included in less than a quarter of frameworks, and health equity was included in less than 10%. We developed a framework that includes key framework components identified by a scoping review, as well as addressing important gaps. This framework can be utilized to inform work on transport, health and health equity by different agencies such as the World Health Organization. It can be used to guide health sector engagement with transport issues to lead to healthier and more equitable transport decision-making globally.

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.

Modelling SARS-CoV-2 disease progression in Australia and New Zealand: an account of an agent-based approach to support public health decision-making.

OBJECTIVE: In 2020, we developed a public health decision-support model for mitigating the spread of SARS-CoV-2 infections in Australia and New Zealand. Having demonstrated its capacity to describe disease progression patterns during both countries' first waves of infections, we describe its utilisation in Victoria in underpinning the State Government's then 'RoadMap to Reopening'. METHODS: Key aspects of population demographics, disease, spatial and behavioural dynamics, as well as the mechanism, timing, and effect of non-pharmaceutical public health policies responses on the transmission of SARS-CoV-2 in both countries were represented in an agent-based model. We considered scenarios related to the imposition and removal of non-pharmaceutical interventions on the estimated progression of SARS-CoV-2 infections. RESULTS: Wave 1 results suggested elimination of community transmission of SARS-CoV-2 was possible in both countries given sustained public adherence to social restrictions beyond 60 days' duration. However, under scenarios of decaying adherence to restrictions, a second wave of infections (Wave 2) was predicted in Australia. In Victoria's second wave, we estimated in early September 2020 that a rolling 14-day average of <5 new cases per day was achievable on or around 26 October. Victoria recorded a 14-day rolling average of 4.6 cases per day on 25 October. CONCLUSIONS: Elimination of SARS-CoV-2 transmission represented in faithfully constructed agent-based models can be replicated in the real world. IMPLICATIONS FOR PUBLIC HEALTH: Agent-based public health policy models can be helpful to support decision-making in novel and complex unfolding public health crises.

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

BACKGROUND: Currently, more than half of the global population lives in cities. Contemporary urban planning practices result in environmental risk factors (e.g. air pollution, noise, lack of green space, excess heat) that put health and well-being of city dwellers at risk and contribute to chronic diseases and premature death. Despite a growing body of evidence on adverse health impacts related to current urban and transport planning practices, especially for cities in the Global North, not much is known about associated health impacts in South American cities. Therefore, we estimated the mortality burden attributable to breaching internationally-recommended or locally-preferable exposure levels of urban planning related environmental exposures in Sao Paulo, Brazil. METHODS: We carried out a health impact assessment study, following the comparative risk assessment framework, to assess preventable mortality impacts of breaching exposure recommendations for air pollution, green spaces and temperature at the census tract (CT) level (n = 18,363). We also assessed the distribution thereof by socioeconomic vulnerability. RESULTS: We estimated that annually 11,372 (95% CI: 7921; 15,910) attributable deaths could be prevented by complying with recommended exposure levels. The largest proportion of preventable mortality was due to breaching air pollution limits (i.e. 8409 attributable deaths), followed by insufficient green space (i.e. 2593), and excess heat (i.e. 370). Adverse health impacts were larger in CTs of lower socioeconomic vulnerability, due to demographic profile, traffic density and residential area configurations. DISCUSSION: Not complying with the health limits for air pollution, green space and temperature exposures resulted in a considerable preventable mortality burden (i.e. 17% of total expected deaths) in Sao Paulo. This burden can be reduced by improving current urban and transport planning practices.

Supporting a Healthy Planet, Healthy People and Health Equity through Urban and Territorial Planning.

The form of human settlements impacts on planetary health, population health and health equity. Yet goals for urban and territorial planning are only tangentially linked to public health outcomes. The WHO and UN-Habitat support actions to bring health to the fore in planning and design of human settlements, recently publishing 'Integrating Health in Urban and Territorial Planning: a sourcebook' focusing on 'why' action is needed, 'how' to initiate it; and curating several existing resources on 'what' to do. Recommendations for research, policy and practice include calls for rapid development of closer relationships between public health and spatial planning.

Effect of COVID-19 response policies on walking behavior in US cities.

The COVID-19 pandemic is causing mass disruption to our daily lives. We integrate mobility data from mobile devices and area-level data to study the walking patterns of 1.62 million anonymous users in 10 metropolitan areas in the United States. The data covers the period from mid-February 2020 (pre-lockdown) to late June 2020 (easing of lockdown restrictions). We detect when users were walking, distance walked and time of the walk, and classify each walk as recreational or utilitarian. Our results reveal dramatic declines in walking, particularly utilitarian walking, while recreational walking has recovered and even surpassed pre-pandemic levels. Our findings also demonstrate important social patterns, widening existing inequalities in walking behavior. COVID-19 response measures have a larger impact on walking behavior for those from low-income areas and high use of public transportation. Provision of equal opportunities to support walking is key to opening up our society and economy.

Padrão de deslocamento ativo da região metropolitana de Campinas, Brasil / Campinas metropolitan region's active commuting pattern

Analisar o padrão do deslocamento ativo da Região Metropolitana Campinas, levando em conside-ração particularidades dos residentes e suas viagens. Utilizando as bases de dados obtidas através da Pesquisa Origem e Destino da Região Metropolitana de Campinas dos anos de 2003 e 2011, foram realizadas estatísticas descritivas e temporais a partir das características dos sujeitos, municípios e via-gens. Para identificarmos diferenças adotamos o intervalo de confiança de 95% (IC 95%). Utilizamos a regressão de Poisson para verificação da correlação entre características individuais e o desfecho ser ciclista ou caminhante, adotando o valor de p < 0,05. Todos os dados foram analisados levando-se em consideração os procedimentos de amostragem para que a amostra fosse representativa. Cons-tatou-se que a frequência de ciclistas e caminhantes e suas respectivas viagens caíram. Encontramos associação positiva para ciclista ser homem e classes econômicas mais baixas, para os caminhantes houve associação positiva ser mulher e crianças/adolescentes. Quanto ao tempo de viagem, notou-se aumento na mediana para os ciclistas e queda para os caminhantes. Não encontramos nenhuma via-gem de bicicleta que faça integração com outro modo de transporte. Quanto ao porte do município, observou-se uma queda em viagens de bicicleta tanto nos municípios pequenos, médios e grandes, e os residentes de Campinas apresentaram as menores frequências

This study analyzes the active commuting pattern of the Metropolitan Region of the City of Campinas, Brazil, by considering its commuters and their features. By using the database of Pesquisa Origem e Destino (a Brazilian instrument for transportation planning) of Campinas Metropolitan Region 2003-2011, we present descriptive and temporal statistics concerning the characteristics of the region's commuters, cities, and journeys. To assess those, we adopted a confidence interval of 95% (CI 95%). We used the Poisson regression to check the correlation between individual characteristics and outcomes of being a cyclist or a pedestrian, adopting the value of p < 0.05. We took into consideration the procedures for datum obtaining to present representative samples, verifying that the number of both cyclists and pedestrians has dropped. We found pos-itive associations regarding low-income males and being a cyclist; as well as females and children/teenagers and being pedestrians. The mean length of commuting time has increased for cycling journeys and decreased for pedestrian ones. We could not find a bicycle journey that integrates with another mean of transportation. Regarding the size of a city, we observed that the number of cycling journeys has dropped in small, medium, and large municipalities; Campinas presents the lowest index

Air pollution, physical activity and health: A mapping review of the evidence.

BACKGROUND: Exposure to air pollution and physical inactivity are both significant risk factors for non-communicable diseases (NCDs). These risk factors are also linked so that the change in exposure in one will impact risks and benefits of the other. These links are well captured in the active transport (walking, cycling) health impact models, in which the increases in active transport leading to increased inhaled dose of air pollution. However, these links are more complex and go beyond the active transport research field. Hence, in this study, we aimed to summarize the empirical evidence on the links between air pollution and physical activity, and their combined effect on individual and population health. OBJECTIVES AND METHODS: We conducted a non-systematic mapping review of empirical and modelling evidence of the possible links between exposure to air pollution and physical activity published until Autumn 2019. We reviewed empirical evidence for the (i) impact of exposure to air pollution on physical activity behaviour, (ii) exposure to air pollution while engaged in physical activity and (iii) the short-term and (iv) long-term health effects of air pollution exposure on people engaged in physical activity. In addition, we reviewed (v) public health modelling studies that have quantified the combined effect of air pollution and physical activity. These broad research areas were identified through expert discussions, including two public events performed in health-related conferences. RESULTS AND DISCUSSION: The current literature suggests that air pollution may decrease physical activity levels during high air pollution episodes or may prevent people from engaging in physical activity overall in highly polluted environments. Several studies have estimated fine particulate matter (PM2.5) exposure in active transport environment in Europe and North-America, but the concentration in other regions, places for physical activity and for other air pollutants are poorly understood. Observational epidemiological studies provide some evidence for a possible interaction between air pollution and physical activity for acute health outcomes, while results for long-term effects are mixed with several studies suggesting small diminishing health gains from physical activity due to exposure to air pollution for long-term outcomes. Public health modelling studies have estimated that in most situations benefits of physical activity outweigh the risks of air pollution, at least in the active transport environment. However, overall evidence on all examined links is weak for low- and middle-income countries, for sensitive subpopulations (children, elderly, pregnant women, people with pre-existing conditions), and for indoor air pollution. CONCLUSIONS: Physical activity and air pollution are linked through multiple mechanisms, and these relations could have important implications for public health, especially in locations with high air pollution concentrations. Overall, this review calls for international collaboration between air pollution and physical activity research fields to strengthen the evidence base on the links between both and on how policy options could potentially reduce risks and maximise health benefits.

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.

Decline in Stroke Mortality Between 1997 and 2012 by Sex: Ecological Study in Brazilians Aged 15 to 49 Years.

This study aimed to analyse the time trends of stroke mortality between 1997 and 2012 according to sex in Brazilians aged 15 to 49 years. This ecological study used data obtained from the Mortality Information System, which is available from the National Health System Department of Informatics - DATASUS and maintained by the Brazilian Ministry of Health. Stroke definition included International Classification of Disease version 10 (ICD-10) codes I60, I61, I63, and I64. Crude and age-standardized mortality rates and respective 95% confidence intervals were estimated per 100,000 inhabitants and stratified by age, region, year, and sex. Linear regression models were used to analyse the time trends with a confidence level of 95%. The statistical program used was Stata 11.0. Between 1997 and 2012, there were 124,866 deaths due to stroke in Brazilians aged 15 to 49 years. There was a decreasing linear trend in stroke mortality among men (ß = -0.46, p < 0.001, R2 = 0.95) and women (ß = -0.40, p < 0.001, R2 = 0.98) during this period. Overall there was no significant difference in stroke mortality trends by sex, except with respect to the age group of 40 to 49 years where there was a difference in the decrease of stroke mortality between men and women (interaction sex * year: ß = 0.238, p = 0.012, R² = 0.96). Mortality rates decrease significantly over time in men and women in the age group 15 to 49 years old, but there is only significant difference in the decrease of rates by sex only in the age group from 40 to 49 years old.

Reporting bias in the literature on the associations of health-related behaviors and statins with cardiovascular disease and all-cause mortality.

Reporting bias in the literature occurs when there is selective revealing or suppression of results, influenced by the direction of findings. We assessed the risk of reporting bias in the epidemiological literature on health-related behavior (tobacco, alcohol, diet, physical activity, and sedentary behavior) and cardiovascular disease mortality and all-cause mortality and provided a comparative assessment of reporting bias between health-related behavior and statin (in primary prevention) meta-analyses. We searched Medline, Embase, Cochrane Methodology Register Database, and Web of Science for systematic reviews synthesizing the associations of health-related behavior and statins with cardiovascular disease mortality and all-cause mortality published between 2010 and 2016. Risk of bias in systematic reviews was assessed using the ROBIS tool. Reporting bias in the literature was evaluated via small-study effect and excess significance tests. We included 49 systematic reviews in our study. The majority of these reviews exhibited a high overall risk of bias, with a higher extent in health-related behavior reviews, relative to statins. We reperformed 111 meta-analyses conducted across these reviews, of which 65% had statistically significant results (P < 0.05). Around 22% of health-related behavior meta-analyses showed small-study effect, as compared to none of statin meta-analyses. Physical activity and the smoking research areas had more than 40% of meta-analyses with small-study effect. We found evidence of excess significance in 26% of health-related behavior meta-analyses, as compared to none of statin meta-analyses. Half of the meta-analyses from physical activity, 26% from diet, 18% from sedentary behavior, 14% for smoking, and 12% from alcohol showed evidence of excess significance bias. These biases may be distorting the body of evidence available by providing inaccurate estimates of preventive effects on cardiovascular and all-cause mortality.

Sedentary behaviour and risk of all-cause, cardiovascular and cancer mortality, and incident type 2 diabetes: a systematic review and dose response meta-analysis.

PURPOSE:  To estimate the strength and shape of the dose-response relationship between sedentary behaviour and all-cause, cardiovascular disease (CVD) and cancer mortality, and incident type 2 diabetes (T2D), adjusted for physical activity (PA). Data Sources: Pubmed, Web of Knowledge, Medline, Embase, Cochrane Library and Google Scholar (through September-2016); reference lists. Study Selection: Prospective studies reporting associations between total daily sedentary time or TV viewing time, and ≥ one outcome of interest. Data Extraction: Two independent reviewers extracted data, study quality was assessed; corresponding authors were approached where needed. Data Synthesis: Thirty-four studies (1,331,468 unique participants; good study quality) covering 8 exposure-outcome combinations were included. For total sedentary behaviour, the PA-adjusted relationship was non-linear for all-cause mortality (RR per 1 h/day: were 1.01 (1.00-1.01) ≤ 8 h/day; 1.04 (1.03-1.05) > 8 h/day of exposure), and for CVD mortality (1.01 (0.99-1.02) ≤ 6 h/day; 1.04 (1.03-1.04) > 6 h/day). The association was linear (1.01 (1.00-1.01)) with T2D and non-significant with cancer mortality. Stronger PA-adjusted associations were found for TV viewing (h/day); non-linear for all-cause mortality (1.03 (1.01-1.04) ≤ 3.5 h/day; 1.06 (1.05-1.08) > 3.5 h/day) and for CVD mortality (1.02 (0.99-1.04) ≤ 4 h/day; 1.08 (1.05-1.12) > 4 h/day). Associations with cancer mortality (1.03 (1.02-1.04)) and T2D were linear (1.09 (1.07-1.12)). CONCLUSIONS:  Independent of PA, total sitting and TV viewing time are associated with greater risk for several major chronic disease outcomes. For all-cause and CVD mortality, a threshold of 6-8 h/day of total sitting and 3-4 h/day of TV viewing was identified, above which the risk is increased.

Why precision medicine is not the best route to a healthier world.

Precision medicine has been announced as a new health revolution. The term precision implies more accuracy in healthcare and prevention of diseases, which could yield substantial cost savings. However, scientific debate about precision medicine is needed to avoid wasting economic resources and hype. In this commentary, we express the reasons why precision medicine cannot be a health revolution for population health. Advocates of precision medicine neglect the limitations of individual-centred, high-risk strategies (reduced population health impact) and the current crisis of evidence-based medicine. Overrated "precision medicine" promises may be serving vested interests, by dictating priorities in the research agenda and justifying the exorbitant healthcare expenditure in our finance-based medicine. If societies aspire to address strong risk factors for non-communicable diseases (such as air pollution, smoking, poor diets, or physical inactivity), they need less medicine and more investment in population prevention strategies.